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Kruth SS, Willers C, Persad E, Sjöström ES, Lagerström SR, Rakow A. Probiotic supplementation and risk of necrotizing enterocolitis and mortality among extremely preterm infants-the Probiotics in Extreme Prematurity in Scandinavia (PEPS) trial: study protocol for a multicenter, double-blinded, placebo-controlled, and registry-based randomized controlled trial. Trials 2024; 25:259. [PMID: 38610034 PMCID: PMC11015611 DOI: 10.1186/s13063-024-08088-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Extremely preterm infants, defined as those born before 28 weeks' gestational age, are a very vulnerable patient group at high risk for adverse outcomes, such as necrotizing enterocolitis and death. Necrotizing enterocolitis is an inflammatory gastrointestinal disease with high incidence in this cohort and has severe implications on morbidity and mortality. Previous randomized controlled trials have shown reduced incidence of necrotizing enterocolitis among older preterm infants following probiotic supplementation. However, these trials were underpowered for extremely preterm infants, rendering evidence for probiotic supplementation in this population insufficient to date. METHODS The Probiotics in Extreme Prematurity in Scandinavia (PEPS) trial is a multicenter, double-blinded, placebo-controlled and registry-based randomized controlled trial conducted among extremely preterm infants (n = 1620) born at six tertiary neonatal units in Sweden and four units in Denmark. Enrolled infants will be allocated to receive either probiotic supplementation with ProPrems® (Bifidobacterium infantis, Bifidobacterium lactis, and Streptococcus thermophilus) diluted in 3 mL breastmilk or placebo (0.5 g maltodextrin powder) diluted in 3 mL breastmilk per day until gestational week 34. The primary composite outcome is incidence of necrotizing enterocolitis and/or mortality. Secondary outcomes include incidence of late-onset sepsis, length of hospitalization, use of antibiotics, feeding tolerance, growth, and body composition at age of full-term and 3 months corrected age after hospital discharge. DISCUSSION Current recommendations for probiotic supplementation in Sweden and Denmark do not include extremely preterm infants due to lack of evidence in this population. However, this young subgroup is notably the most at risk for experiencing adverse outcomes. This trial aims to investigate the effects of probiotic supplementation on necrotizing enterocolitis, death, and other relevant outcomes to provide sufficiently powered, high-quality evidence to inform probiotic supplementation guidelines in this population. The results could have implications for clinical practice both in Sweden and Denmark and worldwide. TRIAL REGISTRATION ( Clinicaltrials.gov ): NCT05604846.
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Affiliation(s)
- Sofia Söderquist Kruth
- Women's Health and Allied Health Professional Theme, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden
| | - Carl Willers
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 14152, Huddinge, Sweden
| | - Emma Persad
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden
| | | | - Susanne Rautiainen Lagerström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- K2 Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Alexander Rakow
- Department of Women's and Children's Health, Karolinska Institutet, 17177, Stockholm, Sweden.
- Department of Neonatology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden.
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Legge N, Popat H, Fitzgerald D. Improved survival at the cost of more chronic lung disease? Current management and outcomes in extremely preterm infants born in New South Wales and the Australian Capital Territory: 2010-2020. World J Pediatr 2024; 20:230-238. [PMID: 37902946 PMCID: PMC10957579 DOI: 10.1007/s12519-023-00761-3] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/10/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Since 2010, most tertiary care hospitals in Australia have changed how they care for extremely premature infants. However, in-hospital and longer-term outcome data have suggested unchanged or even worse health outcomes in later epochs, especially respiratory outcomes. This study examined the trend in outcomes since these changes were introduced, particularly the prevalence of chronic neonatal lung disease (CLD). METHODS This is a retrospective cross-sectional analysis of data from the Neonatal Intensive Care Units' (NICUS) database of all perinatal intensive care units in New South Wales and the Australian Capital Territory, including infants born at ≥ 24 and ≤ 28 weeks of gestational age in tertiary perinatal units between January 1, 2010, and December 31, 2020. Temporal trends and changes in primary outcome were examined by linear and adjusted multivariable logistic regression models. RESULTS This study included 3258 infants. We saw significant changes in antenatal magnesium sulfate (75% increase), delayed cord clamping (66% increase), delivery room intubations (30% decrease), any time (20% decrease), duration on mechanical ventilation (100-hour decrease), and hours on noninvasive ventilation (200-hour increase). Mortality decreased from 17% to 6%. The incidence of CLD increased significantly even when adjusted for confounders (15% increase). Any time and mean hours spent on mechanical ventilation significantly increased the odds of CLD. This study could not find a significant association of any of the protective antenatal treatments on CLD. CONCLUSIONS The last decade saw a significant improvement in survival and survival to discharge without major morbidity. There was increased use of magnesium sulfate, delayed cord clamping, and less invasive respiratory management of extremely preterm infants. The avoidance of mechanical ventilation may impact the incidence of CLD.
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Affiliation(s)
- Nele Legge
- Liverpool Hospital, Corner Elizabeth and Goulburn Streets, Liverpool, NSW, Australia.
- University of Sydney, Camperdown, Australia.
| | - Himanshu Popat
- University of Sydney, Camperdown, Australia
- Children's Hospital Westmead, Westmead, Australia
| | - Dominic Fitzgerald
- University of Sydney, Camperdown, Australia
- Children's Hospital Westmead, Westmead, Australia
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Goupille P, Rollet Q, Prime L, Alexandre C, Dolley P, Dreyfus M. Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France. J Gynecol Obstet Hum Reprod 2024; 53:102735. [PMID: 38280456 DOI: 10.1016/j.jogoh.2024.102735] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 01/29/2024]
Abstract
BACKGROUND Extreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births. OBJECTIVE To conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network. METHODS We undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records. RESULTS One hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth. CONCLUSION Prognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.
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Affiliation(s)
- Pauline Goupille
- Department of Obstetrics, Gynaecology and Reproduction Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France.
| | - Quentin Rollet
- U1086 "ANTICIPE" INSERM, University of Caen Normandy, Centre François Baclesse: 3, Avenue du Général Harris, 14000 Caen, France
| | - Ludovic Prime
- Perinatal Network, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - Cénéric Alexandre
- Department of Neonatology, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - Patricia Dolley
- Department of Obstetrics, Gynaecology and Reproduction Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France
| | - Michel Dreyfus
- Department of Obstetrics, Gynaecology and Reproduction Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14033 Caen, France; University of Caen Normandy, Esplanade de la Paix - CS 14032 Cedex 05, Caen, France
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Dagle JM, Hunter SK, Colaizy TT, McElroy SJ, Harmon HM, McNamara PJ, Klein JM. Care from Birth to Discharge of Infants Born at 22 to 23 Weeks' Gestation. Crit Care Nurs Clin North Am 2024; 36:23-33. [PMID: 38296373 DOI: 10.1016/j.cnc.2023.08.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
The clinical care of infants born at 22 weeks' gestation must be well-designed and standardized if optimal results are to be expected. Although several approaches to care in this vulnerable population are possible, protocols should be neither random nor inconsistent. We describe the approach taken at the University of Iowa Stead Family Children's Hospital neonatal intensive care unit with respect to preterm infants born at 22 weeks' gestation. We have chosen to present our standardize care plan with respect to prenatal, neurologic, nutritional, gastrointestinal, and skin management. Respiratory and cardiopulmonary care will be briefly reviewed, as these strategies have been published previously.
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Affiliation(s)
- John M Dagle
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA; University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
| | - Stephen K Hunter
- Department of Obstetrics & Gynecology, University of Iowa, Iowa City, IA, USA
| | - Tarah T Colaizy
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA; University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Steve J McElroy
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento, CA, USA
| | - Heidi M Harmon
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA; University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA; University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA; Department of Internal Medicine, University of Iowa, Iowa City, IA, USA
| | - Jonathan M Klein
- Division of Neonatology, Department of Pediatrics, University of Iowa, Iowa City, IA, USA; University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
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Vallant N, Thakkar H, Jogeesvaran H, Yardley I. Abdominal Ultrasound Scanning for NEC in Babies at the Threshold of Viability: A Single Centre Experience. J Pediatr Surg 2024; 59:202-205. [PMID: 37957102 DOI: 10.1016/j.jpedsurg.2023.10.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/07/2023] [Indexed: 11/15/2023]
Abstract
AIM Neonatal units are caring for increasing numbers of babies born <24 weeks gestation. These babies are vulnerable to developing necrotising enterocolitis (NEC). Their presentation is often atypical, both clinically and radiologically. Optimal diagnostic strategies are not yet known. We report our experience of abdominal ultrasound scanning (AUSS) to clarify its role. METHODS All babies in a single neonatal surgical centre born <24 weeks gestation undergoing AUSS for suspected NEC from January 2015 to January 2023 were included. We compared abdominal ultrasound findings with plain radiographs and correlated these to intraoperative findings. RESULTS Thirty-nine babies born <24 weeks gestation were diagnosed with NEC during the study period, and of these seventeen had an AUSS and formed the study cohort. Twelve underwent laparotomy at which NEC was confirmed, and the remaining five were managed non-operatively. Abdominal radiograph findings were: Paucity of gas (12), gaseous dilatation (2), paucity of gas with proximal dilatation (1), pneumatosis (1), and lucencies over the liver (1). In twelve cases who underwent surgery, AUSS findings were (more than one possible): Complex ascites (6), inflamed bowel (4), aperistaltic bowel (3), mass/collection (4), pneumatosis (1). All had NEC confirmed at laparotomy. In five cases who did not progress to surgery, findings were: Simple free fluid (2), pneumatosis (2), inflamed bowel (1), aperistaltic bowel (1). None of these cases subsequently underwent surgery or died of complications of NEC. CONCLUSION AUSS is a useful imaging modality for NEC in babies born <24 weeks gestation. It can reliably identify babies who would benefit from surgery. LEVEL OF EVIDENCE: 4 TYPE OF STUDY Retrospective cohort study.
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Affiliation(s)
- Natalie Vallant
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK.
| | - Hemanshoo Thakkar
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK
| | - Haran Jogeesvaran
- Department of Paediatric Radiology, Evelina London Children's Hospital, London, UK
| | - Iain Yardley
- Department of Paediatric Surgery, Evelina London Children's Hospital, London, UK; King's College London, School of Health and Life Sciences, London, UK
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Teplitzky TB, Pickle JC, DeCuzzi JL, Zur KB, Giordano T, Preciado DA, Saini P, Briddell JW, Isaiah A, Pereira KD. Tracheostomy in the extremely premature neonate - Long term outcomes in a multi-institutional study. Int J Pediatr Otorhinolaryngol 2023; 167:111492. [PMID: 36848819 DOI: 10.1016/j.ijporl.2023.111492] [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: 01/13/2023] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVES To describe the long-term outcomes related to breathing, feeding, and neurocognitive development in extremely premature infants requiring tracheostomy. STUDY DESIGN Pooled cross-sectional survey. SETTING Multi-institutional academic children's hospitals. METHODS Extremely premature infants who underwent tracheostomy between January 1, 2012, and December 31, 2019, at four academic hospitals were identified from an existing database. Information was gathered from responses to a questionnaire by caregivers regarding airway status, feeding, and neurodevelopment 2-9 years after tracheostomy. RESULTS Data was available for 89/91 children (96.8%). The mean gestational age was 25.5 weeks (95% CI 25.2-25.7) and mean birth weight was 0.71 kg (95% CI 0.67-0.75). Mean post gestational age at tracheostomy was 22.8 weeks (95% CI 19.0-26.6). At time of the survey, 18 (20.2%) were deceased. 29 (40.8%) maintained a tracheostomy, 18 (25.4%) were on ventilatory support, and 5 (7%) required 24-h supplemental oxygen. Forty-six (64.8%) maintained a gastrostomy tube, 25 (35.2%) had oral dysphagia, and 24 (33.8%) required a modified diet. 51 (71.8%) had developmental delay, 45 (63.4%) were enrolled in school of whom 33 (73.3%) required special education services. CONCLUSIONS Tracheostomy in extremely premature neonates is associated with long term morbidity in the pulmonary, feeding, and neurocognitive domains. At time of the survey, about half are decannulated, with a majority weaned off ventilatory support indicating improvement in lung function with age. Feeding dysfunction is persistent, and a significant number will have some degree of neurocognitive dysfunction at school age. This information may help caregivers regarding expectations and plans for resource management.
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Affiliation(s)
- Taylor B Teplitzky
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, University of Maryland Children's Hospital, Baltimore, MD, USA
| | - Jerrah C Pickle
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland Medical Center, University of Maryland Children's Hospital, Baltimore, MD, USA
| | - Julianna L DeCuzzi
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland Medical Center, University of Maryland Children's Hospital, Baltimore, MD, USA
| | - Karen B Zur
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Terri Giordano
- Department of Otorhinolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diego A Preciado
- Department of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Children's National Medical Center, Washington, DC, USA
| | - Prashant Saini
- Department of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Children's National Medical Center, Washington, DC, USA
| | - Jenna W Briddell
- Division of Otolaryngology, Nemours/A. I. DuPont Hospital for Children, Wilmington, DE, USA; Department of Otolaryngology-Head and Neck Surgery, Sidney Kimmel Medical College, Thomas Jefferson University School of Medicine, Philadelphia, PA, USA
| | - Amal Isaiah
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, University of Maryland Children's Hospital, Baltimore, MD, USA
| | - Kevin D Pereira
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland School of Medicine, University of Maryland Children's Hospital, Baltimore, MD, USA.
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Juul SE, Wood TR, German K, Law JB, Kolnik SE, Puia-Dumitrescu M, Mietzsch U, Gogcu S, Comstock BA, Li S, Mayock DE, Heagerty PJ. Predicting 2-year neurodevelopmental outcomes in extremely preterm infants using graphical network and machine learning approaches. EClinicalMedicine 2023; 56:101782. [PMID: 36618896 PMCID: PMC9813758 DOI: 10.1016/j.eclinm.2022.101782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 12/27/2022] Open
Abstract
Background Infants born extremely preterm (<28 weeks' gestation) are at high risk of neurodevelopmental impairment (NDI) with 50% of survivors showing moderate or severe NDI when at 2 years of age. We sought to develop novel models by which to predict neurodevelopmental outcomes, hypothesizing that combining baseline characteristics at birth with medical care and environmental exposures would produce the most accurate model. Methods Using a prospective database of 692 infants from the Preterm Epo Neuroprotection (PENUT) Trial, which was carried out between December 2013 and September 2016, we developed three predictive algorithms of increasing complexity using a Bayesian Additive Regression Trees (BART) machine learning approach to predict both NDI and continuous Bayley Scales of Infant and Toddler Development 3rd ed subscales at 2 year follow-up using: 1) the 5 variables used in the National Institute of Child Health and Human Development (NICHD) Extremely Preterm Birth Outcomes Tool, 2) 21 variables associated with outcomes in extremely preterm (EP) infants, and 3) a hypothesis-free approach using 133 potential variables available for infants in the PENUT database. Findings The NICHD 5-variable model predicted 3-4% of the variance in the Bayley subscale scores, and predicted NDI with an area under the receiver operator curve (AUROC, 95% CI) of 0.62 (0.56-0.69). Accuracy increased to 12-20% of variance explained and an AUROC of 0.77 (0.72-0.83) when using the 21 pre-selected clinical variables. Hypothesis-free variable selection using BART resulted in models that explained 20-31% of Bayley subscale scores and AUROC of 0.87 (0.83-0.91) for severe NDI, with good calibration across the range of outcome predictions. However, even with the most accurate models, the average prediction error for the Bayley subscale predictions was around 14-15 points, leading to wide prediction intervals. Higher total transfusion volume was the most important predictor of severe NDI and lower Bayley scores across all subscales. Interpretation While the machine learning BART approach meaningfully improved predictive accuracy above a widely used prediction tool (NICHD) as well as a model utilizing NDI-associated clinical characteristics, the average error remained approximately 1 standard deviation on either side of the true value. Although dichotomous NDI prediction using BART was more accurate than has been previously reported, and certain clinical variables such as transfusion exposure were meaningfully predictive of outcomes, our results emphasize the fact that the field is still not able to accurately predict the results of complex long-term assessments such as Bayley subscales in infants born EP even when using rich datasets and advanced analytic methods. This highlights the ongoing need for long-term follow-up of all EP infants. Funding Supported by the National Institute of Neurological Disorders and StrokeU01NS077953 and U01NS077955.
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Affiliation(s)
- Sandra E. Juul
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Thomas R. Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Kendell German
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Janessa B. Law
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Sarah E. Kolnik
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Mihai Puia-Dumitrescu
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Semsa Gogcu
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, NC, USA
| | - Bryan A. Comstock
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Sijia Li
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Dennis E. Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, WA, USA
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Porta R, Ventura PS, Ginovart G, García-Muñoz F, Ávila-Alvarez A, Izquierdo M. Changes in perinatal management and outcomes in infants born at 23 weeks of gestational age during the last decade in Spain. J Matern Fetal Neonatal Med 2022; 35:10296-10304. [PMID: 36176058 DOI: 10.1080/14767058.2022.2122801] [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] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The 2021-updated guidelines of the Spanish Society of Neonatology Guidelines have moved the zone of parental discretion to 23 + 0-23 + 6 weeks. The objective of this study was to describe the changes in perinatal management at this gestational age along the last decade and to determine if a more active perinatal management has contributed to improved outcomes. METHODS Retrospective analysis of prospectively collected data from the 23-week infants included in the Spanish SEN 1500 neonatal network during the period 2010-2019. The main study outcomes were survival at discharge and survival without major morbidity of actively managed infants. Two periods were compared: 2010-2014 (Period 1) and 2015-2019 (Period 2). NICUs were classified into low activity NICUs (less than 50 admissions of very low birth weight infants per year) and high activity NICUs (50 or more admissions). RESULTS A total of 381 infants were included, 182 in Period 1 and 199 in Period 2. In Period 2 an increase in the use of intrapartum magnesium sulfate (21.5% vs 39.9%, p .002), antenatal steroids (56.6% vs 69.3%, p .011) and active neonatal approach in delivery room (76.9% vs 86.9%, p .011) were observed.The clinical outcomes of the actively managed 313 infants were similar in both periods, except for less arterial hypotension in Period 2. Survival was 27.1% in Period 1 and 25% in Period 2 (p .068) and survival without major morbidity was 2.1% and 2.3% respectively (p .914). No difference was found between low and high activity NICUs. CONCLUSION A change to a more active intention to treat infants born at 23 weeks is taking place in Spain. But the survival rate of the actively-managed infants has remained stable around 25-30% during the study period. A multidisciplinary effort is needed to improve outcomes in this population.
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Affiliation(s)
- Roser Porta
- Neonatology Unit, Paediatric Department, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Paula Sol Ventura
- Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona, Badalona, Spain
| | - Gemma Ginovart
- Neonatology Unit, Paediatric Department, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Fermín García-Muñoz
- Division of Neonatology, Complejo Hospitalario Universitario Insular-Materno-Infantil, Las Palmas, Spain
| | - Alejandro Ávila-Alvarez
- Division of Neonatology, Complexo Hospitalario Universitario de A Coruña (CHUAC), SERGAS, A Coruña, Spain
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Indrakanti S, Chavez W, Castro-Aragon I. Normal variant residual germinal matrix in extremely premature infants: radiographic features and imaging pitfalls. J Ultrasound 2022; 25:493-505. [PMID: 35092600 PMCID: PMC9402871 DOI: 10.1007/s40477-021-00612-9] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/12/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND As radiology volume from premature patients increases, previously undescribed imaging findings may be identified, posing diagnostic dilemma to the pediatric radiologist. OBJECTIVE The primary goal of our study is to characterize the previously undescribed imaging finding of subependymal echogenicity at the floor of the frontal horns, which we postulate represents normal variant embryologic remnant residual germinal matrix. Furthermore, we hope to equip the pediatric radiologist with diagnostic criteria to distinguish this normal variant from pathology. MATERIALS AND METHODS Retrospective review of neonates at our institution over a 10 year period was performed to identify extremely premature infants who received head ultrasounds during their hospital stay. Clinical data from EPIC was collected on these patients in addition to retrospective review of their head ultrasound images. RESULTS Literature review of neuroembryology and observed involution of the frontal horn subependymal echogenicity on sequential imaging inform our hypothesis that this imaging finding represents normal variant residual germinal matrix. Two-thirds of the 210 included extremely premature infants demonstrated this finding, which was frequently misinterpreted as grade 1 germinal matrix, intra-choroidal or intra-ventricular hemorrhage. Residual matrix was concomitantly present with additional pathology in 29.4% of the patients. CONCLUSION Previously undescribed subependymal echogenicity at the floor of the frontal horns is favored to represent normal variant embryologic remnant residual germinal matrix. Since this finding may be misinterpreted as germinal matrix, intra-choroidal or intra-ventricular hemorrhage, it is essential for the interpreting radiologist to be aware of this normal variant and not confuse it for pathology.
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Affiliation(s)
- Santoshi Indrakanti
- Department of Radiology, Massachusetts General Hospital, Boston Medical Center, 55 Fruit Street, White 427, Boston, MA, 02114, USA.
| | - Wilson Chavez
- Department of Radiology, Massachusetts General Hospital, Boston Medical Center, 55 Fruit Street, White 427, Boston, MA, 02114, USA
| | - Ilse Castro-Aragon
- Department of Radiology, Massachusetts General Hospital, Boston Medical Center, 55 Fruit Street, White 427, Boston, MA, 02114, USA
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Siffel C, Hirst AK, Sarda SP, Kuzniewicz MW, Li DK. The clinical burden of extremely preterm birth in a large medical records database in the United States: Mortality and survival associated with selected complications. Early Hum Dev 2022; 171:105613. [PMID: 35785690 DOI: 10.1016/j.earlhumdev.2022.105613] [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: 01/27/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preterm birth is a leading cause of infant mortality, particularly for those born extremely prematurely (EP; <28 weeks' gestational age [GA]). Survivors are predisposed to complications such as bronchopulmonary dysplasia (BPD), chronic lung disease (CLD), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). AIMS To examine the epidemiology, complications, and mortality/survival among EP infants. STUDY DESIGN Retrospective analysis of electronic medical records from the Kaiser Permanente Northern California database. SUBJECTS EP infants live-born between 22 and <28 weeks' GA from 1997 to 2016. OUTCOME MEASURES Cumulative all-cause mortality/survival were analyzed and stratified by GA (22 to <24, 24 to <26, 26 to <28 weeks), complications (BPD/CLD, IVH, ROP), and birth period (1997 to 2003, 2004 to 2009, 2010 to 2016). Cox proportional hazard models were constructed to assess the mortality risk associated with BPD/CLD or IVH. RESULTS 2154 EP infants were identified; of these, 916 deaths were recorded. Mortality was highest during the first 3 months (41.7 % cumulative mortality), and few were reported after 2 years (42.5 % cumulative mortality). Mortality decreased with higher GA and over more recent birth periods. BPD/CLD and IVH grade 3/4 were associated with increased mortality risk versus no complications (adjusted hazard ratios 1.41 and 1.78, respectively). CONCLUSIONS The risk of mortality is high during the first few months of life for EP infants, and is even higher for those with BPD and IVH. Despite an overall trend toward increased survival for EP infants, strategies targeting survival of EP infants with these complications are needed.
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Affiliation(s)
- Csaba Siffel
- Global Evidence and Outcomes, Takeda Development Center Americas, Lexington, MA, USA; College of Allied Health Sciences, Augusta University, Augusta, GA, USA.
| | - Andrew K Hirst
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Sujata P Sarda
- Global Evidence and Outcomes, Takeda Development Center Americas, Lexington, MA, USA
| | | | - De-Kun Li
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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11
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De Proost L, Geurtzen R, Ismaili M'hamdi H, Reiss IKMI, Steegers EAPE, Joanne Verweij EJ. Prenatal counseling for extreme prematurity at the limit of viability: A scoping review. Patient Educ Couns 2022; 105:1743-1760. [PMID: 34872804 DOI: 10.1016/j.pec.2021.10.033] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To explore, based on the existing body of literature, main characteristics of prenatal counseling for parents at risk for extreme preterm birth. METHODS A scoping review was conducted searching Embase, Medline, Web of Science, Cochrane, CINAHL, and Google Scholar. RESULTS 46 articles were included. 27 of them were published between 2017 and 2021. More than half of them were conducted in the United States of America. Many different study designs were represented. The following characteristics were identified: personalization, parent-physician relationships, shared decision-making, physician bias, emotions, anxiety, psychosocial factors, parental values, religion, spirituality, hope, quality of life, and uncertainty. CONCLUSIONS Parental values are mentioned in 37 of the included articles. Besides this, uncertainty, shared decision-making, and emotions are most frequently mentioned in the literature. However, reflecting on the interrelation between all characteristics leads us to conclude that personalization is the most notable trend in prenatal counseling practices. More and more, it is valued to adjust the counseling to the parent(s). PRACTICE IMPLICATIONS This scoping review emphasizes again the complexity of prenatal counseling at the limit of viability. It offers an exploration of how it is currently approached, and reflects on how future research can contribute to optimizing it.
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Affiliation(s)
- Lien De Proost
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands; Department of Neonatology, Erasmus MC, Rotterdam, The Netherlands; Department of Obstetrics & Gynecology, Erasmus MC, Rotterdam The Netherlands.
| | - Rosa Geurtzen
- Department of Neonatology, Radboud University Medical Center, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Hafez Ismaili M'hamdi
- Department of Medical Ethics, Philosophy and History of Medicine, Erasmus MC, Rotterdam, The Netherlands
| | | | - E A P Eric Steegers
- Department of Obstetrics & Gynecology, Erasmus MC, Rotterdam The Netherlands
| | - E J Joanne Verweij
- Department of Obstetrics & Gynecology, Erasmus MC, Rotterdam The Netherlands; Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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12
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Regin Y, Gie A, Eerdekens A, Toelen J, Debeer A. Ventilation and respiratory outcome in extremely preterm infants: trends in the new millennium. Eur J Pediatr 2022; 181:1899-1907. [PMID: 35034202 DOI: 10.1007/s00431-022-04378-y] [Citation(s) in RCA: 3] [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: 10/29/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
Ventilation and respiratory care have substantially changed over the last decades in extremely premature neonates but the impact on respiratory health remains largely unclear. To determine changes in respiratory care and disease frequency in extremely premature infants, a retrospective single-centre cohort study of extremely preterm infants was performed. All infants born alive between 24 + 0 and 27 + 6 weeks of gestation in 2000-2001 (Epoch 1), 2009-2010 (Epoch 2), and 2018-2019 (Epoch 3) were included. The primary outcome of this study was the incidence of bronchopulmonary dysplasia (BPD, diagnosed according to three different criteria) or death. Secondary outcomes included the usage of different ventilation modes, changes in pharmacotherapy, and the incidence of significant extra-pulmonary morbidities. A total of 184 neonates were included of whom 151 survived until 36 weeks of corrected GA (cGA). Oxygen or positive pressure dependence increased over time (26.1%, 41.7%, and 56.1% respectively), with higher adjusted odds in Epoch 3 for the composite outcome "BPD or death" (adjusted odds ratio: 2.55 [95%CI 1.19-5.61]). Severity-based definitions showed increasing trends in survivors only. Time spent on invasive mechanical ventilation was similar throughout the years, but the use of non-invasive ventilation significantly increased in Epoch 3 (32.0 [95%CI 25.0-37.0] vs 27.0 [95%CI 26.0-32.0] vs 53.0 [95%CI 46.0-58.0] days). Moreover, mortality-adjusted rates of severe IVH, NEC, or intestinal perforation and multiple sepsis tended to decrease. Conclusion: In spite of significant clinical advancements and adherence to novel treatment guidelines in our neonatal intensive care unit, the incidence of BPD increased over time. What is Known: • Rates of BPD are stable or increase in population-based studies. • Extremely preterm infants are particularly susceptible to developing BPD. What is New: • Despite increased use of evidence-based corticosteroid administration and early initiation of caffeine, the incidence of BPD has not decreased over the past decade. • Increased usage of non-invasive ventilation is associated with an increase of BPD incidence.
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Affiliation(s)
- Yannick Regin
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
| | - Andre Gie
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.,Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, 7505, South Africa
| | - An Eerdekens
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.,Department of Neonatology, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.,Department of Paediatrics, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Anne Debeer
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium. .,Department of Neonatology, University Hospitals Leuven, 3000, Leuven, Belgium.
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13
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Dicky O, Dahan S, Reynaud A, Goffinet F, Lecarpentier E, Deruelle P, Jarreau PH, Kuhn P, Gire C, Pierrat V, Caeymaex L. Current attitudes and beliefs toward perinatal care orientation before 25 weeks of gestation: The French perspective in 2020. Semin Perinatol 2022; 46:151533. [PMID: 34865886 DOI: 10.1016/j.semperi.2021.151533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The survival rate of infants born before 25 weeks of gestational age in France is extremely low compared with that of many other countries: 0%, 1%, and 31% at 22, 23, and 24 weeks' in the last national cohort study. A non-optimal regionalization and variations in practice are prevalent. Some parents in social media and support groups have reported feeling lost and confused with mixed messages leading to lack of trust. These data kindled a major debate in France around perinatal management leading to an investigation exploring neonatologists' perspectives and ways to improve care. The majority (81%) of the responding neonatologists reported more active care and higher survival rates than in 2011, although others continued preferring delivery room comfort care and limited NICU treatment at or before 24 weeks. The desire to improve was an overarching theme in all the respondents' answers to open-ended questions. Barriers to active care included an absence of expertise and of benchmarking to guide optimal care, and limited resources in the NICU and during follow-up - all leading to self-fulfilling prophecies of poor prognosis. Optimization of regionalization, perinatal teamwork and parental involvement, fostering experience by creating specific perinatal centers, stimulating benchmarking, and working with policy makers to allow better long-term outcomes could enable higher survival.
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14
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Abstract
The Small Baby Program at Nationwide Children's Hospital was launched in 2004 in response to a need for better care for infants born extremely preterm. Standardization of care, decreased variability, multidisciplinary support, and robust research and quality improvement have allowed us to greatly improve our outcomes. In addition to the numerous medical and technological advances during this time, a strong commitment to kangaroo care and family-centered care have been integral to the growth and success of our program. The following review of the program aims to highlight the above areas while detailing the specific processes that have contributed to its ongoing success. Key areas of focus have been on respiratory management, neurodevelopmental care, and nutritional optimization. The implementation and continued refinement of the Small Baby Program has allowed us to improve the survival of extremely preterm infants, decrease certain morbidities, and improve long-term neurodevelopmental outcomes.
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Affiliation(s)
- Leeann R Pavlek
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43205, United States.
| | - Clifford Mueller
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Maria R Jebbia
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Matthew J Kielt
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Leif D Nelin
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, Columbus, OH 43205, United States
| | - Edward G Shepherd
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Kristina M Reber
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Omid Fathi
- Small Baby ICU, Division of Neonatology, Nationwide Children's Hospital, Columbus, OH, United States
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15
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Flake AW. A supportive physiologic environment for the extreme premature infant: Improving life outside the womb. J Pediatr Surg 2022; 57:167-71. [PMID: 34823842 DOI: 10.1016/j.jpedsurg.2021.10.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/22/2021] [Indexed: 11/23/2022]
Abstract
Extreme prematurity remains an unsolved problem and is the leading cause of pediatric mortality and morbidity in developed countries. The extreme premature infant is physiologically a fetus, and current supportive measures in our NICUs are for the most part non-physiologic. In order to improve morbidity and mortality in this population, we have developed the Extra-uterine environment for newborn development (EXTEND) system which seeks to mimic as closely as possible the environment of the womb. The primary components of EXTEND include a sterile fluid environment, a pumpless arteriovenous extracorporeal oxygenator circuit, and vascular access via umbilical arterial and venous vessels. While supported on the EXTEND system, premature fetal lambs grow and develop normally for up to 4 weeks. Fetal physiology is maintained, and detailed organ system analysis supports normal development. This article summarizes current progress in the development of EXTEND, the pathway for human translation, ethical considerations related to EXTEND, and anticipated clinical applications of this potentially paradigm changing technology. LEVEL OF EVIDENCE: IV.
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16
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Dagle JM, Rysavy MA, Hunter SK, Colaizy TT, Elgin TG, Giesinger RE, McElroy SJ, Harmon HM, Klein JM, McNamara PJ, Segar JL, Thomas BA, Bischoff AR, Rios DR, Lindower JB, Bermick JR, Lee SS, Wong SW, Roghair RD, Morgan-Harris AT, Niwas R, Arikat S, Boly TJ, Segar JL. Cardiorespiratory management of infants born at 22 weeks' gestation: The Iowa approach. Semin Perinatol 2022; 46:151545. [PMID: 34893337 DOI: 10.1016/j.semperi.2021.151545] [Citation(s) in RCA: 3] [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] [Indexed: 11/28/2022]
Abstract
The approach to clinical care of infants born at 22 weeks' gestation must be consistent and well-designed if optimal results are to be expected. Publications from several international centers have demonstrated that, although there may be variance in aspects of care in this vulnerable population, treatment should be neither random nor inconsistent. In designing a standardized approach, careful attention should be paid to the unique anatomy, physiology, and biochemistry of this vulnerable patient population. Emerging evidence, suggesting a link between cardiopulmonary health and longer-term sequela, highlights the importance of understanding the relationship between cardiorespiratory illnesses of the 22-week infant, treatments provided, and subsequent cardiopulmonary development. In this review we will provide an overview to our approach to cardiopulmonary assessment and treatment, with a particular emphasis on the importance of early recognition of atypical phenotypes, timely interventions with evidence-based treatments, and longitudinal monitoring.
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Affiliation(s)
- John M Dagle
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA.
| | - Matthew A Rysavy
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | | | - Tarah T Colaizy
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Timothy G Elgin
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Regan E Giesinger
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Steve J McElroy
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Heidi M Harmon
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Jonathan M Klein
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA
| | - Patrick J McNamara
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital, Biochemistry, and Epidemiology, University of Iowa, USA; Obstetrics and Gynecology and Internal Medicine, USA; University of Iowa, Iowa City, IA, USA
| | | | | | - Brady A Thomas
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Adrianne R Bischoff
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Danielle R Rios
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Julie B Lindower
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Jennifer R Bermick
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Stephanie S Lee
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Samuel W Wong
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Robert D Roghair
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Ana Tracey Morgan-Harris
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Ram Niwas
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Sunny Arikat
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Timothy J Boly
- Stead Family Division of Neonatology and Departments of Pediatrics, Staff Neonatologist, Stead Family Children's Hospital,Biochemistry, and Epidemiology, University of Iowa, USA
| | - Jeffrey L Segar
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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17
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Bührer C, Heller G, Thome UH. Population-Based Outcome Data of Extremely Preterm Infants in Germany during 2010-2017. Neonatology 2022; 119:370-376. [PMID: 35490674 DOI: 10.1159/000524455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVE Results of five randomized controlled trials (RCT) sequentially published in 2010-2013 suggested that aiming for higher, as opposed to lower oxygen saturation targets, reduces rates of mortality in infants <28 weeks of gestation, while increasing rates of severe retinopathy of prematurity (ROP). Two further RCTs published in 2011 and 2015 demonstrated that avoiding endotracheal intubation by minimally invasive surfactant administration reduces respiratory morbidity. Assuming that such data are likely to affect clinical practice and ultimate outcome, we analyzed population-level results in extremely preterm infants born across Germany during 2010-2017. METHODS We used mandatory German quality surveillance data to compare mortality and morbidities in preterm infants born between 24 weeks 0 days and 27 weeks 6 days of gestation in 2010-2013 versus 2014-2017. RESULTS Mortality decreased from 15.1% (1,366/9,058) in 2010-2013 to 12.7% (1,385/10,924) in 2014-2017, risk ratio (RR) 0.845 (95% confidence interval [CI], 0.784-0.901). Rates of severe ROP (≥grade 3) per survivor increased from 12.1% (930/7,692) to 13.3% (1.269/9,539), RR 1.100 (95% CI: 1.017-1.191). The lowest mortality and highest ROP rates were found in infants born in 2014. There was no change in rates of necrotizing enterocolitis, while those of bronchopulmonary dysplasia (BPD) decreased steadily between 2010 and 2017, alongside the increased proportion of infants who were never intubated. CONCLUSIONS There was a moderate decline in mortality, an insignificant increase in severe ROP, and a steady decline of BPD in Germany during 2010-2017. Avoiding endotracheal intubation may have contributed to lowered BPD rates.
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Affiliation(s)
- Christoph Bührer
- Department of Neonatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Günther Heller
- Institut für Qualität und Transparenz im Gesundheitswesen, Berlin, Germany
| | - Ulrich H Thome
- Division of Neonatology, Center for Pediatric Research, University of Leipzig, Leipzig, Germany
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18
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Treussart C, Decobert F, Tauzin M, Bourgoin L, Danan C, Dassieu G, Carteaux G, Mekontso-Dessap A, Louis B, Durrmeyer X. Patient-Ventilator Synchrony in Extremely Premature Neonates during Non-Invasive Neurally Adjusted Ventilatory Assist or Synchronized Intermittent Positive Airway Pressure: A Randomized Crossover Pilot Trial. Neonatology 2022; 119:386-393. [PMID: 35504256 DOI: 10.1159/000524327] [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: 01/26/2022] [Accepted: 03/22/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Synchronization of non-invasive ventilation is challenging in extremely premature infants. We compared patient-ventilator synchrony between non-invasive neurally adjusted ventilatory assist (NIV-NAVA) using transdiaphragmatic (Edi) catheter and synchronized intermittent positive airway pressure (SiPAP) using an abdominal trigger. METHODS This study was a monocentric, randomized, crossover trial in premature infants born before 28 weeks of gestation, aged 3 days or more, and below 32 weeks postmenstrual age. NIV-NAVA and SiPAP were applied in a random order for 2 h with analysis of data from the second hour. The primary outcome was the asynchrony index. RESULTS Fourteen patients were included (median [IQR] gestational age at birth 25.6 (25.3-26.4) weeks, median [IQR] birth weight 755 [680-824] g, median [IQR] postnatal age 26.5 [19.8-33.8] days). The median (IQR) asynchrony index was significantly lower in NIV-NAVA versus SiPAP (49.9% [44.1-52.6] vs. 85.8% [74.2-90.9], p < 0.001). Ineffective efforts and auto-triggering were significantly less frequent in NIV-NAVA versus SiPAP (3.0% vs. 32.0% p < 0.001 and 10.0% vs. 26.6%, p = 0.004, respectively). Double triggering was significantly less frequent in SiPAP versus NIV-NAVA (0.0% vs. 9.0%, p < 0.001). No significant difference was observed for premature cycling and late cycling. Peak Edi and swing Edi were significantly lower in NIV-NAVA as compared to SiPAP (7.7 [6.1-9.9] vs. 11.0 [6.7-14.5] μV, p = 0.006; 5.4 [4.2-7.6] vs. 7.6 [4.3-10.8] μV, p = 0.007, respectively). No significant difference was observed between NIV-NAVA and SiPAP for heart rate, respiratory rate, COMFORTneo scores, apnoea, desaturations, or bradycardias. DISCUSSION/CONCLUSION NIV-NAVA markedly improves patient-ventilator synchrony as compared to SiPAP in extremely premature infants.
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Affiliation(s)
| | - Fabrice Decobert
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
| | - Laura Bourgoin
- Neonatal Intensive Care Unit, Assistance Publique, Hôpitaux de Marseille, Hôpital de La Conception, Marseille, France
| | - Claude Danan
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Gilles Dassieu
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Guillaume Carteaux
- INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France.,Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.,GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
| | - Armand Mekontso-Dessap
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.,GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
| | - Bruno Louis
- INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France.,GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
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19
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Chikkabyrappa SM, Chaudhary N, Agarwal A, Rastogi D, Filipov P, Rastogi S. Outcomes among preterm infants with patent ductus arteriosus: Relationship with treatment, gestational age, hemodynamic status and timing of treatment. J Neonatal Perinatal Med 2021; 15:219-227. [PMID: 34719442 DOI: 10.3233/npm-210814] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined. STUDY DESIGN This retrospective case-control study including infants < 1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios. RESULTS The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7-4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0-3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6-6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated. CONCLUSION Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.
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Affiliation(s)
| | - N Chaudhary
- Beth Israel Deaconess Medical Center, Harvard University, Boston, MA
| | - A Agarwal
- The Children's Hospital of San Antonio, Baylor College of Medicine, San Antonio, TX
| | - D Rastogi
- Children's National Hospital, George Washington University, Washington, DC
| | - P Filipov
- Maimonides Medical Center, Brooklyn, NY
| | - S Rastogi
- Children's National Hospital, George Washington University, Washington, DC
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Altit G, Bhombal S, Chock VY. End-organ saturations correlate with aortic blood flow estimates by echocardiography in the extremely premature newborn - an observational cohort study. BMC Pediatr 2021; 21:312. [PMID: 34253175 PMCID: PMC8274006 DOI: 10.1186/s12887-021-02790-1] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 06/10/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) measures of cerebral saturation (Csat) and renal saturation (Rsat) in extreme premature newborns may be affected by systemic blood flow fluctuations. Despite increasing clinical use of NIRS to monitor tissue saturation in the premature infant, validation of NIRS measures as a correlate of blood flow is still needed. We compared echocardiography (ECHO) derived markers of ascending aorta (AscAo) and descending aorta (DesAo) blood flow with NIRS measurements obtained during the ECHO. METHODS Newborns < 29 weeks' gestation (2013-2017) underwent routine NIRS monitoring. Csat, Rsat and systemic saturation at the time of ECHO were retrospectively analyzed and compared with Doppler markers of aortic flow. Renal and cerebral fractional tissue oxygen extraction (rFTOE and cFTOE, respectively) were calculated. Mixed effects models evaluated the association between NIRS and Doppler markers. RESULTS Forty-nine neonates with 75 Csat-ECHO and 62 Rsat-ECHO observations were studied. Mean post-menstrual age was 28.3 ± 3.8 weeks during the ECHO. Preductal measures including AscAo velocity time integral (VTI) and AscAo output were correlated with Csat or cFTOE, while postductal measures including DesAo VTI, DesAo peak systolic velocity, and estimated DesAo output were more closely correlated with Rsat or rFTOE. CONCLUSIONS NIRS measures are associated with aortic blood flow measurements by ECHO in the extremely premature population. NIRS is a tool to consider when following end organ perfusion in the preterm infant.
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Affiliation(s)
- Gabriel Altit
- Department of Pediatrics, Division of Neonatology, Montreal Children's Hospital, McGill University Health Center, Montreal, Canada.
| | - Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, USA
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21
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Ireland S, Ray R, Larkins S, Woodward L. Exploring implicit bias in the perceived consequences of prematurity amongst health care providers in North Queensland - a constructivist grounded theory study. BMC Pregnancy Childbirth 2021; 21:55. [PMID: 33441110 DOI: 10.1186/s12884-021-03539-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 01/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background A study was done to explore the attitudes of relevant health care professionals (HCP) towards the provision of intensive care for periviable and extremely premature babies. Methods/design Applying a constructivist grounded theory methodology, HCP were interviewed about their attitudes towards the provision of resuscitation and intensive care for extremely premature babies. These babies are at increased risk of death and neurodisability when compared to babies of older gestations. Participants included HCP of varying disciplines at a large tertiary centre, a regional centre and a remote centre. Staff with a wide range of experience were interviewed. Results Six categories of i) who decides, ii) culture and context of families, iii) the life ahead, iv) to treat a bit or not at all, v) following guidelines and vi) information sharing, emerged. Role specific implicit bias was found as a theoretical construct, which depended on the period for which care was provided relative to the delivery of the baby. This implicit bias is an underlying cause for the negativity seen towards extreme prematurity and is presented in this paper. HCP caring for women prior to delivery have a bias towards healthy term babies that involves overestimation of the risks of extreme prematurity, while neonatal staff were biased towards suffering in the neonatal period and paediatricians recognise positivity of outcomes regardless of neurological status of the child. The implicit bias found may explain negativity towards intensive care of periviable neonates. Conclusion Understanding the presence and origins of role specific implicit bias may enable HCP to work together to improve care for parents preparing for the delivery of extremely premature babies. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03539-5.
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Gkiougki E, Chatziioannidis I, Pouliakis A, Iacovidou N. Periviable birth: A review of ethical considerations. Hippokratia 2021; 25:1-7. [PMID: 35221649 PMCID: PMC8877922] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Advances in perinatology and medical technology have pushed the limits of viability to unprecedented extremes, leading to a growing population of NICU "graduates" with a wide range of health issues. Although survival rates from 22 weeks of gestation onwards have improved over the last 30 years, the incidence of disabilities remains the same. Providing intensive care to a high-risk population with significant mortality and morbidity raises the fundamental conflict between sanctity and quality of life. Potential severe handicap and need for frequent tertiary care inevitably impact the whole family unit and may outweigh the benefit of survival. The aim of this study is to explore and summarize the ethical considerations in neonatal care concerning perivable birth. METHODS Eligible studies published on PubMed were included after a systematic search using the PICO methodology. RESULTS Forty-eight studies were systematically reviewed regarding guidelines, withholding or withdrawing treatment, parental involvement, and principles applied in marginal viability. As periviable birth raises an array of complex ethical and legal concerns, strict guidelines are challenging to implement. CONCLUSIONS Active life-sustaining interventions in neonatology should be balanced against the risk of putting infants through painful and futile procedures and survival with severe sequelae. More evidence is needed on better prediction of long-term outcomes in situations of imminent preterm delivery, while good collaboration between the therapeutic team and the parents for life-and-death decision-making is of utmost importance. HIPPOKRATIA 2021, 25 (1):1-7.
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Affiliation(s)
- E Gkiougki
- Pediatric and Neonatal Department, Centre Hospitalier Reine Astrid, Malmedy, Belgium
| | - I Chatziioannidis
- 2 Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki
| | - A Pouliakis
- 2 Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, University General Hospital "Attikon"
| | - N Iacovidou
- Neonatal Department, School of Medicine, National and Kapodistrian University of Athens, Aretaieio Hospital Athens, Greece
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23
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Houben E, Siffel C, Overbeek J, Penning-van Beest F, Niklas V, Sarda SP. Respiratory morbidity, healthcare resource use, and cost burden associated with extremely preterm birth in The Netherlands. J Med Econ 2021; 24:1290-1298. [PMID: 34709122 DOI: 10.1080/13696998.2021.1999664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Extremely preterm (EP) infants have high rates of respiratory morbidity and correspondingly high healthcare resource utilization. OBJECTIVES Data from the PHARMO Perinatal Research Network were analyzed to quantify the burden of EP birth in the Netherlands. METHODS A retrospective analysis included infants <28 weeks gestational age with a birth record in the Perinatal Registry (1999-2015) and data in the PHARMO Database Network. Outcomes of interest included select comorbidities, hospital readmissions, and costs of hospitalization and medication up to 1- and 2-years corrected age. Outcomes were stratified by birth period (1999-2005, 2000-2009, 2010-2015) and by diagnosis of bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD). RESULTS The cohort included 168 EP infants (37 born 1999-2005, 51 born 2006-2009, 80 born 2010-2015). Median (Q1-Q3) birth weights decreased by birth period from 970 (840-1,035) g in 1999-2005 to 853 (695-983) g in 2010-2015. Overall, BPD and CLD were reported during the birth hospitalization in 40% and 29% of infants, respectively; rates of BPD increased and rates of CLD decreased by birth period. Eighty-four percent of EP infants had an additional comorbidity. Mean (standard deviation) costs of birth hospitalization were €110,600 (€73,000) for 1999-2005, €119,350 (€60,650) for 2006-2009, and €138,800 (€130,100) for 2010-2015. Birth hospitalization and total costs for up to 1- and 2-years corrected age were higher for infants with BPD and/or CLD than for those without either complication. CONCLUSION Healthcare resource utilization and costs for EP infants, especially for those with respiratory morbidities, increased between 1999 and 2015. Future cost-effectiveness analyses are essential to determine the economic impact of this change and underscore the need for new therapeutic interventions to decrease clinical sequelae in this vulnerable population.
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Affiliation(s)
- Eline Houben
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
- Department of Obstetrics and Gynecology, Erasmus MC, Rotterdam, The Netherlands
| | - Csaba Siffel
- Takeda Development Center Americas, Lexington, MA, USA
- College of Allied Health Sciences, Augusta University, Augusta, GA, USA
| | - Jetty Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrecht, The Netherlands
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24
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Ohnstad MO, Stensvold HJ, Tvedt CR, Rønnestad AE. Duration of Mechanical Ventilation and Extubation Success among Extremely Premature Infants. Neonatology 2021; 118:90-97. [PMID: 33611319 DOI: 10.1159/000513329] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/24/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to examine the duration of mechanical ventilation (MV) in days until the first successful extubation and the cumulative duration of MV until discharge of infants with gestational age (GA) <26 weeks. We also aimed to explore associations between early clinical variables and the cumulative duration of MV. DESIGN AND SETTING This population-based study analysed data reported to the Norwegian Neonatal Network on extremely premature infants admitted between January 1, 2013, and December 31, 2018. RESULTS A total of 406 infants were included, of which 293 (72%) survived to discharge. The proportion successfully extubated on their first attempt was 34% of the infants born at GA 22-23 weeks, 50% at GA 24 weeks, and 70% at GA 25 weeks. Median postmenstrual age (PMA) at the first successful extubation was 27 weeks. The median duration of MV was 35, 24, and 12 days for infants born at GA 22-23, 24, and 25 weeks, respectively. Male sex and low 5-min Apgar score were independent early predictors for prolonged MV duration adjusted for GA in regression analyses. CONCLUSIONS Most of the infants born at GA 25 weeks were successfully extubated on the first attempt. However, half of the infants born <26 weeks experienced unsuccessful extubations, indicating a lack of useful clinical predictors of successful extubation. The median duration of MV in survivors was 4 weeks longer for infants at GA 22-23 weeks than for infants born at GA 25 weeks, while the difference in median PMA at the first successful extubation was 2 weeks.
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Affiliation(s)
- Mari Oma Ohnstad
- Unit of Further Education/Postgraduate and Master's Degree, Lovisenberg Diaconal University College, Oslo, Norway, .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway,
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care Unit, Clinic of Pediatric and Adolecent Medicine, Oslo University Hospital, Oslo, Norway
| | - Christine Raaen Tvedt
- Unit of Further Education/Postgraduate and Master's Degree, Lovisenberg Diaconal University College, Oslo, Norway
| | - Arild E Rønnestad
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neonatal Intensive Care Unit, Clinic of Pediatric and Adolecent Medicine, Oslo University Hospital, Oslo, Norway
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Gentle SJ, Ahmed KA, Yi N, Morrow CD, Ambalavanan N, Lal CV, Patel RP. Bronchopulmonary dysplasia is associated with reduced oral nitrate reductase activity in extremely preterm infants. Redox Biol 2020; 38:101782. [PMID: 33166868 PMCID: PMC7658701 DOI: 10.1016/j.redox.2020.101782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 01/08/2023] Open
Abstract
Oral microbiome mediated nitrate reductase (NR) activity regulates nitric oxide (NO) bioavailability and signaling. While deficits in NO-bioavailability impact several morbidities of extreme prematurity including bronchopulmonary dysplasia (BPD), whether oral NR activity is associated with morbidities of prematurity is not known. We characterized NR activity in extremely preterm infants from birth until 34 weeks' post menstrual age (PMA), determined whether changes in the oral microbiome contribute to changes in NR activity, and determined whether changes in NR activity correlated with disease. In this single center prospective cohort study (n = 28), we observed two surprising findings: (1) NR activity unexpectedly peaked at 29 weeks' PMA (p < 0.05) and (2) when infants were stratified for BPD status, infants who developed BPD had significantly less NR activity at 29 weeks' PMA compared to infants who did not develop BPD. Oral microbiota and NR activity may play a role in BPD development in extremely preterm infants, indicating potential for disease prediction and therapeutic targeting.
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Affiliation(s)
- Samuel J Gentle
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Khandaker A Ahmed
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nengjun Yi
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Casey D Morrow
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Charitharth V Lal
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rakesh P Patel
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
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26
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Miletin J, Semberova J, Martin AM, Janota J, Stranak Z. Low cardiac output measured by bioreactance and adverse outcome in preterm infants with birth weight less than 1250 g. Early Hum Dev 2020; 149:105153. [PMID: 32799033 DOI: 10.1016/j.earlhumdev.2020.105153] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 06/21/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recently a new continuous non-invasive cardiac output measurement, bioreactance, has become available. Bioreactance measurement of cardiac output has been shown to correlate with left ventricular output detected by echocardiography in healthy term and preterm neonates. AIMS Our aim was to correlate cardiac output measurements by bioreactance in the first 48 h of life with adverse outcomes attributable to hypoperfusion (peri/intraventricular haemorrhage (PIVH) and/or necrotising enterocolitis (NEC)) in the cohort of extremely preterm infants. STUDY DESIGN A prospective observational cohort study. SUBJECTS Preterm infants with birth weight less than 1250 g. OUTCOME MEASURES Cardiac output was measured between six and 48 h of age by bioreactance. Our primary outcome was a difference in cardiac output between infants with an adverse outcome attributable to hypoperfusion (Group 1), and infants without the predefined adverse outcome (Group 2). RESULTS There were 39 infants enrolled in the study. There were six infants in Group 1. These infants had a significantly lower minimal cardiac output measurement compared to Group 2 (mean 36.7 ml/kg/min vs 64.5 ml/kg/min, p = .0006). The mean cardiac output in Group 1 was significantly lower on day one of life, followed by a significant increase in cardiac output on day two of life compared to Group 2. CONCLUSIONS Infants with birth weight less than 1250 g and PIVH and/or NEC had significantly lower cardiac output compared to infants without these complications on day one of life. This low cardiac output was then followed by a significant increase on day two of life.
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Affiliation(s)
- Jan Miletin
- Coombe Women and Infants University Hospital, Dublin, Ireland; Institute for the Care of Mother and Child, Prague, Czech Republic; UCD School of Medicine, University College Dublin, Dublin, Ireland; 3rd Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Jana Semberova
- Coombe Women and Infants University Hospital, Dublin, Ireland; Institute for the Care of Mother and Child, Prague, Czech Republic; UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Aisling M Martin
- Coombe Women and Infants University Hospital, Dublin, Ireland; UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - Jan Janota
- 1st and 2nd Faculty of Medicine, Charles University, Prague, Czech Republic; Motol University Hospital, Prague, Czech Republic
| | - Zbynek Stranak
- Institute for the Care of Mother and Child, Prague, Czech Republic; 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
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27
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Murthy P, Zein H, Thomas S, Scott JN, Abou Mehrem A, Esser MJ, Lodha A, Metcalfe C, Kowal D, Irvine L, Scotland J, Leijser L, Mohammad K. Neuroprotection Care Bundle Implementation to Decrease Acute Brain Injury in Preterm Infants. Pediatr Neurol 2020; 110:42-48. [PMID: 32473764 DOI: 10.1016/j.pediatrneurol.2020.04.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 03/05/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 01/20/2023]
Abstract
BACKGROUND We assessed the impact of an evidence-based neuroprotection care bundle on the risk of brain injury in extremely preterm infants. METHODS We implemented a neuroprotection care bundle consisting of a combination of neuroprotection interventions such as minimal handling, midline head position, deferred cord clamping, and protocolization of hemodynamic and respiratory managements. These interventions targeted risk factors for acute brain injury in extremely preterm infants (born at gestational age less than 29 weeks) during the first three days of birth. Implementation occurred in a stepwise manner, including care bundle development by a multidisciplinary care team based on previous evidence and experience, standardization of outcome assessment tools, and education. We compared the incidence of the composite outcome of acute preterm brain injury or death preimplementation and postimplementation. RESULTS Neuroprotection care bundle implementation associated with a significant reduction in acute brain injury risk factors such as the use of inotropes (24% before, 7% after, P value < 0.001) and fluid boluses (37% before, 19% after, P value < 0.001), pneumothorax (5% before, 2% after, P value = 0.002), and opioid use (19% before, 7% after, P value < 0.001). Adjusting for confounding factors, the neuroprotection care bundle significantly reduced death or severe brain injury (adjusted odds ratio, 0.34; 95% confidence interval, 0.20 to 0.59; P value < 0.001) and severe brain injury (adjusted odds ratio, 0.31; 95% confidence interval, 0.17 to 0.58; P < 0.001). CONCLUSIONS Implementation of neuroprotection care bundle targeting predefined risk factors is feasible and effective in reducing acute brain injury in extremely preterm infants.
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Affiliation(s)
- Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Sumesh Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - James N Scott
- Division of Neuroradiology, Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Ayman Abou Mehrem
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Michael J Esser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Abhay Lodha
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Cathy Metcalfe
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Derek Kowal
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Leigh Irvine
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Jillian Scotland
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Lara Leijser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
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Ireland S, Larkins S, Ray R, Woodward L. Negativity about the outcomes of extreme prematurity a persistent problem - a survey of health care professionals across the North Queensland region. Matern Health Neonatol Perinatol 2020; 6:2. [PMID: 32368347 PMCID: PMC7189572 DOI: 10.1186/s40748-020-00116-0] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 04/14/2020] [Indexed: 11/10/2022] Open
Abstract
Background Extremely preterm babies are at risk of significant mortality and morbidity due to their physiological immaturity. At periviable gestations decisions may be made to either provide resuscitation and intensive care or palliation based on assessment of the outlook for the baby and the parental preferences. Health care professionals (HCP) who counsel parents will influence decision making depending on their individual perceptions of the outcome for the baby. This paper aims to explore the knowledge and attitudes towards extremely preterm babies of HCP who care for women in pregnancy in a tertiary, regional and remote setting in North Queensland. Methods A cross sectional electronic survey of HCP was performed. Perceptions of survival, severe disability and intact survival data were collected for each gestational age from 22 to 27 completed weeks gestation. Free text comment enabled qualitative content analysis. Results Almost all 113 HCP participants were more pessimistic than the actual outcome data suggests. HCP caring for women antenatally were the most pessimistic for survival (p = 0.03 at 23 weeks, p = 0.02 at 25,26 and 27 weeks), severe disability (p = 0.01 at 24 weeks) and healthy outcomes (p = 0.01 at 24 weeks), whilst those working in regional and remote centres were more negative than those in tertiary unit for survival (p = 0.03 at 23,24,25 weeks). Perception became less negative as gestational age increased. Conclusion Pessimism of HCP may be negatively influencing decision making and will negatively affect the way in which parents perceive the chances of a healthy outcome for their offspring.
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Affiliation(s)
- Susan Ireland
- The neonatal unit, Townsville University Hospital, Angus Smith Drive, Douglas, Queensland 4814 Australia.,2Department Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Sarah Larkins
- 2Department Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Robin Ray
- 2Department Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Lynn Woodward
- 2Department Medicine and Dentistry, James Cook University, Townsville, Australia
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Hughes O, Crosby D, O'Connell M. Case report and literature review of management of preterm prelabour rupture of membranes before fetal viability. J Matern Fetal Neonatal Med 2020; 35:201-203. [PMID: 32070167 DOI: 10.1080/14767058.2020.1712706] [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] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Preterm prelabour rupture of membranes (PPROM) complicates up to 3% of pregnancy and is responsible for one third of preterm deliveries. PPROM at extremely preterm gestations (<24 weeks) affects 0.4% of pregnancies and is associated with low neonatal survival rates, high rate of neonatal complications in survivors, and carries major risk of maternal morbidity and mortality. We present a rare case of pregnancy complicated by PPROM at 14 weeks which resulted in a term delivery and a good neonatal outcome.
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Affiliation(s)
- Oxana Hughes
- Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - David Crosby
- Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Michael O'Connell
- Department of Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
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30
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Baraldi E, Allodi MW, Löwing K, Smedler AC, Westrup B, Ådén U. Stockholm preterm interaction-based intervention (SPIBI) - study protocol for an RCT of a 12-month parallel-group post-discharge program for extremely preterm infants and their parents. BMC Pediatr 2020; 20:49. [PMID: 32007087 PMCID: PMC6995087 DOI: 10.1186/s12887-020-1934-4] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 01/16/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Improved neonatal care has resulted in increased survival rates among infants born after only 22 gestational weeks, but extremely preterm children still have an increased risk of neurodevelopmental delays, learning disabilities and reduced cognitive capacity, particularly executive function deficits. Parent-child interaction and parental mental health are associated with infant development, regardless of preterm birth. There is a need for further early interventions directed towards extremely preterm (EPT) children as well as their parents. The purpose of this paper is to describe the Stockholm Preterm Interaction-Based Intervention (SPIBI), the arrangements of the SPIBI trial and the chosen outcome measurements. METHODS The SPIBI is a randomized clinical trial that includes EPT infants and their parents upon discharge from four neonatal units in Stockholm, Sweden. Inclusion criteria are EPT infants soon to be discharged from a neonatal intensive care unit (NICU), with parents speaking Swedish or English. Both groups receive three initial visits at the neonatal unit before discharge during the recruitment process, with a strengths-based and development-supportive approach. The intervention group receives ten home visits and two telephone calls during the first year from a trained interventionist from a multi-professional team. The SPIBI intervention is a strengths-based early intervention programme focusing on parental sensitivity to infant cues, enhancing positive parent-child interaction, improving self-regulating skills and supporting the infant's next small developmental step through a scaffolding process and parent-infant co-regulation. The control group receives standard follow-up and care plus extended assessment. The outcomes of interest are parent-child interaction, child development, parental mental health and preschool teacher evaluation of child participation, with assessments at 3, 12, 24 and 36 months corrected age (CA). The primary outcome is emotional availability at 12 months CA. DISCUSSION If the SPIBI shows positive results, it could be considered for clinical implementation for child-support, ethical and health-economic purposes. Regardless of the outcome, the trial will provide valuable information about extremely preterm children and their parents during infancy and toddlerhood after regional hospital care in Sweden. TRIAL REGISTRATION The study was registered in ClinicalTrials.gov in October 2018 (NCT03714633).
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Affiliation(s)
- Erika Baraldi
- Department of Special Education, Specialpedagogiska institutionen Stockholms universitet, Stockholm University, Frescati Hagväg 10, 106 91 Stockholm, Sweden
| | - Mara Westling Allodi
- Department of Special Education, Specialpedagogiska institutionen Stockholms universitet, Stockholm University, Frescati Hagväg 10, 106 91 Stockholm, Sweden
| | - Kristina Löwing
- Department of Women’s and Children’s Health, Institutionen för kvinnors och barns hälsa, Karolinska Institutet, Karolinska Institutet, 171 77 Stockholm, Sweden
- Functional Area Occupational Therapy & Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Ann-Charlotte Smedler
- Department of Psychology, Psykologiska institutionen Stockholms universitet, Stockholm University, Frescati Hagväg 8, 106 91 Stockholm, Sweden
| | - Björn Westrup
- Department of Women’s and Children’s Health, Institutionen för kvinnors och barns hälsa, Karolinska Institutet, Karolinska Institutet, 171 77 Stockholm, Sweden
- Neonatology unit, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Ulrika Ådén
- Department of Women’s and Children’s Health, Institutionen för kvinnors och barns hälsa, Karolinska Institutet, Karolinska Institutet, 171 77 Stockholm, Sweden
- Neonatology unit, Karolinska University Hospital, 171 76 Stockholm, Sweden
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Morgan AS, Khoshnood B, Diguisto C, Foix L'Helias L, Marchand-Martin L, Kaminski M, Zeitlin J, Bréart G, Goffinet F, Ancel PY. Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study. BMC Pediatr 2020; 20:8. [PMID: 31910799 PMCID: PMC6945524 DOI: 10.1186/s12887-019-1856-1] [Citation(s) in RCA: 3] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/25/2019] [Indexed: 11/10/2022] Open
Abstract
Background Perinatal decision-making affects outcomes for extremely preterm babies (22–26 weeks’ gestational age (GA)): more active units have improved survival without increased morbidity. We hypothesised such units may gain skills and expertise meaning babies at higher gestational ages have better outcomes than if they were born elsewhere. We examined mortality and morbidity outcomes at age two for babies born at 27–28 weeks’ GA in relation to the intensity of perinatal care provided to extremely preterm babies. Methods Fetuses from the 2011 French national prospective EPIPAGE-2 cohort, alive at maternal admission to a level 3 hospital and delivered at 27–28 weeks’ GA, were included. Morbidity-free survival (survival without sensorimotor (blindness, deafness or cerebral palsy) disability) and overall survival at age two were examined. Sensorimotor disability and Ages and Stages Questionnaire (ASQ) result below threshold among survivors were secondary outcomes. Perinatal care intensity level was based on birth hospital, grouped using the ratio of 24–25 weeks’ GA babies admitted to neonatal intensive care to fetuses of the same gestation alive at maternal admission. Sensitivity analyses used ratios based upon antenatal steroids, Caesarean section, and newborn resuscitation. Multiple imputation was used for missing data; hierarchical logistic regression accounted for births nested within centres. Results 633 of 747 fetuses (84.7%) born at 27–28 weeks’ GA survived to age two. There were no differences in survival or morbidity-free survival: respectively, fully adjusted odds ratios were 0.96 (95% CI: 0.54 to 1.71) and 1.09 (95% CI: 0.59 to 2.01) in medium and 1.12 (95% CI: 0.63 to 2.00) and 1.16 (95% CI: 0.62 to 2.16) in high compared to low-intensity hospitals. Among survivors, there were no differences in sensorimotor disability or ASQ below threshold. Sensitivity analyses were consistent with the main results. Conclusions No difference was seen in survival or morbidity-free survival at two years of age among fetuses alive at maternal hospital admission born at 27–28 weeks’ GA, or in sensorimotor disability or presence of an ASQ below threshold among survivors. There is no evidence for an impact of intensity of perinatal care for extremely preterm babies on births at a higher gestational age.
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Affiliation(s)
- Andrei Scott Morgan
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France. .,UCL Elizabeth Garrett Anderson Institute for Women's Health, 74 Huntley Street, London, WC1E 6AU, UK. .,SAMU 93 - SMUR Pédiatrique, CHI André Gregoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.
| | - Babak Khoshnood
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Caroline Diguisto
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - Laurence Foix L'Helias
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,UPMC Université Paris 6, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hopital Armand Trousseau, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Laetitia Marchand-Martin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Monique Kaminski
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Jennifer Zeitlin
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - Gérard Bréart
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France
| | - François Goffinet
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,Maternité Port-Royal, University Paris-Descartes, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre-Yves Ancel
- Université de Paris, Epidemiology and Statistics Research Center/CRESS, INSERM (U1153 - Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé)), INRA, Hôpital Tenon, Bâtiment Recherche, Rue de la Chine, Paris, 75020, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
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Mayock DE, Xie Z, Comstock BA, Heagerty PJ, Juul SE. High-Dose Erythropoietin in Extremely Low Gestational Age Neonates Does Not Alter Risk of Retinopathy of Prematurity. Neonatology 2020; 117:650-657. [PMID: 33113526 PMCID: PMC7855231 DOI: 10.1159/000511262] [Citation(s) in RCA: 4] [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: 05/23/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The Preterm Erythropoietin (Epo) Neuroprotection (PENUT) Trial sought to determine the safety and efficacy of early high-dose Epo as a potential neuroprotective treatment. We hypothesized that Epo would not increase the incidence or severity of retinopathy of prematurity (ROP). METHODS A total of 941 infants born between 24-0/7 and 27-6/7 weeks' gestation were randomized to 1,000 U/kg Epo or placebo intravenously for 6 doses, followed by subcutaneous or sham injections of 400 U/kg Epo 3 times a week through 32 weeks post-menstrual age. In this secondary analysis of PENUT trial data, survivors were evaluated for ROP. A modified intention-to-treat approach was used to compare treatment groups. In addition, risk factors for ROP were evaluated using regression methods that account for multiples and allow for adjustment for treatment and gestational age at birth. RESULTS Of 845 subjects who underwent ROP examination, 503 were diagnosed with ROP with similar incidence and severity between treatment groups. Gestational age at birth, birth weight, prenatal magnesium sulfate, maternal antibiotic exposure, and presence of heart murmur at 2 weeks predicted the development of any ROP, while being on high-frequency oscillator or high-frequency jet ventilation (HFOV/HFJV) at 2 weeks predicted severe ROP. CONCLUSION Early high-dose Epo followed by maintenance dosing through 32 weeks does not increase the risk of any or severe ROP in extremely low gestational age neonates. Gestational age, birth weight, maternal treatment with magnesium sulfate, antibiotic use during pregnancy, and presence of a heart murmur at 2 weeks were associated with increased risk of any ROP. Treatment with HFOV/HFJV was associated with an increased risk of severe ROP.
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Affiliation(s)
- Dennis E Mayock
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA,
| | - Zimeng Xie
- Division of Biomedical Statistics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Bryan A Comstock
- Division of Biomedical Statistics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Patrick J Heagerty
- Division of Biomedical Statistics, Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Sandra E Juul
- Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
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Kaempf JW, Morris M, Austin J, Steffen E, Wang L, Dunn M. Sustained quality improvement collaboration and composite morbidity reduction in extremely low gestational age newborns. Acta Paediatr 2019; 108:2199-2207. [PMID: 31194257 DOI: 10.1111/apa.14895] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/06/2019] [Accepted: 06/11/2019] [Indexed: 12/14/2022]
Abstract
AIM Continuous quality improvement has failed to consistently reduce morbidities in extremely low gestational age newborns 23-27 weeks. 10 Vermont Oxford Network NICUs describe a novel, sustained collaboration for progress. METHODS We emphasised a) commitment to inter-NICU trust with face-to-face meetings, site visits, teleconferences, scrutiny of quality improvement methodology, b) transparent process and outcomes sharing, c) evidence-based formulation of an orchestrated testing matrix to select potentially better practices, d) family integration, e) benchmarking with a composite mortality-morbidity score (Benefit Metric). RESULTS A total of 4709 infants, mean (SD) gestational age 25.8 (1.4) weeks, admitted to 10 NICUs 1.01.2010 to 12.31.2016. The orchestrated matrix offered 45 potentially better practices; NICUs implemented mean 29 (range 19-40). There was widespread adoption of delivery room, respiratory care and infection prevention practices, but no uniform pattern. Our Benefit Metric was significantly greater than the Vermont Oxford Network all seven years (p < 0.001). Six major morbidities decreased, two significantly (p < 0.05), mortality unchanged (14%). 34% of survivors had no morbidities, 35% just one. CONCLUSION Cultivating trust, transparent outcomes sharing, and tailored, potentially better practice selection is associated with encouraging improvement in 23- to 27-week survival without morbidity. Our outcomes are objective but the optimal implementation pathway to sustain progress remains murky, reflective of NICUs as complex adaptive networks.
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Affiliation(s)
- Joseph W. Kaempf
- Providence St. Joseph Health, Women and Children’s Services Medical Data and Research Center Portland OR USA
| | | | - June Austin
- June Austin Consulting Sherwood Park Alberta Canada
| | | | - Lian Wang
- Providence St. Joseph Health, Women and Children’s Services Medical Data and Research Center Portland OR USA
| | - Michael Dunn
- Department of Newborn and Developmental Paediatrics Sunnybrook Health Sciences Centre Toronto Ontario Canada
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Bry A, Wigert H. Psychosocial support for parents of extremely preterm infants in neonatal intensive care: a qualitative interview study. BMC Psychol 2019; 7:76. [PMID: 31783784 PMCID: PMC6883543 DOI: 10.1186/s40359-019-0354-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 11/15/2019] [Indexed: 01/25/2023] Open
Abstract
Background Extremely premature infants (those born before 28 weeks’ gestational age) are highly immature, requiring months of care at a neonatal intensive care unit (NICU). For parents, their child’s grave medical condition and prolonged hospitalization are stressful and psychologically disruptive. This study aimed at exploring the needs of psychosocial support of parents of extremely premature infants, and how the NICU as an organization and its staff meets or fails to meet these needs. Method Sixteen open-ended interviews were conducted with 27 parents after their infant’s discharge from the NICU. Inductive content analysis was performed. Results Four themes were identified: Emotional support (with subthemes Empathic treatment by staff, Other parents as a unique source of support, Unclear roles of the various professions); Feeling able to trust the health care provider; Support in balancing time spent with the infant and other responsibilities; Privacy. Parents of extremely premature infants needed various forms of emotional support at the NICU, including support from staff, professional psychological help and/or companionship with other patients’ parents. Parents were highly variable in their desire to discuss their emotional state with staff. The respective roles of nursing staff, social workers and psychologists in supporting parents emotionally and identifying particularly vulnerable parents appeared unclear. Parents also needed to be able to maintain a solid sense of trust in the NICU and its staff. Poor communication with and among staff, partly due to staff discontinuity, damaged trust. Parents struggled with perceived pressure from staff to be at the hospital more than they could manage and with the limited privacy of the NICU. Conclusions The complex and individual psychosocial needs of parents of extremely preterm infants present many challenges for the NICU and its staff. Increasing staffing and improving nurses’ competence in addressing psychosocial aspects of neonatal care would help both nurses and families. Clarifying the roles of different professions in supporting parents and developing their teamwork would lessen the burden on nurses. Communicating with parents about their needs and informing them early in their NICU stay about available support would be essential in helping them cope with their infant’s hospitalization.
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Affiliation(s)
- Anna Bry
- Division of Neonatology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Helena Wigert
- Division of Neonatology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden
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35
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Morgan AS, Foix L'Helias L, Diguisto C, Marchand-Martin L, Kaminski M, Khoshnood B, Zeitlin J, Bréart G, Durrmeyer X, Goffinet F, Ancel PY. Intensity of perinatal care, extreme prematurity and sensorimotor outcome at 2 years corrected age: evidence from the EPIPAGE-2 cohort study. BMC Med 2018; 16:227. [PMID: 30514388 PMCID: PMC6280378 DOI: 10.1186/s12916-018-1206-4] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/01/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Emerging evidence suggests intensity of perinatal care influences survival for extremely preterm babies. We evaluated the effect of differences in perinatal care intensity between centres on sensorimotor morbidity at 2 years of age. We hypothesised that hospitals with a higher intensity of perinatal care would have improved survival without increased disability. METHODS Foetuses alive at maternal admission to a level 3 hospital in France in 2011, subsequently delivered between 22 and 26 weeks gestational age (GA) and included in the EPIPAGE-2 national prospective observational cohort study formed the baseline population. Level of intensity of perinatal care was assigned according to hospital of birth, categorised into three groups using 'perinatal intensity' ratios (ratio of 24-25 weeks GA babies admitted to neonatal intensive care to foetuses of the same GA alive at maternal admission to hospital). Multiple imputation was used to account for missing data; hierarchical logistic regression accounting for births nested within centres was then performed. RESULTS One thousand one hundred twelve foetuses were included; 473 survived to 2 years of age (126 of 358 in low-intensity, 140 of 380 in medium-intensity and 207 of 374 in high-intensity hospitals). There were no differences in disability (adjusted odds ratios 0.93 (95% CI 0.28 to 3.04) and 1.04 (95% CI 0.34 to 3.14) in medium- and high- compared to low-intensity hospitals, respectively). Compared to low-intensity hospitals, survival without sensorimotor disability was increased in the population of foetuses alive at maternal admission to hospital and in live-born babies, but there were no differences when considering only babies admitted to NICU or survivors. CONCLUSIONS No difference in sensorimotor outcome for survivors of extremely preterm birth at 2 years of age was found according to the intensity of perinatal care provision. Active management of periviable births was associated with increased survival without sensorimotor disability.
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Affiliation(s)
- Andrei S Morgan
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France. .,Institute for Womens' Health, UCL, 74 Huntley Street, London, WC1E 6AU, UK. .,SAMU 93 - SMUR Pédiatrique, CHI André Gregoire, Groupe Hospitalier Universitaire Paris Seine-Saint-Denis, Assistance Publique des Hôpitaux de Paris, Montreuil, France.
| | - Laurence Foix L'Helias
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,UPMC Université Paris 6, Sorbonne Universités, Paris, France.,Service de Néonatologie, Hôpital Armand Trousseau, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Caroline Diguisto
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France.,Université François Rabelais, Tours, France
| | - Laetitia Marchand-Martin
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Monique Kaminski
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Babak Khoshnood
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Jennifer Zeitlin
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Gérard Bréart
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France
| | - Xavier Durrmeyer
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,Service de Médecine Néonatale, Centre Hospitalier Intercommunal de Creteil, Clinical Research Center CHI Créteil, Créteil, France
| | - François Goffinet
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,Maternité Port-Royal, University Paris-Descartes, Hôpitaux Universitaires Paris Centre, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Pierre-Yves Ancel
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (EPOPé), Centre for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Hôpital Tenon, Rue de la Chine, Paris, 75020, France.,URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu, Assistance Publique des Hôpitaux de Paris, Paris, France
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Gonya J, Feldman K, Brown K, Stein M, Keim S, Boone K, Rumpf W, Ray W, Chawla N, Butter E. Human interaction in the NICU and its association with outcomes on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). Early Hum Dev 2018; 127:6-14. [PMID: 30218893 DOI: 10.1016/j.earlhumdev.2018.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/11/2018] [Accepted: 08/27/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Extremely preterm infants represent one of the highest risk categories for impairments in social competence. Few studies have explored the impact of the neonatal intensive care unit (NICU) environment on social development. However, none have specifically analyzed the effects of the care structure the infant receives during hospitalization on later social competence indicators. OBJECTIVE To identify associations between the care structures received by extremely preterm infants in the NICU and scores on the Brief Infant-Toddler Social and Emotional Assessment (BITSEA) post-discharge. PARTICIPANTS 50 extremely preterm infants (mean gestational age: 25 weeks during hospitalization; mean chronological age during follow-up assessment: 2 years, 4 months). METHODS A secondary analysis of BITSEA data was performed exploring its relation to care structure data we extracted from electronic medical records (i.e., how much time infants were engaged in human interaction during their first thirty days of hospitalization and what types of interaction they were exposed to). RESULTS Extremely preterm infants spend a considerable amount of time alone during hospitalization (80%) with nursing care comprising the majority of human interaction. Infants who experienced greater human interaction scored significantly higher on the Social Competence (p = 0.01) and lower on the Dysregulation (p = 0.03) BITSEA subscales. CONCLUSION Human interaction and isolation in the NICU is associated with social competence and dysregulation outcomes in extremely preterm infants. Further research is needed to understand how various NICU care structures including centralized nursing teams, parental skin-to-skin care, and early therapy may synergistically play a positive role in developing social competence.
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Geurtzen R, Draaisma J, Hermens R, Scheepers H, Woiski M, van Heijst A, Hogeveen M. Various experiences and preferences of Dutch parents in prenatal counseling in extreme prematurity. Patient Educ Couns 2018; 101:2179-2185. [PMID: 30029812 DOI: 10.1016/j.pec.2018.07.003] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/28/2018] [Accepted: 07/03/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To investigate experienced and preferred prenatal counseling among parents of extremely premature babies. METHODS A Dutch nationwide, multicenter, cross-sectional study using an online survey. Surveys were sent to all parents of extremely premature babies born between 2010 and 2013 at 24+0/7-24+6/7 weeks of gestation. RESULTS Sixty-one out of 229 surveys were returned. A minority (14%) had no counseling conversation. Conversations were done more often by neonatologists (90%) than by obstetricians (39%) and in 37% by both these experts. Supportive material was rarely used (19%). Mortality (92%) and short-term morbidity (88%) were discussed the most, and more frequently than long-term morbidity (65%), practical items (63%) and delivery mode (52%). Most decisions on active care or palliative comfort care were perceived as decisions by doctor and parents together (61%). 80% felt they were involved in decision-making. The preferred way of involvement in decision-making varied among parents. CONCLUSION The vast majority of parents were counseled: mostly by neonatologists, and mainly about mortality and short-term morbidity. Parents wanted to be involved in the decision-making process but differed on the preferred extent of involvement. Practice implications Understanding of shared decision-making may contribute to meet the various preferences of parents.
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Affiliation(s)
- Rosa Geurtzen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands.
| | - Jos Draaisma
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Rosella Hermens
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of IQ Healthcare, Nijmegen, The Netherlands
| | | | - Mallory Woiski
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Gynecology, Nijmegen, The Netherlands
| | - Arno van Heijst
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Department of Pediatrics, Nijmegen, The Netherlands
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Azria E. [Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]. ACTA ACUST UNITED AC 2018; 46:1076-88. [PMID: 30409732 DOI: 10.1016/j.gofs.2018.10.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis. METHODS The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO4 to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed. CONCLUSION The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.
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Schrijvers NM, Geurtzen R, Draaisma JM, Halamek LP, Yamada NK, Hogeveen M. Perspectives on periviability counselling and decision-making differed between neonatologists in the United States and the Netherlands. Acta Paediatr 2018; 107:1710-1715. [PMID: 29603788 DOI: 10.1111/apa.14347] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 12/27/2017] [Accepted: 03/23/2018] [Indexed: 11/28/2022]
Abstract
AIM American guidelines suggest that neonatal resuscitation be considered at 23 weeks of gestation, one week earlier than in the Netherlands, but how counselling practices differ at the threshold of viability is unknown. This pilot study compared prenatal periviability counselling in the two countries. METHODS In 2013, a cross-sectional survey was sent to 121 Dutch neonatologists as part of a nationwide evaluation of prenatal counselling. In this pilot study, the same survey was sent to a convenience sample of 31 American neonatologists in 2014. The results were used to compare the organisation, content and decision-making processes in prenatal counselling at 24 weeks of gestation between the two countries. RESULTS The survey was completed by 17 (55%) American and 77 (64%) Dutch neonatologists. American neonatologists preferred to meet with parents more frequently, for longer periods of time, and to discuss more intensive care topics, including long-term complications, than Dutch neonatologists. Neonatologists from both countries preferred shared decision-making when deciding whether to initiate intensive care. CONCLUSION Neonatologists in the United States and the Netherlands differed in their approach to prenatal counselling at 24 weeks of gestation. Cross-cultural differences may play a role.
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Affiliation(s)
| | - Rosa Geurtzen
- Radboudumc Amalia Children's Hospital; Nijmegen the Netherlands
| | | | - Louis P. Halamek
- Center for Advanced Pediatric and Perinatal Education; Stanford University; Palo Alto CA USA
| | - Nicole K. Yamada
- Center for Advanced Pediatric and Perinatal Education; Stanford University; Palo Alto CA USA
| | - Marije Hogeveen
- Radboudumc Amalia Children's Hospital; Nijmegen the Netherlands
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Church JT, Perkins EM, Coughlin MA, McLeod JS, Boss K, Bentley JK, Hershenson MB, Rabah R, Bartlett RH, Mychaliska GB. Perfluorocarbons Prevent Lung Injury and Promote Development during Artificial Placenta Support in Extremely Premature Lambs. Neonatology 2018; 113:313-321. [PMID: 29478055 PMCID: PMC5980738 DOI: 10.1159/000486387] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 12/19/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extremely premature neonates suffer high morbidity and mortality. An artificial placenta (AP) using extracorporeal life support (ECLS) is a promising therapy. OBJECTIVES We hypothesized that intratracheal perfluorocarbon (PFC) instillation during AP support would reduce lung injury and promote lung development relative to intratracheal amniotic fluid or crystalloid. METHODS Lambs at an estimated gestational age (EGA) 116-121 days (term 145 days) were placed on venovenous ECLS with jugular drainage and umbilical vein reinfusion and intubated. Airways were managed by the instillation of amniotic fluid and tracheal occlusion (TO; n = 4), or lactated Ringer's (LR; n = 4) or perfluorodecalin (a PFC) without occlusion (n = 4). After 7 days, the animals were sacrificed. Early (EGA 116-121 days) and late (EGA 125-131 days) tissue control lambs were delivered and sacrificed. Lungs were formalin-inflated to 30 cm H2O and sectioned for histology. Injury was scored by an unbiased pathologist. Slides were immunostained for PDGFR-α and α-actin; development was quantified by the area fraction of double-positive tips. Surfactant protein-C (SP-C) concentration in bronchoalveolar lavage fluid was quantified using ELISA. RESULTS Total injury scores were lower in PFC lungs (1.8 ± 1.7) than in TO (6.5 ± 2.1; p = 0.01) and LR lungs (5.5 ± 2.4; p = 0.01). The area fraction of double-positive alveolar tips appeared higher in PFC lungs than in TO lungs (0.18 ± 0.007 vs. 0.008 ± 0.004; p = 0.07). SP-C concentration was higher in PFC lungs than in TO lungs (37.9 ± 7.6 vs. 20.0 ± 5.4 pg/mL; p = 0.005), and both early (12.4 ± 1.7 g/mL; p = 0.007) and late tissue control lungs (15.1 ± 5.0 pg/mL; p = 0.0008). CONCLUSION During AP support, intratracheal PFC prevents lung injury and promotes normal lung development better than crystalloid or amniotic fluid with TO.
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Mugarab-Samedi V, Lodha A, ElSharkawy A, Al Awad E. Aplasia cutis congenita as a result of interstitial laser therapy for fetal reduction in monochorionic twins: Conservative approach and outcome. Int J Surg Case Rep 2017; 41:68-70. [PMID: 29040903 PMCID: PMC5645009 DOI: 10.1016/j.ijscr.2017.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 10/02/2017] [Accepted: 10/02/2017] [Indexed: 11/29/2022] Open
Abstract
Laser therapy for fetal reduction could be associate with Aplasia Cutis Congenita. Despite of size of lesion conservative treatment could be an effective option. Extreme prematurity did not affected degree of spontaneous epithelization. Patient was followed up to 5 years and no complications were detected.
Monochorionic (MC) twin pregnancies are known to carry a high risk of twin-to-twin transfusion syndrome (TTTS) that could lead to miscarriage and perinatal death. Demise of one fetus is frequently associated with co-fetal death. Fetal reduction by interstitial laser therapy is an effective procedure to prevent this outcome, but it may be associated with significant risks for both mother and fetus. Aplasia Cutis Congenita (ACC) may occur in up to 8% cases of fetal reduction by laser therapy. We report ACC in a preterm infant, a survivor of interstitial laser therapy for fetal reduction in MC pregnancy. Despite of massive skin lesions we were able to manage this case conservatively. Follow-up at 5 years of age revealed minimal scarring and no motor function limitations.
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Affiliation(s)
| | - Abhay Lodha
- Division of Neonatology, Faculty of Pediatrics, University of Calgary, Calgary, Canada.
| | - Adel ElSharkawy
- Division of Neonatology, Faculty of Pediatrics, University of Calgary, Calgary, Canada.
| | - Essa Al Awad
- Division of Neonatology, Faculty of Pediatrics, University of Calgary, Calgary, Canada.
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Vashishta N, Surapaneni V, Chawla S, Kapur G, Natarajan G. Association among prematurity (<30 weeks' gestational age), blood pressure, urinary albumin, calcium, and phosphate in early childhood. Pediatr Nephrol 2017; 32:1243-1250. [PMID: 28391546 DOI: 10.1007/s00467-017-3581-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 06/03/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is a paucity of data on blood pressures (BP), urinary albumin, and mineral excretion in early childhood in contemporary cohorts of extremely low gestational age (GA) neonates. Our aim was to compare BPs and the urinary excretion of albumin, calcium, and phosphate in preterm and term-born cohorts in early childhood. METHODS This was a prospective observational study conducted at a single center, involving children <5 years age, born preterm (GA <30 weeks) or at term (≥37 weeks' GA). Urinary albumin (mg/L), calcium and phosphate levels indexed to creatinine (mg/dL), and BP were measured. RESULTS The median (IQR) follow-up age of our cohort (n = 106) was 30 (16-48) months. Preterm-born children (n = 55) had a significantly lower mean GA and birth weight and higher mean systolic, diastolic, and mean BPs, compared with term (n = 51) controls. A significantly higher proportion of preterm-born children weighed <10th centile and had systolic BP >95th centile at follow-up. Albumin and calcium excretion did not differ between the groups; median urine-phosphate creatinine ratios were higher in the preterm group. On logistic regression, lower GA and younger age at follow-up were significantly associated with an increased risk of systolic and diastolic BP above the 95th centile; male gender was associated with decreased risk of diastolic hypertension. CONCLUSIONS Even in early childhood, children born preterm had significantly elevated BP, compared with their term-born counterparts. Closer monitoring of BPs in this population may be warranted.
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Affiliation(s)
- Namrata Vashishta
- Division of Neonatology, Wayne State University, Detroit, MI, USA.,St. John Providence Hospital, Southfield, MI, USA
| | - Vidya Surapaneni
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Sanjay Chawla
- Division of Neonatology, Wayne State University, Detroit, MI, USA
| | - Gaurav Kapur
- Division of Pediatric Nephrology, Wayne State University, Detroit, MI, USA
| | - Girija Natarajan
- Division of Neonatology, Wayne State University, Detroit, MI, USA. .,Division of Neonatology, Department of Pediatrics, Wayne State University, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI, 48201, USA.
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Hendriks MJ, Klein SD, Bucher HU, Baumann-Hölzle R, Streuli JC, Fauchère JC. Attitudes towards decisions about extremely premature infants differed between Swiss linguistic regions in population-based study. Acta Paediatr 2017; 106:423-429. [PMID: 27880025 DOI: 10.1111/apa.13680] [Citation(s) in RCA: 7] [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: 07/05/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 11/29/2022]
Abstract
AIM Studies have provided insights into the different attitudes and values of healthcare professionals and parents towards extreme prematurity. This study explored societal attitudes and values in Switzerland with regard to this patient group. METHODS A nationwide trilingual telephone survey was conducted in the French-, German- and Italian-speaking regions of Switzerland to explore the general population's attitudes and values with regard to extreme prematurity. Swiss residents of 18 years or older were recruited from the official telephone registry using quota sampling and a logistic regression model assessed the influence of socio-demographic factors on end-of-life decision-making. RESULTS Of the 5112 people contacted, 1210 (23.7%) participated. Of these 5% were the parents of a premature infant and 26% knew parents with a premature infant. Most participants (77.8%) highlighted their strong preference for shared decision-making, and 64.6% said that if there was dissent then the parents should have the final word. Overall, our logistic regression model showed that regional differences were the most significant factors influencing decision-making. CONCLUSION The majority of the Swiss population clearly favoured shared decision-making. The context of sociocultural demographics, especially the linguistic region in which the decision-making took place, strongly influenced attitudes towards extreme prematurity and decision-making.
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Affiliation(s)
- Manya J. Hendriks
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
- Institute of Biomedical Ethics and History of Medicine; University of Zurich; Zurich Switzerland
| | - Sabine D. Klein
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Hans Ulrich Bucher
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
| | - Ruth Baumann-Hölzle
- Dialogue Ethics Foundation; Interdisciplinary Institute for Ethics in Healthcare; Zurich Switzerland
| | - Jürg C. Streuli
- Institute of Biomedical Ethics and History of Medicine; University of Zurich; Zurich Switzerland
| | - Jean-Claude Fauchère
- Department of Neonatology; Perinatal Centre; University Hospital Zurich; University of Zurich; Zurich Switzerland
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Kimura T, Takeuchi M, Imai T, Tanaka S, Kawakami K. Neurodevelopment at 3 Years in Neonates Born by Vaginal Delivery versus Cesarean Section at <26 Weeks of Gestation: Retrospective Analysis of a Nationwide Registry in Japan. Neonatology 2017; 112:258-266. [PMID: 28715797 DOI: 10.1159/000477293] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [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: 12/18/2016] [Accepted: 05/04/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND A high proportion of extremely preterm (EPT) infants are born by cesarean section (CS). However, whether the mode of delivery is related to long-term neurodevelopment in these infants is unclear. OBJECTIVES This study aimed to determine whether the mode of delivery is associated with mortality and long-term outcomes in EPT infants. METHODS We analyzed data of the Neonatal Research Network in Japan (NRNJ), a population-based, nationwide registry. Inclusion criteria were neonates who were born between 2003 and 2012 with a gestational age <26 weeks. The primary composite outcome was death before 3 years or neurodevelopmental impairment (NDI) at 3 years. Confounder-adjusted odds ratios (OR) were estimated by logistic generalized linear mixed models, which accounted for clustering within hospitals. RESULTS 2,138 eligible infants (703 by vaginal delivery [VD] and 1,435 by CS) were identified for primary analysis. The composite outcome of death or NDI was not different between both groups (66.7% by VD and 62.7% by CS, p = 0.075). After multivariate analysis adjusting for confounders, we found that CS did not improve the composite outcome of death or NDI (OR = 0.839, 95% confidence interval = 0.816-1.328, p = 0.742). For secondary outcomes, mortality (OR = 0.824, p = 0.150), NDI (OR = 1.237, p = 0.165), and other neurodevelopmental outcomes were not different between the groups. CONCLUSIONS Among neonates born at <26 weeks, CS does not improve mortality and neurodevelopmental outcomes at 3 years in the NRNJ cohort. However, because of several potential biases such as high rates of infants lost to follow-up, further evidence may be required.
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Affiliation(s)
- Takeshi Kimura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
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Geurtzen R, van Heijst A, Draaisma J, Ouwerkerk L, Scheepers H, Woiski M, Hermens R, Hogeveen M. Professionals' preferences in prenatal counseling at the limits of viability: a nationwide qualitative Dutch study. Eur J Pediatr 2017; 176:1107-1119. [PMID: 28687856 PMCID: PMC5511326 DOI: 10.1007/s00431-017-2952-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [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: 12/19/2016] [Revised: 06/12/2017] [Accepted: 06/13/2017] [Indexed: 11/27/2022]
Abstract
UNLABELLED Prenatal counseling practices at the limits of viability do vary, and constructing a counseling framework based on guidelines, professional and parental preferences, might achieve more homogeneity. We aimed to gain insight into professionals' preferences on three domains of counseling, particularly content, organization, and decision making and their influencing factors. A qualitative, nationwide in-depth exploration among Dutch perinatal professionals by semi-structured interviews in focus groups was performed. Regarding content of prenatal counseling, preparing parents on the short-term situation (delivery room care) and revealing their perspectives on "quality of life" were considered important. Parents should be informed on the kind of decision, on the difficulty of individual outcome predictions, on survival and mortality figures, short- and long-term morbidity, and the burden of hospitalization. For organization, the making of and compliance with agreements between professionals may promote joint counseling by neonatologists and obstetricians. Supportive materials were considered useful but only when up-to-date, in addition to the discussion and with opportunity for personalization. Regarding decision making, it is not always clear to parents that a prenatal decision needs to be made and they can participate, influencing factors could be, e.g., unclear language, directive counseling, overload of information, and an immediate delivery. There is limited familiarity with shared decision making although it is the preferred model. CONCLUSION This study gained insight into preferred content, organization, and decision making of prenatal counseling at the limits of viability and their influencing factors from a professionals' perspective. What is Known: • Heterogeneity in prenatal counseling at the limits of viability exists • Differences between preferred counseling and actual practice also exists What is New: • Insight into preferred content, organization, and decision making of prenatal periviability counseling and its influencing factors from a professionals' perspective. Results should be taken into account when performing counseling. • Particularly the understanding of true shared decision making needs to be improved. Furthermore, implementation of shared decision making in daily practice needs more attention.
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Affiliation(s)
- Rosa Geurtzen
- Department of Pediatrics, Radboud University Medical Center Amalia Children's Hospital, PO Box 9101, 6500HB, Nijmegen, Internal Code 804, The Netherlands.
| | - Arno van Heijst
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | - Jos Draaisma
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | - Laura Ouwerkerk
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
| | | | - Mallory Woiski
- Department of Gynecology, Radboud university medical center, Nijmegen, The Netherlands
| | - Rosella Hermens
- Scientific Institute for Quality of Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Marije Hogeveen
- Department of Pediatrics, Radboud University Medical Center Amalia Children’s Hospital, PO Box 9101, 6500HB Nijmegen, Internal Code 804, The Netherlands
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Morgan AS, Marlow N, Draper ES, Alfirević Z, Hennessy EM, Costeloe K. Impact of obstetric interventions on condition at birth in extremely preterm babies: evidence from a national cohort study. BMC Pregnancy Childbirth 2016; 16:390. [PMID: 27964717 PMCID: PMC5154160 DOI: 10.1186/s12884-016-1154-y] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 11/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background To investigate perinatal decision-making and the use of obstetric interventions, we examined the effects of antenatal steroids, tocolysis, and delivery mode on birth in a good condition (defined as presence of an infant heart rate >100 at five minutes of age) and delivery-room (DR) death in extremely preterm deliveries. Methods Prospective cohort of all singleton births in England in 2006 at 22–26 weeks of gestation where the fetus was alive at the start of labour monitoring or decision to perform caesarean section. Odds ratios adjusted for potential confounders (aOR) were calculated using logistic regression. Results One thousand seven hundred twenty two singleton pregnancies were included. 1231 women received antenatal steroids, 437 tocolysis and 356 delivered by Caesarean section. In babies born vaginally, aOR between a partial course of steroids and improved condition at birth was 1.84, 95% CI: 1.20 to 2.82 and, for a complete course, 1.63, 95% CI: 1.08 to 2.47; for DR death, aORs were 0.34 (0.21 to 0.55) and 0.41 (0.26 to 0.64) for partial and complete courses of steroids. No association was seen for steroid use in babies delivered by Caesarean section. Tocolysis was associated with improved condition at birth (aOR 1.45, 95% CI: 1.05 to 2.0) and lower odds of death (aOR 0.48, 95% CI: 0.32 to 0.73). In women without spontaneous labour, Caesarean delivery at ≤24 and 25 weeks was associated with improved condition at birth ((aORs 12.67 (2.79 to 57.60) and 4.94 (1.44 to 16.90), respectively) and lower odds of DR death (aORs 0.03 (0.01 to 0.21) and 0.13 (0.03 to 0.55)). There were no differences at 26 weeks gestation or in women with spontaneous labour. Conclusions Antenatal steroids are strongly associated with improved outcomes in babies born vaginally. Tocolysis was associated with improvements in all analyses. Effects persisted after adjustment for perinatal decision-making. However, associations between delivery mode and birth outcomes may be attributable to case selection. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1154-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrei S Morgan
- Institute for Womens' Health, UCL, 74 Huntley Street, London, WC1E 6AU, UK.
| | - Neil Marlow
- Institute for Womens' Health, UCL, 74 Huntley Street, London, WC1E 6AU, UK
| | | | - Zarko Alfirević
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Enid M Hennessy
- The Wolfson Institute, Queen Mary University of London, London, UK
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Abstract
Medium- and long-term outcomes have been collected and described among survivors of neonatal intensive care units for decades, for a number of purposes: (1) quality control within units, (2) comparisons of outcomes between NICUs, (3) clinical trials (whether an intervention improves outcomes), (4) end-of-life decision-making, (5) to better understand the effects of neonatal conditions and/or interventions on organs and/or long-term health, and finally (6) to better prepare parents for the future. However, the outcomes evaluated have been selected by investigators, based on feasibility, availability, cost, stability, and on what investigators consider to be important. Many of the routinely measured outcomes have major limitations: they may not correlate well with long-term difficulties, they may artificially divide continuous outcomes into dichotomous ones, and may have no clear relationship with quality of life and functioning of children and their families. Several investigations, such as routine term cerebral resonance imaging for preterm infants, have also not yet been shown to improve the outcome of children nor their families. In this article, the most common variables used in neonatology as well as some variables which are rarely measured but may be of equal importance for families are presented. The manner in which these outcomes are communicated to families will be examined, as well as recommendations to optimize communication with parents.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics, Université de Montréal; Division of Neonatology and centre de recherche, CHU Sainte-Justine, Montréal, Canada; Bureau de l'Éthique Clinique, Université de Montréal, Canada; Unité d'éthique clinique, unité de soins palliatifs, unité de recherche en éthique clinique et partenariat famille, Hôpital Sainte-Justine, Montréal, Canada.
| | - Barbara Farlow
- Parent and patient representative, patients for Patient Safety Canada, Edmonton, Alberta, Canada; The deVeber Institute for Bioethics and Social Research, North York, Ontario Canada
| | - Jason Baardsnes
- Parent representative, Human Health Therapeutics, National Research Council, Montréal, Canada
| | - Rebecca Pearce
- Parent representative, Villa Maria High School, Montreal, Quebec'
| | - Keith J Barrington
- Department of Pediatrics, Université de Montréal; Division of Neonatology and centre de recherche, CHU Sainte-Justine, Montréal, Canada
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Mirza H, Laptook AR, Oh W, Vohr BR, Stoll BJ, Kandefer S, Stonestreet BS. Effects of indomethacin prophylaxis timing on intraventricular haemorrhage and patent ductus arteriosus in extremely low birth weight infants. Arch Dis Child Fetal Neonatal Ed 2016; 101:F418-22. [PMID: 26733540 PMCID: PMC4935651 DOI: 10.1136/archdischild-2015-309112] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [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: 06/04/2015] [Accepted: 12/03/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Indomethacin prophylaxis (IP) reduces the risk of intraventricular haemorrhage (IVH) and patent ductus arteriosus (PDA) in preterm infants. However, the optimal time to administer IP has not been determined. We hypothesised that IP at ≤6 h is associated with a lower incidence of IVH or death than if administered at >6-24 h of age. METHODS We performed a retrospective cohort study of extremely low birth weight infants (≤1000 g birth weight) treated in the neonatal intensive care units in the Neonatal Research Network from 2003 to 2010 and who received IP in the first 24 h of age. Infants were dichotomised based upon receipt of IP at ≤6 or >6-24 h of age. The primary outcomes were IVH alone and IVH or death. Secondary outcomes were PDA alone and PDA or death. We used multivariable analyses to determine associations between the age of IP and the study outcomes expressed as an OR and 95% CI. RESULTS IP was given at ≤6 h to 2340 infants and at >6-24 h to 1915 infants. Infants given IP at ≤6 h had more antenatal steroid exposure, more inborn and less cardiopulmonary resuscitation (p<0.01). After multivariable analyses, age of IP receipt was not associated with IVH, and IVH or death but PDA receiving treatment/ligation or death was lower among IP at ≤6 h compared with IP at >6-24 h (OR 0.83, 95% CI 0.71 to 0.98). CONCLUSIONS IP at ≤6 h of age is not associated with less IVH or death, but is associated with less PDA receiving treatment/ligation or death.
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Affiliation(s)
- Hussnain Mirza
- Center for Neonatal Care, Florida Hospital for Children/UCF College of Medicine. Orlando. FL. 32804
| | - Abbot R. Laptook
- Department of Pediatrics, The Alpert Medical School of Brown University. Women & Infants Hospital of Rhode Island, Providence, RI, 02905
| | - William Oh
- Department of Pediatrics, The Alpert Medical School of Brown University. Women & Infants Hospital of Rhode Island, Providence, RI, 02905
| | - Betty R. Vohr
- Department of Pediatrics, The Alpert Medical School of Brown University. Women & Infants Hospital of Rhode Island, Providence, RI, 02905
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine. 201 Dowman Drive. Atlanta. GA. 30322
| | - Sarah Kandefer
- Research Statistician at RTI International/ Neonatal Research Network
| | - Barbara S. Stonestreet
- Department of Pediatrics, The Alpert Medical School of Brown University. Women & Infants Hospital of Rhode Island, Providence, RI, 02905
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Morgan AS, Marlow N, Costeloe K, Draper ES. Investigating increased admissions to neonatal intensive care in England between 1995 and 2006: data linkage study using Hospital Episode Statistics. BMC Med Res Methodol 2016; 16:57. [PMID: 27206571 PMCID: PMC4875750 DOI: 10.1186/s12874-016-0152-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 04/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A 44 % increase was observed in admissions to neonatal intensive care of babies born ≤26 weeks completed gestational age in England between 1995 and 2006. Hospital Episode Statistics (HES) may provide supplementary information to investigate this. The methods and results of a probabilistic data linkage exercise are reported. METHODS Two data sets were linked for each year (1995 and 2006) using 3 different algorithms (Fellegi and Sunter, Contiero and estimation-maximisation). RESULTS In 1995, linkage was performed between 668 EPICure and 486,705 HES records; 1,820 linked pairs were identified of which 422 (63.17 %) were confirmed. In 2006, from 2,750 EPICure and 631,401 HES records, 8,913 linked pairs were identified with 1,662 (60.40 %) confirmed as true. Reported births in HES at <26 weeks gestation increased 37.0 % from 867 to 1188. CONCLUSIONS Results support the EPICure findings that there was an increase in the birth rate for extremely premature babies between 1995 and 2006. There were insufficient data available for detailed investigation. Routine data sources may not be suitable for investigations at the margins of viability.
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Affiliation(s)
- Andrei S. Morgan
- />Institute for Womens’ Health, UCL, 74 Huntley Street, London, UK
| | - Neil Marlow
- />Institute for Womens’ Health, UCL, 74 Huntley Street, London, UK
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50
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Fischi-Gomez E, Muñoz-Moreno E, Vasung L, Griffa A, Borradori-Tolsa C, Monnier M, Lazeyras F, Thiran JP, Hüppi PS. Brain network characterization of high-risk preterm-born school-age children. Neuroimage Clin 2016; 11:195-209. [PMID: 26955515 PMCID: PMC4761723 DOI: 10.1016/j.nicl.2016.02.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/20/2016] [Accepted: 02/04/2016] [Indexed: 01/14/2023]
Abstract
Higher risk for long-term cognitive and behavioral impairments is one of the hallmarks of extreme prematurity (EP) and pregnancy-associated fetal adverse conditions such as intrauterine growth restriction (IUGR). While neurodevelopmental delay and abnormal brain function occur in the absence of overt brain lesions, these conditions have been recently associated with changes in microstructural brain development. Recent imaging studies indicate changes in brain connectivity, in particular involving the white matter fibers belonging to the cortico-basal ganglia-thalamic loop. Furthermore, EP and IUGR have been related to altered brain network architecture in childhood, with reduced network global capacity, global efficiency and average nodal strength. In this study, we used a connectome analysis to characterize the structural brain networks of these children, with a special focus on their topological organization. On one hand, we confirm the reduced averaged network node degree and strength due to EP and IUGR. On the other, the decomposition of the brain networks in an optimal set of clusters remained substantially different among groups, talking in favor of a different network community structure. However, and despite the different community structure, the brain networks of these high-risk school-age children maintained the typical small-world, rich-club and modularity characteristics in all cases. Thus, our results suggest that brain reorganizes after EP and IUGR, prioritizing a tight modular structure, to maintain the small-world, rich-club and modularity characteristics. By themselves, both extreme prematurity and IUGR bear a similar risk for neurocognitive and behavioral impairment, and the here defined modular network alterations confirm similar structural changes both by IUGR and EP at school age compared to control. Interestingly, the combination of both conditions (IUGR + EP) does not result in a worse outcome. In such cases, the alteration in network topology appears mainly driven by the effect of extreme prematurity, suggesting that these brain network alterations present at school age have their origin in a common critical period, both for intrauterine and extrauterine adverse conditions.
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Affiliation(s)
- Elda Fischi-Gomez
- Signal Processing Laboratory 5, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; Division of Development and Growth, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland.
| | - Emma Muñoz-Moreno
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Lana Vasung
- Division of Development and Growth, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Alessandra Griffa
- Signal Processing Laboratory 5, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; Department of Radiology, University Hospital Center (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Cristina Borradori-Tolsa
- Division of Development and Growth, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Maryline Monnier
- Follow-up Unit, Neonatology Service, Department of Pediatrics University Hospital Center (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - François Lazeyras
- Department of Radiology and Medical Informatics, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jean-Philippe Thiran
- Signal Processing Laboratory 5, École Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland; Department of Radiology, University Hospital Center (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Petra S Hüppi
- Division of Development and Growth, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
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