The Effect of Continuous PEEP Administration during Surfactant Instillation on Cerebral Hemodynamics in Intubated Preterm Infants: A NIRS Study

OBJECTIVE

There is an ongoing debate about the best and comfortable way to administer surfactant. We hypothesized that uninterrupted respiratory support and continuous PEEP implementation while instilling surfactant via endotracheal tube (ETT) with side port will result in higher regional cerebral tissue oxygenation (rcSO2) and the alterations in cerebral hemodynamics will be minimal.

STUDY DESIGN

Preterm infants who required intubation in the delivery room and/or in the first 24 hours of life with gestational age <32 were enrolled. Patients were intubated either via conventional ETT or ETT with side port (Vygon) with appropriate sizes. Following neonatal intensive care unit admission a near-infrared spectroscopy (NIRS) probe was placed on the forehead and each infant was started to be monitored with NIRS. In conventional ETT group, patients separated from the ventilator while surfactant was instilled. In ETT with side port group, respiratory support was not interrupted during instillation. Heart rate, oxygen saturation, rcSO2, cerebral fractional tissue oxygen extraction (cFTOE), and blood pressures were recorded.

RESULTS

A total of 46 infants were analyzed. Surfactant was instilled with conventional ETT in 23 and ETT with side port in 23 infants. Birth weights (1,037 ± 238 vs. 1,152 ± 277 g) and gestational ages (28 ± 2.3 vs. 29 ± 1.6 weeks) did not differ between groups. During instillation of surfactant, rcSO2 levels [61.5 (49-90) vs. 70 (48-85)] and cFTOE levels 0.28 (0.10-0.44) vs. 0.23 (0.03-0.44)] were similar (p = 0.58 and 0.82, respectively).

CONCLUSION

Interruption of respiratory support during surfactant instillation did not significantly alter the cerebral tissue oxygenation. These results did not support our hypothesis and should be confirmed with further studies.

KEY POINTS

· Monitoring intracerebral oxygenation changes during surfactant administration with NIRS is feasible.. · The surfactant administration method does not significantly alter the cerebral oxygenation.. · Surfactant administration itself rather than the method caused a transient drop in cerebral NIRS readings..

Thyroid Function in Neonates with Hypoxic Ischemic Encephalopathy

We aimed to examine heel prick (capillary) and serum thyroid function test (TFT) results in neonates with hypoxic ischemic encephalopathy (HIE) to evaluate the effect of asphyxia and therapeutic hypothermia (TH) on thyroid functions. This retrospective chart review included infants who were born after 34 weeks of gestation, were diagnosed and treated for HIE. The patients were divided into those who did and did not undergo TH and the groups were compared in terms of demographic characteristics, laboratory results, capillary thyroid-stimulating hormone (cTSH) levels, and serum thyroid-stimulating hormone (TSH) and free thyroxine (fT4) levels. A total of 111 neonates were included in the study. There was no difference between the TH group (n = 90) and the nonhypothermia group (n = 21) in terms of median gestational age (38.3 ± 2.1 weeks vs. 38.6 ± 1.8 weeks, p = 0.42) or birth weight (3182 ± 509 g vs. 3174 ± 573 g, p = 0.72). Serum TFT was performed at a median of 10 days (range, 2-43) and capillary TSH analyzed at a median of 6 days (range, 1-26). Capillary TSH at 96 hours was analyzed in 36 patients in the TH group and 19 patients in the nonhypothermia group. Serum TSH and fT4 levels were similar in both groups (p = 0.29, p = 0.1). Overall cTSH and cTSH obtained in the first 4 days were 2.2 (0.5-10) and 4.3 (0.5-94), p = 0.059; 2 (0.5-22) and 5 (0.5-94), p = 0.04, respectively, whereas cTSH obtained after day 4 was similar in both groups (p = 0.058). Abnormal serum TSH (>5.5 mU/mL) was more frequent in the hypothermia group (44.4% vs. 19%, p = 0.026). Our results suggest that TH may cause some alterations on TFTs. Therefore, it may be reasonable to repeat TSH screening after TH.

Prognostic value of the oxygenation index to predict survival in infants with congenital diaphragmatic hernia

Background: Congenital Diaphragmatic Hernia (CDH) is associated with significant morbidity and mortality. We aimed to investigate the relationship between survival and oxygenation index calculated in the first 12 hours of life in neonates with CDH.  Methods: Various scoring systems have been developed to predict and determine the course of the disease in this disease group with a high mortality rate. In our study, we planned to investigate the use of APGAR scores, Neonatal acute physiological perinatal spread score-II, and oxygenation index in predicting survival. Patients born in Ankara City Hospital between March 2019 and November 2021 and followed up due to congenital diaphragmatic hernia were included in the study. Preductal oxygen saturation (sPO2) was manipulated to be 80-95% and postductal >70%. Target PaCO2 values were set to be 50-70 mmHg. Oxygenation index scores were calculated using the formula mean airway pressure (MAP) (cmH2O) x fraction of inspired oxygen (FiO2) (%) / partial pressure of arterial oxygen (PaO2) (mmHg). Results: The 5th-minute APGAR scores of the patients with the congenital diaphragmatic hernia in our study were lower in the non-survivors group than the survivors group (p=0.010). SNAPPE-II and OI scores were statistically significantly higher in the nonsurvivors group (p=0.003 and p=0.002). Conclusion: The oxygenation index was determined to be an independent predictive parameter in mortality (OR: 4.519 CI: 1.301-654.645, p=0.034). The results of our study show that the oxygenation index is a reliable parameter in predicting survival.

The Effect of Antenatal Steroid Therapy on Early Inflammation Markers and Leukocyte Counts in Premature Infants

ObjectiveWe investigated the effect of antenatal steroid therapy(AST) on white blood cell (WBC) and neutrophil counts and the inflammatory markers C-reactive protein(CRP), interleukin 6(IL-6), interleukin 10(IL-10), and beta-2 microglobulin(ß2M) in preterm infants.Materials MethodNeonates born at ≤34 weeks of gestation and admitted at hospital between May and November 2018 were included. The neonates were divided into three groups based on AST dose administered: 24 mg betamethasone (full course), 12 mg betamethasone (incomplete course), and no AST. 170 infants were analyzed.ResultsOf these, 45.2% (n = 77) received a full course of AST, 38.8% (n = 66) received an incomplete course of AST, and 15.8% (n = 27) did not receive AST. WBC, CRP, IL-6, IL-10, and ß2M levels were similar between the three groups, whereas neutrophil count was significantly lower in full course AST group.ConclusionConsistent with the literature data, AST was associated with reduced neutrophil count but did not affect the other inflammatory markers studied.

Factors associated with neurodevelopmental impairment in preterm infants with bronchopulmonary dysplasia

OBJECTIVE

Bronchopulmonary dysplasia (BPD) is a common and serious complication in preterm infants with very low birth weight and is known to lead to poor neurodevelopmental outcomes. This study aimed to identify factors associated with neurodevelopmental impairment (NDI) in patients with moderate to severe BPD.

SUBJECTS AND METHODS

A total of 83 preterm infants born between 24- and 29-weeks' gestation who were admitted to the neonatal intensive care unit and developed moderate/severe BPD between 2013 and 2017 were retrospectively evaluated. Developmental assessment was performed at 18 to 24 months of corrected age using the Bayley Scales of Infant Development II (BSID-II). Patients with NDI (n=41) and without NDI (n=42) were compared.

RESULTS

BSID-II Mental Development Index and Psychomotor Development Index scores were 87±11 and 83±8 in the non-NDI group and 57±12 and 52±8 in the NDI group, respectively (p<0.001). The NDI group had significantly lower birth weight (847±174 vs. 1012±192 g) and gestational age (26.1±1.3 and 27.6±1.6 weeks) compared to the non-NDI group (p<0.001). Intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, exposure to steroids, duration of respiratory support, and length of hospital stay were significantly higher in the NDI group (p<0.001).

CONCLUSIONS

Many of the conditions in this study were found to be associated with poor neurodevelopmental outcomes in patients with BPD, such as prolonged respiratory support, prolonged hospitalization, intraventricular hemorrhage, retinopathy, and steroid therapy, can be avoided or prevented with strict protocols and prevention strategies. Appropriate management of comorbid risk factors may help prevent poor neurodevelopmental outcomes.

Cycled Lighting Versus Continuous Near Darkness in Preterm Infants: A Randomized Controlled Trial

OBJECTIVE

To compare the effectiveness of cycled lighting (CL) or continuous near darkness (CND) on weight in preterm infants.

STUDY DESIGN

Total 147 infants with a gestational age 25-32 weeks and/or a birth weight 750-1500 g were included in the study. The infants were classified into two groups: CL and CND. Weight on postnatal day 14, weight at corrected 35 weeks, mean rectal temperature and serum growth hormone, cortisol, melatonin levels at 35 weeks' post menstrual age (PMA), weekly weight gain, full enteral feeding time, duration of mechanical ventilation, retinopathy of prematurity (ROP), length of stay in the hospital, weight and length at three and six months corrected age were compared between the groups.

RESULTS

There were no differences between weights on postnatal day 14. Anthropometric parameters and mean rectal temperatures of groups also were not different at 35 weeks' PMA. There were no differences among the groups in duration of full enteral feeding time, length of stay in hospitalization, duration of mechanical ventilation, ROP and anthropometric parameters. Further, serum growth hormone, cortisol, and melatonin levels were similar between the groups at 35 weeks' PMA.

CONCLUSION

CL and CND did not have any advantages over each other.

Lung Lavage with Dilute Surfactant vs. Bolus Surfactant for Meconium Aspiration Syndrome

OBJECTIVE

To compare the effectiveness of lung lavage with surfactant vs. bolus surfactant treatment in meconium aspiration syndrome (MAS).

PATIENTS AND METHODS

This randomized controlled trial included newborns ventilated with MAS. In lavage group (n = 17) 30 ml/kg of diluted porcine surfactant was instilled into the lung. In bolus group (n = 16) porcine surfactant (100 mg/kg) was administered as bolus. Respiratory outcomes and mortality were compared between groups.

RESULTS

Duration of respiratory support was found to be similar between lavage and bolus groups (3 vs. 3.5 days, p = 0.36). Death or requirement for extracorporeal membrane oxygenation (ECMO) was 12% vs. 6%; respectively (RR: 2, 95% CI 0.16-24.48; p = 1.0). Duration of oxygen therapy, high-frequency ventilation or inhaled nitric oxide requirement did not differ among the groups.

CONCLUSION

Lung lavage did not show any advantage over bolus therapy on duration of respiratory support. The incidence of pneumothorax and surfactant re-administration decreased nonsignificantly in lavage group.

CLINICAL TRIAL REGISTRATION

We registered the trial to ClinicalTrials.gov (http://clinicaltrials.gov) under identifier NCT02041546.

REGISTRY NAME

Lung Lavage With Dilute Poractant Alfa for Meconium Aspiration Syndrome.

Five-year single center experience on surfactant treatment in preterm infants with respiratory distress syndrome: LISA vs INSURE

BACKGROUND

Surfactant administration traditionally involved endotracheal intubation and mechanical ventilation, which is associated with a risk of barotrauma and volutrauma.

OBJECTIVE

To compare the morbidity and mortality rates between LISA-treated and INSURE-treated premature babies with respiratory distress syndrome (RDS).

METHODS

We assessed retrospectively the medical records of preterm infants who were born at 25^0/7 to 29^6/7 weeks of gestation and were administered surfactant initially either with LISA or INSURE method over a five-year period.

RESULTS

Analysis of the data of 205 LISA-treated and 178 INSURE-treated infants revealed the mean gestational age as 28.1 ± 1.3 and 28 ± 1.3 weeks and mean birth weight as 1041 ± 205 and 1029 ± 222 g in LISA and INSURE groups, respectively. The mechanical ventilation requirement in the first 72 h of life (%26.8-%42.1, p = 0.002) and the incidence of moderate-severe BPD (%12.2-%21.9, p = 0.01) were lower in LISA-treated infants. LISA method was found as an independent factor in reducing mechanical ventilation requirement in the first 72 h of life and incidence of moderate-severe BPD [RR: -0.49 (%95 CI -0.28 to -0.85), p = 0.01].

CONCLUSION

Data obtained from our five-year clinical experience are comparable with the recent literature. LISA is currently the most suitable method of surfactant administration and it should be the first choice in spontaneously breathing infants considering its favorable effects on respiratory morbidities in preterm infants with RDS.

Sustained lung inflation at birth via short binasal prong in very low birth weight preterm infants: A retrospective study

BACKGROUND AND OBJECTIVES

It is believed, that sustained lung inflation (SLI) at birth in preterm infants reduces the need for mechanical ventilation (MV) and improves respiratory outcomes. The aim of this study was to compare need for MV in preterm infants at high risk for respiratory distress syndrome (RDS) after prophylactic SLI via short binasal prongs at birth combined with early nasal continuous positive airway pressure (nCPAP) versus nCPAP alone.

METHODS

Medical records of infants born at 26^0/7 to 29^6/7 weeks gestation through 2015 and 2017 were retrospectively assessed. Infants who get sustained inflations at 25 cmH₂ O pressure for 15 s following delivery via binasal short prongs comprised the study group. Gestational age matched infants who was supported solely with nCPAP (6 cmH₂ O PEEP) comprised the control group. Early rescue surfactant (200 mg/kg poractant alfa) was delivered using the less invasive surfactant administration technique in infants with established RDS.

RESULTS

A total of 215 infants were analyzed. Fewer infants in the SLI group required MV within the first 72 h of life compared to the control group (25.7% vs 56.9%, P < 0.001). In multiple logistic regression analysis, SLI emerged as an independent factor for reduced MV need. Bronchopulmonary dysplasia (BPD) incidence including mild BPD was significantly lower in the SLI group (31.9% vs 48%, P = 0.01); however, moderate and severe BPD rates did not reach to a statistical significance (11.5% vs 20.6%, P = 0.06).

CONCLUSION

Prophylactic SLI maneuver at birth for preterm infants with impending RDS reduces the need for MV with no adverse effects.

Evaluation of prolonged pain in preterm infants with pneumothorax using heart rate variability analysis and EDIN (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) scores

Purpose

The EDIN scale (Échelle Douleur Inconfort Nouveau-Né, neonatal pain and discomfort scale) and heart rate variability has been used for the evaluation of prolonged pain. The aim of our study was to assess the value of the newborn infant parasympathetic evaluation (NIPE) index and EDIN scale for the evaluation of prolonged pain in preterm infants with chest tube placement due to pneumothorax.

Methods

This prospective observational study assessed prolonged pain in preterm infants with a gestational age between 33 and 35 weeks undergoing installation of chest tubes. Prolonged pain was assessed using the EDIN scale and NIPE index.

Results

There was a significant correlation between the EDIN scale and NIPE index (r=-0.590, P=0.003). Prolonged pain is significantly more severe in the first 6 hours following chest tube installation (NIPE index: 60 [50–86] vs. 68 [45–89], P<0.002; EDIN score: 8 [7–11] vs. 6 [4–8], P<0.001).

Conclusion

Prolonged pain can be accurately assessed with the EDIN scale and NIPE index. However, evaluation with the EDIN scale is time-consuming. The NIPE index can provide instantaneous assessment of prolonged and continuous pain.

Effects of Pacifier Use on Transition Time from Gavage to Breastfeeding in Preterm Infants: A Randomized Controlled Trial

BACKGROUND

Nonnutritive sucking (NNS) has been identified as having many benefits for preterm infants. NNS may improve the efficacy of oral feeding, reduce the length of time spent in orogastric (OG) tube feeding, and shorten the length of hospital stays for preterm infants.

AIM

This study aimed to assess the effect of pacifiers on preterm infants in the transition from gavage to oral feeding, their time to discharge, weight gain, and time for transition to full breastfeeding.

METHODS

A prospective, randomized controlled trial was conducted in our center. Ninety infants were randomized into two groups: a pacifier group (PG) (n = 45) and a control group (n = 45). Eligibility criteria included body weight less than or equal to 1,500 g, gestational age (GA) younger than 32 weeks, tolerating at least 100 kcals/kg/day by OG feeding, growth parameters appropriate for GA, and a stable clinical condition.

RESULTS

Mean GAs were 29.2 ± 1.86 versus 28.4 ± 1.84 weeks (p = 0.46), and birth weights were 1,188.2 ± 272 versus 1,112.8 ± 267 g (p = 0.72) in the PG and CG groups, respectively. The time for transition to full oral feeding (38 ± 19.2 days), time to transition to full breastfeeding (38.1 ± 20 days), and time to discharge (48.4 ± 19.2 days) in the PG were significantly shorter compared with the control group (49.8 ± 23.6, 49.1 ± 22, 65.3 ± 30.6 days, respectively) (p < 0.05). For preterm infants with gastrointestinal motility disturbance, similar symptoms (regurgitation, vomiting, abdominal distension) (n = 6, 22%) in the PG were significantly lower than the control group (n = 21, 77.8%) (p < 0.05).

CONCLUSION

In this study, we determined that the method of giving pacifiers to preterm infants during gavage feeding reduced the infants' transition period to oral feeding and the duration of hospital stay. In addition, the pacifiers could be used during gavage feeding and in the transition from gavage to oral/breastfeeding in preterm infants to encourage the development of sucking ability.

Risk Factors for Hospitalization due to Lower Respiratory Tract Infection in Preterm Infants on Palivizumab Prophylaxis

OBJECTIVE

To determine the risk factors associated with lower respiratory tract infections (LRTI) related hospitalizations in preterm infants receiving palivizumab throughout the high season for respiratory syncytial virus (RSV) infection.

METHODS

Premature infants who were commenced on palivizumab prophylaxis during the RSV season were included in the study following parental consent. Information on demographic, social, prenatal and postnatal clinical characteristics was recorded and risk factors associated with hospitalization were evaluated for each patient.

FINDINGS

While 234 participants (Group 1, 92.8%) did not require hospitalization during the study period, 18 patients (Group 2, 7.2%) were hospitalized at least once for LRTI during the RSV season. The rate of moderate-severe bronchopulmonary dysplasia (BPD) was significantly higher in group 2 compared to group 1 (38.9% vs 16.2%; P=0.016). Of the 18 infants who were hospitalized, 6 (33.3%) tested positive for RSV while the remaining 12 patients (66.7%) were negative for RSV. Odds ratio (OR) analysis of several risk factors revealed the presence of BPD (OR: 3.28; 95%CI: 1.19-9), being from a family with low socioeconomic status (OR: 3.64; 95%CI 1.08-12.3) to be associated with a higher likelihood of LRTI-related hospitalization.

CONCLUSION

Our data demonstrated that RSV is an important LRTI agent and cause of hospitalization especially in preterm infants with additional risks such as BPD, gestational age of <28 weeks and low socioeconomic status. We suggest that improving care conditions and decreased BPD with prematurity would help in prevention of LRTI hospitalization.

The effect of histological chorioamnionitis on the short-term outcome of preterm infants ≤32 weeks: a single-center study

BACKGROUND AND OBJECTIVES

Chorioamnionitis (CA) is an acute inflammation of the membranes and chorion of the placenta. The aim of this study was to determine the effect of histological CA on the short-term outcome of preterm infants.

SUBJECTS AND METHODS

The clinical characteristics and outcomes of the preterm infant including respiratory distress syndrome, duration of mechanical ventilation, patent ductus arteriosus (PDA) requiring medical treatment or ligation, necrotizing enterocolitis, bronchopulmonary dysplasia, death and intraventricular hemorrhage (IVH; grade III-IV) were analyzed.

RESULTS

Two hundred and eighty-one infants born at ≤32 weeks gestational ages were included. Infants were divided into two groups: one with histological CA (n = 145) and without histological CA (n = 136). Mean gestational age was 28.8 ± 2.6 weeks and 29.1 ± 2.5 weeks, and mean birth weight was 1138 ± 350 g and 1210 ± 299 g, respectively. There were no differences in gestational age and birth weight among the groups. Compared with the group, histological CA was associated with early onset sepsis (p = 0.007), PDA (p = 0.003), IVH (p = 0.03), and death (p = 0.04).

CONCLUSION

Maternal histological CA is an important risk factor for preterm deliveries and associated with serious morbidities such as early onset sepsis, IVH, PDA and increased mortality.

Povidone-iodine for persistent air leak in an extremely low birth weight infant

Chemical pleurodesis with povidone-iodine has been used to treat congenital idiopathic chylothorax in neonates. We report successful use of povidone-iodine in an extremely premature infant to treat a pneumothorax that had persisted for more than one week despite high-frequency ventilation.

The association of a cervical length of <25 mm in high-risk pregnancies on neonatal morbidity and mortality in preterm infants

PURPOSE

To evaluate and compare the effects of a short cervix (<25 mm) on neonatal morbidity and mortality as opposed to a normal cervical length (≥25 mm). The predictive value of a short cervix on neonatal outcome is also investigated.

METHODS

Preterm infants who were admitted to the neonatal intensive care unit and whose mothers had undergone a pre-delivery evaluation for cervical length (CL) and cervical cultures were included in the study. Infants were stratified into two groups based on CL measurements (Group 1, CL < 25 mm; Group 2, CL ≥ 25 mm).

RESULTS

A total of 203 infants were included in the final analysis. Group 1 consisted of 105 neonates while Group 2 had 98 newborns. Cervical culture positivity rate was 46.7 % (n = 49) in Group 1 compared to 19.4 % (n = 19) in Group 2 (p = 0.0001). Frequencies of early onset neonatal sepsis (EOS) in Group 1 and Group 2 were 31.5 and 18.4 %, respectively (p = 0.032), whereas respective frequencies of proven sepsis in the two groups were 18.1 and 8.2 % (p = 0.037). A CL < 25 mm was found to increase the risk of cervical culture positivity, EOS and proven EOS by odds ratios of 3.63, 2.03 and 2.48, respectively.

CONCLUSIONS

This is the first clinical study to demonstrate a significant link between CL and each of cervical culture positivity, EOS and neonatal morbidity and mortality. Preterm infants born to high-risk mothers with short CL should be monitored closely for the risk of EOS.