Preterm Infant Outcomes after Randomization to Initial Resuscitation with FiO2 0.21 or 1.0

OBJECTIVE

To determine rates of death or neurodevelopmental impairment (NDI) at 2 years corrected age (primary outcome) in children <32 weeks' gestation randomized to initial resuscitation with a fraction of inspired oxygen (FiO₂) value of 0.21 or 1.0.

STUDY DESIGN

Blinded assessments were conducted at 2-3 years corrected age with the Bayley Scales of Infant and Toddler Development, Third Edition or the Ages and Stages Questionnaire by intention to treat.

RESULTS

Of the 290 children enrolled, 40 could not be contacted and 10 failed to attend appointments. Among the 240 children for whom outcomes at age 2 years were available, 1 child had a lethal congenital anomaly, 1 child had consent for follow-up withdrawn, and 23 children died. The primary outcome, which was available in 238 (82%) of those randomized, occurred in 47 of the 117 (40%) children assigned to initial FiO₂ 0.21 and in 38 of the 121 (31%) assigned to initial FiO₂ 1.0 (OR, 1.47; 95% CI, 0.86-2.5; P = .16). No difference in NDI was found in 215 survivors randomized to FiO₂ 0.21 vs 1.0 (OR, 1.26; 95% CI, 0.70-2.28; P = .11). In post hoc exploratory analyses in the whole cohort, children with a 5-minute blood oxygen saturation (SpO₂) <80% were more likely to die or to have NDI (OR, 1.85; 95% CI, 1.07-3.2; P = .03).

CONCLUSIONS

Initial resuscitation of infants <32 weeks' gestation with initial FiO₂ 0.21 had no significant effect on death or NDI compared with initial FiO₂ 1.0. Further evaluation of optimum initial FiO₂, including SpO₂ targeting, in a large randomized controlled trial is needed.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Network Registry ACTRN 12610001059055 and the National Malaysian Research Registry NMRR-07-685-957.

Targeted Oxygen in the Resuscitation of Preterm Infants, a Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Lower concentrations of oxygen (O₂) (≤30%) are recommended for preterm resuscitation to avoid oxidative injury and cerebral ischemia. Effects on long-term outcomes are uncertain. We aimed to determine the effects of using room air (RA) or 100% O₂ on the combined risk of death and disability at 2 years in infants <32 weeks' gestation.

METHODS

A randomized, unmasked study designed to determine major disability and death at 2 years in infants <32 weeks' gestation after delivery room resuscitation was initiated with either RA or 100% O₂ and which were adjusted to target pulse oximetry of 65% to 95% at 5 minutes and 85% to 95% until NICU admission.

RESULTS

Of 6291 eligible patients, 292 were recruited and 287 (mean gestation: 28.9 weeks) were included in the analysis (RA: n = 144; 100% O₂: n = 143). Recruitment ceased in June 2014, per the recommendations of the Data and Safety Monitoring Committee owing to loss of equipoise for the use of 100% O₂. In non-prespecified analyses, infants <28 weeks who received RA resuscitation had higher hospital mortality (RA: 10 of 46 [22%]; than those given 100% O₂: 3 of 54 [6%]; risk ratio: 3.9 [95% confidence interval: 1.1-13.4]; P = .01). Respiratory failure was the most common cause of death (n = 13).

CONCLUSIONS

Using RA to initiate resuscitation was associated with an increased risk of death in infants <28 weeks' gestation. This study was not a prespecified analysis, and it was underpowered to address this post hoc hypothesis reliably. Additional data are needed.

A Review of Research on Child Abuse in Malaysia

The aim of this review was to summarise published literature on child abuse and neglect and its consequences in Malaysia, to discuss the implications of the research findings and to identify gaps in the local literature on child abuse and neglect. Medical and social literature in the English language published between the year 2000 to 2015 were searched for, resulting in forty four papers to be reviewed inclusive of a few key papers in the earlier years to provide some background information. The literature shows that child abuse and neglect is an important impact factor on mental health outcomes, involvement in substance abuse and delinquency due to the slant of the research interest from social studies. At least 70% of perpetrators are known to the affected children according to school-based prevalence studies. Safety programs and rehabilitation outcome studies involve small cohort groups. Studies on childhood mortality from child abuse or neglect are very limited. Overall, there are a few comprehensive studies involving school children but overall available studies are too patchy in to advocate for resource allocation, change in statutory procedures or training requirements. More extensive studies looking at the complex interaction of social environment, parenting skills, societal attitudes and responses, resilience factors and child safety nets and statutory response and their impact on different types of abuse or neglect are required.

Neural tube defects in Malaysia: data from the Malaysian National Neonatal Registry

This study aimed to determine the prevalence and early outcome of neural tube defects (NTDs) in Malaysia. This prospective study included all neonates with NTDs (spina bifida, anencephaly, encephalocoele) born in 2009 in 32 Malaysian hospitals in the Malaysian National Neonatal Network. The prevalence of NTDs was 0.42 per 1000 live births, being highest among the indigenous people of Sarawak (1.09 per 1000 live births) and lowest among Malaysians of Chinese descent (0.09 per 1000 live births). The most common type of NTDs was anencephaly (0.19 per 1000 live births), followed by spina bifida (0.11 per 1000 live births) and encephalocoele (0.07 per 1000 live births). Majority of the infants with anencephaly (94.5%, n = 51), 45.8% (n = 11) with encephalocoele and 9.5% (n = 4) with spina bifida died. The median duration of hospital stay was 4 (range: 0-161) days.

CONCLUSION

NTDs were common in Malaysia. Mortality was high. Long-term monitoring of NTD prevalence following folic fortification of food is recommended.

Parotid abscess in a late premature infant: a case report

Parotid abscess is uncommon in neonates. It is frequently related to prematurity, prolonged gavage feeding and dehydration. We report a case of a late preterm infant who developed the classical manifestation of unilateral acute Staphylococcus aureus suppurative parotitis progressing to formation of abscess which responded to surgical drainage and antibiotic therapy.

Clinical clues for head injuries amongst Malaysian infants: accidental or non-accidental?

Identifying the differences between infants with non-accidental head injuries (NAHI) and accidental head injuries (AHI) may help alert clinicians to recognize markers of abuse. A retrospective review of infants <1 year of age admitted to a tertiary referral centre in Malaysia over a two year period with a diagnosis of head injury or abnormal computed tomography head scans was conducted to identify the clinical features pointing towards a diagnosis of NAHI by comparing the socio-demographics, presenting complaints, clinical features and the extent of hospital investigations carried out. NAHI infants were more likely to be symptomatic, under a non-related caregiver's supervision, and presented with inconsistent or no known mechanism of injury. Subdural haemorrhages were more common in NAHI infants. The history, mechanism of injury, presenting signs and symptoms as well as the nature of the injuries sustained are all valuable clues as to whether a head injury sustained during infancy is likely to be accidental or not.