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van de Loo M, van Kaam A, Offringa M, Doyle LW, Cooper C, Onland W. Corticosteroids for the prevention and treatment of bronchopulmonary dysplasia: an overview of systematic reviews. Cochrane Database Syst Rev 2024; 4:CD013271. [PMID: 38597338 PMCID: PMC11005325 DOI: 10.1002/14651858.cd013271.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) remains an important complication of prematurity. Pulmonary inflammation plays a central role in the pathogenesis of BPD, explaining the rationale for investigating postnatal corticosteroids. Multiple systematic reviews (SRs) have summarised the evidence from numerous randomised controlled trials (RCTs) investigating different aspects of administrating postnatal corticosteroids. Besides beneficial effects on the outcome of death or BPD, potential short- and long-term harms have been reported. OBJECTIVES The primary objective of this overview was to summarise and appraise the evidence from SRs regarding the efficacy and safety of postnatal corticosteroids in preterm infants at risk of developing BPD. METHODS We searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase, CINAHL, and Epistemonikos for SRs in April 2023. We included all SRs assessing any form of postnatal corticosteroid administration in preterm populations with the objective of ameliorating pulmonary disease. All regimens and comparisons were included. Two review authors independently checked the eligibility of the SRs comparing corticosteroids with placebo, and corticosteroids with different routes of administration and regimens. The included outcomes, considered key drivers in the decision to administer postnatal corticosteroids, were the composite outcome of death or BPD at 36 weeks' postmenstrual age (PMA), its individual components, long-term neurodevelopmental sequelae, sepsis, and gastrointestinal tract perforation. We independently assessed the methodological quality of the included SRs by using AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) and ROBIS (Risk Of Bias In Systematic reviews) tools. We assessed the certainty of the evidence using GRADE. We provided a narrative description of the characteristics, methodological quality, and results of the included SRs. MAIN RESULTS We included nine SRs (seven Cochrane, two non-Cochrane) containing 87 RCTs, 1 follow-up study, and 9419 preterm infants, investigating the effects of postnatal corticosteroids to prevent or treat BPD. The quality of the included SRs according to AMSTAR 2 varied from high to critically low. Risk of bias according to ROBIS was low. The certainty of the evidence according to GRADE ranged from very low to moderate. Early initiated systemic dexamethasone (< seven days after birth) likely has a beneficial effect on death or BPD at 36 weeks' PMA (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.81 to 0.95; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 10 to 41; I2 = 39%; 17 studies; 2791 infants; moderate-certainty evidence) and on BPD at 36 weeks' PMA (RR 0.72, 95% CI 0.63 to 0.82; NNTB 13, 95% CI 9 to 21; I2 = 39%; 17 studies; 2791 infants; moderate-certainty evidence). Early initiated systemic hydrocortisone may also have a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.90, 95% CI 0.82 to 0.99; NNTB 18, 95% CI 9 to 594; I2 = 43%; 9 studies; 1376 infants; low-certainty evidence). However, these benefits are likely accompanied by harmful effects like cerebral palsy or neurosensory disability (dexamethasone) or gastrointestinal perforation (both dexamethasone and hydrocortisone). Late initiated systemic dexamethasone (≥ seven days after birth) may have a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.75, 95% CI 0.67 to 0.84; NNTB 5, 95% CI 4 to 9; I2 = 61%; 12 studies; 553 infants; low-certainty evidence), mostly contributed to by a beneficial effect on BPD at 36 weeks' PMA (RR 0.76, 95% CI 0.66 to 0.87; NNTB 6, 95% CI 4 to 13; I2 = 14%; 12 studies; 553 infants; low-certainty evidence). No harmful side effects were shown in the outcomes chosen as key drivers to the decision to start or withhold late systemic dexamethasone. No effects, either beneficial or harmful, were found in the subgroup meta-analyses of late hydrocortisone studies. Early initiated inhaled corticosteroids probably have a beneficial effect on death and BPD at 36 weeks' PMA (RR 0.86, 95% CI 0.75 to 0.99; NNTB 19, 95% CI not applicable; I2 = 0%; 6 studies; 1285 infants; moderate-certainty evidence), with no apparent adverse effects shown in the SRs. In contrast, late initiated inhaled corticosteroids do not appear to have any benefits or harms. Endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier likely has a beneficial effect on death or BPD at 36 weeks' PMA (RR 0.60, 95% CI 0.49 to 0.74; NNTB 4, 95% CI 3 to 6; I2 = 0%; 2 studies; 381 infants; moderate-certainty evidence) and on BPD at 36 weeks' PMA. No evidence of harmful effects was found. There was little evidence for effects of different starting doses or timing of systemic corticosteroids on death or BPD at 36 weeks' PMA, but potential adverse effects were observed for some comparisons. Lowering the dose might result in a more unfavourable balance of benefits and harms. Moderately early initiated systemic corticosteroids, compared with early systemic corticosteroids, may result in a higher incidence of BPD at 36 weeks' PMA. Pulse dosing instead of continuous dosing may have a negative effect on death and BPD at 36 weeks' PMA. We found no differences for the comparisons of inhaled versus systemic corticosteroids. AUTHORS' CONCLUSIONS This overview summarises the evidence of nine SRs investigating the effect of postnatal corticosteroids in preterm infants at risk for BPD. Late initiated (≥ seven days after birth) systemic administration of dexamethasone is considered an effective intervention to reduce the risk of BPD in infants with a high risk profile for BPD, based on a favourable balance between benefits and harms. Endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier is a promising intervention, based on the beneficial effect on desirable outcomes without (so far) negative side effects. Pending results of ongoing large, multicentre RCTs investigating both short- and long-term effects, endotracheal instillation of corticosteroids (budesonide) with surfactant as a carrier is not appropriate for clinical practice at present. Early initiated (< seven days after birth) systemic dexamethasone and hydrocortisone and late initiated (≥ seven days after birth) hydrocortisone are considered ineffective interventions, because of an unfavourable balance between benefits and harms. No conclusions are possible regarding early and late inhaled corticosteroids, as more research is needed.
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Affiliation(s)
- Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Anton van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
| | - Lex W Doyle
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Parkville, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, Australia
| | - Chris Cooper
- Cochrane Neonatal Group, Vermont Oxford Network, Burlington, USA
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
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2
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Prins S, Linn AJ, van Kaam AHLC, van de Loo M, van Woensel JBM, van Heerde M, Dijk PH, Kneyber MCJ, de Hoog M, Simons SHP, Akkermans AA, Smets EMA, de Vos MA. Diversity of Parent Emotions and Physician Responses During End-of-Life Conversations. Pediatrics 2023; 152:e2022061050. [PMID: 37575087 DOI: 10.1542/peds.2022-061050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To provide support to parents of critically ill children, it is important that physicians adequately respond to parents' emotions. In this study, we investigated emotions expressed by parents, physicians' responses to these expressions, and parents' emotions after the physicians' responses in conversations in which crucial decisions regarding the child's life-sustaining treatment had to be made. METHODS Forty-nine audio-recorded conversations between parents of 12 critically ill children and physicians working in the neonatal and pediatric intensive care units of 3 Dutch university medical centers were coded and analyzed by using a qualitative inductive approach. RESULTS Forty-six physicians and 22 parents of 12 children participated. In all 49 conversations, parents expressed a broad range of emotions, often intertwining, including anxiety, anger, devotion, grief, relief, hope, and guilt. Both implicit and explicit expressions of anxiety were prevalent. Physicians predominantly responded to parental emotions with cognition-oriented approaches, thereby limiting opportunities for parents. This appeared to intensify parents' expressions of anger and protectiveness, although their anxiety remained under the surface. In response to more tangible emotional expressions, for instance, grief when the child's death was imminent, physicians provided parents helpful support in both affect- and cognition-oriented ways. CONCLUSIONS Our findings illustrate the diversity of emotions expressed by parents during end-of-life conversations. Moreover, they offer insight into the more and less helpful ways in which physicians may respond to these emotions. More training is needed to help physicians in recognizing parents' emotions, particularly implicit expressions of anxiety, and to choose helpful combinations of responses.
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Affiliation(s)
- Sanne Prins
- Department of Pediatrics, Emma Children's Hospital
| | - Annemiek J Linn
- Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Moniek van de Loo
- Department of Pediatrics, Division of Neonatology, Emma Children's Hospital
| | - Job B M van Woensel
- Department of Pediatrics, Division of Pediatric Intensive Care, Emma Children's Hospital
| | - Marc van Heerde
- Department of Pediatrics, Division of Pediatric Intensive Care, Emma Children's Hospital
| | | | - Martin C J Kneyber
- Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Sinno H P Simons
- Neonatology, Department of Pediatrics, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Aranka A Akkermans
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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3
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Akkermans A, Prins S, Spijkers AS, Wagemans J, Labrie NHM, Willems DL, Schultz MJ, Cherpanath TGV, van Woensel JBM, van Heerde M, van Kaam AH, van de Loo M, Stiggelbout A, Smets EMA, de Vos MA. Argumentation in end-of-life conversations with families in Dutch intensive care units: a qualitative observational study. Intensive Care Med 2023; 49:421-433. [PMID: 37004524 PMCID: PMC10119246 DOI: 10.1007/s00134-023-07027-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/01/2023] [Indexed: 04/04/2023]
Abstract
PURPOSE In intensive care units (ICUs), decisions about the continuation or discontinuation of life-sustaining treatment (LST) are made on a daily basis. Professional guidelines recommend an open exchange of standpoints and underlying arguments between doctors and families to arrive at the most appropriate decision. Yet, it is still largely unknown how doctors and families argue in real-life conversations. This study aimed to (1) identify which arguments doctors and families use in support of standpoints to continue or discontinue LST, (2) investigate how doctors and families structure their arguments, and (3) explore how their argumentative practices unfold during conversations. METHOD A qualitative inductive thematic analysis of 101 audio-recorded conversations between doctors and families. RESULTS Seventy-one doctors and the families of 36 patients from the neonatal, pediatric, and adult ICU (respectively, N-ICU, P-ICU, and A-ICU) of a large university-based hospital participated. In almost all conversations, doctors were the first to argue and families followed, thereby either countering the doctor's line of argumentation or substantiating it. Arguments put forward by doctors and families fell under one of ten main types. The types of arguments presented by families largely overlapped with those presented by doctors. A real exchange of arguments occurred in a minority of conversations and was generally quite brief in the sense that not all possible arguments were presented and then discussed together. CONCLUSION This study offers a detailed insight in the argumentation practices of doctors and families, which can help doctors to have a sharper eye for the arguments put forward by doctors and families and to offer room for true deliberation.
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Affiliation(s)
- Aranka Akkermans
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands.
| | - Sanne Prins
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Amber S Spijkers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Jean Wagemans
- Department of Speech Communication, Argumentation Theory, and Rhetoric, University of Amsterdam, Amsterdam, The Netherlands
| | - Nanon H M Labrie
- Department of Language, Literature and Communication, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dick L Willems
- Department of Ethics, Law and Humanities, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Thomas G V Cherpanath
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc van Heerde
- Department of Pediatric Intensive Care, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Moniek van de Loo
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anne Stiggelbout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, North Holland, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Mirjam A de Vos
- Department of Pediatrics, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
BACKGROUND Systematic reviews showed that systemic postnatal corticosteroids reduce the risk of bronchopulmonary dysplasia (BPD) in preterm infants. However, corticosteroids have also been associated with an increased risk of neurodevelopmental impairment. It is unknown whether these beneficial and adverse effects are modulated by differences in corticosteroid treatment regimens related to type of steroid, timing of treatment initiation, duration, pulse versus continuous delivery, and cumulative dose. OBJECTIVES To assess the effects of different corticosteroid treatment regimens on mortality, pulmonary morbidity, and neurodevelopmental outcome in very low birth weight infants. SEARCH METHODS We conducted searches in September 2022 of MEDLINE, the Cochrane Library, Embase, and two trial registries, without date, language or publication- type limits. Other search methods included checking the reference lists of included studies for randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA We included RCTs comparing two or more different treatment regimens of systemic postnatal corticosteroids in preterm infants at risk for BPD, as defined by the original trialists. The following comparisons of intervention were eligible: alternative corticosteroid (e.g. hydrocortisone) versus another corticosteroid (e.g. dexamethasone); lower (experimental arm) versus higher dosage (control arm); later (experimental arm) versus earlier (control arm) initiation of therapy; a pulse-dosage (experimental arm) versus continuous-dosage regimen (control arm); and individually-tailored regimens (experimental arm) based on the pulmonary response versus a standardized (predetermined administered to every infant) regimen (control arm). We excluded placebo-controlled and inhalation corticosteroid studies. DATA COLLECTION AND ANALYSIS Two authors independently assessed eligibility and risk of bias of trials, and extracted data on study design, participant characteristics and the relevant outcomes. We asked the original investigators to verify if data extraction was correct and, if possible, to provide any missing data. We assessed the following primary outcome: the composite outcome mortality or BPD at 36 weeks' postmenstrual age (PMA). Secondary outcomes were: the components of the composite outcome; in-hospital morbidities and pulmonary outcomes, and long-term neurodevelopmental sequelae. We analyzed data using Review Manager 5 and used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 16 studies in this review; of these, 15 were included in the quantitative synthesis. Two trials investigated multiple regimens, and were therefore included in more than one comparison. Only RCTs investigating dexamethasone were identified. Eight studies enrolling a total of 306 participants investigated the cumulative dosage administered; these trials were categorized according to the cumulative dosage investigated, 'low' being < 2 mg/kg, 'moderate' being between 2 and 4 mg/kg, and 'high' > 4 mg/kg; three studies contrasted a high versus a moderate cumulative dose, and five studies a moderate versus a low cumulative dexamethasone dose. We graded the certainty of the evidence low to very low because of the small number of events, and the risk of selection, attrition and reporting bias. Overall analysis of the studies investigating a higher dose versus a lower dosage regimen showed no differences in the outcomes BPD, the composite outcome death or BPD at 36 weeks' PMA, or abnormal neurodevelopmental outcome in survivors assessed. Although there was no evidence of a subgroup difference for the higher versus lower dosage regimens comparisons (Chi2 = 2.91, df = 1 (P = 0.09), I2 = 65.7%), a larger effect was seen in the subgroup analysis of moderate-dosage regimens versus high-dosage regimens for the outcome cerebral palsy in survivors. In this subgroup analysis, there was an increased risk of cerebral palsy (RR 6.85, 95% CI 1.29 to 36.36; RD 0.23, 95% CI 0.08 to 0.37; P = 0.02; I² = 0%; NNTH 5, 95% CI 2.6 to 12.7; 2 studies, 74 infants). There was evidence of subgroup differences for higher versus lower dosage regimens comparisons for the combined outcomes death or cerebral palsy, and death and abnormal neurodevelopmental outcomes (Chi2 = 4.25, df = 1 (P = 0.04), I2 = 76.5%; and Chi2 = 7.11, df = 1 (P = 0.008), I2 = 85.9%, respectively). In the subgroup analysis comparing a high dosage regimen of dexamethasone versus a moderate cumulative-dosage regimen, there was an increased risk of death or cerebral palsy (RR 3.20, 95% CI 1.35 to 7.58; RD 0.25, 95% CI 0.09 to 0.41; P = 0.002; I² = 0%; NNTH 5, 95% CI 2.4 to 13.6; 2 studies, 84 infants; moderate-certainty evidence), and death or abnormal neurodevelopmental outcome (RR 3.41, 95% CI 1.44 to 8.07; RD 0.28, 95% CI 0.11 to 0.44; P = 0.0009; I² = 0%; NNTH 4, 95% CI 2.2 to 10.4; 2 studies, 84 infants; moderate-certainty evidence). There were no differences in outcomes between a moderate- and a low-dosage regimen. Five studies enrolling 797 infants investigated early initiation of dexamethasone therapy versus a moderately early or delayed initiation, and showed no significant differences in the overall analyses for the primary outcomes. The two RCTs investigating a continuous versus a pulse dexamethasone regimen showed an increased risk of the combined outcome death or BPD when using the pulse therapy. Finally, three trials investigating a standard regimen versus a participant-individualized course of dexamethasone showed no difference in the primary outcome and long-term neurodevelopmental outcomes. We assessed the GRADE certainty of evidence for all comparisons discussed above as moderate to very low, because the validity of all comparisons is hampered by unclear or high risk of bias, small samples of randomized infants, heterogeneity in study population and design, non-protocolized use of 'rescue' corticosteroids and lack of long-term neurodevelopmental data in most studies. AUTHORS' CONCLUSIONS The evidence is very uncertain about the effects of different corticosteroid regimens on the outcomes mortality, pulmonary morbidity, and long term neurodevelopmental impairment. Despite the fact that the studies investigating higher versus lower dosage regimens showed that higher-dosage regimens may reduce the incidence of death or neurodevelopmental impairment, we cannot conclude what the optimal type, dosage, or timing of initiation is for the prevention of BPD in preterm infants, based on current level of evidence. Further high quality trials would be needed to establish the optimal systemic postnatal corticosteroid dosage regimen.
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Affiliation(s)
- Wes Onland
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Moniek van de Loo
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Division of Neonatology, The Hospital for Sick Children, Toronto, Canada
| | - Anton van Kaam
- Emma Children's Hospital, Amsterdam University Medical Centers, Department of Neonatology, Amsterdam, Netherlands
- Amsterdam Reproduction & Development, Amsterdam, Netherlands
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5
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Kochen EM, Grootenhuis MA, Teunissen SCCM, Boelen PA, Tataranno ML, Fahner JC, de Jonge RR, Houben ML, Kars MC, van Berkestijn F, Falkenburg J, Frohn-Mulder I, Knoester H, Molderink A, van de Loo M, Michiels E. A grounded theory study on the dynamics of parental grief during the children's end of life. Acta Paediatr 2023; 112:1101-1108. [PMID: 36806310 DOI: 10.1111/apa.16716] [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] [Received: 10/16/2022] [Revised: 02/12/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023]
Abstract
AIM Parents are increasingly confronted with loss during their child's end of life. Healthcare professionals struggle with parental responses to loss. This study aimed to understand parental coping with grief during their child's end of life. METHODS A grounded theory study was performed, using semi-structured interviews with parents during the child's end of life and recently bereaved parents. Data were collected in four children's university hospitals and paediatric homecare services between October 2020 and December 2021. A multidisciplinary team conducted the analysis. RESULTS In total, 38 parents of 22 children participated. Parents strived to sustain family life, to be a good parent and to ensure a full life for their child. Meanwhile parents' grief increased because of their hypervigilance towards signs of loss. Parents' coping with grief is characterised by an interplay of downregulating grief and connecting with grief, aimed at creating emotional space to be present and connect with their child. Parents connected with grief when it was forced upon them or when they momentarily allowed themselves to. CONCLUSION The parents' ability to engage with grief becomes strained during the end of life. Healthcare professionals should support parents in their search for a balance that facilitates creating emotional space.
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Affiliation(s)
- Eline M Kochen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Martha A Grootenhuis
- Department of Psycho-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Saskia C C M Teunissen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paul A Boelen
- Department of clinical psychology, Utrecht University, Utrecht, The Netherlands.,ARQ National Psychotrauma Centre, Diemen, The Netherlands
| | - Maria-Luisa Tataranno
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jurrianne C Fahner
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roos R de Jonge
- Center for Research and Development of Education, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Michiel L Houben
- Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marijke C Kars
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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6
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Prins S, Linn AJ, van Kaam AHLC, van de Loo M, van Woensel JBM, van Heerde M, Dijk PH, Kneyber MCJ, de Hoog M, Simons SHP, Akkermans AA, Smets EMA, Hillen MA, de Vos MA. How Physicians Discuss Uncertainty With Parents in Intensive Care Units. Pediatrics 2022; 149:188092. [PMID: 35603505 DOI: 10.1542/peds.2021-055980] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Accepted: 02/23/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Physicians and parents of critically ill neonates and children receiving intensive care have to make decisions on the child's behalf. Throughout the child's illness and treatment trajectory, adequately discussing uncertainties with parents is pivotal because this enhances the quality of the decision-making process and may positively affect the child's and parents' well-being. We investigated how physicians discuss uncertainty with parents and how this discussion evolves over time during the trajectory. METHODS We asked physicians working in the NICU and PICU of 3 university medical centers to audio record their conversations with parents of critically ill children from the moment doubts arose whether treatment was in the child's best interests. We qualitatively coded and analyzed the anonymized transcripts, thereby using the software tool MAXQDA 2020. RESULTS Physicians were found to adapt the way they discussed uncertainty with parents to the specific phase of the child's illness and treatment trajectory. When treatment options were still available, physicians primarily focused on uncertainty related to diagnostic procedures, treatment options, and associated risks and effects. Particularly when the child's death was imminent, physicians had less "scientific" guidance to offer. They eliminated most uncertainty and primarily addressed practical uncertainties regarding the child's dying process to offer parents guidance. CONCLUSIONS Our insights may increase physicians' awareness and enhance their skills in discussing uncertainties with parents tailored to the phase of the child's illness and treatment trajectory and to parental needs in each specific phase.
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Affiliation(s)
| | - Annemiek J Linn
- Amsterdam School of Communication Research, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Job B M van Woensel
- Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Marc van Heerde
- Pediatric Intensive Care, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Peter H Dijk
- Department of Pediatrics, Divisions of Neonatology
| | - Martin C J Kneyber
- Pediatric Critical Care Medicine, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Sinno H P Simons
- Neonatology, Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Aranka A Akkermans
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Ellen M A Smets
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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7
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van de Loo M, van Kaam A, Offringa M, Doyle LW, Onland W. Corticosteroids for the prevention and treatment of bronchopulmonary dysplasia: an overview of systematic reviews. Hippokratia 2019. [DOI: 10.1002/14651858.cd013271] [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: 11/12/2022]
Affiliation(s)
- Moniek van de Loo
- Emma Children's Hospital AMC, University of Amsterdam; Department of Neonatology; Amsterdam Netherlands
| | - Anton van Kaam
- Emma Children's Hospital AMC, University of Amsterdam; Department of Neonatology; Amsterdam Netherlands
| | - Martin Offringa
- Hospital for Sick Children; Child Health Evaluative Sciences; 555 University Avenue Toronto ON Canada M5G 1X8
| | - Lex W Doyle
- The University of Melbourne; Department of Obstetrics and Gynaecology; Parkville Victoria Australia 3052
- Murdoch Children's Research Institute; Flemington Road Parkville Victoria Australia 3052
- The Royal Women's Hospital; Parkville Vicotoria Australia
| | - Wes Onland
- Emma Children's Hospital AMC, University of Amsterdam; Department of Neonatology; Amsterdam Netherlands
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8
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Bouman A, Waisfisz Q, Admiraal J, van de Loo M, van Rijn RR, Micha D, Oostra R, Mathijssen IB. Homozygous
DMRT2
variant associates with severe rib malformations in a newborn. Am J Med Genet A 2018; 176:1216-1221. [DOI: 10.1002/ajmg.a.38668] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 02/15/2018] [Accepted: 02/16/2018] [Indexed: 01/29/2023]
Affiliation(s)
- Arjan Bouman
- Department of Clinical GeneticsAcademic Medical CenterAmsterdam The Netherlands
- Department of Clinical GeneticsErasmus Medical CenterRotterdam The Netherlands
| | - Quinten Waisfisz
- Department of Clinical GeneticsVU University Medical CenterAmsterdam The Netherlands
| | - Jop Admiraal
- Department of NeonatologyEmma Children's HospitalAmsterdam The Netherlands
| | - Moniek van de Loo
- Department of NeonatologyEmma Children's HospitalAmsterdam The Netherlands
| | - Rick R. van Rijn
- Department of RadiologyAcademic Medical CenterAmsterdam The Netherlands
| | - Dimitra Micha
- Department of Clinical GeneticsVU University Medical CenterAmsterdam The Netherlands
| | - Roelof‐Jan Oostra
- Department of Anatomy, Embryology & PhysiologyAcademic Medical CenterAmsterdam The Netherlands
| | - Inge B. Mathijssen
- Department of Clinical GeneticsAcademic Medical CenterAmsterdam The Netherlands
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9
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Sol JJ, van de Loo M, Boerma M, Bergman KA, Donker AE, van der Hoeven MAHBM, Hulzebos CV, Knol R, Djien Liem K, van Lingen RA, Lopriore E, Suijker MH, Vijlbrief DC, Visser R, Veening MA, van Weissenbruch MM, van Ommen CH. NEOnatal Central-venous Line Observational study on Thrombosis (NEOCLOT): evaluation of a national guideline on management of neonatal catheter-related thrombosis. BMC Pediatr 2018; 18:84. [PMID: 29475450 PMCID: PMC5824541 DOI: 10.1186/s12887-018-1000-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 12/14/2016] [Accepted: 01/21/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In critically ill (preterm) neonates, central venous catheters (CVCs) are increasingly used for administration of medication or parenteral nutrition. A serious complication, however, is the development of catheter-related thrombosis (CVC-thrombosis), which may resolve by itself or cause severe complications. Due to lack of evidence, management of neonatal CVC-thrombosis varies among neonatal intensive care units (NICUs). In the Netherlands an expert-based national management guideline has been developed which is implemented in all 10 NICUs in 2014. METHODS The NEOCLOT study is a multicentre prospective observational cohort study, including 150 preterm and term infants (0-6 months) admitted to one of the 10 NICUs, developing CVC-thrombosis. Patient characteristics, thrombosis characteristics, risk factors, treatment strategies and outcome measures will be collected in a web-based database. Management of CVC-thrombosis will be performed as recommended in the protocol. Violations of the protocol will be noted. Primary outcome measures are a composite efficacy outcome consisting of death due to CVC-thrombosis and recurrent thrombosis, and a safety outcome consisting of the incidence of major bleedings during therapy. Secondary outcomes include individual components of primary efficacy outcome, clinically relevant non-major and minor bleedings and the frequency of risk factors, protocol variations, residual thrombosis and post thrombotic syndrome. DISCUSSION The NEOCLOT study will evaluate the efficacy and safety of the new, national, neonatal CVC-thrombosis guideline. Furthermore, risk factors as well as long-term consequences of CVC-thrombosis will be analysed. TRIAL REGISTRATION Trial registration: Nederlands Trial Register NTR4336 . Registered 24 December 2013.
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Affiliation(s)
- Jeanine J Sol
- Department of Pediatrics, Groene Hart Hospital, Gouda, the Netherlands.,Neonatal Intensive Care Unit, Sophia Children's Hospital Erasmus MC, Rotterdam, the Netherlands
| | - Moniek van de Loo
- Neonatal Intensive Care Unit, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - Marit Boerma
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Postbus 2060, 3015 CN, Rotterdam, the Netherlands
| | - Klasien A Bergman
- Neonatal Intensive Care Unit, Beatrix Children's Hospital UMCG, Groningen, the Netherlands
| | - Albertine E Donker
- Department of Pediatric Hematology, Maxima Medisch Centrum, Veldhoven, the Netherlands
| | | | - Christiaan V Hulzebos
- Neonatal Intensive Care Unit, Neonatal Intensive Care Unit, Beatrix Children's Hospital UMCG, Groningen, the Netherlands
| | - Ronny Knol
- Neonatal Intensive Care Unit, Sophia Children's Hospital Erasmus MC, Rotterdam, the Netherlands
| | - K Djien Liem
- Neonatal Intensive Care Unit, Amalia Children's Hospital Radboud UMC, Nijmegen, the Netherlands
| | | | - Enrico Lopriore
- Neonatal Intensive Care Unit, Willem-Alexander Hospital LUMC, Leiden, the Netherlands
| | - Monique H Suijker
- Department of Pediatric Hematology, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - Daniel C Vijlbrief
- Neonatal Intensive Care Unit, Wilhelmina Children's Hospital UMCU, Utrecht, the Netherlands
| | - Remco Visser
- Neonatal Intensive Care Unit, Willem-Alexander Hospital LUMC, Leiden, the Netherlands
| | | | | | - C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Postbus 2060, 3015 CN, Rotterdam, the Netherlands.
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van Rossem MC, van de Loo M, Laan BJ, de Sonnaville ESV, Tamminga P, van Kaam AH, Onland W. Accuracy of the Diagnosis of Bronchopulmonary Dysplasia in a Referral-Based Health Care System. J Pediatr 2015; 167:540-4.e1. [PMID: 26047684 DOI: 10.1016/j.jpeds.2015.05.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/10/2015] [Accepted: 05/06/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the accuracy of the diagnosis of bronchopulmonary dysplasia (BPD) in a national database of a referral-based health care system, where preterm infants are often transferred back to regional hospitals before 36 weeks postmenstrual age (PMA). STUDY DESIGN We evaluated preterm infants <32 weeks, born between 2004 and 2008 in the Academic Medical Center in Amsterdam with a high-risk profile for BPD. In addition to patient characteristics and outcomes, we collected data on respiratory support at 36 weeks PMA. True incidence of BPD, defined as needing supplemental oxygen and/or positive pressure support at 36 weeks PMA, was compared with the diagnosis registered in the National Perinatal Registry. Two imputation algorithms for patients transferred before 36 weeks PMA were validated. RESULTS We identified 243 preterm infants with a high-risk BPD profile. Sixty-seven percent of these infants had a correct BPD diagnosis recorded in the National Perinatal Registry, 2% had a false positive, and 31% a false negative diagnosis. Infants with a false negative diagnosis of BPD were twice as often transferred to a regional hospital before 36 weeks PMA compared with a true positive diagnosis. Imputation algorithms did not improve the accuracy of BPD registration. CONCLUSIONS Registration of the diagnosis BPD in a national database in countries with a referral-based health care system may not be accurate. Optimizing data collection and monitoring data entry is necessary to improve BPD registration before data can be used for national and international benchmarking.
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Affiliation(s)
- Maaike C van Rossem
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Moniek van de Loo
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Bart J Laan
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Eleonore S V de Sonnaville
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Pieter Tamminga
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands
| | - Wes Onland
- Department of Neonatology, Academic Medical Center, Emma Children's Hospital, Amsterdam, The Netherlands.
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