Predictors of Mortality in Very Low Birth Weight Neonates With Congenital Diaphragmatic Hernia

BACKGROUND

Limited data exists regarding the mortality of very low birth weight (VLBW) neonates with congenital diaphragmatic hernia (CDH). This study aims to quantify and determine predictors of mortality in VLBW neonates with CDH.

METHODS

This analysis of 829 U.S. NICUs included VLBW [birth weight ≤1500g] neonates, born 2011-2021 with and without CDH. The primary outcome was in-hospital mortality. A generalized estimating equation regression model determined the adjusted risk ratio (ARR) of mortality.

RESULTS

Of 426,140 VLBW neonates, 535 had CDH. In neonates with CDH, 48.4% had an additional congenital anomaly vs 5.5% without. In-hospital mortality for neonates with CDH was 70.4% vs 12.6% without. Of those with CDH, 73.3% died by day of life 3. Of VLBW neonates with CDH, 38% were repaired. A subgroup analysis was performed on 60% of VLBW neonates who underwent delivery room intubation or mechanical ventilation, as an indicator of active treatment. Mortality in this group was 62.7% for neonates with CDH vs 16.4% without. Higher Apgars at 1 min and repair of CDH were associated with lower mortality (ARR 0.91; 95%CI 0.87,0.96 and ARR 0.28; 0.21,0.39). The presence of additional congenital anomalies was associated with higher mortality (ARR 1.14; 1.01,1.30).

CONCLUSION

These benchmark data reveal that VLBW neonates with CDH have an extremely high mortality. Almost half of the cohort have an additional congenital anomaly which significantly increases the risk of death. This study may be utilized by providers and families to better understand the guarded prognosis of VLBW neonates with CDH.

TYPE OF STUDY

Level II.

LEVEL OF EVIDENCE

Level II.

Comparison of volume and frequency advancement feeding protocols in very low birth weight neonates

Objective:

To determine the outcomes in very low birth weight (VLBW) neonates receiving volume advancement versus frequency advancement feeding protocols.

Methods:

This controlled clinical trial was conducted in Children Hospital Multan within duration of 6 months from February 2017 to August 2017. VLBW neonates having weight < 1500 g at the time of birth were included. The protocol for frequency advancement (FA) group was to give 1 ml/kg human or pre-formula milk after every 8 hours and in volume advancement (VA) group after every 3 hours initially. After three days, in FA group duration of feeds was decreased gradually from 8 to 2 hours and feed volume of 10 ml.kg^-1.day^-1 until full-recommended dose of feeding i.e. 150 ml.kg^-1.day^-1 reached. While in VA group, volume of 20 ml.kg^-1.day^-1 was given until full-recommended dose of feeding reached. Days to achieve full feed, weight gain, and length of hospital stay were primary study outcomes.

Results:

Baseline weight of neonates was 1148 (111) grams in VA 1179 (106) grams in FA groups (p-value 0.18). In VA group, full feed was achieved in 11.04 (2.38) days versus 15.76 (2.48) days in FA group (P-value <0.001). Duration of IV fluid therapy were 13.5 (8.4) days in FA group versus 9.4 (7.6) in VA group (p-value <0.001). Moreover weight gain at the end of feeding protocol was significantly higher in VA group 1440 (78) grams versus 1284 (99) grams in FA group (P-value <0.001). Necrotizing entero-colitis occurred in only one neonate that was belonging to volume advancement group.

Conclusion:

Volume advancement (VA) feeding is better as compared to frequency advancement (FA) feeding in very low birth weight neonates.

[Parenteral nutrition in premature babies with a birth weight <1500g: a systematic single-center analysis and comparison with current guidelines]

BACKGROUND

Parenteral and enteral nutrition are essential for both growth and development of preterm infants. Based on the results of many studies, the rate of nutritional growth and the amount of substrate delivered parenterally are under debate.

OBJECTIVE

The main aim of this study was to assess parenteral nutrition in very and extremely immature preterm infants, i.e. very low birth weight (VLBW, birth weight <1500g) and extremely low birth weight (ELBW, birth weight <1000g) neonates, and to compare the amount of parenterally delivered substrate in our neonatal intensive care unit (NICU) to current German guidelines.

METHODS

Retrospective audit at our tertiary NICU at the University Children's Hospital of Saarland, Homburg, Germany between 1 January 2009 and 31 December 2010.

RESULTS

In total, 100 premature neonates were included. The mean gestational age was 29.6 weeks (range 24.4-34.1 weeks) and the mean birth weight was 1119 g ± 260 g (range 570 g-1490 g). Comparing the amount of fluids, glucose, amino acids, lipids and kcals with the current guidelines of the German Society for Nutritional Medicine in preterm infants, only glucose was adequately given; however, a substantial number of weight-dependent (more often in ELBW neonates) episodes of hyperglycemia requiring insulin treatment were also seen. During the first 3 weeks of life a substantial drop in body weight, length and head circumference occurred in our study cohort. In contrast, at 2 years corrected age, catch-up growth was seen in our cohort with anthropometric data now comparable to healthy term infants. Using the Bayley II test for developmental outcome assessment, at 2 years corrected age 78.6% (33/42) of infants demonstrated normal development.

CONCLUSIONS

This retrospective data analysis demonstrated inadequate provision of parenteral nutrition in our NICU, which was often not in line with current German guidelines. This was associated with inadequate growth in our cohort, most notably during the first 3 weeks of life; however, implementation of current guidelines is impeded by metabolic disturbances in this cohort, most notably in ELBW neonates. Whether adherence to published guidelines will result in better early ex utero growth, and whether this normalized growth pattern will translate into better long-term outcome on a metabolic and neurological level, remains unclear.

Assessment of optimal initial dosing regimen with vancomycin pharmacokinetics model in very low birth weight neonates

INTRODUCTION

Pharmacokinetic of vancomycin in very low birth weight neonates showed big variety, and limited data were available due to very minor population. These facts make it difficult to adjust its optimal initial dosage. Therefore, this study was to develop optimal dosing regimen of vancomycin in very low birth weight neonates.

METHODS

Between 2010 and 2015, low birth weight neonates (≤1500 g) were included in a population pharmacokinetics analysis. Based on the pharmacokinetic parameters we estimated, we simulated individual blood concentrations of vancomycin and evaluated the probability of its pharmacokinetics/pharmacodynamics (PK/PD) target attainment, such as 24-h area under the concentration-time curve (AUC₂₄)/MIC (≥400) and blood trough concentration (10-20 μg/mL), as primary measure for several dosing regimens by Monte Carlo simulation method.

RESULTS

Ten patients were prescribed vancomycin and detected its blood concentrations as routine pharmacy practice to adjust the dosage. A one-compartment model was used and clearance significantly correlated with serum creatinine and the volume of infusion. In this model, vancomycin dose at 10 mg/kg three times a day (TID) was predicted to result 86.7% of neonates for an MIC of 1 μg/mL achieving AUC/MIC of ≥400 and 30.6% of the neonates for an MIC of 2 μg/mL. Moreover, the probability of reaching the target trough concentration was 70.5% for patients treated with vancomycin 10 mg/kg TID.

DISCUSSION

We recommended vancomycin 10 mg/kg TID as initial dosage regimens for low birth weight neonates infected with the pathogens showed MIC of ≤1 μg/mL.