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Caljé E, Oyston C, Wang Z, Bloomfield F, Marriott J, Dixon L, Groom K. The fatigue after infusion or transfusion pilot trial and feasibility study: A three-armed randomized pilot trial of intravenous iron and blood transfusion for the treatment of postpartum anemia. Transfusion 2024; 64:301-314. [PMID: 38149691 DOI: 10.1111/trf.17621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Evidence for the management of moderate-to-severe postpartum anemia is limited. A randomized trial is needed; recruitment may be challenging. STUDY DESIGN AND METHODS Randomized pilot trial with feasibility surveys. INCLUSION hemoglobin 65-79 g/L, ≤7 days of birth, hemodynamically stable. EXCLUSION ongoing heavy bleeding; already received, or contraindication to intravenous (IV)-iron or red blood cell transfusion (RBC-T). Intervention/control: IV-iron; RBC-T; or IV-iron and RBC-T. PRIMARY OUTCOME number of recruits; proportion of those approached; proportion considered potentially eligible. SECONDARY OUTCOMES fatigue, depression, baby-feeding, and hemoglobin at 1, 6 and 12 weeks; ferritin at 6 and 12 weeks. Surveys explored attitudes to trial participation. RESULTS Over 16 weeks and three sites, 26/34 (76%) women approached consented to trial participation, including eight (31%) Māori women. Of those potentially eligible, 26/167 (15.6%) consented to participate. Key participation enablers were altruism and study relevance. For clinicians and stakeholders the availability of research assistance was the key barrier/enabler. Between-group rates of fatigue and depression were similar. Although underpowered to address secondary outcomes, IV-iron and RBC-T compared with RBC-T were associated with higher hemoglobin concentrations at 6 (mean difference [MD] 11.7 g/L, 95% confidence interval [CI] 2.7-20.7) and 12 (MD 12.8 g/L, 95% CI 1.5-24.2) weeks, and higher ferritin concentrations at 6 weeks (MD 136.8 mcg/L, 95% CI 76.6-196.9). DISCUSSION Willingness to participate supports feasibility for a future trial assessing the effectiveness of IV-iron and RBC-T for postpartum anemia. Dedicated research assistance will be critical to the success of an appropriately powered trial including women-centered outcomes.
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Affiliation(s)
- Esther Caljé
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Charlotte Oyston
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
- Middlemore Hospital, Auckland, New Zealand
| | - Zeke Wang
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Frank Bloomfield
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Joy Marriott
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lesley Dixon
- New Zealand College of Midwives, Christchurch, New Zealand
| | - Katie Groom
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- National Women's Health, Auckland City Hospital, Auckland, New Zealand
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Stamp LK, Harwood M, Dalziel S, Love T, Moore D, Woock K, Sharples K, Bloomfield F. Towards a national equitable and sustainable clinical research infrastructure for Aotearoa New Zealand. N Z Med J 2023; 136:100-112. [PMID: 37414080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Clinical trials are a critical element of a modern, high-functioning, learning healthcare system. Clinical trials provide access to novel, as yet unfunded treatments, and deliver cutting-edge healthcare. Evidence from clinical trials ensures appropriateness of healthcare, allows disinvestment from practices that are found not to improve outcomes or be cost-effective, and supports the introduction of new approaches, all of which leads to improvement in health outcomes. In 2020, Manatū Hauora - Ministry of Health and The Health Research Council of New Zealand funded a project to understand the current state of clinical trial activity in Aotearoa New Zealand and to propose the infrastructure required to support equitable clinical trial activity, in order to ensure that trials benefiting from publicly funded infrastructure are responsive to the needs of New Zealanders and ultimately enable equitable delivery of the best healthcare we can achieve to all New Zealanders. This viewpoint reports the process that was undertaken to develop the final proposed infrastructure and the rationale for the approach. The restructuring of the Aotearoa New Zealand health system into Te Whatu Ora - Health New Zealand and Te Aka Whai Ora - Māori Health Authority that will both operate hospital services and commission primary and community healthcare at a national level provides the ideal opportunity to integrate and embed research into Aotearoa New Zealand's healthcare system. Integration of clinical trials and research more broadly into the public healthcare system will require a significant shift in the culture within our healthcare system. Research must be recognised and promoted as a core activity for clinical staff at all levels of the healthcare system, rather than something to be tolerated or even hindered. Strong leadership will be required from the top of Te Whatu Ora - Health New Zealand down to ensure the required cultural shift to recognise the value of clinical trials to all aspects of the healthcare system, and to grow capability and capacity of the health research workforce. The investment required by the Government to implement the proposed clinical trial infrastructure will be substantial, but now is the ideal time for investment in clinical trials infrastructure in Aotearoa New Zealand. We urge the Government to be bold and invest now to ensure the benefits can be reaped for all New Zealanders in years to come.
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Affiliation(s)
- Lisa K Stamp
- Rheumatologist, Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Matire Harwood
- General Practitioner, Papakura Marae Health Clinic, and Department of General Practice and Primary Healthcare, Auckland, New Zealand
| | - Stuart Dalziel
- Paediatrician, Cure Kids Chair, Department of Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Tom Love
- Director Sapere Research Group, Wellington, New Zealand
| | - David Moore
- Managing Director, Sapere Research Group, Wellington, New Zealand
| | - Kelvin Woock
- Senior Consultant, Sapere Research Group, Wellington, New Zealand
| | - Katrina Sharples
- Biostatistician, Department of Mathematics and Statistics, University of Otago, Dunedin, New Zealand
| | - Frank Bloomfield
- Paediatrician, The University of Auckland; Liggins Institute, Auckland, New Zealand
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3
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Soszyn N, Cloete E, Sadler L, de Laat MWM, Crengle S, Bloomfield F, Finucane K, Gentles TL. Factors influencing the choice-of-care pathway and survival in the fetus with hypoplastic left heart syndrome in New Zealand: a population-based cohort study. BMJ Open 2023; 13:e069848. [PMID: 37055204 PMCID: PMC10106067 DOI: 10.1136/bmjopen-2022-069848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 04/15/2023] Open
Abstract
OBJECTIVES To better understand the relative influence of fetal and maternal factors in determining the choice-of-care pathway (CCP) and outcome in the fetus with hypoplastic left heart syndrome (HLHS). DESIGN A retrospective, population-based study of fetuses with HLHS from a national dataset with near-complete case ascertainment from 20 weeks' gestation. Fetal cardiac and non-cardiac factors were recorded from the patient record and maternal factors from the national maternity dataset. The primary endpoint was a prenatal decision for active treatment after birth (intention-to-treat). Factors associated with a delayed diagnosis (≥24 weeks' gestation) were also reviewed. Secondary endpoints included proceeding to surgical treatment, and 30-day postoperative mortality in liveborns with an intention-to-treat. SETTING New Zealand population-wide. PARTICIPANTS Fetuses with a prenatal diagnosis of HLHS between 2006 and 2015. RESULTS Of 105 fetuses, the CCP was intention-to-treat in 43 (41%), and pregnancy termination or comfort care in 62 (59%). Factors associated with intention-to-treat by multivariable analysis included a delay in diagnosis (OR: 7.8, 95% CI: 3.0 to 20.6, p<0.001) and domicile in the maternal fetal medicine (MFM) region with the most widely dispersed population (OR: 5.3, 95% CI: 1.4 to 20.3, p=0.02). Delay in diagnosis was associated with Māori maternal ethnicity compared with European (OR: 12.9, 95% CI: 3.1 to 54, p<0.001) and greater distance from the MFM centre (OR: 3.1, 95% CI: 1.2 to 8.2, p=0.02). In those with a prenatal intention-to-treat, a decision not to proceed to surgery was associated with maternal ethnicity other than European (p=0.005) and the presence of major non-cardiac anomalies (p=0.01). Thirty-day postoperative mortality occurred in 5/32 (16%) and was more frequent when there were major non-cardiac anomalies (p=0.02). CONCLUSIONS Factors associated with the prenatal CCP relate to healthcare access. Anatomic characteristics impact treatment decisions after birth and early postoperative mortality. The association of ethnicity with delayed prenatal diagnosis and postnatal decision-making suggests systemic inequity and requires further investigation.
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Affiliation(s)
- Natalie Soszyn
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Elza Cloete
- The University of Auckland Liggins Institute, Auckland, New Zealand
- Neonatal Unit, Christchurch Women's Hospital, Te Whatu Ora - Health New Zealand, Waitaha Canterbury, Christchurch, New Zealand
| | - Lynn Sadler
- Women's Health, Auckland City Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
- The University of Auckland Department of Obstetrics and Gynaecology, Auckland, New Zealand
| | - Monique W M de Laat
- Women's Health, Auckland City Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Sue Crengle
- Otago Medical School Department of Preventive and Social Medicine, Dunedin, New Zealand
| | - Frank Bloomfield
- The University of Auckland Liggins Institute, Auckland, New Zealand
| | - Kirsten Finucane
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
| | - Thomas L Gentles
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Te Whatu Ora - Health New Zealand, Te Toka Tumai Auckland, Auckland, New Zealand
- Faculty of Medical and Health Sciences, The University of Auckland Department of Paediatrics Child and Youth Health, Auckland, New Zealand
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Chan J, Mackay L, Bloomfield F, Crowther C, Lee A, Morris JM, Hay R, Oakes-Ter Bals M, Thurnell C, De Jong P, Carlsen V, Williams T, Groom KM. Corticosteroids to safely reduce neonatal respiratory morbidity after late preterm and term planned caesarean section birth? A randomised placebo-controlled feasibility study. BMJ Open 2022; 12:e062309. [PMID: 36691173 PMCID: PMC9454046 DOI: 10.1136/bmjopen-2022-062309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/06/2022] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To assess the feasibility of conducting a randomised placebo-controlled trial of corticosteroids prior to planned caesarean section from 35+0 to 39+6 weeks. DESIGN A triple-blind, placebo-controlled, parallel, trial randomised at the participant level (1:1 ratio). Additional feasibility data obtained by questionnaires from trial participants and women who declined trial participation, and focus groups with local site researchers and clinicians. SETTING Three obstetric units in New Zealand including tertiary and secondary care; public and private care, and research active and non-active units. PARTICIPANTS Women undergoing a planned caesarean section from 35+0 to 39+6 weeks; local site researchers and clinicians. INTERVENTIONS Two doses of 11.4 mg betamethasone or saline placebo. Questionnaires and focus group meetings. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome: trial recruitment rate of eligible women. SECONDARY OUTCOMES trial recruitment by gestational age, site and delivery indication; proportion of babies who completed measurements of blood glucose concentrations as per protocol; overall incidence neonatal respiratory distress requiring >60 min of respiratory support; overall incidence of neonatal hypoglycaemia, and barriers and enablers to trial participation by participants, researchers and clinicians. RESULTS The recruitment rate was 8.9% (88/987) overall and 11.2% (88/789) for those approached about the trial. Neonatal blood glucose concentrations were measured as per protocol in 87/92 (94.6%) babies. For potential participants, key enablers to participation were contributing to research, a feeling of relevance and a good understanding; key barriers were a lack of understanding and concerns over safety. For researchers and clinicians, themes representing enablers and barriers included relevance, communication and awareness, influences on women's decision-making, resource challenges and trial process practicalities. CONCLUSIONS Some women are willing to participate in a randomised placebo-controlled trial of corticosteroids prior to a planned caesarean section birth at late preterm and term gestations. Participation in such a trial can be enhanced.
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Affiliation(s)
- Johanna Chan
- National Women's Health, Auckland City Hospital, Auckland, New Zealand
| | - Laura Mackay
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Frank Bloomfield
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Caroline Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Arier Lee
- Section of Epidemiology and Biostatistics, The University of Auckland, Auckland, New Zealand
| | - Jonathan M Morris
- Perinatal Research, Kolling Institute of Medical Research, St Leonards, New South Wales, Australia
| | - Rebecca Hay
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | | | - Phoebe De Jong
- Obstetris and Gynaecology, Tauranga Hospital, Tauranga, New Zealand
| | - Victoria Carlsen
- Obstetrics and Gynaecology, Waikato Hospital, Hamilton, New Zealand
| | - Tracey Williams
- Obstetrics and Gynaecology, Waikato Hospital, Hamilton, New Zealand
| | - K M Groom
- National Women's Health, Auckland City Hospital, Auckland, New Zealand
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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5
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Calje E, Marriott J, Oyston C, Dixon L, Bloomfield F, Groom K. Postpartum anaemia in three New Zealand district health board regions: An observational study of incidence and management. Aust N Z J Obstet Gynaecol 2022; 63:178-186. [PMID: 35851951 DOI: 10.1111/ajo.13588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The incidence of postpartum anaemia (PPA) in New Zealand, and the extent of intravenous iron (IV-iron) use in its treatment, are unknown. AIMS To report the incidence of PPA in three district health board (DHB) regions and describe current management of moderate to severe PPA, including by ethnicity. MATERIALS AND METHODS Retrospective observational study of PPA (haemoglobin (Hb) <100 g/L) in three DHBs from July-December 2019. Cases with moderate to severe PPA (Hb <90 g/L) were reviewed and management compared to local and national guidance. Logistic regression examined demographic associations of PPA. RESULTS There were 8849 women who gave birth during the study period: 4076 (46%) had postpartum Hb testing and 1544 (38%) had PPA. Of those tested, and after adjusting for deprivation and region, European women had lower adjusted odds ratios compared to Māori for being identified as having PPA (0.46, 95% CI 0.37-0.57, P < 0.01). Of 681 women with Hb <90 g/L, 278 (41%) received IV-iron only, 66 (10%) red blood cell transfusion (RBC-T) only and 155 (23%) both. Of those receiving RBC-T, 40/221 (18%) were actively bleeding. Māori (92/138, 67%) and Pacific (127/188, 68%) women with Hb <90 g/L had the highest incidence of IV-iron use. No guidelines provided recommendations for haemodynamically stable women without active bleeding. CONCLUSION The incidence and management of PPA differs by ethnicity but fewer than half of the women had Hb testing, making precise determination of incidence impossible. The majority of women with Hb <90 g/L received IV-iron, with or without RBC-T.
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Affiliation(s)
- Esther Calje
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Joy Marriott
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Charlotte Oyston
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, The University of Auckland, Auckland, New Zealand
- Middlemore Hospital, Auckland, New Zealand
| | - Lesley Dixon
- New Zealand College of Midwives, Christchurch, New Zealand
| | - Frank Bloomfield
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Katie Groom
- Liggins Institute, The University of Auckland, Auckland, New Zealand
- National Women's Health, Auckland City Hospital, Auckland, New Zealand
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6
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Uthayakumaran G, Sadler L, Stein-de Laat M, Bloomfield F, Gentles T. Congenital Heart Disease in Stillborn Fetuses in New Zealand: A 10 Year Retrospective Review. Heart Lung Circ 2022. [DOI: 10.1016/j.hlc.2022.06.450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Dai DWT, Franke N, Wouldes TA, Brown GTL, Tottman AC, Harding JE, Alsweiler J, Biggs J, Bevan C, Black J, Bloomfield F, Fredell K, Gamble G, Harding J, Huth S, Jiang Y, Kevan C, Leung M, Phillips G, Poppe T, Rogers J, Stewart H, Thompson B, Tottman A, Williamson K, Wouldes T. The contributions of intelligence and executive function to behaviour problems in school-age children born very preterm. Acta Paediatr 2021; 110:1827-1834. [PMID: 33459419 DOI: 10.1111/apa.15763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Received: 11/10/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 11/29/2022]
Abstract
AIM To examine the contributions of specific neurocognitive skills to behaviour problems in children born very preterm. METHODS We assessed children born <30 weeks' gestation or <1500 g at age 7 years using subtests of the Wechsler Intelligence Scale for Children Fourth Edition, performance and questionnaire-based measures of executive function, and Child Behavior Checklist and Teacher Rating Form. We evaluated the contributions of IQ and executive function to behaviour problems and the moderating effect of sex using multiple regression. RESULTS The 129 children (mean age = 7.2 years) had lower IQ, inferior executive function and increased internalising problems compared with normative samples. Verbal comprehension skills and working memory were associated with total, internalising and externalising problems at school. Performance-based and questionnaire-based executive function were associated with total and externalising behaviour problems both at home and school. Sex moderated the relationships between information processing and parent-reported total problems, and between teacher-rated executive function and total problems. CONCLUSION Both IQ and executive function are related to behaviour problems in children born very preterm, but the relationships are different in boys and girls. Executive function may be a useful target for intervention.
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Affiliation(s)
| | - Nike Franke
- Liggins Institute University of Auckland Auckland New Zealand
| | - Trecia A. Wouldes
- Department of Psychological Medicine University of Auckland Auckland New Zealand
| | - Gavin T. L. Brown
- Faculty of Education & Social Work University of Auckland Auckland New Zealand
| | - Anna C. Tottman
- Liggins Institute University of Auckland Auckland New Zealand
- Neonatal Services Royal Women's Hospital Melbourne Vic. Australia
| | - Jane E. Harding
- Liggins Institute University of Auckland Auckland New Zealand
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8
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Pennalligen S, Gentles T, Dimalapang E, Alsweiler J, Bloomfield F, Muir C, Finucane K. Pre-school Screening to Detect Emotional, Behavioural and Developmental Problems in Children With Critical Congenital Heart Disease. Heart Lung Circ 2021. [DOI: 10.1016/j.hlc.2021.06.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fenton TR, Cormack B, Goldberg D, Nasser R, Alshaikh B, Eliasziw M, Hay WW, Hoyos A, Anderson D, Bloomfield F, Griffin I, Embleton N, Rochow N, Taylor S, Senterre T, Schanler RJ, Elmrayed S, Groh-Wargo S, Adamkin D, Shah PS. "Extrauterine growth restriction" and "postnatal growth failure" are misnomers for preterm infants. J Perinatol 2020; 40:704-714. [PMID: 32214217 DOI: 10.1038/s41372-020-0658-5] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 11/09/2022]
Abstract
Preterm infants are increasingly diagnosed as having "extrauterine growth restriction" (EUGR) or "postnatal growth failure" (PGF). Usually EUGR/PGF is diagnosed when weight is <10th percentile at either discharge or 36-40 weeks postmenstrual age. The reasons why the phrases EUGR/PGF are unhelpful include, they: (i) are not predictive of adverse outcome; (ii) are based only on weight without any consideration of head or length growth, proportionality, body composition, or genetic potential; (iii) ignore normal postnatal weight loss; (iv) are usually assessed prior to growth slowing of the reference fetus, around 36-40 weeks, and (v) are usually based on an arbitrary statistical growth percentile cut-off. Focus on EUGR/PGF prevalence may benefit with better attention to nutrition but may also harm with nutrition delivery above infants' actual needs. In this paper, we highlight challenges associated with such arbitrary cut-offs and opportunities for further refinement of understanding growth and nutritional needs of preterm neonates.
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Affiliation(s)
- Tanis R Fenton
- Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Nutrition Services, Alberta Health Services, Calgary, AB, Canada.
| | - Barbara Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Roseann Nasser
- Saskatchewan Health Authority, Nutrition and Food Services, Regina, SK, Canada
| | - Belal Alshaikh
- Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Misha Eliasziw
- Public Health and Community Medicine, Tufts University, Boston, MA, USA
| | | | - Angela Hoyos
- Clínica del Country, Universidad el Bosque, Bogotá, Colombia
| | - Diane Anderson
- Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Frank Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Ian Griffin
- Clinical and Translational Research, Biomedical research Institute of New Jersey, Cedar Knolls, NJ, USA
| | - Nicholas Embleton
- Newcastle Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Niels Rochow
- Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Sarah Taylor
- Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | | | - Richard J Schanler
- Neonatal Services, Cohen Children's Medical Center, Northwell Health, Zucker School of Medicine at Hofstra, New York, NY, USA
| | - Seham Elmrayed
- Community Health Sciences, Institute of Public Health, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sharon Groh-Wargo
- Pediatrics and Nutrition, Case Western Reserve University, Cleveland, OH, USA
| | - David Adamkin
- Pediatrics, University of Louisville, Louisville, KY, USA
| | - Prakesh S Shah
- Paediatrics and Institute of HPME, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
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10
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Lin L, Crowther C, Gamble G, Bloomfield F, Harding JE. Sex-specific effects of nutritional supplements in infants born early or small: protocol for an individual participant data meta-analysis (ESSENCE IPD-MA). BMJ Open 2020; 10:e033438. [PMID: 31919126 PMCID: PMC6955477 DOI: 10.1136/bmjopen-2019-033438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Preterm and small for gestational age (SGA) infants are at increased risk of poor growth, disability and delayed development. While growing up they are also at increased risk of obesity, diabetes and later heart disease. The risk of such adverse outcomes may be altered by how preterm and SGA infants are fed after birth. Faltering postnatal growth is common due to failure to achieve recommended high energy and protein intakes, and thus preterm and SGA infants are often provided with supplemental nutrition soon after birth. Enhanced nutrition has been associated with improved early growth and better cognitive development. However, limited evidence suggests that faster growth may increase the risk for later adiposity, metabolic and cardiovascular disease, and that such risks may differ between girls and boys. METHODS AND ANALYSIS We will search Ovid MEDLINE, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, controlled-trials.com, ClinicalTrials.gov and anzctr.org.au for randomised trials that studied the effects of macronutrient supplements for preterm and SGA infants on (i) developmental and metabolic and (ii) growth outcomes after hospital discharge. The outcomes will be (i) cognitive impairment and metabolic risk (co-primary) and (ii) body mass index. Individual participant data (IPD) from all available trials will be included using an intention-to-treat approach. A one-stage procedure for IPD meta-analysis (MA) will be used, accounting for clustering of participants within studies. Exploratory subgroup analyses will further investigate sources of heterogeneity, including sex and size of infants, different timing, duration and type of supplements. ETHICS AND DISSEMINATION This IPD-MA is approved by the University of Auckland Human Participants Ethics Committee (reference number: 019874). Individual studies have approval from relevant local ethics committees. Results will be disseminated in a peer-reviewed journal and presented at international conferences. PROSPERO REGISTRATION NUMBER CRD42017072683.
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Affiliation(s)
- Luling Lin
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Caroline Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Greg Gamble
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Frank Bloomfield
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, Auckland, New Zealand
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11
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Bearer C, Agostoni C, Anand KJS, Ambalavanan N, Bhandari V, Bliss JM, Bloomfield F, Bonifacio SL, Buhimschi I, Cilio MR, Coppes M, Czinn SJ, El-Khuffash A, Embleton N, Felderhoff-Müser U, Ferriero DM, Florin T, Fuentes-Afflick E, Gardner W, Gospe SM, Gunn A, Gressens P, Guissani D, Haiden N, Hauptman M, Kim KS, Klebanoff M, Lachman P, Lanphear B, Ozen S, Roehr C, Roland D, Rosenblum N, Schwarz M, Staiano A, Stroustrup A, Valente EM, Wilson-Costello D, Wynn J, Molloy E. Toward the elimination of bias in Pediatric Research. Pediatr Res 2019; 86:680-681. [PMID: 31533126 DOI: 10.1038/s41390-019-0583-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Cynthia Bearer
- Department of Pediatrics, University of Maryland, Baltimore, MD, USA.
| | - Carlo Agostoni
- Department of Pediatrics, IRCCS Ospedale Maggiore, Policlinico, University of Milan, Milan, Italy
| | | | | | - Vineet Bhandari
- Department of Neonatology, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Joseph M Bliss
- Brown University, Women and Infants Hospital, Providence, RI, USA
| | - Frank Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Sonia L Bonifacio
- Neonatal and Developmental Medicine, NICU, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Irina Buhimschi
- Center for Perinatal Research, Nationwide Childrens Hospital, Columbus, OH, USA
| | - Maria Roberta Cilio
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Max Coppes
- Pediatrics; UNSOM - Pediatrics, University of Nevada School of Medicine, Reno, NV, USA.,Renown Health, Renown Children's Hospital, Reno, NV, USA
| | - Steven J Czinn
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Afif El-Khuffash
- The Rotunda Hospital, Neonatology, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nicholas Embleton
- Newcastle Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Ursula Felderhoff-Müser
- Department of Pediatrics I, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Todd Florin
- Cincinnati Children's Hospital Medical Center, Pediatrics - Pediatric Emergency Medicine, Cincinnati, OH, USA
| | - Elena Fuentes-Afflick
- Department of Pediatrics, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | | | - Sidney M Gospe
- Seattle Children's Hospital, Neurology, Seattle, WA, USA
| | - Alistair Gunn
- Dept of Physiology, University of Auckland, Auckland, New Zealand
| | | | - Dino Guissani
- Physiology Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Nadja Haiden
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | | | - Mark Klebanoff
- Nationwide Children's Hospital, Center for Perinatal Research, Columbus, OH, USA
| | - Peter Lachman
- International Society for Quality in Health Care, Dublin, Ireland
| | | | - Seza Ozen
- Hacettepe Univeristy School of Medicine, Pediatrics, Ankara, Turkey
| | - Charles Roehr
- John Radcliffe Hospital, Newborn Care, Oxfordshire, UK
| | - Damian Roland
- College of Life Sciences, University of Leicester, Leicester, UK
| | | | - Margaret Schwarz
- Indiana University School of Medicine, Pediatrics, South Bend, IN, USA
| | | | - Annemarie Stroustrup
- Friedman Brain Institute, Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Enza Maria Valente
- Department of Medicine and Surgery, University of Salerno, Baronissi, Italy
| | - Dee Wilson-Costello
- Division of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - James Wynn
- University of Florida College of Medicine, Gainesville, FL, USA
| | - Eleanor Molloy
- Paediatrics and Child Health, Trinity College, Trinity Academic Centre, Tallaght Hospital, The University of Dublin, Dublin, Ireland
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12
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Ward K, Dixon L, Cloete E, Gentles T, Bloomfield F. Health professionals' views of newborn pulse oximetry screening in a midwifery-led maternity setting. "It's a good thing to do, but fund it!". Midwifery 2019; 81:102593. [PMID: 31812128 DOI: 10.1016/j.midw.2019.102593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/29/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To understand from health professionals who care for newborns their views on the introduction of pulse oximetry screening for the detection of hypoxaemia in a midwifery-led maternity setting. Although oximetry screening for newborns is internationally accepted, national screening is not yet introduced in New Zealand. In this context, we drew on maternity carers' reflections during a feasibility study of oximetry screening to provide perspectives on barriers and enablers to universal screening. METHODS Data were generated from nine focus groups during five months of 2018 in two north island regions of New Zealand. Participants' (n = 45) opinions about the use of oximetry screening in newborns were analysed thematically using an inductive approach. FINDINGS Overall, participants stated pulse oximetry screening was easy to do, non-invasive, and worthwhile. Midwives were reassured by screening that provided evidence of either a healthy baby or a need for urgent review. From participants' reports, we identified three themes: (1) oximetry screening for newborns is reassuring, practical and worthwhile; (2) midwifery services workload expectations and under-resourcing will hinder universal screening, and (3) location of the baby at the time of screening could impede universal access. CONCLUSION AND IMPLICATIONS FOR PRACTICE Midwives viewed implementing a national pulse oximetry screening programme as sensible but problematic unless resourced and funded appropriately. Policymakers should view the concerns of midwives about human and physical resources as significant and account for the need to resource this screening programme appropriately as a priority before implementation.
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Affiliation(s)
- Kim Ward
- The Liggins Institute, University of Auckland, Auckland, New Zealand.
| | - Lesley Dixon
- New Zealand College of Midwives, Christchurch, Auckland, New Zealand
| | - Elza Cloete
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Tom Gentles
- Starship Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Frank Bloomfield
- The Liggins Institute, University of Auckland, Auckland, New Zealand
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13
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Knol M, Wang H, Bloomfield F, Piet T, Damhuis S, Khalil A, Ganzevoort W, Gordijn S. Development of a Core Outcome Set and Minimum Reporting Set for intervention studies in growth restriction in the NEwbOrN (COSNEON): study protocol for a Delphi study. Trials 2019; 20:511. [PMID: 31420053 PMCID: PMC6697910 DOI: 10.1186/s13063-019-3588-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/16/2019] [Indexed: 12/27/2022] Open
Abstract
Background Growth restriction in the newborn (GRN) can predispose to severe complications including hypoglycemia, sepsis, and necrotizing enterocolitis. Different interventions and treatments, such as feeding strategies, for GRN have specific benefits and risks. Comparing results from studies investigating intervention studies in GRN is challenging due to the use of different baseline and study characteristics and differences in reported study outcomes. In order to be able to compare study results and to allow pooling of data, uniform reporting of study characteristics (minimum reporting set [MRS]) and outcomes (core outcome set [COS]) are needed. We aim to develop both an MRS and a COS for interventional and treatment studies in GRN. Methods/design The MRS and COS will be developed according to Delphi methodology. First, a scoping literature search will be performed to identify study characteristics and outcomes in research focused on interventions/treatments in the GRN. An international group of stakeholders, including experts (clinicians working with GRN, and researchers who focus on GRN) and lay experts ([future] parents of babies with GRN), will be questioned to rate the importance of the study characteristics and outcomes in three rounds. After three rounds there will be two consensus meetings: a face-to-face meeting and an electronic meeting. During the consensus meetings multiple representatives of stakeholder groups will reach agreement upon which study characteristics and outcomes will be included into the COS and MRS. The second electronic consensus meeting will be used to test if an electronic meeting is as effective as a face-to-face meeting. Discussion In our opinion a COS alone is not sufficient to compare and aggregate trial data. Hence, to ensure optimum comparison we also will develop an MRS. Interventions in GRN infants are often complicated by coexisting preterm birth. A COS already has been developed for preterm birth. The majority of GRN infants are born at term, however, and we therefore chose to develop a separate COS for interventions in GRN, which can be combined (with expected overlap) in intervention studies enrolling preterm GRN babies. Trial registration Not applicable. This study is registered in the Core Outcome Measures for Effectiveness (COMET) database. Registered on 30 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3588-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martine Knol
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Helena Wang
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Tabitha Piet
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Stefanie Damhuis
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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14
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Townsend R, Sileo F, Stocker L, Kumbay H, Healy P, Gordijn S, Ganzevoort W, Beune I, Baschat A, Kenny L, Bloomfield F, Daly M, Devane D, Papageorghiou A, Khalil A. Variation in outcome reporting in randomized controlled trials of interventions for prevention and treatment of fetal growth restriction. Ultrasound Obstet Gynecol 2019; 53:598-608. [PMID: 30523658 DOI: 10.1002/uog.20189] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Although fetal growth restriction (FGR) is well known to be associated with adverse outcomes for the mother and offspring, effective interventions for the management of FGR are yet to be established. Trials reporting interventions for the prevention and treatment of FGR may be limited by heterogeneity in the underlying pathophysiology. The aim of this study was to conduct a systematic review of outcomes reported in randomized controlled trials (RCTs) assessing interventions for the prevention or treatment of FGR, in order to identify and categorize the variation in outcome reporting. METHODS MEDLINE, EMBASE and The Cochrane Library were searched from inception until August 2018 for RCTs investigating therapies for the prevention and treatment of FGR. Studies were assessed systematically and data on outcomes that were reported in the included studies were extracted and categorized. The methodological quality of the included studies was assessed using the Jadad score. RESULTS The search identified 2609 citations, of which 153 were selected for full-text review and 72 studies (68 trials) were included in the final analysis. There were 44 trials relating to the prevention of FGR and 24 trials investigating interventions for the treatment of FGR. The mean Jadad score of all studies was 3.07, and only nine of them received a score of 5. We identified 238 outcomes across the included studies. The most commonly reported were birth weight (88.2%), gestational age at birth (72.1%) and small-for-gestational age (67.6%). Few studies reported on any measure of neonatal morbidity (27.9%), while adverse effects of the interventions were reported in only 17.6% of trials. CONCLUSIONS There is significant variation in outcome reporting across RCTs of therapies for the prevention and treatment of FGR. The clinical applicability of future research would be enhanced by the development of a core outcome set for use in future trials. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Townsend
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - F Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - L Stocker
- Women and Children Division, University Hospital Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - H Kumbay
- GKT School of Medicine, King's College, London, UK
| | - P Healy
- Health Research Board - Trials Methodology Research Network, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
| | - S Gordijn
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Ganzevoort
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - I Beune
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - A Baschat
- Johns Hopkins Center for Fetal Therapy, Baltimore, MD, USA
| | - L Kenny
- The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - F Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - M Daly
- Advocacy and Policymaking, Irish Neonatal Health Alliance, Wicklow, Ireland
| | - D Devane
- Health Research Board - Trials Methodology Research Network, Galway, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
| | - A Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Nuffield Department of Women's & Reproductive Health, University of Oxford, John Radcliffe Hospital Women's Centre, Oxford, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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15
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Soszyn N, Cloete E, Sadler L, Laat MSD, Crengle S, Bloomfield F, Gentles T. Does Disease Severity Contribute to Disparity in Outcome Amongst Ethnic Groups in Patients with Hypoplastic Left Heart syndrome in New Zealand? Heart Lung Circ 2019. [DOI: 10.1016/j.hlc.2019.06.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Alsweiler J, Williamson K, Bloomfield F, Chase G, Harding J. Computer-determined dosage of insulin in the management of neonatal hyperglycaemia (HINT2): protocol of a randomised controlled trial. BMJ Open 2017; 7:e012982. [PMID: 28264826 PMCID: PMC5353287 DOI: 10.1136/bmjopen-2016-012982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Neonatal hyperglycaemia is frequently treated with insulin, which may increase the risk of hypoglycaemia. Computer-determined dosage of insulin (CDD) with the STAR-GRYPHON program uses a computer model to predict an effective dose of insulin to treat hyperglycaemia while minimising the risk of hypoglycaemia. However, CDD models can require more frequent blood glucose testing than common clinical protocols. The aim of this trial is to determine if CDD using STAR-GRYPHON reduces hypoglycaemia in hyperglycaemic preterm babies treated with insulin independent of the frequency of blood glucose testing. METHODS AND ANALYSIS Design: Multicentre, non-blinded, randomised controlled trial. SETTING Neonatal intensive care units in New Zealand and Australia. PARTICIPANTS 138 preterm babies ≤30 weeks' gestation or ≤1500 g at birth who develop hyperglycaemia (two consecutive blood glucose concentrations ≥10 mmol/L, at least 4 hours apart) will be randomised to one of three groups: (1) CDD using the STAR-GRYPHON model-based decision support system: insulin dose and frequency of blood glucose testing advised by STAR-GRYPHON, with a maximum testing interval of 4 hours; (2) bedside titration: insulin dose determined by medical staff, maximum blood glucose testing interval of 4 hours; (3) standard care: insulin dose and frequency of blood glucose testing determined by medical staff. The target range for blood glucose concentrations is 5-8 mmol/L in all groups. A subset of babies will have masked continuous glucose monitoring. PRIMARY OUTCOME is the number of babies with one or more episodes of hypoglycaemia (blood glucose concentration <2.6 mmol/L), during treatment with insulin. ETHICS AND DISSEMINATION This protocol has been approved by New Zealand's Health and Disability Ethics Committee: 14/STH/26. A data safety monitoring committee has been appointed to oversee the trial. Findings will be disseminated to participants and carers, peer-reviewed journals, guideline developers and the public. TRIAL REGISTRATION NUMBER 12614000492651.
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Affiliation(s)
- Jane Alsweiler
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kathryn Williamson
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Frank Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Geoffrey Chase
- Mechanical Engineering Department, University of Canterbury, Christchurch, New Zealand
| | - Jane Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
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17
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Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, Khong TY, Silver RM, Smith GCS, Boyle FM, Lawn JE, Blencowe H, Leisher SH, Gross MM, Horey D, Farrales L, Bloomfield F, McCowan L, Brown SJ, Joseph KS, Zeitlin J, Reinebrant HE, Cacciatore J, Ravaldi C, Vannacci A, Cassidy J, Cassidy P, Farquhar C, Wallace E, Siassakos D, Heazell AEP, Storey C, Sadler L, Petersen S, Frøen JF, Goldenberg RL. Stillbirths: recall to action in high-income countries. Lancet 2016; 387:691-702. [PMID: 26794070 DOI: 10.1016/s0140-6736(15)01020-x] [Citation(s) in RCA: 378] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19,439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20-30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.
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Affiliation(s)
- Vicki Flenady
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; International Stillbirth Alliance, NJ, USA.
| | - Aleena M Wojcieszek
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; International Stillbirth Alliance, NJ, USA
| | - Philippa Middleton
- International Stillbirth Alliance, NJ, USA; Women's & Children's Health Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - David Ellwood
- International Stillbirth Alliance, NJ, USA; Griffith University and Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Jan Jaap Erwich
- International Stillbirth Alliance, NJ, USA; University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michael Coory
- International Stillbirth Alliance, NJ, USA; Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - T Yee Khong
- International Stillbirth Alliance, NJ, USA; SA Pathology, University of Adelaide, Adelaide, SA, Australia
| | - Robert M Silver
- International Stillbirth Alliance, NJ, USA; University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Gordon C S Smith
- National Institute for Health Research, Biomedical Research Centre and Cambridge University, Cambridge, UK
| | - Frances M Boyle
- School of Public Health, University of Queensland, Brisbane, QLD Australia; International Stillbirth Alliance, NJ, USA
| | - Joy E Lawn
- London School of Hygiene & Tropical Medicine, London, UK
| | | | - Susannah Hopkins Leisher
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; International Stillbirth Alliance, NJ, USA
| | - Mechthild M Gross
- Hannover Medical School, Hannover, Germany; Zurich University of Applied Sciences, Institute for Midwifery, Winterthur, Switzerland
| | - Dell Horey
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; La Trobe University, Melbourne, VIC, Australia
| | - Lynn Farrales
- International Stillbirth Alliance, NJ, USA; Still Life Canada: Stillbirth and Neonatal Death Education, Research and Support Society, Vancouver, Canada; University of British Columbia, Vancouver, Canada
| | | | - Lesley McCowan
- International Stillbirth Alliance, NJ, USA; Liggins Institute, Auckland, New Zealand
| | - Stephanie J Brown
- Murdoch Childrens Research Institute and General Practice and Primary Health Care Academic Centre, University of Melbourne, Parkville, VIC, Australia
| | - K S Joseph
- University of British Columbia, Vancouver, Canada
| | - Jennifer Zeitlin
- Institut National de la Santé et de la Recherche Médicale, Obstetrical, Perinatal and Paediatric Epidemiology Research Team, Centre for Epidemiology and Biostatistics (U1153), Paris-Descartes University, Paris, France
| | - Hanna E Reinebrant
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; International Stillbirth Alliance, NJ, USA
| | | | - Claudia Ravaldi
- International Stillbirth Alliance, NJ, USA; CiaoLapo Onlus, Charity for High-Risk Pregnancies and Perinatal Grief Support, Prato, Italy
| | - Alfredo Vannacci
- International Stillbirth Alliance, NJ, USA; CiaoLapo Onlus, Charity for High-Risk Pregnancies and Perinatal Grief Support, Prato, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Jillian Cassidy
- International Stillbirth Alliance, NJ, USA; Umamanita, Girona, Spain
| | - Paul Cassidy
- International Stillbirth Alliance, NJ, USA; Umamanita, Girona, Spain
| | | | - Euan Wallace
- International Stillbirth Alliance, NJ, USA; Monash University, Melbourne, VIC, Australia
| | - Dimitrios Siassakos
- International Stillbirth Alliance, NJ, USA; University of Bristol, Bristol, UK; Southmead Hospital, Bristol, UK
| | - Alexander E P Heazell
- International Stillbirth Alliance, NJ, USA; Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK; St Mary's Hospital, Central Manchester University Hospitals, NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Lynn Sadler
- University of Auckland, Auckland, New Zealand
| | - Scott Petersen
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; Mater Health Services, Brisbane, QLD, Australia
| | - J Frederik Frøen
- Mater Research Institute, University of Queensland, Brisbane, QLD Australia; Griffith University and Gold Coast University Hospital, Gold Coast, QLD, Australia; Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway; Center for Intervention Science for Maternal and Child Health, University of Bergen, Bergen, Norway
| | - Robert L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
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18
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Berry M, Jaquiery A, Oliver M, Harding J, Bloomfield F. Preterm birth has sex-specific effects on autonomic modulation of heart rate variability in adult sheep. PLoS One 2013; 8:e85468. [PMID: 24386475 PMCID: PMC3873460 DOI: 10.1371/journal.pone.0085468] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 11/27/2013] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION Globally, 11% of infants are born preterm. In adulthood, individuals born preterm are at increased risk of cardiovascular morbidity and mortality, but the mechanistic basis of this remains unknown. Clinically overt cardiovascular disease may be preceded by altered cardiac autonomic activity characterised by increased sympathetic activity and/or reduced parasympathetic activity. Thus, altered cardiac autonomic activity in survivors of preterm birth may underlie later cardiovascular risk. OBJECTIVE To investigate the impact of gestational age on cardiac autonomic activity in juvenile and adult sheep. METHODS AND RESULTS Singleton-bearing ewes were randomised antenatally to spontaneous term birth (TC; n=73) or corticosteroid induced preterm birth (PT; n=60). Cardiac autonomic modulation was assessed using heart rate variability analysis in juvenile and adult offspring. Preterm birth in adult males was associated with altered sympatho-vagal modulation (LFnu: PT 64 ± 4 vs. TC 49 ± 4, p<0.05; LogLF/HF: PT 1.8 ± 0.1 vs. TC 1.5 ± 0.1, p<0.05) and reduced parasympathetic modulation (LogRMSSD: PT 2.9 ± 0.2 vs. TC 3.4 ± 0.1, p<0.05; LogNN50: PT 0.3 ± 0.4 vs. TC 1.6 ± 0.4, p<0.05). Within the range of term birth, each one-day increment in gestational age was associated with a decrement in LFnu in juvenile females and with a decrement in LFnu and LF/HF ratio, but an increment in RMSSD and NN50 in adult females. CONCLUSIONS Cardiac autonomic function in adult sheep is affected in a sex-specific manner by gestational age at birth, even within the term range. Altered cardiac autonomic function may contribute to increased later cardiovascular morbidity in those born preterm.
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Affiliation(s)
- Mary Berry
- Liggins Institute, University of Auckland, Auckland, New Zealand
- * E-mail:
| | - Anne Jaquiery
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Gravida: National Centre for Growth and Development, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Mark Oliver
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Gravida: National Centre for Growth and Development, University of Auckland, Auckland, New Zealand
| | - Jane Harding
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Frank Bloomfield
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Gravida: National Centre for Growth and Development, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
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Begum G, Davies A, Stevens A, Oliver M, Jaquiery A, Challis J, Harding J, Bloomfield F, White A. Maternal undernutrition programs tissue-specific epigenetic changes in the glucocorticoid receptor in adult offspring. Endocrinology 2013; 154:4560-9. [PMID: 24064364 DOI: 10.1210/en.2013-1693] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [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: 12/27/2022]
Abstract
Epidemiological data indicate that an adverse maternal environment during pregnancy predisposes offspring to metabolic syndrome with increased obesity, and type 2 diabetes. The mechanisms are still unclear although epigenetic modifications are implicated and the hypothalamus is a likely target. We hypothesized that maternal undernutrition (UN) around conception in sheep would lead to epigenetic changes in hypothalamic neurons regulating energy balance in the offspring, up to 5 years after the maternal insult. We found striking evidence of decreased glucocorticoid receptor (GR) promoter methylation, decreased histone lysine 27 trimethylation, and increased histone H3 lysine 9 acetylation in hypothalami from male and female adult offspring of UN mothers. These findings are entirely compatible with the increased GR mRNA and protein observed in the hypothalami. The increased GR predicted the decreased hypothalamic proopiomelanocortin expression and increased obesity that we observed in the 5-year-old adult males. The epigenetic and expression changes in GR were specific to the hypothalamus. Hippocampal GR mRNA and protein were decreased in UN offspring, whereas pituitary GR was altered in a sex-specific manner. In peripheral polymorphonuclear leukocytes there were no changes in GR methylation or protein, indicating that this epigenetic analysis did not predict changes in the brain. Overall, these results suggest that moderate changes in maternal nutrition, around the time of conception, signal life-long and tissue-specific epigenetic alterations in a key gene regulating energy balance in the hypothalamus.
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Affiliation(s)
- Ghazala Begum
- Faculties of Life Sciences and Medical and Human Sciences, Manchester Academic Health Sciences Centre, University of Manchester, 3.016 AV Hill Building, Manchester M13 9PT United Kingdom.
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Bloomfield F, Harding J, Hancock S, Begum G, White A, Stevens A, Challis J, Jaquiery A, Oliver M. Periconceptional origins of adult obesity. Obes Res Clin Pract 2012. [DOI: 10.1016/j.orcp.2012.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Growth charts are the mainstay of monitoring growth in babies who were born small or preterm. A variety of different charts are available, each with specific limitations. Most birthweight centile charts underestimate growth restriction in preterm babies and there are few good charts for monitoring longitudinal growth in preterm babies; it is important to be aware of the limitations of using cross-sectional data for monitoring longitudinal growth. Customised centile charts of fetal growth are used increasingly for antenatal monitoring for small-for-gestational age fetuses despite a lack of robust evidence. It is also unclear whether customised centile charts should be used for assessing birthweight, particularly in babies born at term. Faltering post-natal growth in preterm babies is very common but need not be universal with close attention to nutrition. Monitoring of growth trajectories through infancy following either fetal growth restriction or post-natal faltering growth is important to ensure proportional growth, particularly during periods of accelerated growth. This review will discuss these issues in the context of current practice in Australia and New Zealand.
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Affiliation(s)
- David Tudehope
- Mothers and Babies Research Theme, Mater Medical Research Institute, Brisbane, Queensland, Australia.
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Begum G, Stevens A, Smith EB, Connor K, Challis JRG, Bloomfield F, White A. Epigenetic changes in fetal hypothalamic energy regulating pathways are associated with maternal undernutrition and twinning. FASEB J 2012; 26:1694-703. [PMID: 22223754 DOI: 10.1096/fj.11-198762] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Undernutrition during pregnancy is implicated in the programming of offspring for the development of obesity and diabetes. We hypothesized that maternal programming causes epigenetic changes in fetal hypothalamic pathways regulating metabolism. This study used sheep to examine the effect of moderate maternal undernutrition (60 d before to 30 d after mating) and twinning to investigate changes in the key metabolic regulators proopiomelanocortin (POMC) and the glucocorticoid receptor (GR) in fetal hypothalami. Methylation of the fetal hypothalamic POMC promoter was reduced in underfed singleton, fed twin, and underfed twin groups (60, 73, and 63% decrease, respectively). This was associated with reduced DNA methyltransferase activity and altered histone methylation and acetylation. Methylation of the hypothalamic GR promoter was decreased in both twin groups and in maternally underfed singleton fetuses (52, 65, and 55% decrease, respectively). This correlated with changes in histone methylation and acetylation and increased GR mRNA expression in the maternally underfed singleton group. Alterations in GR were hypothalamic specific, with no changes in hippocampi. Unaltered levels of OCT4 promoter methylation indicated gene-specific effects. In conclusion, twinning and periconceptional undernutrition are associated with epigenetic changes in fetal hypothalamic POMC and GR genes, potentially resulting in altered energy balance regulation in the offspring.
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Affiliation(s)
- Ghazala Begum
- Department of Endocrinology and Diabetes, University of Manchester, Manchester, UK
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23
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Stevens A, Begum G, Cook A, Connor K, Rumball C, Oliver M, Challis J, Bloomfield F, White A. Epigenetic changes in the hypothalamic proopiomelanocortin and glucocorticoid receptor genes in the ovine fetus after periconceptional undernutrition. Endocrinology 2010; 151:3652-64. [PMID: 20573728 DOI: 10.1210/en.2010-0094] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [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: 11/19/2022]
Abstract
Maternal food restriction is associated with the development of obesity in offspring. This study examined how maternal undernutrition in sheep affects the fetal hypothalamic glucocorticoid receptor (GR) and the appetite-regulating neuropeptides, proopiomelanocortin (POMC) and neuropeptide Y, which it regulates. In fetuses from ewes undernourished from -60 to +30 d around conception, there was increased histone H3K9 acetylation (1.63-fold) and marked hypomethylation (62% decrease) of the POMC gene promoter but no change in POMC expression. In the same group, acetylation of histone H3K9 associated with the hypothalamic GR gene was increased 1.60-fold and the GR promoter region was hypomethylated (53% decrease). In addition, there was a 4.7-fold increase in hypothalamic GR expression but no change in methylation of GR gene expression in the anterior pituitary or hippocampus. Interestingly, hypomethylation of both POMC and GR promoter markers in fetal hypothalami was also identified after maternal undernutrition from -60 to 0 d and -2 to +30 d. In comparison, the Oct4 gene, was hypermethylated in both control and underfed groups. Periconceptional undernutrition is therefore associated with marked epigenetic changes in hypothalamic genes. Increase in GR expression in the undernourished group may contribute to fetal programming of a predisposition to obesity, via altered GR regulation of POMC and neuropeptide Y. These epigenetic changes in GR and POMC in the hypothalamus may also predispose the offspring to altered regulation of food intake, energy expenditure, and glucose homeostasis later in life.
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Affiliation(s)
- Adam Stevens
- Faculties of Life Sciences and Medical and Human Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester M13 9PT, UK
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