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Massaro AN, Boyer B, Gill M, Kim D, Laughon M, Walsh M, Lemmon ME, Pilon B, Baer G. Measuring Clinical Benefit in Neonatal Randomized Clinical Trials: Challenges and Opportunities. J Pediatr 2024; 269:113972. [PMID: 38401783 DOI: 10.1016/j.jpeds.2024.113972] [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: 01/03/2024] [Revised: 02/01/2024] [Accepted: 02/16/2024] [Indexed: 02/26/2024]
Affiliation(s)
- An N Massaro
- Office of Pediatric Therapeutics, Office of the Commisioner, US FDA, Silver Spring, MD.
| | - Beth Boyer
- Duke-Margolis Center for Health Policy, Washington, DC
| | - Mira Gill
- Duke-Margolis Center for Health Policy, Washington, DC
| | - Dure Kim
- Duke-Margolis Center for Health Policy, Washington, DC
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michele Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD
| | - Monica E Lemmon
- Duke-Margolis Center for Health Policy, Washington, DC; Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Gerri Baer
- Office of Pediatric Therapeutics, Office of the Commisioner, US FDA, Silver Spring, MD
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2
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Tolleson-Rinehart S, Rosenthal SL, de Roche AM, Laughon M, Sewell TB, Rivera CM, Gozal D, Hirsch R, Orange JS, Davis SD. Supporting Career Transitions of Senior Faculty: Perspectives of Chairs and Full Professors. J Pediatr 2024; 264:113518. [PMID: 37244584 DOI: 10.1016/j.jpeds.2023.113518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Sue Tolleson-Rinehart
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Susan L Rosenthal
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY.
| | - Ariel M de Roche
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Taylor B Sewell
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Christina M Rivera
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - David Gozal
- Department of Child Health, University of Missouri, Columbia, MO
| | - Raphael Hirsch
- Department of Pediatrics, University of California, San Francisco Medical Center, San Francisco, CA
| | - Jordan S Orange
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
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Liguori MB, Ali SKM, Bussman N, Colaizy T, Hundscheid T, Phad N, Clyman R, de Boode WP, de Waal K, El-Khuffash A, Gupta S, Laughon M. Patent Ductus Arteriosus in Premature Infants: Clinical Trials and Equipoise. J Pediatr 2023; 261:113532. [PMID: 37269903 DOI: 10.1016/j.jpeds.2023.113532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/05/2023]
Affiliation(s)
- Macrina B Liguori
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sanoj K M Ali
- Division of Neonatology, Sidra Medicine, Ar-Rayyan, Doha, Qatar
| | - Neidín Bussman
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Tarah Colaizy
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Tim Hundscheid
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Nilkant Phad
- Department of Neonatology, John Hunter Children's Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - Ronald Clyman
- Department of Pediatrics and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Willem-Pieter de Boode
- Division of Neonatology, Department of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Koert de Waal
- Department of Neonatology, John Hunter Children's Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Ar-Rayyan, Doha, Qatar; Department of Neonatology, Durham University, Durham, United Kingdom
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
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4
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Coggins SA, Willis Z, Benjamin DK, Mukhopadhyay S, Laughon M, Greenberg RG, Clark RH, Puopolo KM. Early antibiotic exposure in very-low birth weight infants and infection risk at 3-7 days after birth. J Perinatol 2023; 43:1158-1165. [PMID: 37491474 PMCID: PMC10529484 DOI: 10.1038/s41372-023-01737-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVE To determine rates of late-onset infection (LOI) during postnatal days 3-7 among preterm infants, based on antibiotic exposure during days 0-2. STUDY DESIGN Retrospective cohort study of infants born <1500 grams and ≤30 weeks gestation, 2005-2018. We analyzed the incidence and microbiology of LOI at days 3-7 based on antibiotic exposure during postnatal days 0-2. RESULTS The cohort included 88,574 infants, of whom 85% were antibiotic-exposed. Fewer antibiotic-exposed compared to unexposed infants developed LOI (1.5% vs. 2.1%; adjusted hazard ratio, 0.28, 95% CI 0.24-0.33). Among antibiotic-exposed compared to unexposed infants, Gram-negative (38% vs. 28%, p = 0.002) and fungal (11% vs. 1%, p < 0.001) species were more commonly isolated, and gram-positive organisms (49% vs. 70%, p < 0.001) were less commonly isolated. CONCLUSIONS We observed low overall rates of LOI at days 3-7 after birth, but antibiotic exposure from birth was associated with lower rates, and with differing microbiology, compared to no exposure.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA.
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Zachary Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Sagori Mukhopadhyay
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Reese H Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Karen M Puopolo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Clinical Futures, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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5
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Curtis SF, Cotten CM, Laughon M, Younge N, Peterson J, Clark RH, Greenberg RG. Indomethacin Prophylaxis in Preterm Infants: Changes over Time. Am J Perinatol 2022. [PMID: 35973793 DOI: 10.1055/a-1925-5173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our objective was to examine changes in the use of indomethacin prophylaxis in the neonatal intensive care unit (NICU) between 2008 and 2018. STUDY DESIGN The design of the study included cohort of 19,715 infants born between 220/7 and 266/7 weeks' gestation from 213 NICUs. A nonparametric trend test evaluated indomethacin prophylaxis and the percentage of sites using any prophylaxis over time. We evaluated the prevalence of indomethacin prophylaxis by the center and the correlation between indomethacin prophylaxis and severe intraventricular hemorrhage prevalence among 12 centers with the largest relative change in indomethacin prophylaxis prevalence. RESULTS In total, 16% of infants received indomethacin prophylaxis. The use of indomethacin prophylaxis did not significantly decrease between 2008 and 2018 but it significantly decreased between 2014 and 2018 (p = 0.046). Among 74 centers with ≥10 infants included, 20% increased the use of indomethacin prophylaxis, while 57% decreased the use over the study period. Of the 12 centers with the largest relative change in indomethacin prophylaxis prevalence, 50% showed an inverse correlation between indomethacin prophylaxis prevalence and severe intraventricular hemorrhage, while 50% showed a positive correlation. CONCLUSION Receipt of indomethacin prophylaxis remained similar until 2014, decreased from 2014 to 2018, and varied by the center.Key Points · The receipt of indomethacin prophylaxis decreased over time.. · Center change in the use of indomethacin prophylaxis does not correlate with the center prevalence of IVH.. · Variability in the use of indomethacin prophylaxis across centers persists..
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Affiliation(s)
- Samantha F Curtis
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Noelle Younge
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Peterson
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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6
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Curtis SF, Cotten CM, Laughon M, Younge N, Peterson J, Clark RH, Greenberg RG. Indomethacin Prophylaxis in Preterm Infants: Changes over Time. Am J Perinatol 2022. [PMID: 36174589 DOI: 10.1055/s-0042-1756678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Our objective was to examine changes in the use of indomethacin prophylaxis in the neonatal intensive care unit (NICU) between 2008 and 2018. STUDY DESIGN The design of the study included cohort of 19,715 infants born between 220/7 and 266/7 weeks' gestation from 213 NICUs. A nonparametric trend test evaluated indomethacin prophylaxis and the percentage of sites using any prophylaxis over time. We evaluated the prevalence of indomethacin prophylaxis by the center and the correlation between indomethacin prophylaxis and severe intraventricular hemorrhage prevalence among 12 centers with the largest relative change in indomethacin prophylaxis prevalence. RESULTS In total, 16% of infants received indomethacin prophylaxis. The use of indomethacin prophylaxis did not significantly decrease between 2008 and 2018 but it significantly decreased between 2014 and 2018 (p = 0.046). Among 74 centers with ≥10 infants included, 20% increased the use of indomethacin prophylaxis, while 57% decreased the use over the study period. Of the 12 centers with the largest relative change in indomethacin prophylaxis prevalence, 50% showed an inverse correlation between indomethacin prophylaxis prevalence and severe intraventricular hemorrhage, while 50% showed a positive correlation. CONCLUSION Receipt of indomethacin prophylaxis remained similar until 2014, decreased from 2014 to 2018, and varied by the center.Key Points · The receipt of indomethacin prophylaxis decreased over time.. · Center change in the use of indomethacin prophylaxis does not correlate with the center prevalence of IVH.. · Variability in the use of indomethacin prophylaxis across centers persists..
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Affiliation(s)
- Samantha F Curtis
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Noelle Younge
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Jennifer Peterson
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | | | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Ericson JE, Benjamin DK, Boakye-Agyeman F, Cotten CM, Adler-Shohet F, Laughon M, Poindexter B, Harper B, Payne EH, Kaneshige K, Smith PB, Smith PB. Exposure-safety relationship for acyclovir in the treatment of neonatal herpes simplex virus disease. Early Hum Dev 2022; 170:105616. [PMID: 35763957 PMCID: PMC9645023 DOI: 10.1016/j.earlhumdev.2022.105616] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Received: 11/04/2021] [Accepted: 06/16/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Neonatal herpes simplex virus (HSV) disease has been treated with high-dose (20 mg/kg/dose) acyclovir since 1991. AIMS Determine the safety of acyclovir in infants with neonatal HSV treated with high-dose acyclovir; examine the association between acyclovir dose and exposure with adverse events (AEs). STUDY DESIGN We obtained demographic information and acyclovir dosing via medical records. Acyclovir exposure was calculated using an established pharmacokinetic model. SUBJECTS Infants <120 days of age with neonatal HSV discharged from four academic children's hospitals. OUTCOME MEASURES We identified clinical and laboratory adverse events (AEs). RESULTS AND CONCLUSIONS We identified 49 infants with neonatal HSV treated with acyclovir; 42 infants had complete 21-day dosing information. Median mean daily dose was 59 mg/kg/day. Clinical AEs were common among all gestational and postnatal age groups. Rash was the most common clinical AE (37 %). Mild laboratory AEs occurred in 2-37 % of infants. The median maximum doses (mg/kg/day) were higher among infants with hypokalemia, elevated blood urea nitrogen, and thrombocytosis. For all other laboratory AEs, the median maximum doses for infants without events were higher or equal to the median maximum dose of infants with the AE. The odds of experiencing any clinical or laboratory AE did not differ by predicted acyclovir exposure for either area under the curve (AUC) or maximum concentration (Cmax) (odds ratio [OR] = 1.00 [0.98, 1.03] and OR = 1.01 [0.93, 1.12], respectively). Although AEs were common with high-dose acyclovir exposure, severe AEs were rare. Acyclovir exposure was not associated with AEs.
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Affiliation(s)
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC,Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Felix Boakye-Agyeman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - C. Michael Cotten
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC,Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | - Matthew Laughon
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States of America.
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8
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Gerhart JG, Carreño FO, Ford JL, Edginton A, Perrin EM, Watt KM, Muller WJ, Atz AM, Al‐Uzri A, Delmore P, Gonzalez D, Benjamin DK, Hornik C, Zimmerman K, Kennel P, Beci R, Dang Hornik C, Kearns GL, Laughon M, Paul IM, Sullivan J, Wade K, Delmore P, Taylor‐Zapata P, Lee J, Anand R, Sharma G, Simone G, Kaneshige K, Taylor L, Al‐Uzri A, Hornik C, Sokol G, Speicher D, Sullivan J, Mourani P, Mendley S, Meyer M, Atkins R, Flynn J, Vaughns J, Sherwin C, Delmore P, Goldstein S, Rathore M, Melloni C, Muller W, Delmore P, Tremoulet A, James L, Mendley S, Blackford M, Atz A, Adu‐Darko M, Mourani P, Watt K, Hornik C, Al‐Uzri A, Sullivan J, Laughon M, Brian Smith P, Watt K, Cheifetz I, Atz A, Bhatt‐Mehta V, Fernandez A, Lowry J. Use of
physiologically‐based
pharmacokinetic modeling to inform dosing of the opioid analgesics fentanyl and methadone in children with obesity. CPT Pharmacometrics Syst Pharmacol 2022; 11:778-791. [PMID: 35491971 PMCID: PMC9197535 DOI: 10.1002/psp4.12793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 11/12/2022] Open
Abstract
Obesity is an increasingly alarming public health threat, with nearly 20% of children classified as obese in the United States today. Children with obesity are commonly prescribed the opioids fentanyl and methadone, and accurate dosing is critical to reducing the risk of serious adverse events associated with overexposure. However, pharmacokinetic studies in children with obesity are challenging to conduct, so there is limited information to guide fentanyl and methadone dosing in these children. To address this clinical knowledge gap, physiologically‐based pharmacokinetic models of fentanyl and methadone were developed in adults and scaled to children with and without obesity to explore the interplay of obesity, age, and pharmacogenomics. These models included key obesity‐induced changes in physiology and pharmacogenomic effects. Model predictions captured observed concentrations in children with obesity well, with an overall average fold error of 0.72 and 1.08 for fentanyl and methadone, respectively. Model simulations support a reduced fentanyl dose (1 vs. 2 μg/kg/h) starting at an earlier age (6 years) in virtual children with obesity, highlighting the importance of considering both age and obesity status when selecting an infusion rate most likely to achieve steady‐state concentrations within the target range. Methadone dosing simulations highlight the importance of considering genotype in addition to obesity status when possible, as cytochrome P450 (CYP)2B6*6/*6 virtual children with obesity required half the dose to match the exposure of wildtype children without obesity. This physiologically‐based pharmacokinetic modeling approach can be applied to explore dosing of other critical drugs in children with obesity.
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Affiliation(s)
- Jacqueline G. Gerhart
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Fernando O. Carreño
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Jennifer L. Ford
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | | | - Eliana M. Perrin
- Department of Pediatrics, School of Medicine and School of Nursing Johns Hopkins University Baltimore Maryland USA
| | - Kevin M. Watt
- Division of Pediatric Clinical Pharmacology, School of Medicine University of Utah Salt Lake City Utah USA
| | - William J. Muller
- Ann and Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
| | - Andrew M. Atz
- Medical University of South Carolina Children's Hospital Charleston South Carolina USA
| | - Amira Al‐Uzri
- Oregon Health and Science University Portland Oregon USA
| | | | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, The University of North Carolina Eshelman School of Pharmacy The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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9
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Sanderson K, Warady B, Carey W, Tolia V, Boynton MH, Benjamin DK, Jackson W, Laughon M, Clark RH, Greenberg RG. Mortality Risk Factors among Infants Receiving Dialysis in the Neonatal Intensive Care Unit. J Pediatr 2022; 242:159-165. [PMID: 34798078 PMCID: PMC8882152 DOI: 10.1016/j.jpeds.2021.11.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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] [Received: 08/11/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To identify risk factors associated with mortality for infants receiving dialysis in the neonatal intensive care unit (NICU). STUDY DESIGN In this retrospective cohort study, we extracted data from the Pediatrix Clinical Data Warehouse on all infants who received dialysis in the NICU from 1999 to 2018. Using a Cox proportional hazards model with robust SEs we estimated the mortality hazard ratios associated with demographics, birth details, medical complications, and treatment exposures. RESULTS We identified 273 infants who received dialysis. Median gestational age at birth was 35 weeks (interquartile values 33-37), median birth weight was 2570 g (2000-3084), 8% were small for gestational age, 41% white, and 72% male. Over one-half of the infants (59%) had a kidney anomaly; 71 (26%) infants died before NICU hospital discharge. Factors associated with increased risk of dying after dialysis initiation included lack of kidney anomalies, Black race, gestational age of <32 weeks, necrotizing enterocolitis, dialysis within 7 days of life, and receipt of paralytics or vasopressors (all P < .05). CONCLUSION In this cohort of infants who received dialysis in the NICU over 2 decades, more than 70% of infants survived. The probability of death was greater among infants without a history of a kidney anomaly and those with risk factors consistent with greater severity of illness at dialysis initiation.
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Affiliation(s)
- Keia Sanderson
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC
| | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO
| | - William Carey
- Division of Neonatal Medicine, Mayo Clinic, Rochester, MN
| | - Veeral Tolia
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL,Division of Neonatology, Department of Pediatrics, Baylor University Medical Center, Dallas, TX
| | - Marcella H. Boynton
- Department of Medicine-Internal Medicine, University of North Carolina, Chapel Hill, NC,North Carolina Translational and Clinical Sciences Institute, Chapel Hill, NC
| | | | - Wesley Jackson
- Division of Neonatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Matthew Laughon
- Division of Neonatology, Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Reese H. Clark
- The MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL,Greenville Health System, Greenville, SC
| | - Rachel G. Greenberg
- Division of Neonatology, Department of Pediatrics, Duke University, Durham, NC,Duke Clinical Research Institute, Durham, NC
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10
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Stark A, Smith PB, Hornik CP, Zimmerman KO, Hornik CD, Pradeep S, Clark RH, Benjamin DK, Laughon M, Greenberg RG. Medication Use in the Neonatal Intensive Care Unit and Changes from 2010 to 2018. J Pediatr 2022; 240:66-71.e4. [PMID: 34481808 PMCID: PMC9394450 DOI: 10.1016/j.jpeds.2021.08.075] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [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] [Received: 05/12/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To provide up-to-date medication prescribing patterns in US neonatal intensive care units (NICUs) and to examine trends in prescribing patterns over time. STUDY DESIGN We performed a cohort study of 799 016 infants treated in NICUs managed by the Pediatrix Medical Group from 2010 to 2018. We used 3 different methods to report counts of medication: exposure, courses, and days of use. We defined the change in frequency of medication administration by absolute change and relative change. We examined the Food and Drug Administration (FDA) package insert for each medication to determine whether a medication was labeled for use in infants and used PubMed to search for pharmacokinetics (PK) studies. RESULTS The most frequently prescribed medications included ampicillin, gentamicin, caffeine citrate, poractant alfa, morphine, vancomycin, furosemide, fentanyl, midazolam, and acetaminophen. Of the top 50 medications used in infants with extremely low birth weight, only 20 (40%) are FDA-labeled for use in infants; of the 30 that are not labeled for use in infants, 13 (43%) had at least 2 published PK studies. The medications with the greatest relative increase in use from 2010 to 2018 included dexmedetomidine, clonidine, rocuronium, levetiracetam, atropine, and diazoxide. The medications with the greatest relative decrease in use included tromethamine acetate, pancuronium, chloral hydrate, imipenem + cilastatin, and amikacin. CONCLUSION Trends of medication use in the NICU change substantially over time. It is imperative to identify changes in medication use in the NICU to better inform further prospective studies.
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Affiliation(s)
- Ashley Stark
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Chi D Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | | | | | - Daniel K Benjamin
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
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11
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Lane MD, Kishnani S, Udemadu O, Danquah SE, Treadway RM, Langman A, Balevic S, Jackson WM, Laughon M, Hornik CP, Greenberg RG, Clark RH, Zimmerman KO. Comparative efficacy and safety of late surfactant preparations: a retrospective study. J Perinatol 2021; 41:2639-2644. [PMID: 34285358 PMCID: PMC8290378 DOI: 10.1038/s41372-021-01142-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/12/2020] [Revised: 05/25/2021] [Accepted: 06/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Characterize the use, efficacy, and safety of poractant alfa and calfactant surfactants compared to beractant in preterm infants receiving late surfactant. STUDY DESIGN We included infants <37 weeks gestational age (GA) discharged from Pediatrix Medical Group-managed neonatal intensive care units (1997-2017). Efficacy and safety outcomes of interest were analyzed. RESULTS Of 184,770 infants administered surfactant at any time, 7846 (4.23%) received late surfactant at a median (25th, 75th percentile) PNA of 8 days (3, 22); specifically, 2976 received poractant alfa (38%), 2890 beractant (37%), and 1936 calfactant (25%). We identified no significant differences in composite efficacy or safety outcomes between surfactants in the primary analysis, but 33-36 week GA infants administered poractant alfa had significantly greater odds of developing a safety event. CONCLUSIONS Compared to beractant, there is no evidence of overall superior efficacy or safety of poractant alfa.
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Affiliation(s)
- Morgan D Lane
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Sujata Kishnani
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Obianuju Udemadu
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | | | | | - Aaliyah Langman
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Stephen Balevic
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Wesley M Jackson
- Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Matthew Laughon
- Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - Rachel G Greenberg
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Department of Pediatrics, Duke University, Durham, NC, USA
| | | | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Duke University, Durham, NC, USA.
- Department of Pediatrics, Duke University, Durham, NC, USA.
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12
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Baud O, Laughon M, Lehert P. Survival without Bronchopulmonary Dysplasia of Extremely Preterm Infants: A Predictive Model at Birth. Neonatology 2021; 118:385-393. [PMID: 34004607 DOI: 10.1159/000515898] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/10/2020] [Accepted: 03/16/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Early prediction of survival without bronchopulmonary dysplasia (BPD) at 36 weeks of postmenstrual age remains challenging for infants born extremely preterm. We aimed to provide a new predictive model including variables available only at or soon after birth based on the literature and existing models. METHODS We conducted a systematic review to identify all variables considered to be significant predictors of BPD and survival at birth in extremely preterm infants. We then assessed the external validity of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network BPD estimator on the PREMILOC cohort, a recent French study with a large sample of extremely preterm infants and a vast number of variables at baseline. Finally, we attempted to improve this model by testing the added value of other early predictors reported in previous studies. RESULTS Restricted to baseline predictors, the NICHD Neonatal Research Network BPD estimator confirmed its calibration and fair discrimination (area under the receiver operating characteristic [auROC] [95% CI] = 0.73 [0.68-0.77] when used with a published model and auROC [95% CI] = 0.77 [0.73-0.81] when fitted to the PREMILOC dataset). We were able to improve the discriminatory power by adding candidate variables at birth associated with BPD in previous studies. The modified best predicting model included gestational age at birth, birthweight, respiratory support at baseline, gender, center effect, and multiple pregnancy as baseline predictors. This model showed significantly better discrimination (auROC [95% CI] = 0.85 [0.82-0.88]) and better confirmed calibration (Hosmer-Lemeshow test, p = 0.45). CONCLUSION This new model, based on 6 early predictors, appears to improve the prediction soon after birth of BPD-free survival in extremely preterm infants.
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Affiliation(s)
- Olivier Baud
- Division of Neonatology and Pediatric Intensive Care, Children's University Hospital of Geneva and University of Geneva, Geneva, Switzerland.,Université Paris Diderot, Sorbonne Paris Cité, INSERM U1141, Paris, France
| | - Matthew Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Philippe Lehert
- Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia.,Faculty of Economics, University of Louvain, Ottignies-Louvain-la-Neuve, Belgium
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13
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Thompson EJ, Benjamin DK, Greenberg RG, Kumar KR, Zimmerman KO, Laughon M, Clark RH, Smith PB, Hornik CP. Pharmacoepidemiology of Furosemide in the Neonatal Intensive Care Unit. Neonatology 2020; 117:780-784. [PMID: 33027793 PMCID: PMC7878291 DOI: 10.1159/000510657] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Furosemide is commonly used off-label in the neonatal intensive care unit (NICU), but current dosing practices vary widely. OBJECTIVES To describe dosing practices including route, dose, and duration of exposure to furosemide in a large number of community and tertiary NICUs across North America. METHOD Using the Pediatrix Medical Group Clinical Data Warehouse, we identified infants who received ≥1 dose of furosemide between 1997 and 2016. We excluded infants with incomplete dosing data. We calculated average daily furosemide dose, cumulative dose, total days of exposure, and maximum daily dose. We compared dosing between infants born at <32 weeks gestational age (GA) and ≥32 weeks GA. RESULTS A total of 18,572 infants had complete dosing data. The median (interquartile value) postnatal age at first exposure was 11 days (4, 26), the median maximum daily dose was 1.0 mg/kg (0.97, 1.6), the median average daily dose was 1.0 mg/kg (0.88, 1.1), and the median cumulative dose was 2.0 mg/kg (1.0, 4.5). The median total duration of exposure was 2 days (1, 4). A total of 177 (1%) infants received ≥4 mg/kg/day of furosemide. Infants born <32 weeks GA were an older age at initial furosemide exposure compared to those born ≥32 weeks GA: 19 versus 4 days, p < 0.001. CONCLUSIONS Most infants received short courses of furosemide within the labeled dosing parameters. Further studies are needed to assess the safety and efficacy of furosemide in the NICU.
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Affiliation(s)
- Elizabeth J Thompson
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Department of Economics, Clemson University, Clemson, South Carolina, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Karan R Kumar
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kanecia O Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew Laughon
- Division of Neonatal-Perinatal Medicine, UNC Hospital, Chapel Hill, North Carolina, USA
| | - Reese H Clark
- The Pediatrix-Obstetrix Center for Research, Education, and Quality, Sunrise, Florida, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA, .,Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA,
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14
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Ji D, Smith PB, Clark RH, Zimmerman KO, Laughon M, Ku L, Greenberg RG. Wide variation in caffeine discontinuation timing in premature infants. J Perinatol 2020; 40:288-293. [PMID: 31758062 PMCID: PMC7222934 DOI: 10.1038/s41372-019-0561-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/29/2019] [Accepted: 11/13/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess site variability and concomitant respiratory support related to the timing of caffeine discontinuation, and compare clinical characteristics of infants who discontinued caffeine before vs. within the last week of hospitalization. STUDY DESIGN Cohort study of 81,110 infants <35 weeks gestational age and <1500 g birth weight discharged from 304 neonatal intensive care units from 2001-2016. RESULTS The mean postmenstrual age at caffeine discontinuation ranged from 32 to 37 weeks among sites. Respiratory support at the time of discontinuation was common, but variable, with 0-57% of infants receiving positive airway pressure at caffeine discontinuation by site. Infants who discontinued caffeine within the last week of hospitalization had longer total duration of caffeine, but were discharged from the hospital at an earlier postmenstrual age. CONCLUSION There was substantial variability among sites in the timing of caffeine discontinuation before discharge and respiratory support at the time of caffeine discontinuation.
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Affiliation(s)
- Dabin Ji
- grid.259907.0Mercer University School of Medicine, Savannah, GA USA
| | - P. Brian Smith
- 0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA ,0000 0004 1936 7961grid.26009.3dDuke Clinical Research Institute, Durham, NC USA
| | - Reese H. Clark
- 0000 0004 0640 3724grid.459894.dPediatrix Medical Group, Sunrise, FL USA
| | - Kanecia O. Zimmerman
- 0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA
| | - Matthew Laughon
- 0000000122483208grid.10698.36Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | - Lawrence Ku
- 0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA
| | - Rachel G. Greenberg
- 0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA ,0000 0004 1936 7961grid.26009.3dDuke Clinical Research Institute, Durham, NC USA
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15
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Zimmerman KO, Wu H, Laughon M, Greenberg RG, Walczak R, Schulman SR, Smith PB, Hornik CP, Cohen-Wolkowiez M, Watt KM. Dexmedetomidine Pharmacokinetics and a New Dosing Paradigm in Infants Supported With Cardiopulmonary Bypass. Anesth Analg 2019; 129:1519-1528. [PMID: 31743171 PMCID: PMC7687048 DOI: 10.1213/ane.0000000000003700] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Dexmedetomidine is increasingly used off-label in infants and children with cardiac disease during cardiopulmonary bypass (CPB) and in the postoperative period. Despite its frequent use, optimal dosing of dexmedetomidine in the setting of CPB has not been identified but is expected to differ from dosing in those not supported with CPB. This study had the following aims: (1) characterize the effect of CPB on dexmedetomidine clearance (CL) and volume of distribution (V) in infants and young children; (2) characterize tolerance and sedation in patients receiving dexmedetomidine; and (3) identify preliminary dosing recommendations for infants and children undergoing CPB. We hypothesized that CL would decrease, and V would increase during CPB compared to pre- or post-CPB states. METHODS Open-label, single-center, opportunistic pharmacokinetics (PK) and safety study of dexmedetomidine in patients ≤36 months of age administered dexmedetomidine per standard of care via continuous infusion. We analyzed dexmedetomidine PK data using standard nonlinear mixed effects modeling with NONMEM software. We compared model-estimated PK parameters to those from historical patients receiving dexmedetomidine before anesthesia for urologic, lower abdominal, or plastic surgery; after low-risk cardiac or craniofacial surgery; or during bronchoscopy or nuclear magnetic resonance imaging. We investigated the influence of CPB-related factors on PK estimates and used the final model to simulate dosing recommendations, targeting a plasma concentration previously associated with safety and efficacy (0.6 ng/mL). We used the Wilcoxon rank sum test to evaluate differences in dexmedetomidine exposure between infants with hypotension or bradycardia and those who did not develop these adverse events. RESULTS We collected 213 dexmedetomidine plasma samples from 18 patients. Patients had a median (range) age of 3.3 months (0.1-34.0 months) and underwent CPB for 161 minutes (63-394 minutes). We estimated a CL of 13.4 L/h/70 kg (95% confidence interval, 2.6-24.2 L/h/70 kg) during CPB, compared to 42.1 L/h/70 kg (95% confidence interval, 38.7-45.8 L/h/70 kg) in the historical patients. No specific CPB-related factor had a statistically significant effect on PK. A loading dose of 0.7 µg/kg over 10 minutes before CPB, followed by maintenance infusions through CPB of 0.2 or 0.25 µg/kg/h in infants with postmenstrual ages of 42 or 92 weeks, respectively, maintained targeted concentrations. We identified no association between dexmedetomidine exposure and selected adverse events (P = .13). CONCLUSIONS CPB is associated with lower CL during CPB in infants and young children compared to those not undergoing CPB. Further study should more closely investigate CPB-related factors that may influence CL.
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Affiliation(s)
- Kanecia O. Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Richard Walczak
- Perfusion Services, Duke University Hospital, Durham, North Carolina
| | - Scott R. Schulman
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Kevin M. Watt
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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16
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Gonski S, Hupp SR, Cotten CM, Clark RH, Laughon M, Watt K, Hornik CP, Kumar K, Smith PB, Greenberg RG. Risk of development of treated retinopathy of prematurity in very low birth weight infants. J Perinatol 2019; 39:1562-1568. [PMID: 31492920 PMCID: PMC8742217 DOI: 10.1038/s41372-019-0487-6] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 07/23/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Quantify the risk of treatment for retinopathy of prematurity (ROP) among infants meeting current U.S. screening guidelines. STUDY DESIGN Among infants ≤1500 g birth weight or ≤30 weeks gestation screened for ROP from 2006-2015, we developed a risk prediction model to identify infants treated for ROP. We applied our model to a separate infant cohort discharged in 2016. RESULT Seventy-five thousand eight hundred and twenty one infants met inclusion criteria; 2306 (3%) were treated for ROP. Infants with several risk factor combinations (no ventilator support or oxygen on postnatal day 28, no history of necrotizing enterocolitis, and no intraventricular hemorrhage) were at low risk of ROP. Applied to 6127 infants discharged in 2016, our model had 97.9% sensitivity, 63.3% specificity, positive predictive value of 4.0%, and negative predictive value of 99.9%. CONCLUSION Large numbers of infants at low risk of developing ROP are required to undergo screening. Refining current ROP guidelines may reduce unnecessary examinations.
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Affiliation(s)
- Samantha Gonski
- North Carolina School of Science and Mathematics, Durham, NC, USA
| | - Susan R Hupp
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
| | - Matthew Laughon
- School of Medicine, Division of Neonatal-Perinatal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kevin Watt
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Karan Kumar
- Department of Pediatrics, Duke University, Durham, NC, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
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17
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Thompson EJ, Wu H, Melloni C, Balevic S, Sullivan JE, Laughon M, Clark KM, Kalra R, Mendley S, Payne EH, Erinjeri J, Gelber CE, Harper B, Cohen-Wolkowiez M, Hornik CP. Population Pharmacokinetics of Doxycycline in Children. Antimicrob Agents Chemother 2019; 63:AAC.01508-19. [PMID: 31548185 PMCID: PMC6879254 DOI: 10.1128/aac.01508-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 07/29/2019] [Accepted: 09/16/2019] [Indexed: 11/20/2022] Open
Abstract
Doxycycline is a tetracycline-class antimicrobial labeled by the United States (U.S.) Food and Drug Administration for children >8 years of age for many common childhood infections. Doxycycline is not labeled for children ≤8 years of age, due to the association between tetracycline class antibiotics and tooth staining, although doxycycline may be used off-label in severe conditions. Accordingly, there is a paucity of pharmacokinetic (PK) data to guide dosing in children 8 years and younger. We leveraged opportunistically-collected plasma samples after intravenous (IV) and oral doxycycline doses received per standard of care to characterize the PK of doxycycline in children of different ages, and evaluated the effect of obesity and fasting status on PK parameters.We developed a population PK model of doxycycline using data collected from 47 patients 0-18 years of age, including 14 participants ≤8 years. We developed a 1 compartment PK model and found doxycycline clearance to be 3.32 L/h/70 kg and volume to be 96.8 L/70kg for all patients; comparable to values reported in adults. We estimated a bioavailability of 89.6%, also consistent with adult data. Allometrically scaled clearance and volume of distribution did not differ between children 2 to ≤8 years of age and children >8 to ≤18 years of age, suggesting that younger children may be given the same per kg dosing. Obese and fasting status were not selected for inclusion in the final model. Additional doxycycline PK samples collected in future studies may be used to improve model performance and maximize its clinical value.
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Affiliation(s)
| | - Huali Wu
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Stephen Balevic
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Janice E Sullivan
- University of Louisville, Norton Children's Hospital, Louisville, KY, USA
| | | | - Kira M Clark
- Department of Pediatrics, Oregon Health & Science University, Portland, OR, USA
| | - Rohit Kalra
- Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Susan Mendley
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | | | | | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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18
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Puia-Dumitrescu M, Smith PB, Zhao J, Soriano A, Payne EH, Harper B, Bendel-Stenzel E, Moya F, Chhabra R, Ku L, Laughon M, Wade KC. Dosing and Safety of Off-label Use of Caffeine Citrate in Premature Infants. J Pediatr 2019; 211:27-32.e1. [PMID: 31101409 PMCID: PMC6661003 DOI: 10.1016/j.jpeds.2019.04.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/02/2019] [Accepted: 04/11/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To characterize the dosing and safety of off-label caffeine citrate in a contemporary cohort of extremely premature infants. STUDY DESIGN We used electronic health records (2010-2013) from 4 neonatal intensive care units to identify infants of ≤28 weeks of gestational age exposed to caffeine citrate. Safety outcomes included death, bronchopulmonary dysplasia, necrotizing enterocolitis, spontaneous intestinal perforation, intraventricular hemorrhage, patent ductus arteriosus ligation, seizures, and arrhythmias. We used multivariable logistic regression to evaluate the association of caffeine citrate exposure with clinical events. RESULTS Of 410 infants with a median (IQR) gestational age of 26 (24-27) weeks, 95% received caffeine citrate for >0 days. Infants received a median (IQR) daily dose of 8 (5-10) mg/kg/day. Incidences of clinical events on day of caffeine citrate exposure were death 2%, patent ductus arteriosus ligation 12%, and medical and surgical necrotizing enterocolitis 5% and 4%, respectively. Bronchopulmonary dysplasia occurred in 37% of infants and was not associated with caffeine dose. Increased caffeine citrate dose was associated with lower odds of patent ductus arteriosus ligation and necrotizing enterocolitis. CONCLUSIONS Caffeine citrate was used in extremely premature infants at younger gestation, at higher doses, and for longer durations than recommended on the drug label. Increased caffeine citrate exposure, dose, or therapy duration was not associated with increased risk of necrotizing enterocolitis.
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MESH Headings
- Apnea/drug therapy
- Bronchopulmonary Dysplasia/complications
- Caffeine/administration & dosage
- Caffeine/adverse effects
- Cerebral Hemorrhage/complications
- Citrates/administration & dosage
- Citrates/adverse effects
- Ductus Arteriosus, Patent/complications
- Electronic Health Records
- Enterocolitis, Necrotizing/complications
- Female
- Gestational Age
- Humans
- Infant, Extremely Premature
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Intensive Care Units, Neonatal
- Intensive Care, Neonatal
- Male
- Multivariate Analysis
- Off-Label Use
- Treatment Outcome
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Affiliation(s)
- Mihai Puia-Dumitrescu
- Department of Pediatrics, University of Washington, Seattle, WA; Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | | | | | | | - Fernando Moya
- New Hanover Regional Medical Center, Coastal Carolina Neonatology, Wilmington, NC
| | | | - Lawrence Ku
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Matthew Laughon
- Duke Clinical Research Institute, Durham, NC; Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Kelly C Wade
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
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19
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Hornik CP, Atz AM, Bendel C, Chan F, Downes K, Grundmeier R, Fogel B, Gipson D, Laughon M, Miller M, Smith M, Livingston C, Kluchar C, Heath A, Jarrett C, McKerlie B, Patel H, Hunter C. Creation of a Multicenter Pediatric Inpatient Data Repository Derived from Electronic Health Records. Appl Clin Inform 2019; 10:307-315. [PMID: 31067576 DOI: 10.1055/s-0039-1688477] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Integration of electronic health records (EHRs) data across sites and access to that data remain limited. OBJECTIVE We developed an EHR-based pediatric inpatient repository using nine U.S. centers from the National Institute of Child Health and Human Development Pediatric Trials Network. METHODS A data model encompassing 147 mandatory and 99 optional elements was developed to provide an EHR data extract of all inpatient encounters from patients <17 years of age discharged between January 6, 2013 and June 30, 2017. Sites received instructions on extractions, transformation, testing, and transmission to the coordinating center. RESULTS We generated 177 staging reports to process all nine sites' 147 mandatory and 99 optional data elements to the repository. Based on 520 prespecified criteria, all sites achieved 0% errors and <2% warnings. The repository includes 386,159 inpatient encounters from 264,709 children to support study design and conduct of future trials in children. CONCLUSION Our EHR-based data repository of pediatric inpatient encounters utilized a customized data model heavily influenced by the PCORnet format, site-based data mapping, a comprehensive set of data testing rules, and an iterative process of data submission. The common data model, site-based extraction, and technical expertise were key to our success. Data from this repository will be used in support of Pediatric Trials Network studies and the labeling of drugs and devices for children.
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Affiliation(s)
- Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Catherine Bendel
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, United States
| | - Francis Chan
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California, United States
| | - Kevin Downes
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Robert Grundmeier
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Ben Fogel
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Debbie Gipson
- Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, Michigan, United States
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Michael Miller
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
| | - Michael Smith
- Department of Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky, United States.,Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham North Carolina, United States
| | - Chad Livingston
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Cindy Kluchar
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Anne Heath
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Chanda Jarrett
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Brian McKerlie
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Hetalkumar Patel
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Christina Hunter
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
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20
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Greenberg RG, Gayam S, Savage D, Tong A, Gorham D, Sholomon A, Clark RH, Benjamin DK, Laughon M, Smith PB. Furosemide Exposure and Prevention of Bronchopulmonary Dysplasia in Premature Infants. J Pediatr 2019; 208:134-140.e2. [PMID: 30579586 PMCID: PMC6486845 DOI: 10.1016/j.jpeds.2018.11.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/31/2018] [Accepted: 11/26/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate the association between furosemide exposure and risk of bronchopulmonary dysplasia (BPD). STUDY DESIGN This retrospective cohort study included infants (2004-2015) born at 23-29 weeks gestational age and 501-1249 g birth weight. We compared the demographic and clinical characteristics of infants exposed and not exposed to furosemide between postnatal day 7 and 36 weeks postmenstrual age. We examined the association between furosemide exposure and 2 outcomes: BPD and BPD or death. We performed multivariable probit regression models that included demographic and clinical variables in addition to 2 instrumental variables: furosemide exposure by discharge year, and furosemide exposure by site. RESULTS Of 37 693 included infants, 19 235 (51%) were exposed to furosemide; these infants were more premature and had higher respiratory support. Of 33 760 infants who survived to BPD evaluation, 15 954 (47%) had BPD. An increase in the proportion of furosemide exposure days by 10 percentage points was associated with a decrease in both the incidence of BPD (4.6 percentage points; P = .001), and BPD or death (3.7 percentage points; P = .01). CONCLUSIONS More days of furosemide exposure between postnatal day 7 and 36 weeks was associated with decreased risk of BPD and a combined outcome of BPD or death.
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Affiliation(s)
- Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC.
| | - Sreepriya Gayam
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Destiny Savage
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Andrew Tong
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Daniel Gorham
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Ari Sholomon
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | | | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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21
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Watt KM, Hornik CP, Balevic SJ, Mundakel G, Cotten CM, Harper B, Benjamin DK, Anand R, Laughon M, Smith PB, Cohen-Wolkowiez M. Pharmacokinetics of ticarcillin-clavulanate in premature infants. Br J Clin Pharmacol 2019; 85:1021-1027. [PMID: 30710387 DOI: 10.1111/bcp.13882] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 12/04/2018] [Revised: 01/17/2019] [Accepted: 01/20/2019] [Indexed: 01/20/2023] Open
Abstract
Ticarcillin-clavulanate covers a broad spectrum of pathogens that are common in premature infants. In infants <30 weeks gestational age, pharmacokinetic data to guide ticarcillin-clavulanate dosing are lacking. We enrolled 15 premature infants <30 weeks gestational age, determined pharmacokinetic parameters, and performed dosing simulations to determine optimal dosing for ticarcillin-clavulanate. The infants had a median (range) postnatal age (PNA) of 18 days (6-44 days) and gestational age of 25 weeks (23-28 weeks). Clearance was lower in infants with a PNA <14 days (0.050 L/kg/h [range 0.043-0.075]) compared with a PNA ≥14-45 days (0.078 L/kg/h [0.047-0.100]), consistent with maturation of renal function. Dosing simulations determined that ticarcillin 75 mg/kg q12h (PNA <14 days) or q8h (PNA ≥ 14-45 days) achieved the target exposure for organisms with a minimum inhibitory concentration ≤16 μ/mL in >90% of simulated infants. For highly resistant organisms (minimum inhibitory concentration 32 μg/mL), increased dosing frequency or extended infusion are necessary.
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Affiliation(s)
- Kevin M Watt
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Christoph P Hornik
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Stephen J Balevic
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Daniel K Benjamin
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | | | - Matthew Laughon
- University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - P Brian Smith
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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22
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Abstract
OBJECTIVE Pulmonary hypertension causes substantial morbidity and mortality in infants. Although Food and Drug Administration approved to treat pulmonary arterial hypertension in adults, sildenafil is not approved for infants. We sought to describe sildenafil exposure and associated diagnoses and outcomes in infants. STUDY DESIGN Retrospective cohort of neonates discharged from more than 300 neonatal intensive care units from 2001 to 2016. RESULTS Sildenafil was administered to 1,336/1,161,808 infants (0.11%; 1.1 per 1,000 infants); 0/35,977 received sildenafil in 2001 versus 151/90,544 (0.17%; 1.7 per 1,000 infants) in 2016. Among infants <32 weeks' gestational age (GA) with enough data to determine respiratory outcome, 666/704 (95%) had bronchopulmonary dysplasia (BPD). Among infants ≥32 weeks GA, 248/455 (55%) had BPD and 76/552 (14%) were diagnosed with meconium aspiration. Overall, 209/921 (23%) died prior to discharge. CONCLUSION The use of sildenafil has increased since 2001. Exposed infants were commonly diagnosed with BPD. Further studies evaluating dosing, safety, and efficacy of sildenafil are needed.
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Affiliation(s)
| | - Krystle Perez
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Christoph P. Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - P. Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, Florida
| | - Matthew Laughon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Division of Neonatal-Perinatal Medicine, UNC Hospital, Chapel Hill, North Carolina
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23
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Salerno SN, Bernhardt J, Laughon M, Jhaveri R, Massaro M, Gonzalez D. Pharmacokinetics of Ceftaroline in a Preterm Infant With Methicillin-Resistant Staphylococcus Aureus Pneumonia. J Pediatric Infect Dis Soc 2018; 7:342-345. [PMID: 29045693 PMCID: PMC6276030 DOI: 10.1093/jpids/pix084] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/29/2017] [Indexed: 11/14/2022]
Abstract
We report here the first pharmacokinetic-pharmacodynamic relationship for ceftaroline in a preterm infant born at <28 weeks' gestational age who was given ceftaroline (8.5 mg/kg every 8 hours) for pneumonia attributable to methicillin-resistant Staphyloccocus aureus. This dose of ceftaroline was adequate to achieve the pharmacodynamic endpoint associated with efficacy for methicillin-resistant Staphyloccocus aureus.
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MESH Headings
- Anti-Bacterial Agents/administration & dosage
- Anti-Bacterial Agents/pharmacokinetics
- Cephalosporins/administration & dosage
- Cephalosporins/pharmacokinetics
- Drug Therapy, Combination
- Fatal Outcome
- Female
- Humans
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/blood
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/microbiology
- Methicillin-Resistant Staphylococcus aureus/drug effects
- Pneumonia, Staphylococcal/blood
- Pneumonia, Staphylococcal/drug therapy
- Pneumonia, Staphylococcal/microbiology
- Rifampin/therapeutic use
- Ceftaroline
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Affiliation(s)
- Sara N Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy
| | - Janice Bernhardt
- Department of Pediatrics, The University of North Carolina at Chapel Hill
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill
| | - Ravi Jhaveri
- Department of Pediatrics, The University of North Carolina at Chapel Hill
| | - Matthew Massaro
- Department of Pediatrics, The University of North Carolina at Chapel Hill
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy
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24
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Wang LA, Smith PB, Laughon M, Goldberg RN, Ku LC, Zimmerman KO, Balevic S, Clark RH, Benjamin DK, Greenberg RG. Prolonged furosemide exposure and risk of abnormal newborn hearing screen in premature infants. Early Hum Dev 2018; 125:26-30. [PMID: 30193125 PMCID: PMC6186186 DOI: 10.1016/j.earlhumdev.2018.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND At very high doses, furosemide is linked to ototoxicity in adults, but little is known about the risk of hearing loss in premature infants exposed to furosemide. AIMS Evaluate the association between prolonged furosemide exposure and abnormal hearing screening in premature infants. STUDY DESIGN Using propensity scoring, infants with prolonged (≥28 days) exposure to furosemide were matched to infants never exposed. The matched sample was used to estimate the impact of prolonged furosemide exposure on the probability of an abnormal hearing screen prior to hospital discharge. SUBJECTS A cohort of infants 501-1250 g birth weight and 23-29 weeks gestational age discharged home from 210 neonatal intensive care units in the United States (2004-2013). OUTCOME MEASURES We defined abnormal hearing screen as a result of either "fail" or "refer" for either ear. RESULTS Altogether, 1020 infants exposed to furosemide for ≥28 days were matched to 790 unique infants never exposed, yielding a total of 1042 matches due to sampling with replacement and propensity score ties. Matching resulted in a population similar in baseline characteristics. After adjusting for covariates, the proportion of infants with an abnormal hearing screen in the furosemide-exposed group was not significantly higher than the never-exposed group (absolute difference 3.0% [95% CI -0.2-6.2%], P = 0.07). CONCLUSIONS Prolonged furosemide exposure was associated with a positive, but not statistically significant, difference in abnormal hearing screening in premature infants. Additional studies with post-hospital discharge audiology follow-up are needed to further evaluate the safety of furosemide in this population.
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Affiliation(s)
| | - P Brian Smith
- Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Kanecia O Zimmerman
- Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | | | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
| | | | - Rachel G Greenberg
- Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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25
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Thompson EJ, Greenberg RG, Kumar K, Laughon M, Smith PB, Clark RH, Crowell A, Shaw L, Harrison L, Scales G, Bell N, Hornik CP. Association between Furosemide Exposure and Patent Ductus Arteriosus in Hospitalized Infants of Very Low Birth Weight. J Pediatr 2018; 199:231-236. [PMID: 29752171 PMCID: PMC6063759 DOI: 10.1016/j.jpeds.2018.03.067] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 02/26/2018] [Accepted: 03/27/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To evaluate the association between furosemide exposure and patent ductus arteriosus (PDA) in a large, contemporary cohort of hospitalized infants with very low birth weight (VLBW). STUDY DESIGN Using the Pediatrix Medical Group Clinical Data Warehouse, we identified all inborn infants of VLBW <37 weeks of gestation discharged from the neonatal intensive care unit after the first postnatal week from 2011 to 2015. We defined PDA as any medical (ibuprofen or indomethacin) or surgical PDA therapy. We collected data up to the day of PDA treatment or postnatal day 18 for infants not diagnosed with PDA. We performed multivariable logistic regression to evaluate the association between PDA and exposure to furosemide. RESULTS We included 43 576 infants from 337 neonatal intensive care units, of whom 6675 (15%) underwent PDA treatment. Infants with PDA were more premature and more often exposed to mechanical ventilation and inotropes. Furosemide was prescribed to 4055 (9%) infants. On multivariable regression, exposure to furosemide was associated with decreased odds of PDA treatment (OR 0.72; 95% CI 0.65-0.79). Increasing percentage of days with furosemide exposure was not associated with PDA treatment (OR 1.01; 95% CI 0.97-1.06). CONCLUSIONS Furosemide exposure was not associated with increased odds of PDA treatment in hospitalized infants of VLBW. Further studies are needed to characterize the efficacy and safety of furosemide in premature infants.
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Affiliation(s)
| | - Rachel G Greenberg
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Karan Kumar
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Matthew Laughon
- Department of Pediatrics & Division of Neonatology, University of North Carolina, Chapel Hill, NC
| | - P Brian Smith
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Reese H Clark
- The Pediatrix-Obstetrix Center for Research, Education, and Quality, Sunrise, FL
| | | | - Layla Shaw
- Duke Star Program, Duke Clinical Research Institute, Durham, NC
| | - Louis Harrison
- Duke Star Program, Duke Clinical Research Institute, Durham, NC
| | | | - Nicole Bell
- Duke Star Program, Duke Clinical Research Institute, Durham, NC
| | - Christoph P Hornik
- Duke Clinical Research Institute & Department of Pediatrics, Duke University School of Medicine, Durham, NC.
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26
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Dallefeld SH, Atz AM, Yogev R, Sullivan JE, Al-Uzri A, Mendley SR, Laughon M, Hornik CP, Melloni C, Harper B, Lewandowski A, Mitchell J, Wu H, Green TP, Cohen-Wolkowiez M. A pharmacokinetic model for amiodarone in infants developed from an opportunistic sampling trial and published literature data. J Pharmacokinet Pharmacodyn 2018; 45:419-430. [PMID: 29435949 PMCID: PMC5955725 DOI: 10.1007/s10928-018-9576-y] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 01/31/2018] [Indexed: 01/18/2023]
Abstract
Amiodarone is a first-line antiarrhythmic for life-threatening ventricular fibrillation or ventricular tachycardia in children, yet little is known about its pharmacokinetics (PK) in this population. We developed a population PK (PopPK) model using samples collected via an opportunistic study design of children receiving amiodarone per standard of care supplemented by amiodarone PK data from the literature. Both study data and literature data were predominantly from infants < 2 years old, so our analysis was restricted to this group. The final combined dataset consisted of 266 plasma drug concentrations in 45 subjects with a median (interquartile range) postnatal age of 40.1 (11.0-120.4) days and weight of 3.9 (3.1-5.1) kg. Since the median sampling time after the first dose was short (study: 95 h; literature: 72 h) relative to the terminal half-life estimated in adult PopPK studies, values of the deep compartment volume and flow were fixed to literature values. A 3-compartment model best described the data and was validated by visual predictive checks and non-parametric bootstrap analysis. The final model included body weight as a covariate on all volumes and on both inter-compartmental and elimination clearances. The empiric Bayesian estimates for clearance (CL), volume of distribution at steady state, and terminal half-life were 0.25 (90% CL 0.14-0.36) L/kg/h, 93 (68-174) L/kg, and 266 (197-477) h, respectively. These studies will provide useful information for future PopPK studies of amiodarone in infants and children that could improve dosage regimens.
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Affiliation(s)
- Samantha H Dallefeld
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Andrew M Atz
- Medical University of South Carolina Children's Hospital, Charleston, SC, USA
| | - Ram Yogev
- Ann and Robert H. Lurie Children's Hospital of Chicago/Northwestern University, Chicago, IL, USA
| | - Janice E Sullivan
- University of Louisville-KCPCRU and Norton Children's Hospital, Louisville, KY, USA
| | - Amira Al-Uzri
- Oregon Health and Science University, Portland, OR, USA
| | | | - Matthew Laughon
- University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Chiara Melloni
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Barrie Harper
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | | | | | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA
| | - Thomas P Green
- Ann and Robert H. Lurie Children's Hospital of Chicago/Northwestern University, Chicago, IL, USA
| | - Michael Cohen-Wolkowiez
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St, Durham, NC, 27705, USA.
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27
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Le J, Poindexter B, Sullivan JE, Laughon M, Delmore P, Blackford M, Yogev R, James LP, Melloni C, Harper B, Mitchell J, Benjamin DK, Boakye-Agyeman F, Cohen-Wolkowiez M. Comparative Analysis of Ampicillin Plasma and Dried Blood Spot Pharmacokinetics in Neonates. Ther Drug Monit 2018; 40:103-108. [PMID: 29271816 PMCID: PMC5764797 DOI: 10.1097/ftd.0000000000000466] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dried blood spot (DBS) is a practical sampling strategy for pharmacokinetic studies in neonates. The utility of DBS to determine the population pharmacokinetics (pop-PK) of ampicillin, as well as accuracy versus plasma samples, was evaluated. METHODS An open-label, multicenter, opportunistic, prospective study was conducted in neonates. Ampicillin concentrations from plasma and DBS (CONCPlasma and CONCDBS) were measured by liquid chromatographic tandem mass spectrometry and analyzed using pop-PK and statistical (including transformation) approaches. RESULTS A total of 29 paired plasma and DBS samples from 18 neonates were analyzed. The median (range) gestational age and postnatal age were 37 (27-41) weeks and 8 (1-26) days, respectively. The geometric mean of CONCDBS to CONCPlasma ratio was 0.56. Correlation analysis demonstrated strong association between CONCPlasma and CONCDBS (r = 0.902, analysis of variance P < 0.001). Using linear regression transformation, the estimated CONCPlasma (eCONCPlasma) was derived using (CONCDBS - 3.223)/0.51. The median bias and geometric mean ratio improved to -11% and 0.88 (Wilcoxon signed-rank test, P < 0.001), respectively, when comparing eCONCPlasma to CONCPlasma. Furthermore, using pop-PK modeling, the median bias (interquartile range) for clearance and individual predicted concentrations improved to 8% (-11 to 50) and -8% (-34 to 11), respectively, when eCONCPlasma was used. CONCLUSIONS After transformation, DBS sampling accurately predicted ampicillin exposure in neonates.
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Affiliation(s)
- Jennifer Le
- University of California, San Diego, Skaggs School of Pharmacy, CA
| | - Brenda Poindexter
- Indiana University School of Medicine, Indianapolis, IN, and Cincinnati Children's, Cincinnati, OH
| | - Janice E. Sullivan
- University of Louisville, Norton Children's Hospital and Kosair Charities Pediatric Clinical Research Unit, Louisville, KY
| | - Matthew Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - Ram Yogev
- Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Laura P. James
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital at Little Rock, Little Rock, AR
| | - Chiara Melloni
- Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | | | | | - Daniel K. Benjamin
- Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
| | - Felix Boakye-Agyeman
- Duke University Medical Center, Durham, NC
- Duke Clinical Research Institute, Durham, NC
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28
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Vora NL, Parker J, Mieczkowski P, Smeester L, Laughon M, Fry R, Boggess K. 262: Fetal immune function gene expression varies by gestational age and race. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.190] [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: 11/29/2022]
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29
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Vora NL, Parker J, Mieczkowski P, Smeester L, Laughon M, Fry R, Boggess K. 261: RNA sequencing of umbilical cord blood to investigate gene expression in preterm birth. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.189] [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: 10/18/2022]
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30
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Steinhorn R, Davis JM, Göpel W, Jobe A, Abman S, Laughon M, Bancalari E, Aschner J, Ballard R, Greenough A, Storari L, Thomson M, Ariagno RL, Fabbri L, Turner MA. Chronic Pulmonary Insufficiency of Prematurity: Developing Optimal Endpoints for Drug Development. J Pediatr 2017; 191:15-21.e1. [PMID: 29173299 DOI: 10.1016/j.jpeds.2017.08.006] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/29/2017] [Accepted: 08/03/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Robin Steinhorn
- Center for Hospital Based Specialties, Children's National Medical Center, Washington, DC.
| | - Jonathan M Davis
- The Floating Hospital for Children at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, MA
| | - Wolfgang Göpel
- Department of Pediatrics, University of Lübeck, Lübeck, Germany
| | - Alan Jobe
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Steven Abman
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, CO
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Eduardo Bancalari
- Department of Pediatrics, Miller School of Medicine, University of Miami, Jackson Memorial Hospital, Miami, FL
| | - Judy Aschner
- Department of Pediatrics, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, NY
| | - Roberta Ballard
- Department of Pediatrics, University of California, San Francisco, CA
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital, London, UK
| | | | | | - Ronald L Ariagno
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | | | - Mark A Turner
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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31
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Shah M, Phillips MR, Klein M, Marzinsky A, Rice C, Laughon M, Lee S. A Single Institution Study of Umbilical Vein Complications and Necrotizing Enterocolitis in Premature Infants. Am Surg 2017; 83:e364-e366. [PMID: 30454354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Mansi Shah
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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32
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Greenberg RG, Wu H, Laughon M, Capparelli E, Rowe S, Zimmerman KO, Smith PB, Cohen-Wolkowiez M. Population Pharmacokinetics of Dexmedetomidine in Infants. J Clin Pharmacol 2017; 57:1174-1182. [PMID: 28444697 PMCID: PMC5561462 DOI: 10.1002/jcph.904] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 01/19/2017] [Accepted: 03/02/2017] [Indexed: 12/31/2022]
Abstract
Despite limited pharmacokinetic (PK) data, dexmedetomidine is increasingly being used off-label for sedation in infants. We aimed to characterize the developmental PK changes of dexmedetomidine during infancy. In this open-label, single-center PK study of dexmedetomidine in infants receiving dexmedetomidine per clinical care, ≤10 blood samples per infant were collected. A set of structural PK models and residual error models were explored using nonlinear mixed-effects modeling in NONMEM. Covariates including postmenstrual age (PMA), serum creatinine, and recent history of cardiac surgery requiring cardiopulmonary bypass were investigated for their influence on PK parameters. Univariable generalized estimating equation models were used to evaluate the association of hypotension with dexmedetomidine concentrations. A total of 89 PK samples were collected from 20 infants with a median PMA of 44 weeks (range, 33-61). The median maximum dexmedetomidine infusion dose during the study period was 1.8 μg/(kg·h) (0.5-2.5), and 16/20 infants had a maximum dose >1 μg/(kg·h). A 1-compartment model best described the data. Younger PMA was a significant predictor of lower clearance. Infants with a history of cardiac surgery had ∼40% lower clearance compared to those without a history of cardiac surgery. For infants with PMA of 33 to 61 weeks and body weight of 2 to 6 kg, the estimated clearance and volume of distribution were 0.87 to 2.65 L/(kg·h) and 1.5 L/kg, respectively. No significant associations were found between dexmedetomidine concentrations and hypotension. Infants with younger PMA and recent cardiac surgery may require relatively lower doses of dexmedetomidine to achieve exposure similar to older patients and those without cardiac surgery.
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Affiliation(s)
- Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Huali Wu
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Edmund Capparelli
- Department of Pediatrics and Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California, San Diego, CA, USA
| | - Stevie Rowe
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Kanecia O. Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Shah M, Phillips MR, Klein M, Marzinsky A, Rice C, Laughon M, Lee S. A Single Institution Study of Umbilical Vein Complications and Necrotizing Enterocolitis in Premature Infants. Am Surg 2017. [DOI: 10.1177/000313481708300909] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mansi Shah
- Department of Surgery University of North Carolina Chapel Hill, North Carolina
| | - Michael R. Phillips
- Department of Surgery University of North Carolina Chapel Hill, North Carolina
| | - Mia Klein
- Department of Surgery University of North Carolina Chapel Hill, North Carolina
| | - Amy Marzinsky
- Division of Pediatric Surgery University of North Carolina Chapel Hill, North Carolina
| | - Colleen Rice
- Division of Pediatric Surgery University of North Carolina Chapel Hill, North Carolina
| | - Matthew Laughon
- Division of Pediatrics University of North Carolina Chapel Hill, North Carolina
| | - Sang Lee
- Division of Pediatric Surgery University of North Carolina Chapel Hill, North Carolina
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Zimmerman KO, Smith PB, Benjamin DK, Laughon M, Clark R, Traube C, Stürmer T, Hornik CP. Sedation, Analgesia, and Paralysis during Mechanical Ventilation of Premature Infants. J Pediatr 2017; 180:99-104.e1. [PMID: 27522446 PMCID: PMC5183489 DOI: 10.1016/j.jpeds.2016.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/31/2016] [Accepted: 07/01/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To characterize administration of sedatives, analgesics, and paralytics in a large cohort of mechanically ventilated premature infants. STUDY DESIGN Retrospective cohort study including all infants <1500 g birth weight and <32 weeks gestational age (GA) mechanically ventilated at 348 Pediatrix Medical Group neonatal intensive care units from 1997 to 2012. The primary outcome is the proportion of mechanically ventilated days in which infants were administered drugs of interest. Multivariable logistic regression was used to evaluate the predictors of administration of drugs of interest. RESULTS We identified 85 911 mechanically ventilated infants. Infants received a drug of interest (opioids, benzodiazepines, other sedatives, and paralytics) on 433 587/1 305 413 (33%) of mechanically ventilated infant days. The administration of opioids increased during the study period from 5% of infant days in 1997 to 32% in 2012. The administration of benzodiazepines increased during the study period from 5% of infant days in 1997 to 24% in 2012. Use of paralytics and other drugs remained ≤1% throughout the study period. Predictors of drug administration included younger GA, small for GA status, male sex, presence of a major congenital anomaly, older postnatal age at intubation, exposure to high-frequency ventilation, exposure to inotropes, more recent year of discharge, and neonatal intensive care unit site. CONCLUSIONS Administration of opioids and benzodiazepines in mechanically ventilated premature infants increased over time. Because infant characteristics were unchanged, site-specific differences in practice likely explain our observations. Increased administration over time is concerning given limited evidence of benefit and potential for harm.
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Affiliation(s)
- Kanecia O Zimmerman
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | - P Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | | | - Matthew Laughon
- Department of Pediatrics, Division of Neonatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Reese Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, New York, NY
| | - Til Stürmer
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christoph P Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC.
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Lemyre B, Laughon M, Bose C, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev 2016; 12:CD005384. [PMID: 27976361 PMCID: PMC6463790 DOI: 10.1002/14651858.cd005384.pub2] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [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: 11/10/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) is a strategy for maintaining positive airway pressure throughout the respiratory cycle through the application of bias flow of respiratory gas to an apparatus attached to the nose. Treatment with NCPAP is associated with decreased risk of mechanical ventilation and might be effective in reducing chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation during which patients are exposed intermittently to higher levels of airway pressure, along with NCPAP through the same nasal device. OBJECTIVES To examine the risks and benefits of early NIPPV versus early NCPAP alone for preterm infants at risk of or in respiratory distress within the first hours after birth.Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), air leaks, duration of respiratory support, duration of oxygen therapy, intraventricular hemorrhage, and incidence of mortality. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9), MEDLINE via PubMed (1966 to September 28, 2015), Embase (1980 to September 28, 2015), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to September 28, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. A member of the Cochrane Neonatal Review Group handsearched abstracts from the European Society of Pediatric Research (ESPR). We contacted the authors of ongoing clinical trials to ask for information. SELECTION CRITERIA We considered all randomized and quasi-randomized controlled trials. Studies selected compared NIPPV versus NCPAP treatment, starting at birth or shortly thereafter in preterm infants (< 37 weeks' gestational age). DATA COLLECTION AND ANALYSIS We performed data collection and analysis using the recommendations of the Cochrane Neonatal Review Group. MAIN RESULTS Ten trials, enrolling a total of 1061 infants, met criteria for inclusion in this review. Meta-analyses of these studies showed significantly reduced risk of meeting respiratory failure criteria (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; typical risk difference (RD) -0.09, 95% CI -0.13 to -0.04) and needing intubation (typical RR 0.78, 95% CI 0.64 to 0.94; typical RD -0.07, 95% CI -0.12 to -0.02) among infants treated with early NIPPV compared with early NCPAP. The meta-analysis did not demonstrate a reduction in the risk of CLD among infants randomized to NIPPV (typical RR 0.78, 95% CI 0.58 to 1.06). Investigators observed no evidence of harm. Review authors graded the quality of the evidence as moderate (unblinded studies). AUTHORS' CONCLUSIONS Early NIPPV does appear to be superior to NCPAP alone for decreasing respiratory failure and the need for intubation and endotracheal tube ventilation among preterm infants with respiratory distress syndrome. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.
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Affiliation(s)
- Brigitte Lemyre
- Children's Hospital of Eastern OntarioDivision of Neonatology401 Smyth RoadOttawaONCanadaKlH 8L1
| | - Matthew Laughon
- The University of North Carolina at Chapel HillDepartment of Pediatrics, Division of Neonatal‐Perinatal MedicineCB# 75964th Floor, UNC HospitalsChapel HillNorth CarolinaUSA27599
| | - Carl Bose
- The University of North Carolina at Chapel HillDepartment of Pediatrics, Division of Neonatal‐Perinatal MedicineCB# 75964th Floor, UNC HospitalsChapel HillNorth CarolinaUSA27599
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Aliaga S, Zhang J, Long DL, Herring AH, Laughon M, Boggess K, Reddy UM, Grantz KL. Center Variation in the Delivery of Indicated Late Preterm Births. Am J Perinatol 2016; 33:1008-16. [PMID: 27120474 PMCID: PMC4972671 DOI: 10.1055/s-0036-1582129] [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: 10/21/2022]
Abstract
Objective Evidence for optimal timing of delivery for some pregnancy complications at late preterm gestation is limited. The purpose of this study was to identify center variation of indicated late preterm births. Study design We performed an analysis of singleton late preterm and term births from a large U.S. retrospective obstetrical cohort. Births associated with spontaneous preterm labor, major congenital anomalies, chorioamnionitis, and emergency cesarean were excluded. We used modified Poisson fixed effects logistic regression with interaction terms to assess center variation of indicated late preterm births associated with four medical/obstetric comorbidities after adjusting for socio-demographics, comorbidities, and hospital/provider characteristics. Results We identified 150,055 births from 16 hospitals; 9,218 were indicated late preterm births. We found wide variation of indicated late preterm births across hospitals. The extent of center variation was greater for births associated with preterm premature rupture of membranes (risk ratio [RR] across sites: 0.45-3.05), hypertensive disorders of pregnancy (RR across sites: 0.36-1.27), and placenta previa/abruption (RR across sites: 0.48-1.82). We found less center variation for births associated with diabetes (RR across sites: 0.65-1.39). Conclusion Practice variation in the management of indicated late preterm deliveries might be a source of preventable late preterm birth.
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Affiliation(s)
- Sofia Aliaga
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, Pediatrics CB#7596, 101 Manning Drive, Chapel Hill, NC 27599; ;
| | - Jun Zhang
- MOE-Shanghai Key Laboratory of Children’s Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, 800 Dongchuan Rd., Minhang District, Shanghai, China;
| | - D. Leann Long
- Department of Biostatistics, West Virginia University, PO Box 9190, Morgantown, WV 26506;
| | - Amy H. Herring
- Department of Biostatistics, West Virginia University, PO Box 9190, Morgantown, WV 26506; ,Carolina Population Center, 206 West Franklin St., Rm. 208, Chapel Hill, NC 27516;
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, Pediatrics CB#7596, 101 Manning Drive, Chapel Hill, NC 27599; ;
| | - Kim Boggess
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, The University of North Carolina, 101 Manning Drive, CB #7516, Old Clinic Building, Chapel Hill, NC 27599;
| | - Uma M. Reddy
- Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6100 Executive Blvd Room 7B03M, MSC 7510, Bethesda, MD 20852;
| | - Katherine Laughon Grantz
- Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, 6100 Executive Blvd Room 7B03M, MSC 7510, Bethesda, MD 20852;
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England A, Wade K, Smith PB, Berezny K, Laughon M. Optimizing operational efficiencies in early phase trials: The Pediatric Trials Network experience. Contemp Clin Trials 2016; 47:376-82. [PMID: 26968616 PMCID: PMC4997801 DOI: 10.1016/j.cct.2016.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [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: 11/30/2015] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 01/09/2023]
Abstract
Performing drug trials in pediatrics is challenging. In support of the Best Pharmaceuticals for Children Act, the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded the formation of the Pediatric Trials Network (PTN) in 2010. Since its inception, the PTN has developed strategies to increase both efficiency and safety of pediatric drug trials. Through use of innovative techniques such as sparse and scavenged blood sampling as well as opportunistic study design, participation in trials has grown. The PTN has also strived to improve consistency of adverse event reporting in neonatal drug trials through the development of a standardized adverse event table. We review how the PTN is optimizing operational efficiencies in pediatric drug trials to increase the safety of drugs in children.
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Affiliation(s)
- Amanda England
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, N.C. Memorial Hospital, 101 Manning Drive, CB#7596, Chapel Hill, NC 27599-7596, USA
| | - Kelly Wade
- Division of Neonatology, Children's Hospital of Pennsylvania, CHOP Newborn Care at the Hospital of the University of Pennsylvania, 800 Spruce St., Philadelphia, PA 19107, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC 27710, USA; Duke Clinical Research Institute, Duke University School of Medicine, P.O. Box 17969, Durham, NC 27715, USA
| | - Katherine Berezny
- Duke Clinical Research Institute, Duke University School of Medicine, P.O. Box 17969, Durham, NC 27715, USA
| | - Matthew Laughon
- Division of Neonatal-Perinatal Medicine, The University of North Carolina at Chapel Hill, N.C. Memorial Hospital, 101 Manning Drive, CB#7596, Chapel Hill, NC 27599-7596, USA.
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Abstract
OBJECTIVE Compare invasive blood pressure (IBP) and noninvasive blood pressure (NIBP) measurement methods in the neonatal intensive care unit (NICU) across various gestational age and postmenstrual age (PMA), and determine the effect of gestational age and PMA on accuracy of NIBP measurements. STUDY DESIGN Retrospective chart review of paired mean IBP and NIBP measurements from infants admitted to a single NICU from January 2008 through December 2010. Infants with congenital anomalies or receiving therapeutic hypothermia were excluded. Difference between paired measurements was analyzed using Bland-Altman method. We examined the association between PMA, sex, race, mechanical ventilation, medications, and axillary temperature, and the difference in measurements using a mixed effects linear regression model. RESULTS Eighty-seven infants had 243 observations. The mean (range) gestational age at birth was 31.9 (23-41) weeks and PMA at time of measurement ranged from 26 to 52 weeks. We found poor agreement between IBP and NIBP measurements, with mean difference (95% limits of agreement) of -8.8 (11, -28.7) mm Hg. The mean blood pressure percent difference ( ± SD) was -28.3 ( ± 35.6%). A greater blood pressure percent difference between the two measurement techniques was associated with lower PMA and lower mean IBP. CONCLUSION NIBP measurements overestimate IBP measurements particularly in smaller, sicker infants at lower IBP measurements.
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Affiliation(s)
- Shaeequa Dasnadi
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Sofia Aliaga
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Matthew Laughon
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Diane D Warner
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Wayne A Price
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
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Ambalavanan N, Carlo WA, Wrage LA, Das A, Laughon M, Cotten CM, Kennedy KA, Laptook AR, Shankaran S, Walsh MC, Higgins RD. PaCO2 in surfactant, positive pressure, and oxygenation randomised trial (SUPPORT). Arch Dis Child Fetal Neonatal Ed 2015; 100:F145-9. [PMID: 25425651 PMCID: PMC4336211 DOI: 10.1136/archdischild-2014-306802] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [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: 11/03/2022]
Abstract
OBJECTIVE To determine the association of arterial partial pressure of carbon dioxide PaCO2 with severe intraventricular haemorrhage (sIVH), bronchopulmonary dysplasia (BPD), and neurodevelopmental impairment (NDI) at 18-22 months in premature infants. DESIGN Secondary exploratory data analysis of Surfactant, Positive Pressure, and Oxygenation Randomised Trial (SUPPORT). SETTING Multiple referral neonatal intensive care units. PATIENTS 1316 infants 24 0/7 to 27 6/7 weeks gestation randomised to different oxygenation (SpO2 target 85-89% vs 91-95%) and ventilation strategies. MAIN OUTCOME MEASURES Blood gases from postnatal day 0 to day14 were analysed. Five PaCO2 variables were defined: minimum (Min), maximum (Max), SD, average (time-weighted), and a four level categorical variable (hypercapnic (highest quartile of Max PaCO2), hypocapnic (lowest quartile of Min PaCO2), fluctuators (hypercapnia and hypocapnia), and normocapnic (middle two quartiles of Max and Min PaCO2)). PaCO2 variables were compared for infants with and without sIVH, BPD and NDI (±death). Multivariable logistic regression models were developed for adjusted results. RESULTS sIVH, BPD and NDI (±death) were associated with hypercapnic infants and fluctuators. Association of Max PaCO2 and outcomes persisted after adjustment (per 10 mm Hg increase: sIVH/death: OR 1.27 (1.13 to 1.41); BPD/death: OR 1.27 (1.12 to 1.44); NDI/death: OR 1.23 (1.10 to 1.38), death: OR 1.27 (1.12 to 1.44), all p<0.001). No interaction was found between PaCO2 category and SpO2 treatment group for sIVH/death, NDI/death or death. Max PaCO2 was positively correlated with maximum FiO2 (rs0.55, p<0.0001) and ventilator days (rs0.61, p<0.0001). CONCLUSIONS Higher PaCO2 was an independent predictor of sIVH/death, BPD/death and NDI/death. Further trials are needed to evaluate optimal PaCO2 targets for high-risk infants.
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Affiliation(s)
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Lisa A. Wrage
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | | | - Kathleen A. Kennedy
- Department of Pediatrics, University of Texas Medical School at Houston, Houston, TX
| | - Abbot R. Laptook
- Department of Pediatrics, Women and Infants Hospital, Providence, RI
| | | | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
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Tremoulet A, Le J, Poindexter B, Sullivan JE, Laughon M, Delmore P, Salgado A, Ian-U Chong S, Melloni C, Gao J, Benjamin DK, Capparelli EV, Cohen-Wolkowiez M. Characterization of the population pharmacokinetics of ampicillin in neonates using an opportunistic study design. Antimicrob Agents Chemother 2014; 58:3013-20. [PMID: 24614374 PMCID: PMC4068432 DOI: 10.1128/aac.02374-13] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/01/2014] [Indexed: 11/20/2022] Open
Abstract
Although ampicillin is the most commonly used drug in neonates, developmental pharmacokinetic (PK) data to guide dosing are lacking. Ampicillin is primarily renally eliminated, and developmental changes are expected to influence PK. We conducted an open-label, multicenter, opportunistic, prospective PK study of ampicillin in neonates stratified by gestational age (GA) (≤ 34 or >34 weeks) and postnatal age (PNA) (≤ 7 or >7 days). Drug concentrations were measured by tandem mass spectrometry. PK data were analyzed using population nonlinear mixed-effects modeling in NONMEM 7.2. Monte Carlo simulations were conducted to determine the probability of target attainment for the time in which the total steady-state ampicillin concentrations remained above the MIC (T>MIC) for 50%, 75%, and 100% of the dosing interval. A total of 142 PK samples from 73 neonates were analyzed (median [range] GA, 36 [24 to 41] weeks; PNA, 5 [0 to 25] days). The median ampicillin dose was 200 (100 to 350) mg/kg/day. Postmenstrual age and serum creatinine were covariates for ampicillin clearance (CL). A simplified dosing regimen of 50 mg/kg every 12 h for GA of ≤ 34 weeks and PNA of ≤ 7 days, 75 mg/kg every 12 h for GA of ≤ 34 weeks and PNA of ≥ 8 and ≤ 28 days, and 50 mg/kg every 8 h for GA of >34 weeks and PNA of ≤ 28 days achieved the prespecified surrogate efficacy target in 90% of simulated subjects. Ampicillin CL was associated with neonatal development. A simplified dosing regimen stratified by GA and PNA achieves the desired surrogate therapeutic target in the vast majority of neonates.
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Affiliation(s)
- Adriana Tremoulet
- University of California, San Diego, School of Medicine, San Diego, California, USA Rady Children's Hospital, San Diego, California, USA
| | - Jennifer Le
- University of California, San Diego, Skaggs School of Pharmacy, San Diego, California, USA
| | | | - Janice E Sullivan
- University of Louisville & Kosair Children's Hospital, Louisville, Kentucky, USA
| | - Matthew Laughon
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Andrea Salgado
- University of California, San Diego, School of Medicine, San Diego, California, USA
| | - Sandy Ian-U Chong
- University of California, San Diego, Skaggs School of Pharmacy, San Diego, California, USA
| | - Chiara Melloni
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jamie Gao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel K Benjamin
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Edmund V Capparelli
- University of California, San Diego, School of Medicine, San Diego, California, USA University of California, San Diego, Skaggs School of Pharmacy, San Diego, California, USA
| | - Michael Cohen-Wolkowiez
- Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Durham, North Carolina, USA
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Aliaga S, Clark RH, Laughon M, Walsh TJ, Hope WW, Benjamin DK, Kaufman D, Arrieta A, Benjamin DK, Smith PB. Changes in the incidence of candidiasis in neonatal intensive care units. Pediatrics 2014; 133:236-42. [PMID: 24446441 PMCID: PMC3904270 DOI: 10.1542/peds.2013-0671] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Neonatal invasive candidiasis is associated with significant morbidity and mortality. We describe the association between invasive candidiasis and changes in use of antifungal prophylaxis, empirical antifungal therapy, and broad-spectrum antibacterial antibiotics over time. METHODS We examined data from 709,325 infants at 322 NICUs managed by the Pediatrix Medical Group from 1997 to 2010. We determined the cumulative incidence of invasive candidiasis and use of antifungal prophylaxis, broad-spectrum antibacterial antibiotics, and empirical antifungal therapy by year. RESULTS We identified 2063 (0.3%) infants with 2101 episodes of invasive candidiasis. Over the study period, the annual incidence of invasive candidiasis decreased from 3.6 episodes per 1000 patients to 1.4 episodes per 1000 patients among all infants, from 24.2 to 11.6 episodes per 1000 patients among infants with a birth weight of 750-999 g, and from 82.7 to 23.8 episodes per 1000 patients among infants with a birth weight <750 g. Fluconazole prophylaxis use increased among all infants with a birth weight <1000 g (or <1500 g), with the largest effect on birth weights <750 g, increasing from 3.8 per 1000 patients in 1997 to 110.6 per 1000 patients in 2010. The use of broad-spectrum antibacterial antibiotics decreased among all infants from 275.7 per 1000 patients in 1997 to 48.5 per 1000 patients in 2010. The use of empirical antifungal therapy increased over time from 4.0 per 1000 patients in 1997 to 11.5 per 1000 patients in 2010. CONCLUSIONS The incidence of invasive candidiasis in the NICU decreased over the 14-year study period. Increased use of fluconazole prophylaxis and empirical antifungal therapy, along with decreased use of broad-spectrum antibacterial antibiotics, may have contributed to this observation.
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Affiliation(s)
- Sofia Aliaga
- Division of Neonatal-Perinatal Medicine, University of North Carolina, Chapel Hill, North Carolina
| | | | - Matthew Laughon
- Division of Neonatal-Perinatal Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Thomas J. Walsh
- Transplantation-Oncology Infectious Disease Program and
- Departments of Pediatrics and
- Microbiology, Weill Cornell Medical Center, New York, New York
| | - William W. Hope
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom
| | | | - David Kaufman
- Department of Pediatrics, University of Virginia Health Systems, Charlottesville, Virginia
| | - Antonio Arrieta
- Department of Pediatrics, Children’s Hospital of Orange County, Orange, California
| | - Daniel K. Benjamin
- Department of Pediatrics, Duke University, Durham, North Carolina; and
- Duke Clinical Research Institute, Durham, North Carolina
| | - P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina; and
- Duke Clinical Research Institute, Durham, North Carolina
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Abstract
OBJECTIVE Determine sildenafil exposure and hemodynamic effect in children after Fontan single-ventricle surgery. DESIGN Prospective dose-escalation trial. SETTING Single-center pediatric catheterization laboratory. PATIENTS Nine children post Fontan single-ventricle surgical palliation and undergoing elective cardiac catheterization: median (range) age and weight, 5.2 years (2.5-9.4 yr) and 16.3 kg (9.5-28.1 kg). Five children (55%) were boys, and six of nine (67%) had a systemic right ventricle. INTERVENTIONS Catheterization and echocardiography performed before and immediately after single-dose IV sildenafil (0.25, 0.35, or 0.45 mg/kg over 20 min). MEASUREMENTS AND MAIN RESULTS Peak sildenafil and desmethyl sildenafil concentration, change in hemodynamic variables measured by cardiac catheterization and echocardiography. Maximum sildenafil concentrations ranged from 124 to 646 ng/mL and were above the in vitro threshold needed for 77% phosphodiesterase type-5 inhibition in eight of nine children and 90% inhibition in seven of seven children with doses more than or equal to 0.35 mg/kg. Sildenafil improved stroke volume (+22%, p = 0.05) and cardiac output (+10%, p = 0.01) with no significant change in heart rate in eight of nine children. Sildenafil also lowered systemic (-16%, p = 0.01) and pulmonary vascular resistance index in all nine children (median baseline pulmonary vascular resistance index 2.4 [range, 1.3-3.7]; decreased to 1.9 [0.8-2.7] Wood Units × m; p = 0.01) with no dose-response effect. Pulmonary arterial pressures decreased (-10%, p = 0.02) and pulmonary blood flow increased (9%, p = 0.02). There was no change in myocardial performance index and no adverse events. CONCLUSIONS After Fontan surgery, sildenafil infusion acutely improves cardiopulmonary hemodynamics, increasing cardiac index. For the range of doses studied, exposure was within the acute safety range reported in adult subjects.
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Affiliation(s)
- Robert D. Tunks
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Piers C. A. Barker
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniel K. Benjamin
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Gregory A. Fleming
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer S. Li
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin D. Hill
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Trembath A, Hornik CP, Clark R, Smith PB, Daniels J, Laughon M. Comparative effectiveness of surfactant preparations in premature infants. J Pediatr 2013; 163:955-60.e1. [PMID: 23769501 PMCID: PMC3779477 DOI: 10.1016/j.jpeds.2013.04.053] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 04/11/2013] [Accepted: 04/25/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare effectiveness of 3 surfactant preparations (beractant, calfactant, and poractant alfa) in premature infants for preventing 3 outcomes: (1) air leak syndromes; (2) death; and (3) bronchopulmonary dysplasia (BPD) or death (composite outcome). STUDY DESIGN We conducted a comparative effectiveness study of premature infants admitted to 322 neonatal intensive care units in the US from 2005-2010 who were treated with beractant, calfactant, or poractant alfa. We compared the incidence of air leak syndromes, death, and BPD or death, adjusting for gestational age (GA), antenatal steroids, discharge year, and small for GA status. RESULTS A total of 51282 infants received surfactant; 40% received beractant, 30% calfactant, and 30% poractant alfa. Median birth weight was 1435 g (IQR 966-2065); median GA was 30 weeks (27-33). On adjusted analysis, we observed a similar risk of air leak syndromes (calfactant vs beractant OR = 1.17 [95% CI: 0.95, 1.43]; calfactant vs poractant OR = 1.23 [0.98, 1.56]; beractant vs poractant OR = 1.06 [0.87, 1.29]), death (calfactant vs beractant OR = 1.14 [0.93, 1.39]; calfactant vs poractant OR = 0.98 [0.78, 1.23]; beractant vs poractant OR = 0.86 [0.72, 1.04]), and BPD or death (calfactant vs beractant OR = 1.08 [0.93, 1.26]; calfactant vs poractant OR = 1.19 [1.00, 1.41]; beractant vs poractant OR = 1.10 [0.96, 1.27]). CONCLUSIONS Beractant, calfactant, and poractant alfa demonstrated similar effectiveness in prevention of air leak syndromes, death, and BPD or death in premature infants when adjusted for site. Previously described differences in mortality between surfactants likely do not represent true differences in effectiveness but may relate to site variation in outcomes.
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Affiliation(s)
- Andrea Trembath
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Christoph P. Hornik
- Department of Pediatrics and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Reese Clark
- Pediatrix Center for Research and Education, Sunrise, FL, and Pediatrix Medical Group, Greenville Memorial Hospital, Greenville, SC
| | - P. Brian Smith
- Department of Pediatrics and Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Julie Daniels
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
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Hill KD, Tunks RD, Barker PCA, Benjamin DK, Cohen-Wolkowiez M, Fleming GA, Laughon M, Li JS. Sildenafil exposure and hemodynamic effect after stage II single-ventricle surgery. Pediatr Crit Care Med 2013; 14:593-600. [PMID: 23823195 PMCID: PMC3782306 DOI: 10.1097/pcc.0b013e31828aa5ee] [Citation(s) in RCA: 16] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine sildenafil exposure and hemodynamic effect in children after stage II single-ventricle surgery. DESIGN Prospective, dose escalation trial. SETTING Single-center, pediatric catheterization laboratory. PATIENTS Twelve children poststage II single-ventricle surgical palliation and undergoing elective cardiac catheterization: median age 1.9 years (range, 0.8, 4.0), weight 11 kg (8, 13), nine females, and 10 with a single right ventricle. INTERVENTIONS Catheterization and echocardiography performed before and immediately after single-dose IV sildenafil (0.125, 0.25, 0.35, or 0.45 mg/kg over 20 min). MEASUREMENTS Peak sildenafil and desmethyl sildenafil concentration, change in hemodynamic parameters measured by cardiac catheterization and echocardiography including indexed pulmonary vascular resistance, and myocardial performance. MAIN RESULTS Maximum sildenafil concentrations ranged from 92 to 775 ng/mL and were above the in vitro threshold needed for 77% phosphodiesterase type 5 (PDE-5) inhibition in 80% of subjects and 90% inhibition in 80% of subjects with doses ≥0.35 mg/kg. Sildenafil lowered pulmonary vascular resistance index in all 12 subjects (median pulmonary vascular resistance index 2.2 [range, 1.6, 7.9]; decreased to 1.7 [1.2, 5.4] WU × m; p < 0.01) with no dose-response effect. Sildenafil improved pulmonary blood flow (+8% [0, 20], p = 0.04) and saturations (+2% [0, 16], p = 0.04) in those with baseline pulmonary vascular resistance index ≥ 2 WU × m (n = 7). Change in saturations correlated inversely with change in pulmonary vascular resistance index (r = 0.74, p < 0.01). Sildenafil also lowered mean blood pressure (-12% [-20, +10]; p = 0.04). There was no change in cardiac index and no effect on myocardial performance. There were no adverse events. CONCLUSIONS Sildenafil demonstrated nonlinear exposure with high interindividual variability but was well tolerated and effectively lowered pulmonary vascular resistance index in all subjects. Sildenafil did not acutely improve myocardial performance or increase cardiac index.
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Affiliation(s)
- Kevin D Hill
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA.
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Cohen-Wolkowiez M, Poindexter B, Bidegain M, Weitkamp JH, Schelonka RL, Randolph DA, Ward RM, Wade K, Valencia G, Burchfield D, Arrieta A, Mehta V, Walsh M, Kantak A, Rasmussen M, Sullivan JE, Finer N, Rich W, Brozanski BS, van den Anker J, Blumer J, Laughon M, Watt KM, Kearns GL, Capparelli EV, Martz K, Berezny K, Benjamin DK, Smith PB. Safety and effectiveness of meropenem in infants with suspected or complicated intra-abdominal infections. Clin Infect Dis 2012; 55:1495-502. [PMID: 22955430 DOI: 10.1093/cid/cis758] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Intra-abdominal infections are common in young infants and lead to significant morbidity and mortality. Meropenem is a broad-spectrum antimicrobial with excellent activity against pathogens associated with intra-abdominal infections. The purpose of this study was to determine the safety and effectiveness of meropenem in young infants with suspected or complicated intra-abdominal infections. METHODS Preterm and term infants <91 days of age with suspected or confirmed intra-abdominal infections hospitalized in 24 neonatal intensive care units were studied in an open-label, multiple-dose study. Adverse events and serious adverse events were collected through 3 and 30 days following the last meropenem dose, respectively. Effectiveness was assessed by 3 criteria: death, bacterial cultures, and presumptive clinical cure score. RESULTS Of 200 subjects enrolled in the study, 99 (50%) experienced an adverse event, and 34 (17%) had serious adverse events; no adverse events were probably or definitely related to meropenem. The most commonly reported adverse events were sepsis (6%), seizures (5%), elevated conjugated bilirubin (5%), and hypokalemia (5%). Only 2 of the serious adverse events were determined to be possibly related to meropenem (isolated ileal perforation and an episode of fungal sepsis). Effectiveness was evaluable in 192 (96%) subjects, and overall treatment success was 84%. CONCLUSIONS Meropenem was well tolerated in this cohort of critically ill infants, and the majority of infants treated with meropenem met the definition of therapeutic success. CLINICAL TRIALS REGISTRATION NCT00621192.
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Smith PB, Ambalavanan N, Li L, Cotten CM, Laughon M, Walsh MC, Das A, Bell EF, Carlo WA, Stoll BJ, Shankaran S, Laptook AR, Higgins RD, Goldberg RN. Approach to infants born at 22 to 24 weeks' gestation: relationship to outcomes of more-mature infants. Pediatrics 2012; 129:e1508-16. [PMID: 22641761 PMCID: PMC3362905 DOI: 10.1542/peds.2011-2216] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [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: 11/24/2022] Open
Abstract
OBJECTIVE We sought to determine if a center's approach to care of premature infants at the youngest gestational ages (22-24 weeks' gestation) is associated with clinical outcomes among infants of older gestational ages (25-27 weeks' gestation). METHODS Inborn infants of 401 to 1000 g birth weight and 22 0/7 to 27 6/7 weeks' gestation at birth from 2002 to 2008 were enrolled into a prospectively collected database at 20 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Markers of an aggressive approach to care for 22- to 24-week infants included use of antenatal corticosteroids, cesarean delivery, and resuscitation. The primary outcome was death before postnatal day 120 for infants of 25 to 27 weeks' gestation. Secondary outcomes were the combined outcomes of death or a number of morbidities associated with prematurity. RESULTS Our study included 3631 infants 22 to 24 weeks' gestation and 5227 infants 25 to 27 weeks' gestation. Among the 22- to 24-week infants, use of antenatal corticosteroids ranged from 28% to 100%, cesarean delivery from 13% to 65%, and resuscitation from 30% to 100% by center. Centers with higher rates of antenatal corticosteroid use in 22- to 24-week infants had reduced rates of death, death or retinopathy of prematurity, death or late-onset sepsis, death or necrotizing enterocolitis, and death or neurodevelopmental impairment in 25- to 27-week infants. CONCLUSIONS This study suggests that physicians' willingness to provide care to extremely low gestation infants as measured by frequency of use of antenatal corticosteroids is associated with improved outcomes for more-mature infants.
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Affiliation(s)
- P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Lei Li
- RTI International, Research Triangle Park, North Carolina
| | | | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Abhik Das
- RTI International, Research Triangle Park, North Carolina
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, and Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island; and
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is associated with high morbidity and mortality among infants admitted for intensive care. The factors associated with mortality and catastrophic presentation remain poorly understood. Our objective was to describe the factors associated with mortality in infants with NEC and to quantify the degree to which catastrophic presentation contributes to mortality in infants with NEC. Catastrophic NEC was defined before data analysis as NEC that led to death within 7 days of diagnosis. STUDY DESIGN We performed a retrospective review of the Pediatrix's Clinical Data Warehouse (1997 to 2009, n=560,227) to compare the demographic, therapeutic and outcome characteristics of infants who survived NEC vs those who died. Associations were tested by bivariate and multivariate analysis. RESULT We compared the 5594 infants diagnosed with NEC and who were discharged home with 1505 infants diagnosed with NEC who died. In multivariate analysis, the factors associated with death (P<0.01 in analysis) were lower estimated gestational age, lower birth weight, treatment with assisted ventilation on the day of diagnosis of NEC, treatment with vasopressors at the time of diagnosis, and Black race. Patients who received only ampicillin and gentamicin on the day of diagnosis were less likely to die. Two-thirds of NEC deaths occurred quickly (<7 days from diagnosis), with a median time of death of one day from time of diagnosis. Infants who died within 7 days of diagnosis had a higher birth weight, more often were on vasopressors and high frequency ventilation at the time of diagnosis compared with patients who died at 7 or more days. Although mortality decreased with increasing gestational age, the proportion of deaths that occurred within 7 days was relatively consistent (65 to 75% of the patients who died) across all gestational ages. CONCLUSION Mortality among infants who have NEC remains high and infants who die of NEC commonly (66%) die quickly. Most of the factors associated with mortality are related to immaturity, low birth weight and severity of illness.
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Affiliation(s)
- R H Clark
- The Pediatrix-Obstetrix Center for Research, Education and Quality, Sunrise, FL, USA.
| | - P Gordon
- Tulane School of Medicine, Department of Pediatrics, New Orleans, LA, USA
| | - W M Walker
- Department of Pediatrics, Pediatrix Medical Group, Greenville Memorial Hospital, Greenville, SC, USA
| | - M Laughon
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, UNC-CH, Chapel Hill, NC, USA
| | - P B Smith
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - A R Spitzer
- The Pediatrix-Obstetrix Center for Research, Education and Quality, Sunrise, FL, USA
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Jean-Baptiste N, Benjamin DK, Cohen-Wolkowiez M, Fowler VG, Laughon M, Clark RH, Smith PB. Coagulase-negative staphylococcal infections in the neonatal intensive care unit. Infect Control Hosp Epidemiol 2011; 32:679-86. [PMID: 21666399 DOI: 10.1086/660361] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Coagulase-negative staphylococci (CoNS) are the most commonly isolated pathogens in the neonatal intensive care unit (NICU). CoNS infections are associated with increased morbidity, including neurodevelopmental impairment. OBJECTIVE To describe the epidemiology of CoNS infections in the NICU. To determine mortality among infants with definite, probable, or possible CoNS infections. METHODS We performed a retrospective cohort study of all blood, urine, and cerebrospinal fluid cultures from samples obtained from infants aged <121 postnatal days. SETTING A total of 248 NICUs managed by the Pediatrix Medical Group from 1997 to 2009. RESULTS We identified 16,629 infants with 17,624 episodes of CoNS infection: 1,734 (10%) definite, 3,093 (17%) probable, and 12,797 (73%) possible infections. Infants with a lower gestational age and birth weight had a higher incidence of CoNS infection. When controlling for gestational age, birth weight, and 5-minute Apgar score, we found that infants with definite, probable, or possible CoNS infection had lower mortality (odds ratio [OR], 0.74 [95% confidence interval {CI}: 0.61, 0.89], 0.68 [95% CI, 0.59, 0.79], and 0.69 [95% CI, 0.63, 0.76], respectively) compared with infants who had negative culture results (P = .001). No significant difference in overall mortality was found in infants who had definite CoNS infection compared with those who had probable or possible CoNS infection (OR, 0.93 [95% CI, 0.75, 1.16] and 0.85 [95% CI, 0.70, 1.03], respectively). CONCLUSIONS CoNS infection was strongly related to lower gestational age and birth weight. Infants with clinical sepsis and culture-positive CoNS infection had lower mortality rates than infants with clinical sepsis and negative blood culture results. No difference in mortality between infants with a diagnosis of definite, probable, or possible CoNS infection was observed.
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Laughon M, Bose C, Allred EN, O’Shea TM, Ehrenkranz RA, Van Marter LJ, Leviton A. Patterns of blood protein concentrations of ELGANs classified by three patterns of respiratory disease in the first 2 postnatal weeks. Pediatr Res 2011; 70:292-6. [PMID: 21646942 PMCID: PMC3152639 DOI: 10.1203/pdr.0b013e3182274f35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [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] [Indexed: 11/06/2022]
Abstract
We examined the association between elevated concentrations of 25 blood proteins in blood spots collected on postnatal d 1, 7, and 14 from infants <28 wk gestation who survived to 24 mo and the risk of two patterns of early lung disease i.e. early and persistent pulmonary dysfunction (EPPD) and normal early pulmonary function followed by pulmonary deterioration (PD). Thirty-eight percent (n = 347) of our cohort had PD, and 43% (n = 383) had EPPD. On postnatal d 14, elevated concentrations of two proteins (RANTES and VEGF) were associated with reduced risk of PD. Similarly, the risk of EPPD was also reduced if three proteins had elevated concentrations on postnatal d 14 (RANTES, MMP-1, and VEGF). In contrast, the risk of EPPD was increased if on d 14 two proteins had elevated concentrations (IL-8 and ICAM-1). Inflammation might influence the risk of EPPD and PD or be a consequence of lung damage or therapies to minimize lung dysfunction.
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Affiliation(s)
- Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
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50
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Greenberg RG, Benjamin DK, Cohen-Wolkowiez M, Clark RH, Cotten CM, Laughon M, Smith PB. Repeat lumbar punctures in infants with meningitis in the neonatal intensive care unit. J Perinatol 2011; 31:425-9. [PMID: 21164430 PMCID: PMC3103623 DOI: 10.1038/jp.2010.142] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [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: 11/09/2022]
Abstract
OBJECTIVE The purpose of this study is to examine the results of repeat lumbar puncture in infants with initial positive cerebrospinal fluid (CSF) cultures in order to determine the clinical characteristics and outcomes of infants with repeat positive cultures. STUDY DESIGN Cohort study of infants with an initial positive CSF culture undergoing repeat lumbar puncture between 1997 and 2004 at 150 neonatal intensive care units managed by the Pediatrix Medical group. We compared the clinical outcomes of infants with repeat positive cultures and infants with repeat negative cultures. RESULT We identified 118 infants with repeat CSF cultures. Of these, 26 infants had repeat positive cultures. A higher proportion with repeat positive cultures died compared with those with repeat negative cultures, 6/23 (26%) vs. 6/81 (7%), respectively (P=0.02). CONCLUSION Among infants with a positive CSF culture, a repeat positive CSF culture is common. The presence of a second positive culture is associated with increased mortality.
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Affiliation(s)
| | - Daniel K. Benjamin
- Department of Pediatrics, Duke University, Durham, North Carolina, Duke Clinical Research Institute, Durham, North Carolina
| | - Michael Cohen-Wolkowiez
- Department of Pediatrics, Duke University, Durham, North Carolina, Duke Clinical Research Institute, Durham, North Carolina
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | | | - Matthew Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina, Duke Clinical Research Institute, Durham, North Carolina
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