Interaction of hydrocortisone and illness severity on head growth in cohort of ELBW infants

BACKGROUND

Extremely low birth weight (ELBW) infants comprise a fragile population at risk for neurodevelopmental disabilities (NDD). Systemic steroids were previously associated with NDD, but more recent studies suggest hydrocortisone (HCT) may improve survival without increasing NDD. However, the effects of HCT on head growth adjusted for illness severity during NICU hospitalization are unknown. Thus, we hypothesize that HCT will protect head growth, accounting for illness severity using a modified neonatal Sequential Organ Failure Assessment (M-nSOFA) score.

METHODS

We conducted a retrospective study that included infants born at 23-29 weeks gestational age (GA) and < 1000 g. Our study included 73 infants, 41% of whom received HCT.

RESULTS

We found negative correlations between growth parameters and age, similar between HCT and control patients. HCT-exposed infants had lower GA but similar normalized birth weights; HCT-exposed infants also had higher illness severity and longer lengths of hospital stay. We found an interaction between HCT exposure and illness severity on head growth, such that infants exposed to HCT had better head growth compared to those not exposed to HCT when adjusted for illness severity.

CONCLUSION

These findings emphasize the importance of considering patient illness severity and suggest that HCT use may offer additional benefits not previously considered.

IMPACT

This is the first study to assess the relationship between head growth and illness severity in extremely preterm infants with extremely low birth weights during their initial NICU hospitalization. Infants exposed to hydrocortisone (HCT) were overall more ill than those not exposed, yet HCT exposed infants had better preserved head growth relative to illness severity. Better understanding of the effects of HCT exposure on this vulnerable population will help guide more informed decisions on the relative risks and benefits for HCT use.

A prospective audit to investigate the level of consciousness of children requiring conscious sedation using an 'alternative technique'

The aim of this prospective pragmatic audit was to investigate the level of consciousness experienced by children requiring conscious sedation in a primary care sedation service, using an 'alternative technique' to avoid referral to hospital for general anaesthesia. This technique was only applied to children who were unable to accept treatment with the use of standard inhalation sedation. The technique involved titrated inhaled oxygen and nitrous oxide and titrated sevoflurane with intravenous fentanyl and titrated midazolam. The described technique was provided by an experienced team with appropriate facilities that complied with contemporary standards and guidance. During treatment and recovery the consciousness level of children was recorded using a modified Wilson's scale. Of the sample of 573 children who received the audited technique, 1.9% (11 children) scored level 5 on the modified Wilson scale (eyes closed but responsive to mild physical stimulus). Due to the fine control this technique offers, the duration of this level of consciousness was for mostly less than a minute and no more than five minutes. No children became unresponsive. The results of this audit demonstrate that the technique meets current standards and guidelines for 'alternative' conscious sedation, with a wide margin of safety and the rendering of loss of consciousness unlikely. 99% of patients who would otherwise have required general anaesthetic for dental treatment successfully completed their treatment using this technique.