Compared to CPAP extubation to non-invasive ventilation is associated with higher risk of bronchopulmonary dysplasia in extremely low birth weight infants

OBJECTIVE

While non-invasive ventilation (NIV) has been associated with improved extubation rates, its impact on bronchopulmonary dysplasia (BPD) remains unclear.

METHOD

In this retrospective, chart review study of infants admitted to the Cleveland Clinic, we aimed to compare the incidence of BPD among extremely low birth weight (ELBW) infants extubated to continuous positive pressure (CPAP) versus those extubated to NIV via RAM cannula or biphasic CPAP. Data collected included demographics, ventilatory modes, extubation data, and presence of complications. Infants extubated to either CPAP or NIV were compared using Wilcoxon rank- sum and Chi-square tests, and data were corrected using logistic regression models. Data are presented as medians.

RESULTS

A total of 120 infants were included, of whom 62% were extubated to NIV. The incidence of BPD was significantly lower in the CPAP group vs NIV (57% vs. 78%, p = 0.011). Infants in the CPAP group were heavier (birth weight (BWT) of 833 vs 724 grams, p = 0.005), more mature (gestation age (GA) 27 vs 25 weeks, p <  0.001) and were extubated significantly earlier (2 vs 8 days, p <  0.001). After adjusting for BWT and GA, NIV continued to be significantly associated with higher incidence of BPD among those extubated on the first day of life (odds ratio 5.9; 95% CI: 1.2-29.1, p = 0.029).

CONCLUSION

This study concludes that, as compared to CPAP, early use of NIV is associated with higher risk of BPD in ELBW infants. Further investigation using prospective studies is recommended to validate these findings.

Effects of in-utero exposure to selective serotonin reuptake inhibitors and venlafaxine on term and preterm infants

OBJECTIVE

We hypothesized that in-utero SSRI exposure affects Apgar scores and immediate post-delivery oxygen requirements.

STUDY DESIGN

SSRI in-utero exposure was assessed retrospectively in preterm neonates ≥ 28 weeks gestation and term neonates. Primary outcome was Apgar <7 at five minutes and delivery room oxygen requirements. Secondary endpoints included one-minute Apgar, length of stay, birth weight, and NICU admission.

RESULTS

Fifty-one preterm and 117 term neonates were exposed to a SSRI; mostly to sertraline. Pre-term SSRI-exposed neonates had 4.1 times higher delivery room oxygen requirements. One minute Apgar <7 was 3.5 times higher and NICU admission 5 times higher 95% CI (1.3-19) in SSRI-exposed term neonates. Higher doses of sertraline had associated adverse outcomes.

CONCLUSION

In-utero SSRI exposure was associated with increased neonatal care at birth, differences in Apgar scores compared with controls, and increased NICU admissions. Higher sertraline doses were associated with poorer outcomes.

Administration of 100% oxygen does not hasten resolution of symptomatic spontaneous pneumothorax in neonates

OBJECTIVE

To compare the effectiveness of 100% oxygen therapy vs oxygen treatment with targeted pulse oximetry in the management of symptomatic small to moderate spontaneous pneumothorax (SP). In total, 100% oxygen treatment for SP has been a common practice in neonatology, albeit there is little evidence to validate its efficacy.

STUDY DESIGN

A retrospective chart review of 83 neonatal records with the diagnosis of pneumothorax was conducted. Infants <35 weeks gestation, those with large pneumothoraces requiring chest tube drainage and/or ventilatory support were excluded. Data gathered included demographics, vital signs, treatment information and clinical indicators of resolution of symptoms.

RESULT

In total, 45 neonates with SP were included in the study. Groups were similar for gestational age, birth weight, Apgar scores, gravidity, parity, gender, race, pneumothorax size and location. Patients in the 100% oxygen therapy group received a significantly longer oxygen treatment (21.3 vs 8 h, P < 0.001), required longer intravenous fluid treatment (48.6 ± 29.9 vs 31.3 ± 18.8 h, P = 0.03) and were delayed in reaching full feeds (44.1 ± 25.7 vs 29.5 ± 18.8 h, P = 0.03) compared with the oxygen-targeted treatment group. Time to first oral feeding, time to resolution of tachypnea and length of stay were similar in both groups.

CONCLUSION

There are no clinically significant advantages to using 100% oxygen in the treatment of symptomatic small to moderate SP. In fact, it may result in longer exposure to unnecessary oxygen treatment and toxicity. Oxygen should be reserved for those who are hypoxic and adjusted to comply with accepted saturation levels in neonates.

Severe pulmonary hypertensive vascular disease in two newborns with aneurysmal vein of galen

Arteriovenous malformation of the vein of Galen (AVG) is a rare entity in the newborn with a high morbidity and mortality. We present two cases of fatal AVG with persistent pulmonary hypertension of the newborn and significant pulmonary hypertension documented by autopsy histopathology. The pathophysiology is reviewed and a proposed mechanism of the association between AVG and pulmonary hypertension is discussed.

Estimation of gluconeogenesis in newborn infants

The rate of glucose turnover (R(a)) and gluconeogenesis (GNG) via pyruvate were quantified in seven full-term healthy babies between 24 and 48 h after birth and in twelve low-birth-weight infants on days 3 and 4 by use of [(13)C(6)]glucose and (2)H(2)O. The preterm babies were receiving parenteral alimentation of either glucose or glucose plus amino acid with or without lipids. The contribution of GNG to glucose production was measured by the appearance of (2)H on C-6 of glucose. Glucose R(a) in full-term babies was 30 +/- 1.7 (SD) micromol. kg(-1). min(-1). GNG via pyruvate contributed approximately 31% to glucose R(a). In preterm babies, the contribution of GNG to endogenous glucose R(a) was variable (range 6-60%). The highest contribution was in infants receiving low rates of exogenous glucose infusion. In an additional group of infants of normal and diabetic mothers, lactate turnover and its incorporation into glucose were measured within 4-24 h of birth by use of [(13)C(3)]lactate tracer. The rate of lactate turnover was 38 micromol. kg(-1). min(-1), and lactate C, not corrected for loss of tracer in the tricarboxylic acid cycle, contributed approximately 18% to glucose C. Lactate and glucose kinetics were similar in infants that were small for their gestational age and in normal infants or infants of diabetic mothers. These data show that gluconeogenesis is evident soon after birth in the newborn infant and that, even after a brief fast (5 h), GNG via pyruvate makes a significant contribution to glucose production in healthy full-term infants. These data may have important implications for the nutritional support of the healthy and sick newborn infant.

Effect of reduced inspired oxygen on fetal growth and maternal glucose metabolism in rat pregnancy

The effect of prolonged exposure to a reduced fraction of inspired oxygen ([FiO2] 0.17 for 3 days) on maternal glucose kinetics, placental glucose transporters GLUT1 and GLUT3, and fetal growth was examined in rat pregnancy. Arterial and venous catheters were placed 3 days before the study. [3-(3)H]glucose tracer and deuterium labeling of water were used to measure the rates of glucose turnover and gluconeogenesis (GNG), respectively. Glucose uptake by maternal tissues was measured using [14C]2-deoxyglucose. Exposure to a reduced FiO2 resulted in a significant decrease (mean +/- SE) in fetal weight (room air, 4.02 +/- 0.04 g; 0.17 FiO2, 3.27 +/- 0.6 g, P < .02). There was a significant increase in the maternal-fetal glucose gradient (maternal-fetal glucose ratio: room air, 1.48 +/- 0.11; 0.17 FiO2, 2.26 +/- 0.24, P < .05), but there was no change in the maternal or fetal blood lactate concentration. No significant change in maternal blood pH was observed; however, a significant decrease in the blood partial pressure of O2 (PO2) occurred (room air, 97 +/- 0.5 torr; 0.17 FiO2, 81 +/- 1.8) on day 3. There was no change in the rate of turnover of glucose or GNG in the maternal compartment, nor was there any effect on glucose uptake by the maternal tissues. Placental GLUT1 and GLUT3 mRNA were not different in the control or experimental animals. We conclude that a mild reduction in the FiO2 for 3 days in rat pregnancy results in a significant fetal growth restriction that is not related to any observed alteration in maternal glucose metabolism. The lower glucose concentration in the fetal blood may be the consequence of an increase in fetal glucose metabolism, thereby resulting in an increased maternal-fetal gradient of glucose.

Glycemia-lowering effect of cobalt chloride in the diabetic rat: role of decreased gluconeogenesis

Results of previous studies indicated that treatment of diabetic rats (induced by streptozotocin) with cobalt chloride (CoCl2) resulted in a significant decrement in serum glucose concentration. The present study was designed to determine the potential role of enhanced glucose uptake vs. decreased glucose production in the above response. The rate of systemic appearance of glucose, measured under fasting conditions using [3-3H]glucose tracer, was reduced from 35.5 +/- 2.5 to 17.5 +/- 1.8 micromol . kg-1 . min-1 in diabetic rats treated with 2 mM CoCl2 added to the drinking water for 10-14 days (P < 0.01). Tissue accumulation of intravenously administered 2-deoxy-[14C]glucose was significantly reduced in kidney and eye of diabetic rats treated with CoCl2, whereas the uptake remained unchanged in several other tissues including cerebrum, red and white skeletal muscle, heart, and liver. The relative content of phosphoenolpyruvate carboxykinase (PEPCK) mRNA was increased 3.1-fold in livers of diabetic compared with normal rats (P < 0.001), and treatment of diabetic rats with CoCl2 decreased hepatic PEPCK mRNA levels to normal. The content of PEPCK mRNA in the liver was decreased by 33% in CoCl2-treated normal rats (P < 0.05). Treatment with CoCl2 resulted in no change in cAMP levels in the livers of either diabetic or normal rats. These results suggest that the glycemia-lowering effect of CoCl2 is mediated by reductions in the rate of systemic appearance of glucose and hepatic gluconeogenesis.