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Rocha G, Calejo R, Arnet V, de Lima FF, Cassiano G, Diogo I, Mesquita J, Mimoso G, Proença E, Carvalho C, Pinto CG, Salazar A, Aguiar M, Silva A, Barroso A, Quintas C. The use of two or more courses of low-dose systemic dexamethasone to extubate ventilator-dependent preterm neonates may be associated with a higher prevalence of cerebral palsy at two years of corrected age. Early Hum Dev 2024; 194:106050. [PMID: 38781715 DOI: 10.1016/j.earlhumdev.2024.106050] [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: 04/06/2024] [Revised: 04/25/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Our objective was to determine whether the use of two or more courses of low-dose systemic dexamethasone for extubation of ventilator-dependent preterm infants after the first week of life, as proposed in the DART study, is associated with greater neurodevelopmental harm at two years of corrected age, compared to a single course. METHODS Retrospective review at seven level III neonatal intensive care units. Preterm infants who underwent only one course of systemic dexamethasone for extubation were grouped into DART-1; those who underwent two or more courses were grouped into DART-2. Data and outcomes of infants in DART-2 were compared with those in DART-1. RESULTS 150 preterm infants were studied: 104 in DART-1 and 46 in DART-2. Patients in DART-2 had a lower gestational age (25 vs. 26 weeks, p = 0.031) and greater morbidity. The average dexamethasone cumulative dose for patients in DART-1 was 0.819 mg/kg, vs. 1.697 mg/kg for patients in DART-2. A total of 14 patients died. The neuromotor and neurosensory assessments at two years of corrected age revealed in the DART-2 survivors, after the multivariate analysis, a higher prevalence of cerebral palsy with functional motor class 2 (OR = 6.837; 95%CI: 1.054-44.337; p = 0.044) and ophthalmological problems requiring the use of glasses (OR = 4.157; 95%CI: 1.026-16.837; p = 0.046). CONCLUSIONS In this cohort, the use of more than one course of systemic dexamethasone in low doses for extubation of ventilator-dependent premature infants after the first week of life was associated, at two years of corrected age, with a higher prevalence of cerebral palsy with functional motor class 2 and ophthalmological problems requiring the use of glasses.
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Affiliation(s)
- Gustavo Rocha
- Department of Neonatology, Centro Hospitalar e Universitário de São João, Porto, Portugal.
| | - Rita Calejo
- Department of Neonatology, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Vanessa Arnet
- Department of Neonatology, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Filipa Flôr de Lima
- Department of Neonatology, Centro Hospitalar e Universitário de São João, Porto, Portugal; Faculty of Medicine, University of Porto, Porto, Portugal
| | - Gonçalo Cassiano
- Maternity Dr Alfredo da Costa, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Isabel Diogo
- Maternity Dr Alfredo da Costa, Centro Hospitalar Lisboa Central, Lisbon, Portugal
| | - Joana Mesquita
- Maternity Dr Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Gabriela Mimoso
- Maternity Dr Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Elisa Proença
- Department of Neonatology, Centro Hospitalar e Universitário de Santo António, Porto, Portugal
| | - Carmen Carvalho
- Department of Neonatology, Centro Hospitalar e Universitário de Santo António, Porto, Portugal
| | - Constança Gouvêa Pinto
- Department of Neonatology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Anabela Salazar
- Department of Neonatology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Marta Aguiar
- Department of Neonatology, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Albina Silva
- Department of Neonatology, Hospital de Braga, Braga, Portugal
| | | | - Conceição Quintas
- Department of Neonatology, Centro Hospitalar de Vila Nova de Gaia e Espinho, Vila Nova de Gaia, Portugal
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Mohamed MA, Bergman A, Abdelatif D, Massa-Buck B. A Dose-Limited Dexamethasone and Bubble Continuous Positive Airway Pressure in Ventilation-Dependent Extremely Premature Infants. Am J Perinatol 2024; 41:1359-1365. [PMID: 35981559 DOI: 10.1055/a-1927-0619] [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] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Dexamethasone has been associated with early extubation and shorter duration of mechanical ventilation in preterm infants. High doses or prolonged courses of dexamethasone may be associated with poor neurodevelopmental outcomes. STUDY DESIGN This is an observational cohort study assessing the efficacy of a low-dose short dexamethasone course combined with postextubation bubble continuous positive airway pressure (bCPAP) strategy on rates of successful extubation and reduction of the duration of invasive mechanical ventilation in extremely preterm infants. We compared the short-term outcomes of implementing such strategy on a group of infants with birth weight <750 g to a historical cohort. RESULTS Among infants intubated for at least 10 days, median time to extubation from starting the dexamethasone course was 2 days (interquartile range: 1-3). Total duration of intubation was significantly shorter in infants who received dexamethasone compared with the control groups (21 ± 6 vs. 30 ± 10 days, p = 0.03), and although statistically nonsignificant, duration to wean to 21% bCPAP was shorter compared with the control group (48 ± 13 vs. 74 ± 29 days, p = 0.06). CONCLUSION A low-dose short dexamethasone course combined with postextubation bCPAP intervention may be associated with successful early extubation and shorter duration of mechanical ventilation. KEY POINTS · Noninvasive strategies may not succeed in infants < 750 g birth weight.. · Bubble CPAP has been shown to be associated with reduced complications including chronic lung disease.. · Postnatal dexamethasone therapy may succeed in conjunction with bubble CPAP to reduce reintubation..
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Affiliation(s)
- Mohamed A Mohamed
- Newborn Services Division, the George Washington University Hospital, Washington, District of Columbia
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Aaron Bergman
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, Washington, District of Columbia
- Department of Health, State of Maryland, Baltimore, Maryland
| | - Dinan Abdelatif
- Newborn Services Division, the George Washington University Hospital, Washington, District of Columbia
- Department of Obstetrics and Gynecology, the George Washington University Hospital, Washington, District of Columbia
| | - Beri Massa-Buck
- Newborn Services Division, the George Washington University Hospital, Washington, District of Columbia
- Division of Neonatology, Children's National Medical Center, Washington, District of Columbia
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Benitz WE, Backes CH. At a crossroads for early medical treatment of persistent patent ductus arteriosus in preterm infants. J Perinatol 2024:10.1038/s41372-024-02022-1. [PMID: 38918573 DOI: 10.1038/s41372-024-02022-1] [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: 02/02/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024]
Abstract
Administration of early medical therapy for the patent ductus arteriosus has ebbed and flowed through the years, with a multitude of studies failing to demonstrate a reduction in morbidity or mortality from ductal closure in the preterm population. Concerningly, an increasing number of studies have demonstrated an increase in morbidity, such as bronchopulmonary dysplasia and mortality with the use of early medical therapy to close the ductus. Considering information regarding potential risk without clear benefit in an overall cohort of preterm patients with a patent ductus, use of early medical therapy is increasingly challenging to justify and necessitates studies that will aid in identifying a patient population that would benefit from ductal closure and timing of therapy.
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Affiliation(s)
- William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Carl H Backes
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
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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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Jensen EA, Watterberg KL. Postnatal Corticosteroids To Prevent Bronchopulmonary Dysplasia. Neoreviews 2023; 24:e691-e703. [PMID: 37907402 DOI: 10.1542/neo.24-11-e691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a common, severe chronic respiratory disease that affects very preterm infants. In utero and postnatal exposure to proinflammatory stimuli contribute to the pathophysiology of BPD. Corticosteroids, because of their potent anti-inflammatory properties, may decrease respiratory morbidity and reduce the risk of BPD in very preterm infants. However, these medications can have adverse effects on the developing brain and other organ systems. This review examines current evidence on the risks and benefits of postnatal corticosteroids used to prevent BPD in preterm infants.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
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Bamat NA, Soll RF. Commentary on "Early (<7 Days) Systemic Postnatal Corticosteroids for Prevention of Bronchopulmonary Dysplasia in Preterm Infants". Neonatology 2023; 120:805-811. [PMID: 37699378 DOI: 10.1159/000532079] [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: 06/19/2023] [Accepted: 06/27/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Nicolas A Bamat
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Roger F Soll
- Larner College of Medicine University of Vermont, Burlington, Vermont, USA
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Nuthakki S, Ahmad K, Johnson G, Cuevas Guaman M. Bronchopulmonary Dysplasia: Ongoing Challenges from Definitions to Clinical Care. J Clin Med 2023; 12:jcm12113864. [PMID: 37298058 DOI: 10.3390/jcm12113864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) is the most common complication of extreme prematurity. Its etiology is multifactorial and is attributed to genetic susceptibility to prenatal and postnatal factors. As advancements in neonatology have led to the increased survival of premature infants, a parallel increase in the incidence of BPD has occurred. Over time, the definition and diagnostic criteria for BPD have evolved, as have management strategies. However, challenges continue to exist in the management of these infants, which is not surprising given the complexity of the disease. We summarize the key diagnostic criteria and provide insight into the challenges related to various aspects of BPD definitions, data comparisons, and clinical care implementation.
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Affiliation(s)
- Sushma Nuthakki
- Pediatrix Neonatology of Houston, Houston, TX 77074, USA
- Department of Neonatology, The Woman's Hospital of Texas, Houston, TX 77054, USA
| | - Kaashif Ahmad
- Pediatrix Neonatology of Houston, Houston, TX 77074, USA
- Department of Neonatology, The Woman's Hospital of Texas, Houston, TX 77054, USA
| | - Gloria Johnson
- Pediatrix Neonatology of Houston, Houston, TX 77074, USA
- Department of Neonatology, The Woman's Hospital of Texas, Houston, TX 77054, USA
| | - Milenka Cuevas Guaman
- Department of Pediatrics, Division of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
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Jensen EA, Wiener LE, Rysavy MA, Dysart KC, Gantz MG, Eichenwald EC, Greenberg RG, Harmon HM, Laughon MM, Watterberg KL, Walsh MC, Yoder BA, Lorch SA, DeMauro SB. Assessment of Corticosteroid Therapy and Death or Disability According to Pretreatment Risk of Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. JAMA Netw Open 2023; 6:e2312277. [PMID: 37155165 PMCID: PMC10167571 DOI: 10.1001/jamanetworkopen.2023.12277] [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: 01/06/2023] [Accepted: 03/24/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Meta-analyses suggest that corticosteroids may be associated with increased survival without cerebral palsy in infants at high risk of bronchopulmonary dysplasia (BPD) but are associated with adverse neurologic outcomes in low-risk infants. Whether this association exists in contemporary practice is uncertain because most randomized clinical trials administered corticosteroids earlier and at higher doses than currently recommended. Objective To evaluate whether the pretreatment risk of death or grade 2 or 3 BPD at 36 weeks' postmenstrual age modified the association between postnatal corticosteroid therapy and death or disability at 2 years' corrected age in extremely preterm infants. Design, Setting, and Participants This cohort study analyzed data on 482 matched pairs of infants from 45 participating US hospitals in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database (GDB). Infants were included in the cohort if they were born at less than 27 weeks' gestation between April 1, 2011, and March 31, 2017; survived the first 7 postnatal days; and had 2-year death or developmental follow-up data collected between January 2013 and December 2019. Corticosteroid-treated infants were propensity score matched with untreated controls. Data were analyzed from September 1, 2019, to November 30, 2022. Exposure Systemic corticosteroid therapy to prevent BPD that was initiated between day 8 and day 42 after birth. Main Outcomes and Measures The primary outcome was death or moderate to severe neurodevelopmental impairment at 2 years' corrected age. The secondary outcome was death or moderate to severe cerebral palsy at 2 years' corrected age. Results A total of 482 matched pairs of infants (mean [SD] gestational age, 24.1 [1.1] weeks]; 270 males [56.0%]) were included from 656 corticosteroid-treated infants and 2796 potential controls. Most treated infants (363 [75.3%]) received dexamethasone. The risk of death or disability associated with corticosteroid therapy was inversely associated with the estimated pretreatment probability of death or grade 2 or 3 BPD. The risk difference for death or neurodevelopmental impairment associated with corticosteroids decreased by 2.7% (95% CI, 1.9%-3.5%) for each 10% increase in the pretreatment risk of death or grade 2 or 3 BPD. This risk transitioned from estimated net harm to benefit when the pretreatment risk of death or grade 2 or 3 BPD exceeded 53% (95% CI, 44%-61%). For death or cerebral palsy, the risk difference decreased by 3.6% (95% CI, 2.9%-4.4%) for each 10% increase in the risk of death or grade 2 or 3 BPD and transitioned from estimated net harm to benefit at a pretreatment risk of 40% (95% CI, 33%-46%). Conclusions and Relevance Results of this study suggested that corticosteroids were associated with a reduced risk of death or disability in infants at moderate to high pretreatment risk of death or grade 2 or 3 BPD but with possible harm in infants at lower risk.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Laura Elizabeth Wiener
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas McGovern Medical School, Houston
| | - Kevin C. Dysart
- Neonatal/Perinatal Medicine, Nemours Children’s Hospital, Wilmington, Delaware
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Eric C. Eichenwald
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Rachel G. Greenberg
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Heidi M. Harmon
- Stead Family Department of Pediatrics, University of Iowa, Iowa City
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Scott A. Lorch
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
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Onland W, van de Loo M, Offringa M, van Kaam A. Systemic corticosteroid regimens for prevention of bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2023; 3:CD010941. [PMID: 36912887 PMCID: PMC10015219 DOI: 10.1002/14651858.cd010941.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Systematic reviews showed that systemic postnatal corticosteroids reduce the risk of bronchopulmonary dysplasia (BPD) in preterm infants. However, corticosteroids have also been associated with an increased risk of neurodevelopmental impairment. It is unknown whether these beneficial and adverse effects are modulated by differences in corticosteroid treatment regimens related to type of steroid, timing of treatment initiation, duration, pulse versus continuous delivery, and cumulative dose. OBJECTIVES To assess the effects of different corticosteroid treatment regimens on mortality, pulmonary morbidity, and neurodevelopmental outcome in very low birth weight infants. SEARCH METHODS We conducted searches in September 2022 of MEDLINE, the Cochrane Library, Embase, and two trial registries, without date, language or publication- type limits. Other search methods included checking the reference lists of included studies for randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA We included RCTs comparing two or more different treatment regimens of systemic postnatal corticosteroids in preterm infants at risk for BPD, as defined by the original trialists. The following comparisons of intervention were eligible: alternative corticosteroid (e.g. hydrocortisone) versus another corticosteroid (e.g. dexamethasone); lower (experimental arm) versus higher dosage (control arm); later (experimental arm) versus earlier (control arm) initiation of therapy; a pulse-dosage (experimental arm) versus continuous-dosage regimen (control arm); and individually-tailored regimens (experimental arm) based on the pulmonary response versus a standardized (predetermined administered to every infant) regimen (control arm). We excluded placebo-controlled and inhalation corticosteroid studies. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility and risk of bias of trials, and extracted data on study design, participant characteristics and the relevant outcomes. We asked the original investigators to verify if data extraction was correct and, if possible, to provide any missing data. We assessed the following primary outcome: the composite outcome mortality or BPD at 36 weeks' postmenstrual age (PMA). Secondary outcomes were: the components of the composite outcome; in-hospital morbidities and pulmonary outcomes, and long-term neurodevelopmental sequelae. We analyzed data using Review Manager 5 and used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 16 studies in this review; of these, 15 were included in the quantitative synthesis. Two trials investigated multiple regimens, and were therefore included in more than one comparison. Only RCTs investigating dexamethasone were identified. Eight studies enrolling a total of 306 participants investigated the cumulative dosage administered; these trials were categorized according to the cumulative dosage investigated, 'low' being < 2 mg/kg, 'moderate' being between 2 and 4 mg/kg, and 'high' > 4 mg/kg; three studies contrasted a high versus a moderate cumulative dose, and five studies a moderate versus a low cumulative dexamethasone dose. We graded the certainty of the evidence low to very low because of the small number of events, and the risk of selection, attrition and reporting bias. Overall analysis of the studies investigating a higher dose versus a lower dosage regimen showed no differences in the outcomes BPD, the composite outcome death or BPD at 36 weeks' PMA, or abnormal neurodevelopmental outcome in survivors assessed. Although there was no evidence of a subgroup difference for the higher versus lower dosage regimens comparisons (Chi2 = 2.91, df = 1 (P = 0.09), I2 = 65.7%), a larger effect was seen in the subgroup analysis of moderate-dosage regimens versus high-dosage regimens for the outcome cerebral palsy in survivors. In this subgroup analysis, there was an increased risk of cerebral palsy (RR 6.85, 95% CI 1.29 to 36.36; RD 0.23, 95% CI 0.08 to 0.37; P = 0.02; I² = 0%; NNTH 5, 95% CI 2.6 to 12.7; 2 studies, 74 infants). There was evidence of subgroup differences for higher versus lower dosage regimens comparisons for the combined outcomes death or cerebral palsy, and death and abnormal neurodevelopmental outcomes (Chi2 = 4.25, df = 1 (P = 0.04), I2 = 76.5%; and Chi2 = 7.11, df = 1 (P = 0.008), I2 = 85.9%, respectively). In the subgroup analysis comparing a high dosage regimen of dexamethasone versus a moderate cumulative-dosage regimen, there was an increased risk of death or cerebral palsy (RR 3.20, 95% CI 1.35 to 7.58; RD 0.25, 95% CI 0.09 to 0.41; P = 0.002; I² = 0%; NNTH 5, 95% CI 2.4 to 13.6; 2 studies, 84 infants; moderate-certainty evidence), and death or abnormal neurodevelopmental outcome (RR 3.41, 95% CI 1.44 to 8.07; RD 0.28, 95% CI 0.11 to 0.44; P = 0.0009; I² = 0%; NNTH 4, 95% CI 2.2 to 10.4; 2 studies, 84 infants; moderate-certainty evidence). There were no differences in outcomes between a moderate- and a low-dosage regimen. Five studies enrolling 797 infants investigated early initiation of dexamethasone therapy versus a moderately early or delayed initiation, and showed no significant differences in the overall analyses for the primary outcomes. The two RCTs investigating a continuous versus a pulse dexamethasone regimen showed an increased risk of the combined outcome death or BPD when using the pulse therapy. Finally, three trials investigating a standard regimen versus a participant-individualized course of dexamethasone showed no difference in the primary outcome and long-term neurodevelopmental outcomes. We assessed the GRADE certainty of evidence for all comparisons discussed above as moderate to very low, because the validity of all comparisons is hampered by unclear or high risk of bias, small samples of randomized infants, heterogeneity in study population and design, non-protocolized use of 'rescue' corticosteroids and lack of long-term neurodevelopmental data in most studies. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of different corticosteroid regimens on the outcomes mortality, pulmonary morbidity, and long term neurodevelopmental impairment. Despite the fact that the studies investigating higher versus lower dosage regimens showed that higher-dosage regimens may reduce the incidence of death or neurodevelopmental impairment, we cannot conclude what the optimal type, dosage, or timing of initiation is for the prevention of BPD in preterm infants, based on current level of evidence. Further high quality trials would be needed to establish the optimal systemic postnatal corticosteroid dosage regimen.
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Affiliation(s)
- Wes Onland
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Moniek van de Loo
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - Anton van Kaam
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
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Sangsari R, Saeedi M, Maddah M, Mirnia K, Goldsmith JP. Weaning and extubation from neonatal mechanical ventilation: an evidenced-based review. BMC Pulm Med 2022; 22:421. [DOI: 10.1186/s12890-022-02223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
AbstractMechanical ventilation is a lifesaving treatment used to treat critical neonatal patients. It facilitates gas exchange, oxygenation, and CO2 removal. Despite advances in non-invasive ventilatory support methods in neonates, invasive ventilation (i.e., ventilation via an endotracheal tube) is still a standard treatment in NICUs. This ventilation approach may cause injury despite its advantages, especially in preterm neonates. Therefore, it is recommended that neonatologists consider weaning neonates from invasive mechanical ventilation as soon as possible. This review examines the steps required for the neonate's appropriate weaning and safe extubation from mechanical ventilation.
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Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, Watterberg KL. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022; 46:151638. [PMID: 36085059 PMCID: PMC11075436 DOI: 10.1016/j.semperi.2022.151638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite improvements in the care and outcomes of infants born extremely preterm, bronchopulmonary dysplasia (BPD) remains a common and frustrating complication of prematurity. This review summarizes the BPD-focused research conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). To improve disease classification and outcome prediction, the NRN developed new data-driven diagnostic criteria for BPD and web-based tools that allow clinicians and investigators to reliably estimate BPD risk in preterm infants. Randomized trials of intramuscular vitamin A and prophylactic nasal continuous positive airway pressure conducted by the NRN have contributed to our current use of these therapies as evidence-based approaches to reduce BPD risk. A recent large, randomized trial of hydrocortisone administered beginning between the 2nd and 4th postnatal weeks provided strong evidence that this therapy promotes successful extubation but does not lower BPD rates. Ongoing studies within the NRN will address important, unanswered questions on the risks and benefits of intratracheal surfactant/corticosteroid combinations and treatment versus expectant management of the patent ductus arteriosus to prevent BPD.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara B DeMauro
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Barbara Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristi L Watterberg
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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12
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Bush A, Hilgendorff A. Editorial: Bronchopulmonary Dysplasia: Past, Current and Future Pathophysiologic Concepts and Their Contribution to Understanding Lung Disease. Front Med (Lausanne) 2022; 9:922631. [PMID: 35872795 PMCID: PMC9302436 DOI: 10.3389/fmed.2022.922631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Andrew Bush
- Imperial Centre for Paediatrics and Child Health, London, United Kingdom
- National Heart and Lung Institute, London, United Kingdom
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Anne Hilgendorff
- Center for Comprehensive Developmental Care (CDeC) at the Interdisciplinary Social Pediatric Center, Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, LMU Munich, Ludwig-Maximilians University, Munich, Germany
- Institute for Lung Health and Immunology and Comprehensive Pneumology Center, Helmholtz Zentrum München, Munich, Germany
- German Center for Lung Research (DZL), Giessen, Germany
- *Correspondence: Anne Hilgendorff
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13
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Cummings JJ, Pramanik AK. Postnatal Corticosteroids to Prevent or Treat Chronic Lung Disease Following Preterm Birth. Pediatrics 2022; 149:e2022057530. [PMID: 37917016 DOI: 10.1542/peds.2022-057530] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The American Academy of Pediatrics continues to provide guidance on the use of postnatal corticosteroids to manage or prevent chronic lung disease following preterm birth (formerly referred to as bronchopulmonary dysplasia). Since the last revision of such guidance in 2010, several prospective randomized trials have been published. This revision provides a review of those studies as well as updated recommendations, which include the use of systemic low-dose corticosteroid in preterm neonates with or at high risk for chronic lung disease. High-dose dexamethasone (≥0.5 mg/kg per day) is not recommended. New evidence suggests that inhaled corticosteroids may confer benefit if provided with surfactant as a vehicle, but safety data are lacking. Evidence remains insufficient to make any recommendations regarding routine use of postnatal corticosteroids in preterm infants. Neonatologists and other hospital care providers must continue to use their clinical judgment in individual patients, balancing the potential adverse effects of corticosteroid treatment with those of chronic lung disease. The decision to use postnatal corticosteroids for this purpose should be made together with the infant's parents, and the care providers should document their discussions with parents in the patient's medical record.
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Affiliation(s)
- James J Cummings
- Department of Pediatrics and Bioethics, Albany Medical Center, Albany, New York
| | - Arun K Pramanik
- Department of Pediatrics, Louisiana State University Health, Shreveport, Louisiana
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14
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Szabó H, Baraldi E, Colin AA. Corticosteroids in the prevention and treatment of infants with bronchopulmonary dysplasia: Part I. systemic corticosteroids. Pediatr Pulmonol 2022; 57:600-608. [PMID: 34964559 DOI: 10.1002/ppul.25805] [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: 10/29/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 11/06/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most significant respiratory complication of prematurity, and its consequences last from birth into adulthood. Unfortunately, the dramatic improvements in the management of premature infants have not led to a decreased incidence of BPD, or to breakthroughs in treatments offered for this long-lasting chronic respiratory disorder. Over recent decades the pathological picture of BPD has changed from inflammation, interstitial fibrosis and emphysema attributed to volu-, barotrauma and oxygen toxicity to larger, simplified alveoli and dysmorphic vessels related to arrested alveolarization and vasculogenesis with inflammation maintaining a central role. Corticosteroids (CSs) play a key role in the development of respiratory epithelial cells and lung maturation. These potent anti-inflammatory agents have long been used for the prevention and treatment of BPD; however, the risk/benefit ratio of their use remains unresolved. CSs administered antenatally have contributed to reduce mortality and respiratory distress syndrome, no such effect on BPD reduction has been observed. Postnatal systemic CSs reduced the rate and severity of BPD, yet their long-term neurodevelopmental and respiratory consequences markedly limit routine administration. This is the first in a two-part State-of-the-Art series that reviews the latest relevant clinical trials investigating the short-term and long-term effects of CSs in the prevention and treatment of BPD.
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Affiliation(s)
- Hajnalka Szabó
- Department of Pediatrics, Faculty of Medicine and Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Woman's and Child's Health, Padova University Hospital, Padova, Italy
| | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, Florida, USA
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15
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Puia-Dumitrescu M, Wood TR, Comstock BA, Law JB, German K, Perez KM, Gogcu S, Mayock DE, Heagerty PJ, Juul SE. Dexamethasone, Prednisolone, and Methylprednisolone Use and 2-Year Neurodevelopmental Outcomes in Extremely Preterm Infants. JAMA Netw Open 2022; 5:e221947. [PMID: 35275165 PMCID: PMC8917427 DOI: 10.1001/jamanetworkopen.2022.1947] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Practice variability exists in the use of corticosteroids to treat or prevent bronchopulmonary dysplasia in extremely preterm infants, but there is limited information on longer-term impacts. OBJECTIVE To describe the use of corticosteroids in extremely preterm infants and evaluate the association with neurodevelopmental outcomes. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of data from the Preterm Erythropoietin Neuroprotection (PENUT) randomized clinical trial, conducted at 19 participating sites and 30 neonatal intensive care units (NICUs) in the US. Inborn infants born between 24 0/7 and 27 6/7 weeks gestational age between December 2013 and September 2016 were included in analysis. Data analysis was conducted between February 2021 and January 2022. EXPOSURES Cumulative dose of dexamethasone and duration of therapy for dexamethasone and prednisolone or methyl prednisolone were evaluated. MAIN OUTCOMES AND MEASURES Demographic and clinical characteristics were described in infants who did or did not receive corticosteroids of interest and survived to discharge. Neurodevelopmental outcomes at 2 years of age were evaluated using the Bayley Scales of Infant Development-Third Edition (BSID-III) at corrected age 2 years. RESULTS A total of 828 extremely preterm infants (403 [49%] girls; median [IQR] gestational age, 26 [25-27] weeks) born at 19 sites who survived to discharge were included in this analysis, and 312 infants (38%) were exposed to at least 1 corticosteroid of interest during their NICU stay, including 279 exposed to dexamethasone, 137 exposed to prednisolone or methylprednisolone, and 79 exposed to both. Exposed infants, compared with nonexposed infants, had a lower birth weight (mean [SD], 718 [168] g vs 868 [180] g) and were born earlier (mean [SD] gestational age, 25 [1] weeks vs 26 [1] weeks). The median (IQR) start day was 29 (20-44) days for dexamethasone and 53 (30-90) days for prednisolone or methylprednisolone. The median (IQR) total days of exposure was 10 (5-15) days for dexamethasone and 13 (6-25) days for prednisolone or methylprednisolone. The median (IQR) cumulative dose of dexamethasone was 1.3 (0.9-2.8) mg/kg. After adjusting for potential confounders, treatment with dexamethasone for longer than 14 days was associated with worse neurodevelopmental outcomes, with mean scores in BSID-III 7.4 (95% CI, -12.3 to -2.5) points lower in the motor domain (P = .003) and 5.8 (95% CI, -10.9 to -0.6) points lower in the language domain (P = .03), compared with unexposed infants. CONCLUSIONS AND RELEVANCE These findings suggest that long duration and higher cumulative dose of dexamethasone were associated with worse neurodevelopmental scores at corrected age 2 years. Potential unmeasured differences in the clinical conditions of exposed vs unexposed infants may contribute to these findings. Improved standardization of treatment and documentation of indications would facilitate replication studies.
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Affiliation(s)
- Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | | | - Janessa B. Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Kendell German
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Krystle M. Perez
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
| | | | - Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle
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16
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Lin SY, He L, Xie LP, Wang Y, Lin YX, Cao YY, Yan WL, Liu F, Huang GY. Effects of immunoglobulin plus prednisolone in reducing coronary artery lesions in patients with Kawasaki disease: study protocol for a phase III multicenter, open-label, blinded-endpoints randomized controlled trial. Trials 2021; 22:898. [PMID: 34895290 PMCID: PMC8665612 DOI: 10.1186/s13063-021-05807-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 11/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Kawasaki disease (KD) is an acute systemic vasculitis of unclear etiology that mainly affects infants and young children. Strategies to reduce the incidence and severity of coronary artery lesions (CALs), the determinant factor in the long-term prognosis of KD, are currently a focus of studies on KD. Corticosteroids, preferred in the treatment of the majority of vasculitides, are controversial in the treatment of acute KD. In this trial, we will evaluate whether the addition of prednisolone to standard intravenous immunoglobulin (IVIG) plus aspirin therapy can reduce the occurrence of CAL in Chinese patients with KD. Methods This is a multicenter, prospective, open-label, randomized controlled trial, which is expected to be conducted in more than 20 hospitals in China and aims to assess the efficacy and safety of IVIG + prednisolone treatment versus standard treatment. Patients with KD who fulfill the inclusion and exclusion criteria will be recruited and randomized (1:1) to receive either a large dose of IVIG (2 g/kg over 12–24 h with a maximum dose of 60 g) + aspirin 30 mg/kg/d or IVIG (2 g/kg over 12–24 h) + aspirin 30 mg/kg/d + prednisolone (2 mg/kg/d with a maximum dose of 60 mg tapered over 15 days after normalization of C-reactive protein concentration). The primary outcome will be the occurrence of CAL at 1 month of illness. The follow-up duration for each participant will be set as 1 year. Patients and treating physicians will be unmasked to group allocation. Discussion This will be the first multicenter randomized controlled trial to evaluate the efficacy of IVIG + aspirin + prednisolone in Chinese pediatric patients with KD, which may provide high-level evidence for improving the initial treatment for acute KD. Trial registration ClinicalTrials.govNCT04078568. Registered on 16 August 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05807-3.
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Affiliation(s)
- Si-Yuan Lin
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Lan He
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Li-Ping Xie
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yin Wang
- Clinical Trial Unit, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yi-Xiang Lin
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Yin-Yin Cao
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China
| | - Wei-Li Yan
- Clinical Trial Unit, Children's Hospital of Fudan University, Shanghai, 201102, China.
| | - Fang Liu
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China.
| | - Guo-Ying Huang
- Heart Center, Children's Hospital of Fudan University, Shanghai, 201102, China.
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17
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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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18
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Cuna A, Lagatta JM, Savani RC, Vyas-Read S, Engle WA, Rose RS, DiGeronimo R, Logan JW, Mikhael M, Natarajan G, Truog WE, Kielt M, Murthy K, Zaniletti I, Lewis TR. Association of time of first corticosteroid treatment with bronchopulmonary dysplasia in preterm infants. Pediatr Pulmonol 2021; 56:3283-3292. [PMID: 34379886 PMCID: PMC8453128 DOI: 10.1002/ppul.25610] [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: 05/31/2021] [Revised: 07/13/2021] [Accepted: 07/31/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the association between the time of first systemic corticosteroid initiation and bronchopulmonary dysplasia (BPD) in preterm infants. STUDY DESIGN A multi-center retrospective cohort study from January 2010 to December 2016 using the Children's Hospitals Neonatal Database and Pediatric Health Information System database was conducted. The study population included preterm infants <32 weeks' gestation treated with systemic corticosteroids after 7 days of age and before 34 weeks' postmenstrual age. Stepwise multivariable logistic regression was used to assess the association between timing of corticosteroid initiation and the development of Grade 2 or 3 BPD as defined by the 2019 Neonatal Research Network criteria. RESULTS We identified 598 corticosteroid-treated infants (median gestational age 25 weeks, median birth weight 760 g). Of these, 47% (280 of 598) were first treated at 8-21 days, 25% (148 of 598) were first treated at 22-35 days, 14% (86 of 598) were first treated at 36-49 days, and 14% (84 of 598) were first treated at >50 days. Infants first treated at 36-49 days (aOR 2.0, 95% CI 1.1-3.7) and >50 days (aOR 1.9, 95% CI 1.04-3.3) had higher independent odds of developing Grade 2 or 3 BPD when compared to infants treated at 8-21 days after adjusting for birth characteristics, admission characteristics, center, and co-morbidities. CONCLUSIONS Among preterm infants treated with systemic corticosteroids in routine clinical practice, later initiation of treatment was associated with a higher likelihood to develop Grade 2 or 3 BPD when compared to earlier treatment.
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Affiliation(s)
- Alain Cuna
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
| | - Joanne M Lagatta
- Department of Pediatrics, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rashmin C Savani
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Shilpa Vyas-Read
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - William A Engle
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rebecca S Rose
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert DiGeronimo
- Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - J Wells Logan
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michel Mikhael
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, California, USA
| | - Girija Natarajan
- Department of Pediatrics, Wayne State University, Detroit, Missouri, USA
| | - William E Truog
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
| | - Matthew Kielt
- Division of Neonatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karna Murthy
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.,Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Tamorah R Lewis
- Children's Mercy Kansas City, University of Missouri, Kansas, Missouri, USA
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19
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Hennelly M, Greenberg RG, Aleem S. An Update on the Prevention and Management of Bronchopulmonary Dysplasia. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2021; 12:405-419. [PMID: 34408533 PMCID: PMC8364965 DOI: 10.2147/phmt.s287693] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 07/23/2021] [Indexed: 12/22/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is a common morbidity affecting preterm infants and is associated with substantial long-term disabilities. There has been no change in the incidence of BPD over the past 20 years, despite improvements in survival and other outcomes. The preterm lung is vulnerable to injuries occurring as a result of invasive ventilation, hyperoxia, and infections that contribute to the development of BPD. Clinicians caring for infants in the neonatal intensive care unit use multiple therapies for the prevention and management of BPD. Non-invasive ventilation strategies and surfactant administration via thin catheters are treatment approaches that aim to avoid volutrauma and barotrauma to the preterm developing lung. Identifying high-risk infants to receive postnatal corticosteroids and undergo patent ductus arteriosus closure may help to individualize care and promote improved lung outcomes. In infants with established BPD, outpatient management is complex and requires coordination from several specialists and therapists. However, most current therapies used to prevent and manage BPD lack solid evidence to support their effectiveness. Further research is needed with appropriately defined outcomes to develop effective therapies and impact the incidence of BPD.
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Affiliation(s)
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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20
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Lee BH, Waldrop MA, Connolly AM, Ciafaloni E. Time is muscle: A recommendation for early treatment for preterm infants with spinal muscular atrophy. Muscle Nerve 2021; 64:153-155. [PMID: 33959970 DOI: 10.1002/mus.27261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022]
Abstract
Implementation of newborn screening for spinal muscular atrophy (SMA) in 33 US states and increased genetic carrier screening have led to an increase in early, presymptomatic diagnosis of SMA. Early treatment is critically important and is recommended for presymptomatic infants with two to four copies of survival motor neuron 2. Currently, no specific treatment recommendations exist for preterm infants with SMA. The US Food and Drug Administration does not recommend using onasemnogene abeparvovec-xioi in preterm infants. Some insurance companies interpret "preterm" to be less than 40 weeks gestational age (GA) instead of the commonly accepted 37 weeks GA, which can be a barrier to treatment access. Given the risk of rapid decline in some infants, we recommend treatment of preterm infants when they reach 37 weeks GA, based on the definitions of term GA from the World Health Organization and Centers for Disease Control and Prevention, assuming all other treatment criteria are met.
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Affiliation(s)
- Bo Hoon Lee
- Child Neurology Division, Department of Neurology, University of Rochester, Rochester, New York, USA.,Neuromuscular Division, Department of Neurology, University of Rochester, Rochester, New York, USA
| | - Megan A Waldrop
- Center for Gene Therapy, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.,Center for Gene Therapy, Department of Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Anne M Connolly
- Center for Gene Therapy, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA.,Center for Gene Therapy, Department of Neurology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Emma Ciafaloni
- Neuromuscular Division, Department of Neurology, University of Rochester, Rochester, New York, USA
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21
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Ahmed S, Soliman A, De Sanctis V, Alyafie F, Alaaraj N, Hamed N, Ali HA, Kamal A. Defective Cortisol Secretion in Response to Spontaneous Hypoglycemia but Normal Cortisol Response to ACTH stimulation in neonates with Hyperinsulinemic Hypoglycemia (HH). ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021182. [PMID: 33988135 PMCID: PMC8182578 DOI: 10.23750/abm.v92i2.11396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 02/28/2021] [Indexed: 12/04/2022]
Abstract
Introduction: Hyperinsulinemic Hypoglycaemia (HH) is the most common cause of recurrent and persistent hypoglycemia in the neonatal period. Cortisol and GH play an important role as a counterregulatory hormone during hypoglycemia. Both antagonize the peripheral effects of insulin and directly influence glucose metabolism Patients and Methods: We studied cortisol and GH secretion in newborn infants with HH during spontaneous hypoglycemia. In addition, their basal ACTH level was measured and cortisol response to a standard dose ACTH test was performed. Results: Nine newborns with HH were studied during the first 2 weeks of life. During HH, their mean glucose concentration was 1.42 ± 0.7 mmol/L, mean beta hydroxybutyrate level was 0.08 ± 0.04 mmol/L, and mean serum insulin level was 17.78 ± 9.7 μU/mL. Their cortisol and GH levels at the time of spontaneous hypoglycemia were 94.7 ± 83.1 nmol/L and 82.4 ± 29 m IU/L respectively. They had relatively low level of ACTH (range: 14 :72 pg/ml, mean: 39.4 ± 20 pg/mL) during hypoglycemia. All infants had GH concentration > 20 mIU/L at the time of hypoglycemia. All infants underwent ACTH test. Their basal serum cortisol levels did not differ compared to cortisol levels during hypoglycemia, and all had a normal peak cortisol response (> 500 nmol/L) in response to i.v. ACTH stimulation test. Conclusion: Infants with HH have low cortisol response to spontaneous hypoglycemia with normal response to exogenous standard-dose ACTH. Checking hypothalamic-pituitary axis (HPA) axis later in infancy using low dose ACTH may be useful to diagnose persistent HPA abnormalities in these infants. All HH infants had appropriate elevation of GH during hypoglycemia. (www.actabiomedica.it)
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Affiliation(s)
- Shayma Ahmed
- Departments of Pediatrics, Hamad General Hospital, Doha, Qatar.
| | - Ashraf Soliman
- Departments of Pediatrics, Hamad General Hospital, Doha, Qatar.
| | | | - Fawzia Alyafie
- Departments of Pediatrics, Hamad General Hospital, Doha, Qatar.
| | - Nada Alaaraj
- Departments of Pediatrics, Hamad General Hospital, Doha, Qatar.
| | - Noor Hamed
- Departments of Pediatrics, Hamad General Hospital, Doha, Qatar.
| | - Hamdy A Ali
- Departments of Neonatology, Hamad General Hospital, Doha, Qatar.
| | - Abdulla Kamal
- Departments of Pharmacology, Hamad General Hospital, Doha, Qatar.
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22
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Schiliro M, Bartman CM, Pabelick C. Understanding hydrogen sulfide signaling in neonatal airway disease. Expert Rev Respir Med 2021; 15:351-372. [PMID: 33086886 PMCID: PMC10599633 DOI: 10.1080/17476348.2021.1840981] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Airway dysfunction leading to chronic lung disease is a common consequence of premature birth and mechanisms responsible for early and progressive airway remodeling are not completely understood. Current therapeutic options are only partially effective in reducing the burden of neonatal airway disease and premature decline of lung function. Gasotransmitter hydrogen sulfide (H2S) has been recently recognized for its therapeutic potential in lung diseases. AREAS COVERED Contradictory to its well-known toxicity at high concentrations, H2S has been characterized to have anti-inflammatory, antioxidant, and antiapoptotic properties at physiological concentrations. In the respiratory system, endogenous H2S production participates in late lung development and exogenous H2S administration has a protective role in a variety of diseases such as acute lung injury and chronic pulmonary hypertension and fibrosis. Literature searches performed using NCBI PubMed without publication date limitations were used to construct this review, which highlights the dichotomous role of H2S in the lung, and explores its promising beneficial effects in lung diseases. EXPERT OPINION The emerging role of H2S in pathways involved in chronic lung disease of prematurity along with its recent use in animal models of BPD highlight H2S as a potential novel candidate in protecting lung function following preterm birth.
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Affiliation(s)
- Marta Schiliro
- Departments of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Christina Pabelick
- Departments of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA
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Wang LW, Lin YC, Wang ST, Huang CC. Trends in survival, neonatal morbidity and neurodevelopmental outcome of very preterm infants in Tainan, Southern Taiwan, 1995-2016. J Formos Med Assoc 2021; 120:1314-1323. [PMID: 33478783 DOI: 10.1016/j.jfma.2020.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/04/2020] [Accepted: 12/24/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Using regression modeling analysis to investigate the breakpoints of the trends in survival-without-major-neonatal-morbidities (MNM) or -without-neurodevelopmental- impairment (NDI) by year and gestational age (GA) in preterm infants. METHODS We enrolled 2237 preterm infants (GA < 32 weeks) in Tainan, Taiwan. The trends in survival-without-MNM or -without-NDI by year (1995-2016) and GA (23-31 weeks), and the epochs and GA ranges with distinct changes were examined. Adjusted rate ratios (aRR) (95% confidence interval [CI]) were calculated using the rates in infants born at 23 weeks in 1995 as the reference. RESULTS For yearly trend, there were three epochs (1995-2000, 2001-2006, 2007-2016) with distinct changes in the rates of survival-without-MNM (aRR [95% CI] 1.07 [1.02-1.12], 1.04 [1.02-1.07], 1.02 [1.01-1.04]) and -without-NDI (1.03 [1.02-1.07], 1.02 [1.01-1.04], 1.01 [0.98-1.04]). For GA trend, the three GA ranges with different increases in the rates of survival-without-MNM were 23+0-26+6 (1.60 [1.31-1.94]), 27+0-28+6 (1.24 [1.14-1.34]) and 29+0-31+6 weeks (1.17 [1.02-1.34]), while those in the rates of survival-without-NDI were 23+0-25+6 (1.14 [1.03-1.25]), 26+0-28+6 (1.06 [1.02-1.12]) and 29+0-31+6 weeks (1.04 [1.02-1.07]). The trends in survival-without-MNM and -without-NDI increased over years in infants with GA 25-31 but not < 25 weeks. CONCLUSION The yearly trends in survival-without-MNM and -without-NDI had steady increases from 1995 to 2016 with distinct changes in three epochs, and the GA trends also increased with different rates per week in three GA ranges. Infants with GA < 25 weeks did not improve on the rates of survival-without-MNM or -without-NDI per year from 1995 to 2016.
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Affiliation(s)
- Lan-Wan Wang
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan; Department of Biotechnology and Food Technology, Southern Taiwan University of Science and Technology, Tainan, Taiwan; Department of Pediatrics, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Tair Wang
- Research Division, Ditmanson Medical Foundation Chiayi Christian Hospital, Chiayi, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Pediatrics, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan.
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Buchiboyina AK, Yip CSA, Kohan R, Nathan EA, Shrestha D, Davis J, Wang X, Sharp M. Effect of cumulative dexamethasone dose in preterm infants on neurodevelopmental and growth outcomes: a Western Australia experience. Arch Dis Child Fetal Neonatal Ed 2021; 106:69-75. [PMID: 32690582 DOI: 10.1136/archdischild-2020-319147] [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: 03/10/2020] [Revised: 06/04/2020] [Accepted: 06/09/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Comparing the long-term neurodevelopmental and growth outcomes of lower and higher cumulative dexamethasone exposure in preterm infants ventilated for a minimum cumulative duration of 7 days. DESIGN A retrospective cohort medical chart review of infants born in Western Australia <29 weeks' gestation between January 2007 and May 2016 who were mechanically ventilated >7 days. INTERVENTION No dexamethasone (controls) or a total cumulative dexamethasone dose of <2 mg/kg (lower) and ≥2 mg/kg (higher). MAIN OUTCOME MEASURES Long-term disability at 2 and 5 years and growth measurement outcomes at 2 years of age. RESULTS Dexamethasone was given to 104 infants (66 with cumulative dose <2 mg/kg; 38 with cumulative dose ≥2 mg/kg), and 324 infants were controls. There was no difference in odds of long-term disability in infants with any dexamethasone exposure compared with controls (aOR: 0.90, 95% CI 0.34 to 2.02, p=0.784). No difference in long-term disability was found between the lower and higher groups (p=0.494). The prevalence of cerebral palsy (Gross Motor Functional Classification System level ≥2) between the control, lower and high-dose groups did not differ significantly (5.8% vs 4.0% vs 0%). The higher dose group had lower mean weight z-score (mean effect: -0.83, 95% CI: -1.54 to -0.01, p=0.023), height z-score (mean effect: -0.63, 95% CI: -12.5 to -0.01, p=0.048) and head circumference z-score (mean effect: -0.65, 95% CI: -1.25 to -0.05, p=0.035) compared with controls. CONCLUSIONS In our cohort, dexamethasone use was not associated with increased odds of long-term disability. Dexamethasone use was associated with lower growth measurements compared with controls.
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Affiliation(s)
| | | | - Rolland Kohan
- Department of Neonatology, King Edward Memorial Hospital for Women and Newborns, Perth, Western Australia, Australia.,Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia
| | - Elizabeth A Nathan
- Women and Infants Research Foundation, Subiaco, Western Australia, Australia
| | - Damber Shrestha
- Department of Neonatology, King Edward Memorial Hospital for Women and Newborns, Perth, Western Australia, Australia
| | - Jonathon Davis
- Department of Neonatology, King Edward Memorial Hospital for Women and Newborns, Perth, Western Australia, Australia.,Department of Neonatology, Perth Children's Hospital, Nedlands, Perth, Australia
| | - Xiaowei Wang
- Royal Perth Hospital, Victoria Square, Perth, Australia
| | - Mary Sharp
- Department of Neonatology, King Edward Memorial Hospital for Women and Newborns, Perth, Western Australia, Australia.,Centre for Neonatal Research and Education, University of Western Australia, Perth, Western Australia, Australia.,Department of Neonatology, Perth Children's Hospital, Nedlands, Perth, Australia
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25
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Zhu H, Tian Y, Cheng H, Zheng Y, Wang W, Bao T, Wu R, Tian Z. A clinical study on plasma biomarkers for deciding the use of adjuvant corticosteroid therapy in bronchopulmonary dysplasia of premature infants. Int J Med Sci 2021; 18:2581-2588. [PMID: 34104089 PMCID: PMC8176188 DOI: 10.7150/ijms.58650] [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: 01/25/2021] [Accepted: 04/22/2021] [Indexed: 12/05/2022] Open
Abstract
Objective: The study was designed to investigate some plasma markers which help us to decide the use of adjuvant corticosteroid therapy in bronchopulmonary dysplasia (BPD) of premature infants. Methods: Thirty BPD infants were treated by dexamethasone. Among these cases, dexamethasone was significant effective in 10 cases, and no significant effective in 20 cases. These patients were divided into two groups as the significant effect (SE) group (n=10) and the non-significant effect (NE) group (n=20) according to the curative effect of dexamethasone. Fifteen non-BPD infants with gestational age and gender matching were selected as the control group. Plasma samples before and after dexamethasone treatment were collected from three infants chosen randomly from SEG for the data-independent acquisition (DIA) analysis. ELISA was further used to detect the levels of differential proteins LRP1 and S100A8 in all individuals, including SE, NE and control groups. Results: DIA analysis results showed that after dexamethasone treatment, there were a total of 52 plasma proteins that showed significant differences, of which 43 proteins were down-regulated and 9 proteins were up-regulated. LRP1 and S100A8 were two plasma proteins that were significantly changed after dexamethasone treatment. Compared with the control group, plasma LRP1 was significantly increased in BPD. Interestingly, the plasma concentration of LRP1 in the NE group was significantly higher than that in the SE group. S100A8, as an indicator of plasma inflammation, was significantly higher in BPD than the control group. Unlike LRP1, there was no significantly difference between the SE and NE group (P=0.279) before dexamethasone treatment. Conclusion: Elevated plasma LRP1 and S100A8 in BPD infants are two indicators that correlated with the efficacy of dexamethasone, and might be used as biomarkers for deciding the use of adjuvant corticosteroids therapy in the BPD.
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Affiliation(s)
- Haiyan Zhu
- Department of Neonatology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
| | - Yian Tian
- University of Barcelona, TPM-DTI, Barcelona, Catalunya, Spain
| | - Huaiping Cheng
- Department of Neonatology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
| | - Yafei Zheng
- Department of Neonatology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
| | - Wei Wang
- Department of Neonatology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
| | - Tianping Bao
- Department of Neonatology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
| | - Rong Wu
- Neonatal Medical Center, Huai'an Maternity and Child Healthcare Hospital, Yangzhou University Medical College, Huai'an, Jiangsu, China
| | - Zhaofang Tian
- Department of Neonatology, The Affiliated Huaian No.1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu, China
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26
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Nath S, Reynolds AM, Lakshminrusimha S, Ma C, Hudak ML, Ryan RM. Retrospective Analysis of Short-Term Respiratory Outcomes of Three Different Steroids Used in Clinical Practice in Intubated Preterm Infants. Am J Perinatol 2020; 37:1425-1431. [PMID: 31382299 DOI: 10.1055/s-0039-1694004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE This study aimed to compare short-term respiratory outcomes of three steroids (dexamethasone, hydrocortisone, and methylprednisolone) to facilitate extubation by improving respiratory status in preterm infants. STUDY DESIGN This is a retrospective, single-center, cohort study of 98 intubated preterm infants ≤346/7 weeks' gestation, admitted to a 64-bed, level III neonatal intensive care unit at the Women & Children's Hospital of Buffalo, Buffalo, NY, between 2006 and 2012, who received a short course of low-dose steroids for lung disease after first week of life. RESULTS Study infants received dexamethasone (34%), hydrocortisone (44%), or methylprednisolone (22%) based on clinical team preference. By day 7 after initiation of steroids, extubation occurred in 59, 44, and 41%, respectively, in infants on dexamethasone, hydrocortisone, and methylprednisolone (p = 0.3). The mean respiratory severity score (RSS = fraction of inspired oxygen × mean airway pressure), a quantitative measure of respiratory status, decreased by 44% for all infants and by 59% in the dexamethasone group by day 7. CONCLUSION Steroids improved short-term respiratory outcomes in all infants (RSS and extubation); by day 7, dexamethasone treatment was associated with the greatest decrease in RSS. Additional prospective, randomized trials of short-course low-dose steroids are warranted to substantiate these findings to guide clinical decision making and in evaluating differential steroid effects on long-term neurodevelopmental outcomes.
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Affiliation(s)
- Sfurti Nath
- Division of Neonatology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Anne Marie Reynolds
- Division of Neonatal-Perinatal Medicine, Women & Children's Hospital of Buffalo, Buffalo, New York
| | | | - ChangXing Ma
- Department of Biostatistics, School of Public Health, State University of New York at Buffalo, Buffalo, New York
| | - Mark L Hudak
- Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Rita M Ryan
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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27
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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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28
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Gisondo CM, Donn SM. <p>Bronchopulmonary Dysplasia: An Overview</p>. RESEARCH AND REPORTS IN NEONATOLOGY 2020. [DOI: 10.2147/rrn.s271255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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29
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Chen CM, Chang CH, Chao CH, Wang MH, Yeh TF. Biophysical and chemical stability of surfactant/budesonide and the pulmonary distribution following intra-tracheal administration. Drug Deliv 2019; 26:604-611. [PMID: 31204848 PMCID: PMC6586100 DOI: 10.1080/10717544.2019.1618418] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
Intra-tracheal instillation of budesonide using surfactant as a vehicle significantly decreased the incidence of bronchopulmonary dysplasia or death in preterm infants. The formularity of surfactant supplemented with budesonide and biophysical and chemical stability of the suspension has not been well reported. The aims are to investigate the biophysical and chemical stability of two surfactant preparations, Survanta and Curosurf, supplemented with budesonide. Biophysical property of the surface tension of Survanta and Survanta/budesonide suspension and of Curosurf and Curosurf/budesonide suspension was conducted by a pulsating bubble surfactometer and by a drop shape tensiometer. Chemical stability of Survanta/budesonide and of Curosurf/budesonide suspensions was tested by high-performance liquid chromatography analysis (HPLC). Pulmonary distribution of Survanta/18F-budesonide suspension was examined by a Nano/PET digital scan in rats. The Marangoni effect of Survanta, Curosurf, and budesonide was tested by digital high speed photography. For Survanta supplemented with budesonide, with a concentration ratio of ≥50, the surface tension-lowering activity was minimally affected. Similarly, the surface tension-lowering activity of Curosurf was not significantly affected by addition of budesonide, if the concentration ratio was ≥160. With these concentration ratios of both suspensions, HPLC analysis revealed no new compounds identified. Curosurf as compared to Survanta exhibited a significantly higher Marangoni effect. We conclude that with current dosage recommended for Survanta and Curosurf, both surfactant/budesonide suspensions are biophysically and chemically stable. Both surfactants can act as an effective vehicle for budesonide delivery.
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Affiliation(s)
- Chung-Ming Chen
- a Department of Pediatrics , School of Medicine, College of Medicine, Taipei Medical University , Taipei , Taiwan.,b Department of Pediatrics , Taipei Medical University Hospital , Taipei , Taiwan.,c Maternal Child Health Research Center , College of Medicine, Taipei Medical University , Taipei , Taiwan
| | - Chien-Hsiang Chang
- d Department of Chemical Engineering , National Cheng Kung University , Tainan , Taiwan
| | - Chih-Hua Chao
- e Department of Pharmacy , China Medical University , Taichung , Taiwan
| | - Mei-Hui Wang
- f Institute of Nuclear Energy Research , Taoyuan , Taiwan
| | - Tsu-Fu Yeh
- c Maternal Child Health Research Center , College of Medicine, Taipei Medical University , Taipei , Taiwan.,g Department of Pediatrics , Children's Hospital, China Medical University , Taichung , Taiwan
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30
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Abstract
In the absence of effective interventions to prevent preterm births, improved survival of infants who are born at the biological limits of viability has relied on advances in perinatal care over the past 50 years. Except for extremely preterm infants with suboptimal perinatal care or major antenatal events that cause severe respiratory failure at birth, most extremely preterm infants now survive, but they often develop chronic lung dysfunction termed bronchopulmonary dysplasia (BPD; also known as chronic lung disease). Despite major efforts to minimize injurious but often life-saving postnatal interventions (such as oxygen, mechanical ventilation and corticosteroids), BPD remains the most frequent complication of extreme preterm birth. BPD is now recognized as the result of an aberrant reparative response to both antenatal injury and repetitive postnatal injury to the developing lungs. Consequently, lung development is markedly impaired, which leads to persistent airway and pulmonary vascular disease that can affect adult lung function. Greater insights into the pathobiology of BPD will provide a better understanding of disease mechanisms and lung repair and regeneration, which will enable the discovery of novel therapeutic targets. In parallel, clinical and translational studies that improve the classification of disease phenotypes and enable early identification of at-risk preterm infants should improve trial design and individualized care to enhance outcomes in preterm infants.
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31
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Zheng Y, Xiu W, Lin Y, Ren Y, Zhang B, Yang C. Long-term effects of the intratracheal administration of corticosteroids for the prevention of bronchopulmonary dysplasia: A meta-analysis. Pediatr Pulmonol 2019; 54:1722-1734. [PMID: 31397120 DOI: 10.1002/ppul.24452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/27/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is one of the most common complications in premature infants. Since inflammation plays a crucial role in the pathogenesis of BPD, anti-inflammatory drugs, such as corticosteroids, have long been the focus of prevention research. In this meta-analysis, we aim to explore the long-term effects of the intratracheal administration of corticosteroids (IAC) in preventing BPD. METHODS EMBASE, MEDLINE, the Cochrane Library, Web of Science, CINAHL, Clinicaltrials.gov, the ISRCTN registry, and gray literature were searched to identify randomized controlled trials (RCTs) that evaluated the long-term effects of IAC for the prevention of BPD in premature infants. RESULTS Five RCTs (n = 1515) were eligible for further analysis. The meta-analysis revealed that the incidence of neurodevelopmental impairment (NDI) did not significantly differ between the IAC group and the control group (relative risk [RR] 0.9, 95% confidence interval [CI] 0.79 to 1.03, P = .14). There was no significant reduction in long-term mortality (RR, 1.13; 95% CI, 0.9 to 1.41; P = .3) or the incidence of rehospitalization (RR, 0.99; 95% CI, 0.89 to 1.09, P = .82). No significant differences were observed between the IAC group and the control group with regard to height, weight and head circumference at the age of 18 to 36 months of postmenstrual age (PMA) (mean difference [MD], 0.14; 95% CI, -0.26 to 0.54, P = .48). CONCLUSIONS Our study suggests that IAC in preterm infants does not have significant long-term benefits or adverse outcomes. However, before routine use, well-designed studies and studies involving large sample sizes are needed to confirm the pharmacokinetics and long-term effects of IAC.
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Affiliation(s)
- Yirong Zheng
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wenlong Xiu
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yunfeng Lin
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yanli Ren
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Baoquan Zhang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Changyi Yang
- Department of Neonatology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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32
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Ganguly A, Martin RJ. Vulnerability of the developing airway. Respir Physiol Neurobiol 2019; 270:103263. [PMID: 31386914 DOI: 10.1016/j.resp.2019.103263] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 07/02/2019] [Accepted: 07/30/2019] [Indexed: 12/12/2022]
Abstract
Longer term respiratory morbidity is a frequent concern for former preterm infants. Increased airway reactivity and wheezing disorders are extremely common in this population, both in infants who meet diagnostic criteria for bronchopulmonary dysplasia [BPD], and in the absence of this diagnosis. It is, therefore, imperative to gain a better understanding of normal and abnormal postnatal development of the immature airway. Airway hyperreactivity may be secondary to abnormal bronchoalveolar attachments in the face of parenchymal lung injury, or secondary to an imbalance between constrictor and dilator neural pathways. Finally, the airway itself may undergo functional and/or structural changes, including increased airway smooth muscle mass, and changes in airway extracellular matrix which may, in turn, modulate downstream signaling pathways to hyperoxia or pressure exposed vulnerable airways.
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Affiliation(s)
- Abhrajit Ganguly
- Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, United States.
| | - Richard J Martin
- Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Suite RBC 3100, Cleveland, OH 44106-6010, United States.
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33
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Randomized Trial of 42-Day Compared with 9-Day Courses of Dexamethasone for the Treatment of Evolving Bronchopulmonary Dysplasia in Extremely Preterm Infants. J Pediatr 2019; 211:20-26.e1. [PMID: 31349916 DOI: 10.1016/j.jpeds.2019.04.047] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/28/2019] [Accepted: 04/24/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare pulmonary and neurodevelopmental outcomes in extremely preterm infants with evolving bronchopulmonary dysplasia treated with either a 42-day course of dexamethasone or 9-day course(s) of dexamethasone. STUDY DESIGN This was a prospective, randomized study in 59 infants ≤27 weeks of gestation born between October 2006 and December 2010, who at day 10-21 of life had ventilatory support with mean airway pressure ≥8 cm H2O and FiO2 ≥60%. Infants received dexamethasone 0.5 mg/k/day × 3 days followed by a slow taper (42-day group, n = 30) or dexamethasone 0.5 mg/k/day followed by a rapid taper (9-day group, n = 29). Infants in the 9-day group received additional 9-day courses if they again required entry support. The primary outcome was intact survival (normal neurologic examination, IQ >70, and functioning in school without supplemental educational support) at 7 years of age. RESULTS The 42-day and 9-day groups were similar for mean gestational age (25 weeks) and all baseline characteristics. Nineteen of 29 infants (66%) in the 9-day group received only 1 course of dexamethasone; therefore, the total steroid dose for the 42-day group (7.56 mg/kg) was significantly greater than that for the 9-day group (4.04 mg/kg), P < .001. Infants in the 42-day group had shorter duration of ventilation (25 vs 37 days), P < .005, received fewer transfusions (2 vs 3.5), P < .01, and reached full enteral feeds earlier (40 vs 46 days), P < .05. Intact survival at school age was significantly increased in the 42-day group (75%) compared with the 9-day group (34%), P < .005. CONCLUSION A 42-day tapering course of dexamethasone in extremely preterm infants at high risk for bronchopulmonary dysplasia decreased hospital morbidities and increased rate of survival without handicap compared with a treatment protocol that attempted to minimize steroid exposure.
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34
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Abstract
A health care learning community engages providers and families in a collaborative environment to improve outcomes. Vermont Oxford Network (VON), a voluntary organization dedicated to improving the quality, safety and value of care through a coordinated program of data-driven quality improvement, education, and research, is a worldwide learning community in newborn medicine. Through collection of pragmatic structured data items and benchmarking reports, quality improvement collaboratives, pragmatic trials, and observational research, VON facilitates quality improvement by multidisciplinary teams and families in neonatal intensive care units (NICU) in low, middle, and high resource countries. By bringing health professionals and families together across disciplines and geographies to enable shared learning and knowledge dissemination, VON empowers individuals, organizations, and systems to meet the shared vision that every infant around the world can and should achieve their full potential.
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Affiliation(s)
- Erika M Edwards
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA.,Department of Mathematics and Statistics, College of Engineering and Health Sciences, University of Vermont, Burlington, VT, USA
| | - Danielle E Y Ehret
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT, USA.,Department of Pediatrics, Robert Larner, M.D., College of Medicine, University of Vermont, Burlington, VT, USA
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Long-term effects of postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia: Balancing the risks and benefits. Semin Fetal Neonatal Med 2019; 24:197-201. [PMID: 30962159 DOI: 10.1016/j.siny.2019.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Postnatal corticosteroids are effective in preventing or treating bronchopulmonary dysplasia (BPD) in preterm newborns, but their benefits need to exceed their risks. Several types of corticosteroids, and different timing and administration modes have been trialed. Systemic corticosteroids, given either early or late, have proven efficacy for reducing BPD and the combined outcome of death or BPD. Inhaled corticosteroids are less effective. However, systemic dexamethasone given early is associated with more neurosensory disability and cerebral palsy in survivors. The risk of adverse neurodevelopment is highest if dexamethasone is given to preterm infants at low risk of BPD. Current trials focus on corticosteroids, mixed with surfactant, delivered intratracheally directly to the lung, which may avoid some systemic adverse effects of corticosteroids. Early trials of intratracheal corticosteroids are encouraging, but more data are needed to determine whether this method of administration is preferable to systemic corticosteroids for preventing or treating BPD.
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Jung YH, Jang J, Kim HS, Shin SH, Choi CW, Kim EK, Kim BI. Respiratory severity score as a predictive factor for severe bronchopulmonary dysplasia or death in extremely preterm infants. BMC Pediatr 2019; 19:121. [PMID: 31014304 PMCID: PMC6480897 DOI: 10.1186/s12887-019-1492-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/08/2019] [Indexed: 11/27/2022] Open
Abstract
Background Despite significant advances in neonatology, bronchopulmonary dysplasia (BPD) remains the most common cause of serious morbidity and mortality in premature infants. The aim of the present study was to determine associations between the respiratory severity score (RSS) with death or BPD in premature infants. Methods This was a retrospective study conducted between January 2010 and December 2014. We enrolled preterm infants with a gestational age of less than 28 weeks who were supported by mechanical ventilation for more than a week during the first 4 weeks of life. We collected the RSS scores on day of life 2, 7, 14, 21 and 28. The correlations between postnatal RSSs and death or severe BPD were analyzed using multivariate logistic regression. Results Of the 138 eligible infants, 66 infants (47.8%) either died or developed severe BPD. The RSS cut-off values for predicting severe BPD or death were 3.0 for postnatal day (PND) 14 with an odds ratio (OR) of 11.265 (p = 0.0006, 95% confidence interval (CI), 2.842 to 44.646), 3.6 for PND 21 with an OR of 15.162 (p = 0.0003, 95% CI, 3.467 to 66.316), and 3.24 for PND 28 with an OR of 10.713 (p = 0.0005, 95% CI, 2.825 to 40.630). Conclusion Strong correlations were observed between the RSSs on PND 14, 21, and 28 and death or subsequent severe BPD. The RSS could provide a simple estimate of severe BPD or death., Further research with a larger study population is necessary to validate the usefulness of the RSS for predicting severe BPD or death. Electronic supplementary material The online version of this article (10.1186/s12887-019-1492-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Young Hwa Jung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
| | - Jinhee Jang
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea.
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, 13620, South Korea
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Functional outcome at school age of preterm-born children treated with low-dose dexamethasone in infancy. Early Hum Dev 2019; 129:16-22. [PMID: 30597329 DOI: 10.1016/j.earlhumdev.2018.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/21/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Surviving preterm born children, postnatally exposed to high doses of dexamethasone, show an increased risk of neurodevelopmental impairments. Regarding treatment with low doses of dexamethasone, no data exist on outcomes at school age. AIM To assess the functional outcome at school age of preterm-born children treated with low-dose dexamethasone. STUDY DESIGN In this cohort study, twenty-seven very preterm-born infants treated with dexamethasone from eight days after birth, underwent neuropsychological assessments at age 6-13 years. Their scores were compared with those of the norm population, and scores on total IQ and motor functioning also with those of a preterm reference group, using one-sample-chi-square and student's t-tests. RESULTS Compared with the norm population, performance of dexamethasone-treated children was poorer, particularly in the motor domain (mean z-score - 1.81). Dexamethasone-treated children also had lower scores on IQ (-0.29 to -1.12), verbal memory (-0.41 to -0.56), attention (-0.90 to -1.28), and word generation (-0.75). Their parents reported behavioral problems more often. Compared with preterm peers, motor skills remained poor, but total IQs were similar. Adjustment for bronchopulmonary dysplasia did not change our results, because all surviving children had bronchopulmonary dysplasia. CONCLUSIONS At school age, the prevalence of adverse motor, cognitive, and behavioral outcomes of preterm-born children treated with low-dose dexamethasone is increased. This could be the consequence of either dexamethasone or BPD.
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Onland W, Cools F, Kroon A, Rademaker K, Merkus MP, Dijk PH, van Straaten HL, Te Pas AB, Mohns T, Bruneel E, van Heijst AF, Kramer BW, Debeer A, Zonnenberg I, Marechal Y, Blom H, Plaskie K, Offringa M, van Kaam AH. Effect of Hydrocortisone Therapy Initiated 7 to 14 Days After Birth on Mortality or Bronchopulmonary Dysplasia Among Very Preterm Infants Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA 2019; 321:354-363. [PMID: 30694322 PMCID: PMC6439762 DOI: 10.1001/jama.2018.21443] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Dexamethasone initiated after the first week of life reduces the rate of death or bronchopulmonary dysplasia (BPD) but may cause long-term adverse effects in very preterm infants. Hydrocortisone is increasingly used as an alternative, but evidence supporting its efficacy and safety is lacking. OBJECTIVE To assess the effect of hydrocortisone initiated between 7 and 14 days after birth on death or BPD in very preterm infants. DESIGN, SETTING, AND PARTICIPANTS Double-blind, placebo-controlled randomized trial conducted in 19 neonatal intensive care units in the Netherlands and Belgium from November 15, 2011, to December 23, 2016, among preterm infants with a gestational age of less than 30 weeks and/or birth weight of less than 1250 g who were ventilator dependent between 7 and 14 days of life, with follow-up to hospital discharge ending December 12, 2017. INTERVENTIONS Infants were randomly assigned to receive a 22-day course of systemic hydrocortisone (cumulative dose, 72.5 mg/kg) (n = 182) or placebo (n = 190). MAIN OUTCOMES AND MEASURES The primary outcome was a composite of death or BPD assessed at 36 weeks' postmenstrual age. Twenty-nine secondary outcomes were analyzed up to hospital discharge, including death and BPD at 36 weeks' postmenstrual age. RESULTS Among 372 patients randomized (mean gestational age, 26 weeks; 55% male), 371 completed the trial; parents withdrew consent for 1 child treated with hydrocortisone. Death or BPD occurred in 128 of 181 infants (70.7%) randomized to hydrocortisone and in 140 of 190 infants (73.7%) randomized to placebo (adjusted risk difference, -3.6% [95% CI, -12.7% to 5.4%]; adjusted odds ratio, 0.87 [95% CI, 0.54-1.38]; P = .54). Of 29 secondary outcomes, 8 showed significant differences, including death at 36 weeks' postmenstrual age (15.5% with hydrocortisone vs 23.7% with placebo; risk difference, -8.2% [95% CI, -16.2% to -0.1%]; odds ratio, 0.59 [95% CI, 0.35-0.995]; P = .048). Twenty-one outcomes showed nonsignificant differences, including BPD (55.2% with hydrocortisone vs 50.0% with placebo; risk difference, 5.2% [95% CI, -4.9% to 15.2%]; odds ratio, 1.24 [95% CI, 0.82-1.86]; P = .31). Hyperglycemia requiring insulin therapy was the only adverse effect reported more often in the hydrocortisone group (18.2%) than in the placebo group (7.9%). CONCLUSIONS AND RELEVANCE Among mechanically ventilated very preterm infants, administration of hydrocortisone between 7 and 14 days after birth, compared with placebo, did not improve the composite outcome of death or BPD at 36 weeks' postmenstrual age. These findings do not support the use of hydrocortisone for this indication. TRIAL REGISTRATION Netherlands National Trial Register Identifier: NTR2768.
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Affiliation(s)
- Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Filip Cools
- Department of Neonatology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Andre Kroon
- Department of Neonatology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Karin Rademaker
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maruschka P. Merkus
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter H. Dijk
- Department of Neonatology, University Medical Center Groningen, Beatrix Children’s Hospital, University of Groningen, Groningen, the Netherlands
| | | | - Arjan B. Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thilo Mohns
- Department of Neonatology, Maxima Medical Center, Veldhoven, the Netherlands
| | - Els Bruneel
- Department of Neonatology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Arno F. van Heijst
- Department of Neonatology, Radboud University Medical Center–Amalia Children’s Hospital, Nijmegen, the Netherlands
| | - Boris W. Kramer
- Department of Neonatology, Medical University Center Maastricht, Maastricht, the Netherlands
| | - Anne Debeer
- Department of Neonatology, Universitair Ziekenhuis Leuven, Leuven, Belgium
| | - Inge Zonnenberg
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universteit Amsterdam, Amsterdam, the Netherlands
| | - Yoann Marechal
- Department of Neonatology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Henry Blom
- Department of Neonatology, Universitair Ziekenhuis Antwerpen, Antwerp, Belgium
| | - Katleen Plaskie
- Department of Neonatology, St Augustinus Ziekenhuis, Antwerp, Belgium
| | - Martin Offringa
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Division of Neonatology and Child Health Evaluative Sciences, the Hospital for Sick Children Research Institute, University of Toronto, Canada
| | - Anton H. van Kaam
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Department of Neonatology, Emma Children’s Hospital, Amsterdam UMC, Vrije Universteit Amsterdam, Amsterdam, the Netherlands
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Pasha AB, Chen XQ, Zhou GP. Bronchopulmonary dysplasia: Pathogenesis and treatment. Exp Ther Med 2018; 16:4315-4321. [PMID: 30542380 PMCID: PMC6257511 DOI: 10.3892/etm.2018.6780] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/06/2018] [Indexed: 11/06/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease of infancy, which mostly affects premature infants with significant morbidity and mortality. Premature infants who require to be treated for conditions including respiratory distress syndrome have a higher risk of developing BPD. In spite of the improvement in clinical methods, the incidence of BPD has not reduced. In the present review, the pathogenesis of BPD is described along with the treatments available at present and the role of nursing in the management of BPD. Emerging preventive therapies for BPD are also discussed, including the use of recombinant human superoxide dismutase, which has been proven effective in reducing respiratory injury and its long-term effects.
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Affiliation(s)
- Asfia Banu Pasha
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Xiao-Qing Chen
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Guo-Ping Zhou
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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Abstract
Bronchopulmonary dysplasia (BPD) is a chronic lung disease which develops as a result of neonatal/perinatal lung injury. It is the commonest cause of chronic lung disease in infancy and the most frequent morbidity associated with prematurity. The incidence of BPD has continued to rise despite many advances in neonatal care and this increase has been attributed to the increased survival of younger and more premature babies. There have been many advances in the care of patients with early and evolving BPD, yet there is a paucity of data regarding outpatient management of patients with established BPD. There are limited adequately-powered high-quality studies/randomized controlled trials which assess commonly used therapies such as supplemental oxygen, bronchodilators, steroids and diuretics in patients with BPD, beyond short-term effects. Further research is needed to improve our understanding of the role of currently used treatments on the long-term outcomes of patients with established BPD, post-discharge from the neonatal intensive care unit.
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Affiliation(s)
- Anita Bhandari
- Division of Pulmonary Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 11th floor Colket Building, 3501 Civic Center Boulevard, Philadelphia, PA 19446, United States.
| | - Howard Panitch
- Division of Pulmonary Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 11th floor Colket Building, 3501 Civic Center Boulevard, Philadelphia, PA 19446, United States
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Fitzgerald E, Boardman JP, Drake AJ. Preterm Birth and the Risk of Neurodevelopmental Disorders - Is There a Role for Epigenetic Dysregulation? Curr Genomics 2018; 19:507-521. [PMID: 30386170 PMCID: PMC6158617 DOI: 10.2174/1389202919666171229144807] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 04/06/2017] [Accepted: 12/17/2017] [Indexed: 12/29/2022] Open
Abstract
Preterm Birth (PTB) accounts for approximately 11% of all births worldwide each year and is a profound physiological stressor in early life. The burden of neuropsychiatric and developmental impairment is high, with severity and prevalence correlated with gestational age at delivery. PTB is a major risk factor for the development of cerebral palsy, lower educational attainment and deficits in cognitive functioning, and individuals born preterm have higher rates of schizophrenia, autistic spectrum disorder and attention deficit/hyperactivity disorder. Factors such as gestational age at birth, systemic inflammation, respiratory morbidity, sub-optimal nutrition, and genetic vulnerability are associated with poor outcome after preterm birth, but the mechanisms linking these factors to adverse long term outcome are poorly understood. One potential mechanism linking PTB with neurodevelopmental effects is changes in the epigenome. Epigenetic processes can be defined as those leading to altered gene expression in the absence of a change in the underlying DNA sequence and include DNA methylation/hydroxymethylation and histone modifications. Such epigenetic modifications may be susceptible to environmental stimuli, and changes may persist long after the stimulus has ceased, providing a mechanism to explain the long-term consequences of acute exposures in early life. Many factors such as inflammation, fluctuating oxygenation and excitotoxicity which are known factors in PTB related brain injury, have also been implicated in epigenetic dysfunction. In this review, we will discuss the potential role of epigenetic dysregulation in mediating the effects of PTB on neurodevelopmental outcome, with specific emphasis on DNA methylation and the α-ketoglutarate dependent dioxygenase family of enzymes.
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Affiliation(s)
| | | | - Amanda J. Drake
- Address correspondence to this author at the University/BHF Centre for Cardiovascular Science, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh EH16 4TJ, UK; Tel: 44 131 2426748; Fax: 44 131 2426779; E-mail:
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Urs R, Kotecha S, Hall GL, Simpson SJ. Persistent and progressive long-term lung disease in survivors of preterm birth. Paediatr Respir Rev 2018; 28:87-94. [PMID: 29752125 DOI: 10.1016/j.prrv.2018.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/09/2018] [Indexed: 02/05/2023]
Abstract
Preterm birth accounts for approximately 11% of births globally, with rates increasing across many countries. Concurrent advances in neonatal care have led to increased survival of infants of lower gestational age (GA). However, infants born <32 weeks of GA experience adverse respiratory outcomes, manifesting with increased respiratory symptoms, hospitalisation and health care utilisation into early childhood. The development of bronchopulmonary dysplasia (BPD) - the chronic lung disease of prematurity - further increases the risk of poor respiratory outcomes throughout childhood, into adolescence and adulthood. Indeed, survivors of preterm birth have shown increased respiratory symptoms, altered lung structure, persistent and even declining lung function throughout childhood. The mechanisms behind this persistent and sometimes progressive lung disease are unclear, and the implications place those born preterm at increased risk of respiratory morbidity into adulthood. This review aims to summarise what is known about the long-term pulmonary outcomes of contemporary preterm birth, examine the possible mechanisms of long-term respiratory morbidity in those born preterm and discuss addressing the unknowns and potentials for targeted treatments.
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Affiliation(s)
- Rhea Urs
- Telethon Kids Institute, Perth, Australia; School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Graham L Hall
- Telethon Kids Institute, Perth, Australia; School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Australia
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Higgins RD, Jobe AH, Koso-Thomas M, Bancalari E, Viscardi RM, Hartert TV, Ryan RM, Kallapur SG, Steinhorn RH, Konduri GG, Davis SD, Thebaud B, Clyman RI, Collaco JM, Martin CR, Woods JC, Finer NN, Raju TNK. Bronchopulmonary Dysplasia: Executive Summary of a Workshop. J Pediatr 2018; 197:300-308. [PMID: 29551318 PMCID: PMC5970962 DOI: 10.1016/j.jpeds.2018.01.043] [Citation(s) in RCA: 477] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 12/27/2017] [Accepted: 01/12/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Rosemary D Higgins
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD.
| | - Alan H Jobe
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, OH
| | - Marion Koso-Thomas
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD
| | - Eduardo Bancalari
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Rose M Viscardi
- Department of Pediatrics, University of Maryland Baltimore, Baltimore, MD
| | - Tina V Hartert
- Department of Medicine, Division of Allergy, Pulmonology and Critical Care Medicine, Vanderbilt University, Nashville, TN
| | - Rita M Ryan
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Suhas G Kallapur
- Divisions of Neonatology and Developmental Biology Professor of Pediatrics David Geffen School of Medicine at UCLA Mattel Children's Hospital UCLA, Los Angeles, CA
| | - Robin H Steinhorn
- Children's National Health System, Department of Pediatrics, Washington, DC
| | - Girija G Konduri
- Department of Pediatrics, Cardiovascular Research Center and Children's Research Institute, Medical College of Wisconsin, Milwaukee, WI
| | - Stephanie D Davis
- Section of Pediatric Pulmonology, Allergy and Sleep Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Bernard Thebaud
- Department of Pediatrics, Children's Hospital of Eastern Ontario and Children's Hospital of Ontario Research Institute (CHEORI), Ontario, Canada; Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute (OHRI), Ontario, Canada; Department of Cellular and Molecular Biology, University of Ottawa, Ontario, Canada
| | - Ronald I Clyman
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Camilia R Martin
- Department of Neonatology and Division of Translational Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jason C Woods
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Neil N Finer
- Department of Pediatrics, University of California at San Diego, San Diego, CA
| | - Tonse N K Raju
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Bethesda, MD
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Ofman G, Perez M, Farrow KN. Early low-dose hydrocortisone: is the neurodevelopment affected? J Perinatol 2018; 38:636-638. [PMID: 29467523 PMCID: PMC6030452 DOI: 10.1038/s41372-018-0086-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/29/2018] [Indexed: 01/15/2023]
Abstract
TYPE OF INVESTIGATION Prognosis; exploratory secondary analysis of an interventional randomized controlled trial. QUESTION In extremely preterm infant (<28 weeks), is early low-dose hydrocortisone compared to placebo associated with neurodevelopmental impairment at 2 years of age? METHODS Patients: Surviving infants enrolled in the PREMILOC trial conducted in France between 2008 and 2014. INTERVENTION Double-blind, multicenter, randomized, placebo-controlled trial of infants born between 24 0/7 weeks and 27 6/7 weeks of gestation and before 24 h of postnatal age, assigned to receive either placebo or low-dose hydrocortisone (0.5 mg/kg twice per day for 7 days, followed by 0.5 mg/kg per day for 3 days). MAIN RESULTS For the pre-specified exploratory outcome, the distribution of patients without neurodevelopmental impairment (73% in the hydrocortisone group vs. 70% in the placebo group), with mild neurodevelopmental impairment (20% in the hydrocortisone group vs. 18% in the placebo group), or with moderate to severe neurodevelopmental impairment (7% in the hydrocortisone group vs. 11% in the placebo group) was not found to be statistically significantly different between the two groups (p = 0.33). Qualitative assessment of patients using standardized neurological examination also was not statistically significantly different between groups (p = 0.87). STUDY CONCLUSION In this follow-up study of premature infants who were randomly assigned at birth to receive low-dose hydrocortisone or placebo for 10 days, hydrocortisone treatment was not associated with any adverse effects on neurodevelopmental outcome at 22 months of corrected age.
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Affiliation(s)
- Gaston Ofman
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Marta Perez
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kathryn N. Farrow
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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45
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Onland W, Merkus MP, Nuytemans DH, Jansen-van der Weide MC, Holman R, van Kaam AH. Systemic Hydrocortisone To Prevent Bronchopulmonary Dysplasia in preterm infants (the SToP-BPD study): statistical analysis plan. Trials 2018. [PMID: 29523175 PMCID: PMC5845134 DOI: 10.1186/s13063-018-2505-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Bronchopulmonary dysplasia (BPD) is the most common complication of preterm birth with short-term and long-term adverse consequences. Although the glucocorticoid dexamethasone has been proven to be beneficial for the prevention of BPD, there are concerns about an increased risk of adverse neurodevelopmental outcome. Hydrocortisone has been suggested as an alternative therapy. The aim of the Systemic Hydrocortisone To Prevent Bronchopulmonary Dysplasia in preterm infants (SToP-BPD) trial is to assess the efficacy and safety of postnatal hydrocortisone administration for the reduction of death or BPD in ventilator-dependent preterm infants. Methods/design The SToP-BPD study is a multicentre, double-blind, placebo-controlled hydrocortisone trial in preterm infants at risk for BPD. After parental informed consent is obtained, ventilator-dependent infants are randomly allocated to hydrocortisone or placebo treatment during a 22-day period. The primary outcome measure is the composite outcome of death or BPD at 36 weeks postmenstrual age. Secondary outcomes are short-term effects on pulmonary condition and long-term neurodevelopmental sequelae assessed at 2 years corrected age. Complications of treatment, other serious adverse events and suspected unexpected serious adverse reactions are reported as safety outcomes. This pre-specified statistical analysis plan was written and submitted without knowledge of the unblinded data. Trial registration Netherlands Trial Register, NTR2768. Registered on 17 February 2011. EudraCT, 2010-023777-19. Registered on 2 November 2010.
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Affiliation(s)
- Wes Onland
- Department of Neonatology, Emma Children's Hospital, Academic Medical Centre, Room H3-145, PO Box 22700, 1100, DD, Amsterdam, The Netherlands.
| | - Maruschka P Merkus
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Debbie H Nuytemans
- Department of Neonatology, Emma Children's Hospital, Academic Medical Centre, Room H3-145, PO Box 22700, 1100, DD, Amsterdam, The Netherlands
| | | | - Rebecca Holman
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Centre, Room H3-145, PO Box 22700, 1100, DD, Amsterdam, The Netherlands
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Li L, Yang C, Feng X, Du Y, Zhang Z, Zhang Y. Effects of intratracheal budesonide during early postnatal life on lung maturity of premature fetal rabbits. Pediatr Pulmonol 2018; 53:28-35. [PMID: 29028158 DOI: 10.1002/ppul.23889] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 09/01/2017] [Indexed: 12/26/2022]
Abstract
AIM This study aimed to study the effects of intratracheal instillation of budesonide on lung maturity of premature fetal rabbits. The developmental pattern of pulmonary alveoli in rabbits is similar to that in humans. METHOD Fetal rabbits were taken out from female rabbits on the 28th day of pregnancy (full term = 31 days) by cesarean section (c-section). The fetal rabbits were divided into four groups: control (normal saline, NS), budesonide (budesonide, BUD), calf pulmonary surfactant for injection (pulmonary surfactant, PS), and calf pulmonary surfactant + budesonide for injection (pulmonary surfactant + budesonide, PS + BUD). All premature rabbits were kept warm after c-section. After 15-min autonomous respiration, a tracheal cannula was implemented for instilling NS, BUD, PS, and PS + BUD. The morphology of lung tissues of premature fetal rabbits was analyzed using optical and electron microscopes. Surfactant protein B (SP-B) mRNA and protein levels in lung tissues were determined using polymerase chain reaction and Western blotting, respectively. RESULT Intratracheal instillation of BUD could increase the alveolar area of the fetal rabbits (P < 0.01), decrease the alveolar wall thickness (P < 0.01), and increase the mean density of lamellar bodies (P < 0.05) and SP-B protein levels in type II epithelial cells of pulmonary alveoli (P < 0.05). CONCLUSION Intratracheal instillation of BUD during early postnatal life is effective in promoting alveolarization and increasing SP-B expression, the pro-pulmonary maturity of BUD combined with PS is superior to that of BUD or PS alone. However, the long-term effect of BUD on lung development needs further exploration.
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Affiliation(s)
- Ling Li
- Department of Pediatrics, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Chen Yang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Xiuliang Feng
- The Center of Animal Experiment, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Yongping Du
- Department of Traditional Chinese Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Zhihong Zhang
- Department of Pediatrics, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
| | - Yueping Zhang
- Department of Pediatrics, Xijing Hospital, The Fourth Military Medical University, Xi'an, PR China
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Abstract
All definitions of bronchopulmonary dysplasia (BPD) have limitations and a new definition for the purpose of clinical research, benchmarking, and prognostic prediction is needed. Different inhaled and systemic drugs are currently used to prevent or treat BPD. Despite some positive effects on BPD, more information about the effects of inhaled corticosteroids is required to assess overall efficacy and associated risks. One needs to balance the risks of neurodevelopmental impairment owing to systemic corticosteroids against those of BPD itself. Future studies should, therefore, focus on infants with a very high risk of developing BPD and include pharmacokinetics and long-term developmental outcomes.
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Shah SS, Ohlsson A, Halliday HL, Shah VS. Inhaled versus systemic corticosteroids for the treatment of bronchopulmonary dysplasia in ventilated very low birth weight preterm infants. Cochrane Database Syst Rev 2017; 10:CD002057. [PMID: 29035425 PMCID: PMC6485655 DOI: 10.1002/14651858.cd002057.pub4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND This is an update of a review published in 2012. A related review "Inhaled versus systemic corticosteroids for preventing bronchopulmonary dysplasia in ventilated very low birth weight preterm neonates" has been updated as well. Bronchopulmonary dysplasia (BPD) is a serious and common problem among very low birth weight infants, despite the use of antenatal steroids and postnatal surfactant therapy to decrease the incidence and severity of respiratory distress syndrome. Due to their anti-inflammatory properties, corticosteroids have been widely used to treat or prevent BPD. However, the use of systemic steroids has been associated with serious short- and long-term adverse effects. Administration of corticosteroids topically through the respiratory tract may result in beneficial effects on the pulmonary system with fewer undesirable systemic side effects. OBJECTIVES To compare the effectiveness of inhaled versus systemic corticosteroids administered to ventilator-dependent preterm neonates with birth weight ≤ 1500 g or gestational age ≤ 32 weeks after 7 days of life on the incidence of death or BPD at 36 weeks' postmenstrual age. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 1), MEDLINE via PubMed (1966 to 23 February 2017), Embase (1980 to 23 February 2017), and CINAHL (1982 to 23 February 2017). We also searched clinical trials registers, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing inhaled versus systemic corticosteroid therapy (irrespective of dose and duration) starting after the first week of life in ventilator-dependent very low birth weight infants. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by the Cochrane Collaboration. MAIN RESULTS We included three trials that involved a total of 431 participants which compared inhaled versus systemic corticosteroids to treat BPD. No new trials were included for the 2017 update.Although one study randomised infants at < 72 hours (N = 292), treatment started when infants were aged > 15 days. In this larger study, deaths were included from the point of randomisation and before treatment started. Two studies (N = 139) randomised and started treatment at 12 to 21 days.Two trials reported non-significant differences between groups for the primary outcome: incidence of death or BPD at 36 weeks' postmenstrual age among all randomised infants. Estimates for the largest trial were Relative risk (RR) 1.04 (95% Confidence interval (CI) 0.86 to 1.26), Risk difference (RD) 0.03 (95% CI -0.09 to 0.15); (moderate-quality evidence). Estimates for the other trial reporting the primary outcome were RR 0.94 (95% CI 0.83 to 1.05), RD -0.06 (95% CI -0.17 to 0.05); (low-quality evidence).Secondary outcomes that included data from all three trials showed no significant differences in the duration of mechanical ventilation or supplemental oxygen, length of hospital stay, or the incidence of hyperglycaemia, hypertension, necrotising enterocolitis, gastrointestinal bleed, retinopathy of prematurity or culture-proven sepsis moderate- to low-quality evidence).In a subset of 75 surviving infants who were enrolled from the United Kingdom and Ireland, there were no significant differences in developmental outcomes at seven years of age between groups (moderate-quality evidence). One study received grant support and the industry provided aerochambers and metered dose inhalers of budesonide and placebo for the same study. No conflict of interest was identified. AUTHORS' CONCLUSIONS We found no evidence that inhaled corticosteroids confer net advantages over systemic corticosteroids in the management of ventilator-dependent preterm infants. There was no evidence of difference in effectiveness or adverse event profiles for inhaled versus systemic steroids.A better delivery system guaranteeing selective delivery of inhaled steroids to the alveoli might result in beneficial clinical effects without increasing adverse events.To resolve this issue, studies are needed to identify the risk/benefit ratio of different delivery techniques and dosing schedules for administration of these medications. The long-term effects of inhaled steroids, with particular attention to neurodevelopmental outcomes, should be addressed in future studies.
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Affiliation(s)
- Sachin S Shah
- Surya Hospital for Women and ChildrenDepartment of PediatricsPuneIndia
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
| | - Henry L Halliday
- Retired Honorary Professor of Child Health, Queen's University Belfast74 Deramore Park SouthBelfastNorthern IrelandUKBT9 5JY
| | - Vibhuti S Shah
- University of TorontoDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1X5
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Doyle LW, Cheong JLY. Postnatal corticosteroids to prevent or treat bronchopulmonary dysplasia - Who might benefit? Semin Fetal Neonatal Med 2017; 22:290-295. [PMID: 28734731 DOI: 10.1016/j.siny.2017.07.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Newborn infants born very preterm are at high risk of developing bronchopulmonary dysplasia, which is associated with not only mortality but also adverse long-term neurological and respiratory outcomes in survivors. Postnatal corticosteroids might reduce the risk of developing bronchopulmonary dysplasia, or reduce its severity. However, it is important to minimize exposure to the potentially harmful effects of corticosteroids, particularly on the developing brain. Systemic corticosteroids started after the first week of life have shown the most benefit in infants at highest risk of developing bronchopulmonary dysplasia, whereas inhaled corticosteroids have little effect in children with established lung disease. Systemic corticosteroids in the first week of life are not recommended, but inhaled corticosteroids, or corticosteroids instilled into the trachea using surfactant as a vehicle to distribute the corticosteroids through the lungs, offer promise with respect to prevention of bronchopulmonary dysplasia.
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Affiliation(s)
- Lex W Doyle
- Newborn Services, The Royal Women's Hospital, Parkville, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia; Clinical Sciences, Murdoch Children's Research Centre, Parkville, Australia.
| | - Jeanie L Y Cheong
- Newborn Services, The Royal Women's Hospital, Parkville, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia; Clinical Sciences, Murdoch Children's Research Centre, Parkville, Australia
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