An approach to using recombinant erythropoietin for neuroprotection in very preterm infants

OBJECTIVE

Erythropoietin has been shown to be protective against hypoxic-ischemic and inflammatory injuries in cell culture, animal models of brain injury, and clinical trials of adult humans. The rationale for our study was that early administration of high-dose recombinant human erythropoietin may reduce perinatal brain injury (intraventricular hemorrhage and periventricular leukomalacia) in very preterm infants and improve neurodevelopmental outcome. We investigated whether administration of high-dose recombinant human erythropoietin to very preterm infants shortly after birth and subsequently during the first 2 days is safe in terms of short-term outcome.

METHODS

This was a randomized, double-masked, single-center trial with a 2:1 allocation in favor of recombinant human erythropoietin. Preterm infants (gestational age: 24 to 31 weeks) were given recombinant human erythropoietin or NaCl 0.9% intravenously 3, 12 to 18, and 36 to 42 hours after birth.

RESULTS

The percentage of infants who survived without brain injury or retinopathy was 53% in the recombinant human erythropoietin group and 60% in the placebo group. There were no relevant differences regarding short-term outcomes such as intraventricular hemorrhage, retinopathy, sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia. For 5 infants who were in the recombinant human erythropoietin group and had a gestational age of <26 weeks, withdrawal of intensive care was decided (3 of 5 with severe bilateral intraventricular hemorrhage, 2 of 5 with pulmonary insufficiency); no infant of the control group died. Recombinant human erythropoietin treatment did not result in significant differences in blood pressure, cerebral oxygenation, hemoglobin, leukocyte, and platelet count.

CONCLUSIONS

No significant adverse effects of early high-dose recombinant human erythropoietin treatment in very preterm infants were identified. These results enable us to embark on a large multicenter trial with the aim of determining whether early high-dose administration of recombinant human erythropoietin to very preterm infants improves neurodevelopmental outcome at 24 months' and 5 years' corrected age.

Effect of Early Prophylactic High-Dose Recombinant Human Erythropoietin in Very Preterm Infants on Neurodevelopmental Outcome at 2 Years: A Randomized Clinical Trial

IMPORTANCE

Very preterm infants are at risk of developing encephalopathy of prematurity and long-term neurodevelopmental delay. Erythropoietin treatment is neuroprotective in animal experimental and human clinical studies.

OBJECTIVE

To determine whether prophylactic early high-dose recombinant human erythropoietin (rhEPO) in preterm infants improves neurodevelopmental outcome at 2 years' corrected age.

DESIGN, SETTING, AND PARTICIPANTS

Preterm infants born between 26 weeks 0 days' and 31 weeks 6 days' gestation were enrolled in a randomized, double-blind, placebo-controlled, multicenter trial in Switzerland between 2005 and 2012. Neurodevelopmental assessments at age 2 years were completed in 2014.

INTERVENTIONS

Participants were randomly assigned to receive either rhEPO (3000 IU/kg) or placebo (isotonic saline, 0.9%) intravenously within 3 hours, at 12 to 18 hours, and at 36 to 42 hours after birth.

MAIN OUTCOMES AND MEASURES

Primary outcome was cognitive development assessed with the Mental Development Index (MDI; norm, 100 [SD, 15]; higher values indicate better function) of the Bayley Scales of Infant Development, second edition (BSID-II) at 2 years corrected age. The minimal clinically important difference between groups was 5 points (0.3 SD). Secondary outcomes were motor development (assessed with the Psychomotor Development Index), cerebral palsy, hearing or visual impairment, and anthropometric growth parameters.

RESULTS

Among 448 preterm infants randomized (mean gestational age, 29.0 [range, 26.0-30.9] weeks; 264 [59%] female; mean birth weight, 1210 [range, 490-2290] g), 228 were randomized to rhEPO and 220 to placebo. Neurodevelopmental outcome data were available for 365 (81%) at a mean age of 23.6 months. In an intention-to-treat analysis, mean MDI was not statistically significantly different between the rhEPO group (93.5 [SD, 16.0] [95% CI, 91.2 to 95.8]) and the placebo group (94.5 [SD, 17.8] [95% CI, 90.8 to 98.5]) (difference, -1.0 [95% CI, -4.5 to 2.5]; P = .56). No differences were found between groups in the secondary outcomes.

CONCLUSIONS AND RELEVANCE

Among very preterm infants who received prophylactic early high-dose rhEPO for neuroprotection, compared with infants who received placebo, there were no statistically significant differences in neurodevelopmental outcomes at 2 years. Follow-up for cognitive and physical problems that may not become evident until later in life is required.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00413946.

Safety of Early High-Dose Recombinant Erythropoietin for Neuroprotection in Very Preterm Infants

OBJECTIVE

To investigate the safety and short term outcome of high dose recombinant human erythropoietin (rhEpo) given shortly after birth and subsequently over the first 2 days for neuroprotection to very preterm infants.

STUDY DESIGN

Randomized, double masked phase II trial. Preterm infants (gestational age 26 0/7-31 6/7 weeks) were given rhEpo (nt = 229; 3000 U/kg body weight) or NaCl 0.9% (nc = 214) intravenously at 3, 12-18, and 36-42 hours after birth.

RESULTS

There were no relevant differences between the groups for short-term outcomes such as mortality, retinopathy of prematurity, intraventricular hemorrhage, sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia. At day 7-10, we found significantly higher hematocrit values, reticulocyte, and white blood cell counts, and a lower platelet count in the rhEpo group.

CONCLUSIONS

Early high-dose rhEpo administration to very premature infants is safe and causes no excess in mortality or major adverse events.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00413946.

Grief and post-traumatic growth in parents 2-6 years after the death of their extremely premature baby

OBJECTIVE

To assess grief and post-traumatic growth in parents 2-6 years after the death of a premature baby (24-26 weeks' gestation) and to evaluate Pictorial Representation of Illness and Self-Measure (PRISM) in the assessment of bereavement.

METHOD

Fifty-four parents were assessed for their experiences during hospitalization and by questionnaires regarding grief (MTS), post-traumatic growth, affective symptoms and the visual representation of the baby and the self of the parents (PRISM).

RESULTS

Even 2-6 years after the loss of their extremely preterm infant the parents still suffer a lot from their bereavement, mothers more so than fathers (Mann-Whitney U test, U = 230.5, p < 0.05). Having another child reduced the level of grief (U = 119.0, p < 0.05). Mothers showed more post-traumatic growth than fathers (U = 140.5, p < 0.001). For all parents a shorter distance between the baby and the self (PRISM) correlated with greater grief (rho = -0.62, p < 0.001); in multiple regression analysis MTS explained 38% of the SBS-variance.

CONCLUSIONS

Clinicians should be aware that the death of an extremely premature infant triggers not only a painful long-term process of mourning but also of individual personal growth. Adaptation processes after the death differ depending on gender, with mothers experiencing more intense grief but also more growth than fathers. The modified PRISM test is recommended as a visual, non-verbal and easy-to-use instrument to assess bereavement.

Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources

BACKGROUND

The aim of the study was to analyze the neonatal impact of a methadone maintenance program in pregnancy, and the social resources of the families involved.

METHODS

Descriptive analysis of neonatal data in live births after 24 weeks of gestation in pregnant women enrolled in a methadone maintenance program. The data of 86 babies were analyzed.

RESULTS

Median gestational age was 38 (0)/(7) (31-41) weeks; 21 babies (24%) were premature. Median birthweight was 2662 (1340-4050) g; 27% of babies were growth retarded (<3rd centile), and 13% had microcephaly (<3rd centile). Sixty-two percent developed abstinence syndrome requiring pharmacological treatment for a median 47 days. Child Protective Services (CPS) were involved in 56% of cases, and 42% of newborns required placement outside the mother's home.

CONCLUSIONS

Babies born to women on methadone had a fourfold higher incidence of prematurity, a ninefold higher incidence of intrauterine growth retardation (IUGR), and a fourfold higher incidence of microcephaly compared with the normal population. Sixty-two percent required pharmacological treatment for abstinence syndrome and 42% required placement.

Artificial sweetener reduces nociceptive reaction in term newborn infants

BACKGROUND

Sucrose has been shown to have an analgesic effect in preterm and term neonates. Sucrose, however, has a high osmolarity and may have deleterious effects in infants with fructose intolerance. Furthermore, it may favour caries. We therefore investigated the effects of a commercially available artificial sweetener (10 parts cyclamate and 1 part saccharin), glycine (sweet amino acid) or breast milk in reducing reaction to pain as compared with a placebo.

SUBJECTS

Eighty healthy term infants, four days old, with normal birth weight.

INTERVENTIONS

The infants were randomly assigned to one of four groups: 2 ml sweetener, glycine, expressed breast milk or water were given 2 min before a heel prick for the Guthrie test. The procedure was filmed with a video camera and analysed by two observers who did not know which medication the infant had received.

RESULTS

Using a multivariate regression analysis, the following variables had significant correlation with relative crying time and recovery time: behavioural state before the intervention, the pricking nurse, and the type of medication. Relative crying time and recovery time were significantly less in the sweetener group but not in the glycine and the breast milk group.

CONCLUSIONS

The artificial sweetener used in our study reduces pain reaction to a heel prick in term neonates, and thus provides an alternative to sucrose. In contrast, glycine tends to increase pain reaction whereas breast milk has no effect.

Detection of hyperbilirubinaemia in jaundiced full-term neonates by eye or by bilirubinometer?

The aim of this study was to compare predictions of hyperbilirubinaemia by eye, performed by trained physicians and nurses, with predictions obtained using two commercial bilirubinometers. Jaundice was assessed in 92 white and 48 non-white healthy full-term neonates using three non-invasive methods and by total serum bilirubin as the reference method. Clinical assessment of cephalocaudal progression of jaundice was carried out independently by a physician and by nurses. Simultaneously, the Minolta Airshields JM-102 was applied on the sternum, the BiliCheck on both the forehead and the sternum, and finally, serum bilirubin concentrations were determined. The Minolta JM-102 showed the best performance with r2 = 0.90, an intraclass correlation coefficient (ICC) of 0.93, and a 95% confidence interval (CI) of +/- 4 units (approx. 56 micromol/l). The BiliCheck performed slightly better on the forehead than over the sternum with r2=0.90, an ICC of 0.88, and a CI of +/- 62 microtmol/l. Assessment of jaundice by eye was least accurate with r2 = 0.74, an ICC of 0.67, and a CI of +/- 1.5 zones (corresponding to 75 Lmol/l). Skin pigmentation and ambient light both adversely affected noninvasive bilirubin estimation.

CONCLUSION

All three non-invasive methods are well suited for estimation of serum bilirubin but show large confidence intervals. In healthy term newborns, hyperbilirubinaemia (>250 Lmol/l) can be safely ruled out by eye if jaundice does not reach the abdomen or the extremities (Kramer zones 1 and 2), with < 22 units ( < 230 micromol/l) for the Minolta JM-102, or with a cut-off of 190 microlmol/l for the Bili-Check. If these respective thresholds are exceeded, serum bilirubin concentrations should be measured.

Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses

Background

In the last 20 years, the chances for intact survival for extremely preterm infants have increased in high income countries. Decisions about withholding or withdrawing intensive care remain a major challenge in infants born at the limits of viability. Shared decision-making regarding these fragile infants between health care professionals and parents has become the preferred model today. However, there is an ongoing ethical debate on how decisions regarding life-sustaining treatment should be reached and who should have the final word when health care professionals and parents do not agree. We designed a survey among neonatologists and neonatal nurses to analyze practices, difficulties and parental involvement in end-of-life decisions for extremely preterm infants.

Methods

All 552 physicians and nurses with at least 12 months work experience in level III neonatal intensive care units (NICU) in Switzerland were invited to participate in an online survey with 50 questions. Differences between neonatologists and NICU nurses and between language regions were explored.

Results

Ninety six of 121 (79%) physicians and 302 of 431(70%) nurses completed the online questionnaire. The following difficulties with end-of-life decision-making were reported more frequently by nurses than physicians: insufficient time for decision-making, legal constraints and lack of consistent unit policies. Nurses also mentioned a lack of solidarity in our society and shortage of services for disabled more often than physicians. In the context of limiting intensive care in selected circumstances, nurses considered withholding tube feedings and respiratory support less acceptable than physicians. Nurses were more reluctant to give parents full authority to decide on the course of action for their infant. In contrast to professional category (nurse or physician), language region, professional experience and religion had little influence if any on the answers given.

Conclusions

Physicians and nurses differ in many aspects of how and by whom end-of-life decisions should be made in extremely preterm infants. The divergencies between nurses and physicians may be due to differences in ethics education, varying focus in patient care and direct exposure to the patients. Acknowledging these differences is important to avoid potential conflicts within the neonatal team but also with parents in the process of end-of-life decision-making in preterm infants born at the limits of viability.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1040-z) contains supplementary material, which is available to authorized users.

Left ventricular stroke volume in the fetal sheep is limited by extracardiac constraint and arterial pressure

1. Extracardiac constraint and sensitivity to arterial pressure may be critical factors that limit the functional reserves of the developing fetal heart in utero. We hypothesise that extracardiac constraint is the predominant factor that limits fetal stroke volume (SV). To test this hypothesis we studied six chronically instrumented fetal sheep to determine the relative roles that extracardiac constraint and arterial pressure play in determining left ventricular (LV) function. 2. Pregnant ewes (128-131 days gestation, term = 147 days) were anaesthetised (5 mg kg(-1) Propofol I.V., then 1.5 % halothane, 50 % O(2), balance N(2)O by inhalation) and instrumented using sterile surgical techniques to record LV end-diastolic pressure (P(lved)), aortic pressure (P(ao)), pericardial pressure (P(per)), and LV SV. 3. After a minimum of 72 h recovery, LV function was assessed by altering fetal blood volume to vary P(lved). Ventricular function curves were generated using two measures of ventricular function, SV and stroke work index (SWI = SV x P(ao)), and two measures of ventricular filling, P(lved) and LV end-diastolic transmural pressure (P(lved,tm) = P(lved) - P(per)). 4. Although decreasing P(lved) from the resting level decreased SV, increasing P(lved) from the resting level did not increase SV because the ventricular function curve plateaued. This plateau was not explained solely by an increase in aortic pressure, as the plateau remained present in the SWI versus P(lved) curve. When extracardiac constraint was accounted for (SV against P(lved,tm)), the plateau was largely eliminated (approximately 80 %). The remaining portion of the plateau (approximately 20 %) was eliminated when both extracardiac constraint and arterial pressure were accounted for (SWI versus P(lved,tm)). 5. Thus, the major limitation upon LV function in the near-term fetus results from extracardiac constraint limiting ventricular filling while, at the same time, a much smaller limitation arises from increasing arterial pressure.

End-of-life decisions in delivery room and neonatal intensive care unit

BACKGROUND

The increase in neonatal survival in recent decades has been followed by an increase in later disabilities. This has given rise to many new ethical issues. In different countries, efforts are being made to define ethical guidelines regarding withholding or withdrawing intensive care and end-of-life decisions in critically ill newborn infants. These guidelines have to be differentiated from ethical decision-making models which structure the process of decision making for an individual child. Such a framework has been in existence in our clinic for 10 years.

AIM

The aims of this study were to evaluate how end-of-life decisions are taken in our perinatal centre and to analyse whether these decisions are consistent with our framework for structured ethical decision making.

METHODS

199 consecutive neonatal deaths over 5 y were evaluated.

RESULTS

In 157 cases (79%), end-of-life decisions were taken according to our ethical framework; in the remaining 42 cases (21%), the baby died before this could be done. In 92% of cases, parents were involved in the decision and, in all cases but one, agreed with the decision. A patient's life was never intentionally and actively terminated.

CONCLUSION

In contrast to earlier years, in-hospital death in our clinic is nowadays usually preceded by structured and documented medical end-of-life decisions.

A new multichannel near infrared spectrophotometry system for functional studies of the brain in adults and neonates

We have designed a versatile, multi-channel near-infrared spectrophotometry (NIRS) instrument for the purpose of mapping neuronal activation in the neonatal and adult brain in response to motor, tactile, and visual stimulation. The optical linearity, stability, and high signal to noise ratio (>70 dB) of the instrument were demonstrated using an in vitro validation procedure. In vivo measurements on the adult forearm were also performed. Changes in oxygenation, induced by arterial occlusion of the forearm, were recorded and were shown to compare well with measurements acquired using a conventional NIRS instrument. To demonstrate the capabilities of the instrument, functional measurements in adults and neonates were performed. The instrument exhibited the capability to differentiate with a spatial resolution in the order of cm, local activation patterns associated with a finger tapping sequence.

Growth, developmental milestones and health problems in the first 2 years in very preterm infants compared with term infants: a population based study

The outcome of very preterm infants varies widely from centre to centre and from country to country. The aim of this study was to evaluate growth, developmental milestones and post-discharge morbidity of infants born before 32 weeks of gestation in Switzerland. A questionnaire was sent to the parents of 456 survivors born in 1996. A total of 309 (68%) parents responded and their infants were matched with 309 control infants born at term. At the corrected age of 24 months, the very preterm infants had significantly lower weight (-1.0 z-scores), lower length (-1.23 z-scores), and lower head circumference (-.64 z-scores). Very preterm infants were reported to eat with a spoon later than those born at term (50% at 7.5 months corrected for prematurity versus 10 months. P<0.001), to drink later out of a cup (50% at 16.5 months versus 13.5 months, P=0.03) and to walk later independently (50% at 14.5 months versus 13.5 months, P=0.04), whereas timing of sitting unsupported was no different (50% at 7.4 months versus 7.2 months, P=0.9). Of very preterm infants, 16% were not able to walk at least three steps unsupported at 18 months after term which puts them at an increased risk for cerebral palsy. Some 35% of very preterm infants had to be readmitted to hospital during the first 24 months compared with 20% of control infants born at term (P<0.05). There was no difference between very preterm and term infants in respect to episodes of fever > 38.5 degrees C, episodes of coughing > 3 days and treatment with antibiotics.

CONCLUSION

these data based on a national survey allow to quantify growth retardation, developmental delay and post-discharge health problems within the first 2 years in preterm infants born before 32(0)/7 weeks.

Shared or discordant grief in couples 2-6 years after the death of their premature baby: effects on suffering and posttraumatic growth

BACKGROUND

The loss of a baby causes severe short- and long-term distress to parents and their marital relationship, but little is known about how this distress is shared between spouses. The authors hypothesized that the grief-related concordance within a couple 2 to 6 years after the loss of a premature baby could be an indicator of shared emotional distress within a couple.

OBJECTIVE

The authors investigated the long-term grief experience among couples.

METHOD

A group of 44 parents (22 couples) were assessed by questionnaire regarding grief, suffering, posttraumatic growth, and affective symptoms, and semistructured interviews with 6 couples added qualitative information about processes within couples.

RESULTS

The extent of grief concordance was found to be related to different patterns of suffering and posttraumatic growth within couples.

CONCLUSION

The emotional exchange between partners after the loss of the child appears to be crucial for a process of concordant grief, which in turn is associated with a more synchronous process of individual posttraumatic growth.

Health-related quality of life of former very preterm infants in adulthood

AIM

To assess health-related quality of life of young adults born very preterm compared with a term control group.

METHODS

A cohort of preterm infants <1250 g and a term control group, both born between 1983 and 1985, were surveyed as adults at the median age of 23 years. Questionnaires including the Short Form 36 Health Survey (SF 36) and a modified lifestyle questionnaire assessed quality of life, health attitudes, height and weight, chronic diseases, medication and drug consumption.

RESULTS

Fifty-two preterms and 75 controls matched for age and sex participated in the study. There were no significant differences in the quality of life as assessed by SF 36. Former preterms were significantly smaller than their term controls but not so for body mass index. The overall consumption of illicit drugs was significantly lower in former preterms. Moreover, former preterms went significantly less often in for sports. There was a trend for higher prevalence of chronic diseases in male compared to female preterms, but their use of medication was significantly lower.

CONCLUSION

Adults born very preterm show no significant differences in their quality of life when compared to controls in early adulthood. However, based on their lifestyle and health disadvantages, male preterm subjects constitute a risk group when entering early adulthood with a clear need for continued attention.

Slow blood sampling from an umbilical artery catheter prevents a decrease in cerebral oxygenation in the preterm newborn

OBJECTIVE

Blood sampling from an umbilical artery catheter (UAC) placed in a high position (thoracal 6-9) has the potential to produce clinically significant changes in cerebral blood flow and, thereby, in cerebral oxygenation. This may contribute to cerebral impairment in preterm newborn infants. Therefore, we set up a study to determine the effects of different sampling speeds through a UAC on cerebral oxygenation in preterm infants.

METHODS

Thirty pairs of measurements were conducted on 20 preterm infants (median gestational age: 30.14 weeks; median birth weight: 1170 g). For each infant, 2 blood samplings (both 2.3 mL, including flush volume) through the UAC in high position were taken at 2 different speeds (20 and 40 seconds) in alternating sequence. Cerebral oxygenation was measured noninvasively by near-infrared spectroscopy. Concentration changes in cerebral oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb), along with the tissue oxygenation index (TOI; O2Hb/[O2Hb + HHb] x 100), were recorded while blood was withdrawn and subsequently reinfused.

RESULTS

A significant decrease in O2Hb and TOI occurred during blood sampling within 20 seconds (median DeltaO2Hb: -1.5 micromol/L; range: -4.1-2.3; median DeltaTOI: -0.6%; range: -6.3-2.3), whereas HHb increased (median DeltaHHb: 0.4 micromol/L, range: -1.1-3.9). No significant change was found in O2Hb, HHb, and TOI when sampling time was extended to 40 seconds.

CONCLUSION

Our results show that blood withdrawal over 20 seconds from a UAC in high position significantly decreases cerebral O2Hb and TOI in preterm infants. Prolonging sampling time to 40 seconds can prevent this phenomenon.

Interactions between the right ventricle and pulmonary vasculature in the fetus

A midsystolic plateau differentiates the pattern of fetal pulmonary trunk blood flow from aortic flow. To determine whether this plateau arises from interactions between the left (LV) and right ventricle (RV) via the ductus arteriosus or from interactions between the RV and the lung vasculature, we measured blood flows and pressures in the pulmonary trunk and aorta of eight anesthetized (ketamine and alpha-chloralose) fetal lambs. Wave-intensity analysis revealed waves of energy traveling forward, away from the LV and the RV early in systole. During midsystole, a wave of energy traveling back toward the RV decreased blood flow velocity from the RV and produced the plateau in blood flow. Calculations revealed that this backward-traveling wave originated as a forward-traveling wave generated by the RV that was reflected from the lung vasculature back toward the heart and not as a forward-traveling wave generated by the LV that crossed the ductus arteriosus. Elimination of this backward-traveling wave and its associated effect on RV flow may be an important component of the increase in RV output that accompanies birth.

Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland. 2011 revision of the Swiss recommendations

Perinatal care of pregnant women at high risk for preterm delivery and of preterm infants born at the limit of viability (22-26 completed weeks of gestation) requires a multidisciplinary approach by an experienced perinatal team. Limited precision in the determination of both gestational age and foetal weight, as well as biological variability may significantly affect the course of action chosen in individual cases. The decisions that must be taken with the pregnant women and on behalf of the preterm infant in this context are complex and have far-reaching consequences. When counselling pregnant women and their partners, neonatologists and obstetricians should provide them with comprehensive information in a sensitive and supportive way to build a basis of trust. The decisions are developed in a continuing dialogue between all parties involved (physicians, midwives, nursing staff and parents) with the principal aim to find solutions that are in the infant's and pregnant woman's best interest. Knowledge of current gestational age-specific mortality and morbidity rates and how they are modified by prenatally known prognostic factors (estimated foetal weight, sex, exposure or nonexposure to antenatal corticosteroids, single or multiple births) as well as the application of accepted ethical principles form the basis for responsible decision-making. Communication between all parties involved plays a central role. The members of the interdisciplinary working group suggest that the care of preterm infants with a gestational age between 22 0/7 and 23 6/7 weeks should generally be limited to palliative care. Obstetric interventions for foetal indications such as Caesarean section delivery are usually not indicated. In selected cases, for example, after 23 weeks of pregnancy have been completed and several of the above mentioned prenatally known prognostic factors are favourable or well informed parents insist on the initiation of life-sustaining therapies, active obstetric interventions for foetal indications and provisional intensive care of the neonate may be reasonable. In preterm infants with a gestational age between 24 0/7 and 24 6/7 weeks, it can be difficult to determine whether the burden of obstetric interventions and neonatal intensive care is justified given the limited chances of success of such a therapy. In such cases, the individual constellation of prenatally known factors which impact on prognosis can be helpful in the decision making process with the parents. In preterm infants with a gestational age between 25 0/7 and 25 6/7 weeks, foetal surveillance, obstetric interventions for foetal indications and neonatal intensive care measures are generally indicated. However, if several prenatally known prognostic factors are unfavourable and the parents agree, primary non-intervention and neonatal palliative care can be considered. All pregnant women with threatening preterm delivery or premature rupture of membranes at the limit of viability must be transferred to a perinatal centre with a level III neonatal intensive care unit no later than 23 0/7 weeks of gestation, unless emergency delivery is indicated. An experienced neonatology team should be involved in all deliveries that take place after 23 0/7 weeks of gestation to help to decide together with the parents if the initiation of intensive care measures appears to be appropriate or if preference should be given to palliative care (i.e., primary non-intervention). In doubtful situations, it can be reasonable to initiate intensive care and to admit the preterm infant to a neonatal intensive care unit (i.e., provisional intensive care). The infant's clinical evolution and additional discussions with the parents will help to clarify whether the life-sustaining therapies should be continued or withdrawn. Life support is continued as long as there is reasonable hope for survival and the infant's burden of intensive care is acceptable. If, on the other hand, the health care team and the parents have to recognise that in the light of a very poor prognosis the burden of the currently used therapies has become disproportionate, intensive care measures are no longer justified and other aspects of care (e.g., relief of pain and suffering) are the new priorities (i.e., redirection of care). If a decision is made to withhold or withdraw life-sustaining therapies, the health care team should focus on comfort care for the dying infant and support for the parents.

Comparison of a new transcutaneous bilirubinometer (Bilimed) with serum bilirubin measurements in preterm and full-term infants

Background

The gold standard to assess hyperbilirubinemia in neonates remains the serum bilirubin measurement. Unfortunately, this is invasive, painful, and costly. Bilimed^®, a new transcutaneous bilirubinometer, suggests more accuracy compared to the existing non-invasive bilirubinometers because of its new technology. It furthermore takes into account different skin colours. No contact with the skin is needed during measurement, no additional material costs occur. Our aim was to assess the agreement between the Bilimed^® and serum bilirubin in preterm and term infants of different skin colours.

Methods

The transcutaneous bilirubin measurements were performed on the infant's sternum and serum bilirubin was determined simultaneously. The agreement between both methods was assessed by Pearson's correlation and by Bland-Altman analysis.

Results

A total of 117 measurement cycles were performed in 99 term infants (group1), further 47 measurements in 38 preterm infants born between 34 - 36 6/7 gestational weeks (group 2), and finally 21 measurements in 13 preterm infants born between 28 - 33 6/7 gestational weeks (group 3). The mean deviation and variability (+/- 2SD) of the transcutaneous from serum bilirubin were: -14 (+/- 144) μmol/l; -0.82 (+/- 8.4) mg/dl in group 1, +16 (+/- 91) μmol/l;+0.93(+/- 5.3) mg/dl in group 2 and -8 (+/- 76) μmol/l; -0.47 (+/- 4.4) mg/dl in group 3. These limits of agreement are too wide to be acceptable in a clinical setting. Moreover, there was to be a trend towards less good agreement with increasing bilirubin values.

Conclusion

Despite its new technology the Bilimed^® has no advantages, and more specifically no better agreement not only in term and near-term Caucasian infants, but also in non-Caucasian and more premature infants.

Retinopathy of prematurity and bilirubin--no clinical evidence for a beneficial role of bilirubin as a physiological anti-oxidant

The prevention of retinopathy of prematurity (ROP) remains a persistent problem. A previous report has focused on the possible protective effect of bilirubin on the development of ROP. These results still await clinical confirmation by other research groups. Therefore, we undertook a retrospective clinical study trying to confirm this attractive hypothesis. Twelve premature newborns under 32 weeks of gestation with ROP stage 3-4 were matched for gestational age with 12 infants without ROP. Data were collected about the infant's characteristics, medical illnesses, ventilatory settings and treatments. The total serum bilirubin concentrations between the 1st and 8th postnatal day were also gathered. The two matched groups were comparable as to their basic data, clinical characteristics and treatment, except for a slight, but significant longer duration of phototherapy for group ROP 0 (mean, 50.2 h; SD 48,6 vs 31.6 h; SD 42.7 in ROP 3-4; P = 0.02). No statistical difference relative to bilirubin was found between the two groups, neither when expressed as daily mean concentrations, nor as area under the curve (AUC) (mean, ROP 0: 17876.7; SD 6077.3 vs 18888.4; SD 55552.7 in ROP 3-4; P = 0.404) or AUC/h (mean, ROP 0: 135.1; SD 36.3 vs 144.1; SD 23.2 in ROP 3-4; P = 0.515). Our findings do not confirm the hypothesis of a clinically measurable, beneficial role of bilirubin on the development of ROP.

Neurodevelopmental Outcomes at Age 5 Years After Prophylactic Early High-Dose Recombinant Human Erythropoietin for Neuroprotection in Very Preterm Infants

This study reports 5-year neurodevelopmental outcomes for Swiss children born before 32 weeks’ gestation and randomized at birth to receive early high-dose recombinant human erythropoietin (rhEpo) vs placebo.

Long-term neuroprotective effect of erythropoietin on executive functions in very preterm children (EpoKids): protocol of a prospective follow-up study

INTRODUCTION

Premature infants are particularly vulnerable to brain injuries with associated cognitive and behavioural deficits. The worldwide first randomised interventional multicentre trial investigating the neuroprotective effects of erythropoietin (entitled 'Does erythropoietin improve outcome in very preterm infants?' (NCT00413946)) included 450 very preterm infants in Switzerland. MRI at term equivalent age showed less white matter (WM) injury in the erythropoietin group compared with the placebo group. Despite these promising imaging findings, neurodevelopmental outcome at 2 years showed no beneficial effect of early erythropoietin. One explanation could be that the assessment of more complex cognitive functions such as executive functions (EFs) is only possible at a later age. We hypothesise that due to improved WM development and fewer WM injuries, children born preterm treated with early erythropoietin will have better EF abilities at 7-12 years than those treated with placebo.

METHODS AND ANALYSIS

365 children who were included into the primary analysis of the original trial (NCT00413946) will be eligible in this prospective follow-up study at the age of 7-12 years. 185 children born at term will be control children. Primary outcome measures are EF abilities and processing speed, while secondary outcomes are academic performance, IQ, fine motor abilities and global brain connectivity. A comprehensive test battery will be applied to assess EFs. MRI will be performed to assess global brain connectivity. Cognitive scores and MRI measures will be compared between both groups using the Wilcoxon test. Propensity score matching will be used to balance gender, age, socioeconomic status and other potentially unbalanced variables between the children born preterm and the healthy control children.

ETHICS AND DISSEMINATION

The cantonal ethical committee granted ethical approval for this study (KEK 2017-00521). Written consent will be obtained from the parents. Findings from this study will be disseminated via international and national conference presentations and publications in peer-reviewed journals.

Reducing False Alarm Rates in Neonatal Intensive Care: A New Machine Learning Approach

In neonatal intensive care units (NICUs), 87.5% of alarms by the monitoring system are false alarms, often caused by the movements of the neonates. Such false alarms are not only stressful for the neonates as well as for their parents and caregivers, but may also lead to longer response times in real critical situations. The aim of this project was to reduce the rates of false alarms by employing machine learning algorithms (MLA), which intelligently analyze data stemming from standard physiological monitoring in combination with cerebral oximetry data (in-house built, OxyPrem).

MATERIALS & METHODS

Four popular MLAs were selected to categorize the alarms as false or real: (i) decision tree (DT), (ii) 5-nearest neighbors (5-NN), (iii) naïve Bayes (NB) and (iv) support vector machine (SVM). We acquired and processed monitoring data (median duration (SD): 54.6 (± 6.9) min) of 14 preterm infants (gestational age: 26 6/7 (± 2 5/7) weeks). A hybrid method of filter and wrapper feature selection generated the candidate subset for training these four MLAs.

RESULTS

A high specificity of >99% was achieved by all four approaches. DT showed the highest sensitivity (87%). The cerebral oximetry data improved the classification accuracy.

DISCUSSION & CONCLUSION

Despite a (as yet) low amount of data for training, the four MLAs achieved an excellent specificity and a promising sensitivity. Presently, the current sensitivity is insufficient since, in the NICU, it is crucial that no real alarms are missed. This will most likely be improved by including more subjects and data in the training of the MLAs, which makes pursuing this approach worthwhile.