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Dargaville PA, Kamlin COF, Orsini F, Wang X, De Paoli AG, Kanmaz Kutman HG, Cetinkaya M, Kornhauser-Cerar L, Derrick M, Özkan H, Hulzebos CV, Schmölzer GM, Aiyappan A, Lemyre B, Kuo S, Rajadurai VS, O'Shea J, Biniwale M, Ramanathan R, Kushnir A, Bader D, Thomas MR, Chakraborty M, Buksh MJ, Bhatia R, Sullivan CL, Shinwell ES, Dyson A, Barker DP, Kugelman A, Donovan TJ, Goss KCW, Tauscher MK, Murthy V, Ali SKM, Clark HW, Soll RF, Johnson S, Cheong JLY, Carlin JB, Davis PG. Two-Year Outcomes After Minimally Invasive Surfactant Therapy in Preterm Infants: Follow-Up of the OPTIMIST-A Randomized Clinical Trial. JAMA 2023; 330:1054-1063. [PMID: 37695601 PMCID: PMC10495923 DOI: 10.1001/jama.2023.15694] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023]
Abstract
Importance The long-term effects of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome remain to be definitively clarified. Objective To examine the effect of MIST on death or neurodevelopmental disability (NDD) at 2 years' corrected age. Design, Setting, and Participants Follow-up study of a randomized clinical trial with blinding of clinicians and outcome assessors conducted in 33 tertiary-level neonatal intensive care units in 11 countries. The trial included 486 infants with a gestational age of 25 to 28 weeks supported with continuous positive airway pressure (CPAP). Collection of follow-up data at 2 years' corrected age was completed on December 9, 2022. Interventions Infants assigned to MIST (n = 242) received exogenous surfactant (200 mg/kg poractant alfa) via a thin catheter; those assigned to the control group (n = 244) received sham treatment. Main Outcomes and Measures The key secondary outcome of death or moderate to severe NDD was assessed at 2 years' corrected age. Other secondary outcomes included components of this composite outcome, as well as hospitalizations for respiratory illness and parent-reported wheezing or breathing difficulty in the first 2 years. Results Among the 486 infants randomized, 453 had follow-up data available (median gestation, 27.3 weeks; 228 females [50.3%]); data on the key secondary outcome were available in 434 infants. Death or NDD occurred in 78 infants (36.3%) in the MIST group and 79 (36.1%) in the control group (risk difference, 0% [95% CI, -7.6% to 7.7%]; relative risk [RR], 1.0 [95% CI, 0.81-1.24]); components of this outcome did not differ significantly between groups. Secondary respiratory outcomes favored the MIST group. Hospitalization with respiratory illness occurred in 49 infants (25.1%) in the MIST group vs 78 (38.2%) in the control group (RR, 0.66 [95% CI, 0.54-0.81]) and parent-reported wheezing or breathing difficulty in 73 (40.6%) vs 104 (53.6%), respectively (RR, 0.76 [95% CI, 0.63-0.90]). Conclusions and Relevance In this follow-up study of a randomized clinical trial of preterm infants with respiratory distress syndrome supported with CPAP, MIST compared with sham treatment did not reduce the incidence of death or NDD by 2 years of age. However, infants who received MIST had lower rates of adverse respiratory outcomes during their first 2 years of life. Trial Registration anzctr.org.au Identifier: ACTRN12611000916943.
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Affiliation(s)
- Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - C Omar F Kamlin
- Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Xiaofang Wang
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Antonio G De Paoli
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - H Gozde Kanmaz Kutman
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Merih Cetinkaya
- Division of Neonatology, Department of Pediatrics, Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Lilijana Kornhauser-Cerar
- Division of Gynaecology and Obstetrics, Department of Perinatology, University Medical Centre, Ljubljana, Slovenia
| | - Matthew Derrick
- Division of Neonatology, Northshore University Health System, Evanston, Illinois
| | - Hilal Özkan
- Division of Neonatology, Department of Pediatrics, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Christian V Hulzebos
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - Georg M Schmölzer
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Ajit Aiyappan
- Neonatal Services, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Brigitte Lemyre
- Department of Obstetrics, Gynecology, and Newborn Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sheree Kuo
- Department of Pediatrics, Kapi'olani Medical Center for Women and Children, Honolulu, Hawai'i
| | - Victor S Rajadurai
- Department of Neonatology, KK Women's and Children's Hospital, Duke-NUS Medical School, Singapore
| | - Joyce O'Shea
- Neonatal Unit, Royal Hospital for Children, Glasgow, United Kingdom
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, Los Angeles County + USC Medical Center and Good Samaritan Hospital, Keck School of Medicine of USC, Los Angeles, California
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Los Angeles County + USC Medical Center and Good Samaritan Hospital, Keck School of Medicine of USC, Los Angeles, California
| | - Alla Kushnir
- Department of Pediatrics, Children's Regional Hospital, Cooper University Health Care, Camden, New Jersey
| | - David Bader
- Rappaport Faculty of Medicine, Department of Neonatology, Bnai Zion Medical Center, Technion, Haifa, Israel
| | - Mark R Thomas
- Department of Neonatal Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, United Kingdom
| | - Mariam J Buksh
- Newborn Service, Starship Child Health, Auckland Hospital, Auckland, New Zealand
| | - Risha Bhatia
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Carol L Sullivan
- Department of Neonatology, Singleton Hospital, Swansea, United Kingdom
| | - Eric S Shinwell
- Faculty of Medicine, Department of Neonatology, Ziv Medical Center, Bar-Ilan University, Tsfat, Israel
| | - Amanda Dyson
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Woden, New South Wales, Australia
| | - David P Barker
- Neonatal Intensive Care Unit, Dunedin Hospital, Dunedin, New Zealand
| | - Amir Kugelman
- Rappaport Faculty of Medicine, Department of Neonatology, Rambam Medical Center, Technion, Haifa, Israel
| | - Tim J Donovan
- Division of Neonatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Kevin C W Goss
- Neonatal Intensive Care Unit, Princess Anne Hospital, Southampton, United Kingdom
| | - Markus K Tauscher
- Division of Neonatology, Peyton Manning Children's Hospital, Ascension St Vincent, Indianapolis, Indiana
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, The Royal London Hospital-Barts Health NHS Foundation Trust, London, United Kingdom
| | - Sanoj K M Ali
- Division of Neonatology, Sidra Medicine, Doha, Qatar
| | - Howard W Clark
- Faculty of Population Health Sciences, Neonatology, EGA Institute for Women's Health, University College London, London, United Kingdom
| | - Roger F Soll
- Division of Neonatal-Perinatal Medicine, Larner College of Medicine, The University of Vermont, Burlington
| | - Samantha Johnson
- Infant Mortality and Morbidity Studies Research Group, Department of Population Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Jeanie L Y Cheong
- Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - John B Carlin
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Davis
- Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Dargaville PA, Kamlin COF, Orsini F, Wang X, De Paoli AG, Kanmaz Kutman HG, Cetinkaya M, Kornhauser-Cerar L, Derrick M, Özkan H, Hulzebos CV, Schmölzer GM, Aiyappan A, Lemyre B, Kuo S, Rajadurai VS, O’Shea J, Biniwale M, Ramanathan R, Kushnir A, Bader D, Thomas MR, Chakraborty M, Buksh MJ, Bhatia R, Sullivan CL, Shinwell ES, Dyson A, Barker DP, Kugelman A, Donovan TJ, Tauscher MK, Murthy V, Ali SKM, Yossuck P, Clark HW, Soll RF, Carlin JB, Davis PG. Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome: The OPTIMIST-A Randomized Clinical Trial. JAMA 2021; 326:2478-2487. [PMID: 34902013 PMCID: PMC8715350 DOI: 10.1001/jama.2021.21892] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain. OBJECTIVE To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020. INTERVENTIONS Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately. RESULTS Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group. CONCLUSIONS AND RELEVANCE Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000916943.
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Affiliation(s)
- Peter A. Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
| | - C. Omar F. Kamlin
- Neonatal Services, Royal Women’s Hospital, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Xiaofang Wang
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
| | | | - H. Gozde Kanmaz Kutman
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Merih Cetinkaya
- Division of Neonatology, Department of Pediatrics, Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Lilijana Kornhauser-Cerar
- Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre, Ljubljana, Slovenia
| | - Matthew Derrick
- Division of Neonatology, NorthShore University Health System, Evanston, Illinois
| | - Hilal Özkan
- Department of Pediatrics, Division of Neonatology, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Christian V. Hulzebos
- Division of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - Georg M. Schmölzer
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Ajit Aiyappan
- Neonatal Services, Mercy Hospital for Women, Heidelberg, Australia
| | - Brigitte Lemyre
- Department of Obstetrics, Gynecology, and Newborn Care, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sheree Kuo
- Department of Pediatrics, Kapi’olani Medical Center for Women and Children, Honolulu, Hawaii
| | - Victor S. Rajadurai
- Department of Neonatology, KK Women’s and Children’s Hospital, Duke-NUS Medical School, Singapore
| | - Joyce O’Shea
- Neonatal Unit, Royal Hospital for Children, Glasgow, Scotland
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center and Good Samaritan Hospital, Keck School of Medicine of USC, Los Angeles, California
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center and Good Samaritan Hospital, Keck School of Medicine of USC, Los Angeles, California
| | - Alla Kushnir
- Department of Pediatrics, Children’s Regional Hospital, Cooper University Health Care, Camden, New Jersey
| | - David Bader
- Department of Neonatology, Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mark R. Thomas
- Department of Neonatal Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, England
| | | | - Mariam J. Buksh
- Newborn Service, Starship Child Health, Auckland Hospital, Auckland, New Zealand
| | - Risha Bhatia
- Monash Newborn, Monash Children’s Hospital, Clayton, Australia
| | | | - Eric S. Shinwell
- Department of Neonatology, Ziv Medical Center, Faculty of Medicine, Bar-Ilan University, Tsfat, Israel
| | - Amanda Dyson
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Woden, Australia
| | - David P. Barker
- Neonatal Intensive Care Unit, Dunedin Hospital, Dunedin, New Zealand
| | - Amir Kugelman
- Department of Neonatology, Rambam Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tim J. Donovan
- Division of Neonatology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Markus K. Tauscher
- Division of Neonatology, Peyton Manning Children’s Hospital, Ascension St Vincent, Indianapolis, Indiana
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, Royal London Hospital-Barts Health NHS Foundation Trust, London, England
| | | | - Pete Yossuck
- Department of Pediatrics, WVU Medicine Children’s Hospital, Morgantown, West Virginia
| | - Howard W. Clark
- Neonatal Intensive Care Unit, Princess Anne Hospital, Southampton, England
- Department of Neonatology, EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, England
| | - Roger F. Soll
- Division of Neonatal-Perinatal Medicine, Larner College of Medicine, University of Vermont, Burlington
| | - John B. Carlin
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Peter G. Davis
- Neonatal Services, Royal Women’s Hospital, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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Majid A, Blackwell M, Broadbent RS, Barker DP, Al-Sallami HS, Edmonds L, Kerruish N, Wheeler BJ. Newborn Vitamin K Prophylaxis: A Historical Perspective to Understand Modern Barriers to Uptake. Hosp Pediatr 2019; 9:55-60. [PMID: 30593456 DOI: 10.1542/hpeds.2018-0104] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Since its initial discovery almost a century ago, vitamin K has been labeled as both lifesaving and malignancy causing. This has led to debate of not only its use in general but also regarding its appropriate dose and route. In this article, we review through a historical lens the past 90 years of newborn vitamin K from its discovery through to its modern use of preventing vitamin K deficiency bleeding (VKDB). Although researchers in surveillance studies have shown considerable reductions in VKDB following intramuscular vitamin K prophylaxis, ongoing barriers to the universal uptake of vitamin K prophylaxis remain. Reviewing the history of newborn vitamin K provides an opportunity for a greater understanding of the current barriers to uptake that we face. Although at times difficult, improving this understanding may allow us to address contentious issues related to parental and health professional beliefs and values as well as improve overall communication. The ultimate goal is to improve and maintain the uptake of vitamin K to prevent VKDB in newborns.
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Affiliation(s)
- Atif Majid
- Department of Women's and Children's Health, Dunedin School of Medicine
| | - Miranda Blackwell
- Department of Women's and Children's Health, Dunedin School of Medicine
| | | | - David P Barker
- Department of Women's and Children's Health, Dunedin School of Medicine
| | | | - Liza Edmonds
- Department of Women's and Children's Health, Dunedin School of Medicine
| | - Nikki Kerruish
- Department of Women's and Children's Health, Dunedin School of Medicine
- The Bioethics Centre, University of Otago, Dunedin, New Zealand
| | - Benjamin J Wheeler
- Department of Women's and Children's Health, Dunedin School of Medicine,
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Gosai S, Broadbent RS, Barker DP, Jackson PM, Wheeler BJ. Medical and midwifery attitudes towards vitamin K prophylaxis in New Zealand neonates. J Paediatr Child Health 2014; 50:536-9. [PMID: 24528494 DOI: 10.1111/jpc.12490] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2013] [Indexed: 11/30/2022]
Abstract
AIM Neonates are at risk for potentially life-threatening vitamin K deficiency bleeding. This can be readily prevented with prophylactic vitamin K following delivery. In this context, most vitamin K-deficiency bleeding occurs in those whose parents decline newborn vitamin K. One factor influencing parental decision-making is information received from health professionals. This study examined attitudes and perceptions towards newborn vitamin K in relevant health-care professionals. METHODS A literature review and one-on-one semi-structured interviews were conducted to inform questionnaire design. Midwives and selected medical staff employed in the South Island of New Zealand were then invited to complete an anonymous survey exploring attitudes and perceptions towards vitamin K prophylaxis in newborns. RESULTS The survey achieved an overall response rate of 57%. Almost all responding medical staff and 76% of midwives agreed with the current New Zealand Ministry of Health vitamin K guideline. All medical staff but only 55% of midwives feel that all babies should receive vitamin K. Differences were also seen between professionals with respect to vitamin K education and risks. CONCLUSION This is the first study to examine attitudes and perceptions of midwives and doctors to vitamin K prophylaxis in neonates. Considerable discrepancies in attitude are evident, and in some midwives, a lack of confidence in this intervention is apparent. How this affects education to families is unknown. Increased understanding of this phenomenon, along with improved education and communication to professionals and families, is required.
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Affiliation(s)
- Sonal Gosai
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
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Abstract
AIM To determine physiological and hormonal stress responses in ventilated preterm infants. METHODS Physiological and hormonal stress responses were studied in 47 ventilated preterm infants who were judged clinically to require sedation. The correlation between the stress response and severity of illness was examined, and responses were compared between infants with different clinical outcomes. RESULTS Stress hormone concentrations were significantly correlated with severity of illness, assessed using the arterial: alveolar oxygen partial pressure ratio. Noradrenaline showed the strongest correlation, with an exponential pattern of increased secretion. Catecholamine concentrations before sedation were significantly higher among infants who subsequently died (n = 15, at a median age of 6 days) than among survivors: median noradrenaline 4.31 vs 2.16 nmol/l, median adrenaline 0.69 vs 0.31 nmol/l. The observed fall in noradrenaline with sedation was lower among those who died than survivors (median fall 2% vs 40%). CONCLUSION Preterm infants are capable of hormonal stress responses appropriate for the severity of their illness. Extreme catecholamine responses, in the sickest infants, are associated with the worst outcome.
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MESH Headings
- Epinephrine/blood
- Female
- Heroin/administration & dosage
- Humans
- Hydrocortisone/blood
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/mortality
- Male
- Norepinephrine/blood
- Respiration, Artificial
- Stress, Physiological/blood
- Stress, Physiological/mortality
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Affiliation(s)
- D P Barker
- Department of Neonatal Medicine and Surgery, Nottingham City Hospital, Nottingham
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Barrett DA, Barker DP, Rutter N, Pawula M, Shaw PN. Morphine, morphine-6-glucuronide and morphine-3-glucuronide pharmacokinetics in newborn infants receiving diamorphine infusions. Br J Clin Pharmacol 1996; 41:531-7. [PMID: 8799518 PMCID: PMC2042627 DOI: 10.1046/j.1365-2125.1996.03539.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
1. The pharmacokinetics of morphine, morphine-6-glucuronide (M6G) and morphine-3-glucuronide (M3G) were studied in 19 ventilated newborn infants (24-41 weeks gestation) who were given a loading dose of 50 micrograms kg-1 or 200 micrograms kg-1 of diamorphine followed by an intravenous infusion of 15 micrograms kg-1 h-1 of diamorphine. Plasma concentrations of morphine, M3G and M6G were measured during the accrual to steady-state and at steady state of the diamorphine infusion. 2. Following both the 50 micrograms kg-1 or 200 micrograms kg-1 loading doses the mean steady-state plasma concentration (+/- s.d.) of morphine, M3G and M6G were 86 +/- 52 ng ml-1, 703 +/- 400 ng ml-1 and 48 +/- 28 ng ml-1 respectively and morphine clearance was found to be 4.6 +/- 3.2 ml min-1 kg-1. 3. M3G formation clearance was estimated to be 2.5 +/- 1.8 ml min-1 kg-1, and the formation clearance of M6G was estimated to be 0.46 +/- 0.32 ml min-1 kg-1. 4. M3G metabolite clearance was 0.46 +/- 0.60 ml min-1 kg-1, the elimination half-life was 11.1 +/- 11.3 h and the volume of distribution was 0.55 +/- 1.13 l kg-1. M6G metabolite clearance was 0.71 +/- 0.36 ml min-1 kg-1, the elimination half-life was 18.2 +/- 13.6 h and the volume of distribution was 1.03 +/- 0.88 l kg-1. 5. No significant effect of the loading dose (50 micrograms kg-1 or 200 micrograms kg-1) on the plasma morphine or metabolite concentrations or their derived pharmacokinetic parameters was found. 6. We were unable to identify correlations between gestational age of the infants and any of the determined pharmacokinetic parameters. 7. M3G: morphine and M6G: morphine steady-state plasma concentration ratios were 11.0 +/- 10.8 and 0.8 +/- 0.8, respectively. 8. The metabolism of morphine in neonates, in terms of the respective contributions of each glucuronide pathway, was similar to that in adults.
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Affiliation(s)
- D A Barrett
- Department of Pharmaceutical Sciences, Nottingham University, UK
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7
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Abstract
The hypothesis that capillary blood sampling is made easier by warming the heel was examined in a randomised, controlled trial of healthy newborn infants. Sampling was performed using an automated lancet with or without prior warming. The time taken to collect a standard volume of blood, the number of repeat procedures needed, and the infants' behavioural responses were measured. Eighty one procedures were studied in 57 infants. Warming produced a median rise in heel skin temperature of 4.7 degrees C. However, there were no significant differences between the warmed and unwarmed groups in any of the outcome measures. Heel skin temperature is not an important factor in capillary blood sampling. Attention should be directed towards improving sampling devices and technique.
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Affiliation(s)
- D P Barker
- Department of Neonatal Medicine and Surgery, Nottingham City Hospital
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Barker DP, Simpson J, Pawula M, Barrett DA, Shaw PN, Rutter N. Randomised, double blind trial of two loading dose regimens of diamorphine in ventilated newborn infants. Arch Dis Child Fetal Neonatal Ed 1995; 73:F22-6. [PMID: 7552591 PMCID: PMC2528361 DOI: 10.1136/fn.73.1.f22] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
AIMS To compare the safety and efficacy of two loading doses of diamorphine in 27 ventilated newborn infants in a randomised double blind trial. METHODS Fifty or 200 mcg/kg were infused intravenously over 30 minutes, followed by a 15 mcg/kg/hour continuous infusion. Serial measurements were made of physiology, behaviour, and stress hormones. RESULTS Both loading doses produced small but significant falls in blood pressure. The 200 mcg/kg dose produced greater respiratory depression, and two infants deteriorated clinically, requiring resuscitation. Loading reduced respiratory effort in most of the infants, but had little effect on behavioural activity. Stress hormone concentrations were reduced at six hours in both dosage groups; differences between loading doses were not significant. Morphine, morphine-3-glucuronide, and morphine-6-glucuronide were detected in the plasma of all patients. No significant differences in concentrations between loading doses were found. CONCLUSIONS Diamorphine reduces the stress response in ventilated newborn infants. A high loading dose confers no benefit, and may produce undesirable physiological effects. A 50 mcg/kg loading dose seems to be safe and effective.
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Affiliation(s)
- D P Barker
- Department of Neonatal Medicine and Surgery, Nottingham City Hospital
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Abstract
The ability of topically applied lignocaine ointment to produce surface anaesthesia was examined in 45 preterm infants (gestational age 25 to 35 weeks) at a median age of 2 days. Two strengths of ointment, 5% and 30%, were tested at 30 and 60 minutes after application to the dorsum of the foot. Anaesthesia was assessed by comparing the response to skin stimulation at the test and control sites, using von Frey hairs. In 84% of cases responses indicated that there was no surface anaesthesia. Topically applied lignocaine ointment is not an effective local anaesthetic in preterm infants, presumably due to poor absorption.
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Affiliation(s)
- D P Barker
- Department of Neonatal Medicine and Surgery, Nottingham City Hospital
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Abstract
The nature and numbers of invasive procedures were studied in 54 consecutive infants admitted to a neonatal intensive care unit. Over 3000 procedures were recorded, 74% in infants below 31 weeks of gestation. One infant (23 weeks' gestation, birth weight 560 g) underwent 488 procedures. Heel prick blood sampling was the most common procedure (56%), followed by endotracheal suction (26%) and intravenous cannula insertion (8%). Invasive procedures which would cause pain or distress to a child are frequently performed on infants admitted to the neonatal intensive care unit. A reduction in the number of procedures, modifying them, or providing adequate analgesia could relieve some of this pain and distress.
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Affiliation(s)
- D P Barker
- Department of Neonatal Medicine and Surgery, Nottingham City Hospital
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Abstract
Preterm infants undergoing heel blood sampling were randomly allocated to specimen collection by heel puncture (Autolet II Clinisafe) or incision (Tenderfoot 'preemie'). A total of 187 procedures was observed in 47 infants. No significant difference was found in the infants' behavioural response, increase in heart rate, or in the frequency of specimen haemolysis. Collection times for small to medium sized samples were similar, but for large samples (> 1 ml) the Tenderfoot method was superior and fewer repeat procedures were necessary. Tenderfoot has the added advantage of improved safety, but it is too costly for routine use.
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Affiliation(s)
- D P Barker
- Department of Neonatal Medicine and Surgery, Nottingham City Hospital
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15
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16
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Abstract
A telephone questionnaire was targeted at 189 paediatric senior house officers (SHOs) throughout England and Wales in order to evaluate their attitudes towards paediatrics and gain insight into methods by which recruitment could be improved in future years. A total of 152 senior house officers were interviewed. The group consisted mainly of general practice trainees, but included 51 career paediatricians. The majority were female (57%) and 44% were married. Our assessment revealed a perceived high work-load, but also showed that paediatrics remains a satisfying specialty. Training while in post was perceived as unsatisfactory by 32% of those questioned. Sixty per cent reported a decline in their social life since starting their post. Paediatrics was seen as the busiest of a number of specialties. This perception persisted, and in fact increased, between SHO and consultant grade. It is foreseen that this may lead to further problems in recruitment.
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Affiliation(s)
- D P Barker
- Institute of Child Health, University of Bristol, Royal Hospital for Sick Children
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