Multicentre randomised trial of invasive and less invasive surfactant delivery methods showed similar spirometry results at 5-9 years of age

AIM

We explored whether subnormal forced expiratory volume within one second (FEV₁ ) at 5-9 years of age was lower in children born preterm who received less invasive surfactant administration (LISA) rather than surfactant via an endotracheal tube.

METHODS

The multicentre, randomised Nonintubated Surfactant Application trial enrolled 211 preterm infants born at 23-26 weeks of gestation from 13 level III neonatal intensive care units from April 2009 to March 2012. They received surfactant via LISA (n=107) or after conventional endotracheal intubation (n=104). The follow-up assessments were carried out by a single team blinded to the group assignments. The main outcome was FEV₁ <80% of predicted values.

RESULTS

Spirometry was successful in 102/121 children. The other children died or were lost to follow up. Median FEV₁ was 93% (interquartile range 80-113%) of predicted values in the LISA group and 86% (interquartile range 77-102%) in the control group (p=0.685). Rates of FEV₁ < 80% were 11/57 (19%) and 15/45 (33 %) respectively, which was an absolute risk reduction of 14% (95% confidence interval -3.1% to 31.2%, p=0.235). There were no differences in other outcome measures.

CONCLUSION

The proportion of children aged 5-9 years with subnormal FEV₁ was not significantly different between the groups.

Observations on the effects of inhaled isoflurane in long-term sedation of critically Ill children using a modified AnaConDa©-system

Long-term intravenous sedation may present problems due to dependence and side effects. Medical records of children who were administered isoflurane were reviewed. 15 patients (9 boys, 6 girls) with a mean age of 11.8 month (+2.4) were analysed.Analgesia and sedation was given in mean 9.7+1.1 days before commencing inhalation using a modified application device (AnaConDa©). Administration was given over a period of 7.2+1.4 days. Depth of sedation was monitored by using Comfort- and Hartwig-scores. Observations included continuous monitoring of heart-rate, pulse oxymetry, blood pressure and cerebral tissue oxygenation.Within 4 h post administration of isoflurane a satisfactory increase in the depth of sedation was seen and kept till extubation. 6/15 patients received tracheostomies during the observation period. None of the patients observed suffered life-critical events of the modified application of isoflurane proceeded without complications. Ketamine and clonidine infusion rates were significantly reduced (p<0.005) as well as the use and overall infusion rate of midazolam, γ-hydroxy butyrate, fentanyl and morphine (p<0.05).Isoflurane inhalation may provide an additional option for long-term sedation in a specific group of critically ill infants but neurodegenerative toxic effects will have to be taken into account when using volatile anesthetics at any time during infancy.

Hemolytic anemia and methemoglobinemia in a preterm baby as a complication of antenatal intraamnial injection of toluidine blue

A late preterm infant was born 4.5 h after intraamniotic injection of 90 mg of Toluidine blue to confirm premature rupture of membranes. Due to the fetal exposition to the dye, the entire body of the patient was blue stained and the baby suffered from methemoglobinemia, Heinz' body positive hemolytic anemia and hyperbilirubinaemia requiring exchange transfusion. These complications underline that antenatal exposition of toluidine blue may result in considerable postnatal infant morbidity. Therefore intraamniotic application of toluidine blue should be discouraged.

Mothers seeing their VLBW infants within 3 h after birth are more likely to establish a secure attachment behavior: evidence of a sensitive period with preterm infants?

OBJECTIVE

Close contact of mother and child in the first hours after birth is essential for the establishment of a secure attachment behavior in term infants. To date, studies investigating whether a 'sensitive period' also exists for very low birth weight (VLBW) preterm infants are lacking.

STUDY DESIGN

Attachment patterns of 62 VLBW infants were assessed using the 'strange situation' setting and correlated with the time mothers saw their child for the first time. Furthermore, maternal and infant covariates possibly influencing the attachment behavior were analyzed. As maternal factors the mother's age, social status and pregnancy history were recorded and at three time points (time 1, 2 and 3 (t-1, t-2 and t-3)), a semi-structured interview, a depression and a social support questionnaire were performed. As infant factors neonatal basic data, ventilation time and length of hospital stay were recorded. Disease severity was scored using the clinical risk index for babies, score for neonatal acute physiology (SNAP), SNAP perinatal extension and nursery neurobiological risk score. At time points t-2 and t-3, the infants were examined using the second edition of Bayley scales of infant development.

RESULTS

In all, 53.2% of the children showed a secure, 33.9% an insecure-avoidant, 3.2% an insecure-ambivalent and 9.7% an insecure-disorganized attachment behavior. Preterm infants whose mothers had seen them within 3 h after birth had a higher rate of secure attachment than preterm infants with no early contact (76 versus 41%, P=0.009). Firstborns showed a significantly higher rate of insecure attachment behavior (93 versus 67%, P=0.01). No influence on attachment behavior was shown for any other maternal or infant factor.

CONCLUSIONS

Our results support the hypothesis that the first hours after birth are a 'sensitive period' for the development of attachment behavior in VLBW infants. When a mother is enabled to see her infant shortly after birth, the 'sensitive period' right after birth may be used to help forming an important basis for the secure attachment of the preterm infant.

Remifentanil for INSURE in preterm infants: a pilot study for evaluation of efficacy and safety aspects

AIM

To evaluate intubating conditions, extubation times and outcome in preterm infants receiving remifentanil as induction agent for the INSURE procedure.

METHODS

In twenty-one preterm infants of 29 to 32 weeks gestation and signs of respiratory distress, we utilized remifentanil as induction agent for the INSURE procedure. Following intubation and surfactant application, the infants were mechanically ventilated until respiratory drive was judged to be satisfactory for continuing CPAP therapy. Intubating conditions were classified by our own scoring system by rating limb movements, coughing and breathing. Heart rate, blood pressure and oxygen saturation were recorded during the entire INSURE procedure.

RESULTS

Remifentanil provided excellent or good intubating conditions in all patients. We observed no serious side effects after remifentanil infusion, in particular, no thorax rigidity, clinically significant bradycardia or arterial hypotension. Average extubation time after surfactant administration was 16.9 min (1-45 min); none of the infants had to be reintubated. Following extubation, the infants required only 3.3 days (1-8 days) of CPAP therapy. None exhibited serious complications of prematurity like periventricular leucomalacia, intraventricular haemorrhage >I degree, necrotizing enterocolitis or retinopathy.

CONCLUSION

In this pilot study, INSURE with remifentanil was associated with good intubating conditions and early extubation resulting in an excellent neonatal outcome.

Aerosolized Iloprost in the Treatment of Pulmonary Hypertension in Extremely Preterm Infants: A Pilot Study

BACKGROUND

In premature infants with preterm prolonged rupture of membranes, death after birth is often due to persistent pulmonary hyper-tension.

PATIENTS

Aerosolized iloprost was used to treat pulmonary hypertension due to prolonged preterm rupture of fetal membranes (7-56 days) in four extremely low-birthweight neonates (23-25 weeks' gestation, weight 448-645 g) under spontaneous breathing supported by nasal continuous positive airway pressure.

METHOD

Inhalation dose was 2 microg/kg b.w. and between 44 and 65 inhalations were performed in each patient starting within the first hour of life over a total of several days. Single inhalations lasted 5 min and were not repeated until 60 min had elapsed.

RESULTS

After the first inhalation, the PaO2/FiO2 mean ratio increased from 65 (range 35-114) to 194 (148-250) mmHg and oxygenation requirements decreased within the next 7 days. Echocardiography similarly showed reduction in pulmonary resistance. We observed no severe side effects on blood pressure or prolonged bleeding time during inhalation.

CONCLUSIONS

Iloprost inhalation might therefore be an additional treatment for improving oxygenation in cases of persistent pulmonary hypertension in extremely low-birthweight infants under spontaneous breathing. Further randomized clinical studies are required to establish the role of iloprost in this setting.

Symmetrische Tieftonschwerhörigkeit als Hauptsymptom einer Neuroborreliose

In a 9-year-old boy with sudden sensorineural loss of hearing in the lower registers in both ears, serology showed elevated levels of antibodies against Borrelia burgdorferi and examination of the CSF revealed a positive antibody index against Borrelia burgdorferi. The boy was treated with antibiotics for 2 weeks. Audiometry performed 4 weeks after treatment was completely normal. Inner ear involvement in Lyme disease has often been discussed. Treating these patients with antibiotics may lead to an improvement in some.