Non-invasive high-frequency ventilation in newborn infants with respiratory distress

BACKGROUND

Respiratory distress occurs in up to 7% of newborns, with respiratory support (RS) provided invasively via an endotracheal (ET) tube or non-invasively via a nasal interface. Invasive ventilation increases the risk of lung injury and chronic lung disease (CLD). Using non-invasive strategies, with or without minimally invasive surfactant, may reduce the need for mechanical ventilation and the risk of lung damage in newborn infants with respiratory distress.

OBJECTIVES

To evaluate the benefits and harms of nasal high-frequency ventilation (nHFV) compared to invasive ventilation via an ET tube or other non-invasive ventilation methods on morbidity and mortality in preterm and term infants with or at risk of respiratory distress.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and three trial registries in April 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster- or quasi-RCTs of nHFV in newborn infants with respiratory distress compared to invasive or non-invasive ventilation.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials for inclusion, extracted data, assessed the risk of bias, and undertook GRADE assessment.

MAIN RESULTS

We identified 33 studies, mostly in low- to middle-income settings, that investigated this therapy in 5068 preterm and 46 term infants. nHFV compared to invasive respiratory therapy for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 0.67, 95% CI 0.20 to 2.18; 1 study, 80 infants) or the incidence of CLD (RR 0.38, 95% CI 0.09 to 1.59; 2 studies, 180 infants), both very low-certainty. ET intubation, death or CLD, severe intraventricular haemorrhage (IVH) and neurodevelopmental disability (ND) were not reported. nHFV vs nasal continuous positive airway pressure (nCPAP) used for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 1.00, 95% CI 0.41 to 2.41; 4 studies, 531 infants; very low-certainty). nHFV may reduce ET intubation (RR 0.52, 95% CI 0.33 to 0.82; 5 studies, 571 infants), but there may be little or no difference in CLD (RR 1.35, 95% CI 0.80 to 2.27; 4 studies, 481 infants); death or CLD (RR 2.50, 95% CI 0.52 to 12.01; 1 study, 68 participants); or severe IVH (RR 1.17, 95% CI 0.36 to 3.78; 4 studies, 531 infants), all low-certainty evidence. ND was not reported. nHFV vs nasal intermittent positive-pressure ventilation (nIPPV) used for initial RS nHFV may result in little to no difference in mortality before hospital discharge (RR 1.86, 95% CI 0.90 to 3.83; 2 studies, 84 infants; low-certainty). nHFV may have little or no effect in reducing ET intubation (RR 1.33, 95% CI 0.76 to 2.34; 5 studies, 228 infants; low-certainty). There may be a reduction in CLD (RR 0.63, 95% CI 0.42 to 0.95; 5 studies, 307 infants; low-certainty). A single study (36 infants) reported no events for severe IVH. Death or CLD and ND were not reported. nHFV vs high-flow nasal cannula (HFNC) used for initial RS We are very uncertain whether nHFV reduces ET intubation (RR 2.94, 95% CI 0.65 to 13.27; 1 study, 37 infants) or reduces CLD (RR 1.18, 95% CI 0.46 to 2.98; 1 study, 37 participants), both very low-certainty. There were no mortality events before hospital discharge or severe IVH. Other deaths, CLD and ND, were not reported. nHFV vs nCPAP used for RS following planned extubation nHFV probably results in little or no difference in mortality before hospital discharge (RR 0.92, 95% CI 0.52 to 1.64; 6 studies, 1472 infants; moderate-certainty). nHFV may result in a reduction in ET reintubation (RR 0.42, 95% CI 0.35 to 0.51; 11 studies, 1897 infants) and CLD (RR 0.78, 95% CI 0.67 to 0.91; 10 studies, 1829 infants), both low-certainty. nHFV probably has little or no effect on death or CLD (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 966 infants) and severe IVH (RR 0.80, 95% CI 0.57 to 1.13; 3 studies, 1117 infants), both moderate-certainty. We are very uncertain whether nHFV reduces ND (RR 0.92, 95% CI 0.37 to 2.29; 1 study, 74 infants; very low-certainty). nHFV versus nIPPV used for RS following planned extubation nHFV may have little or no effect on mortality before hospital discharge (RR 1.83, 95% CI 0.70 to 4.79; 2 studies, 984 infants; low-certainty). There is probably a reduction in ET reintubation (RR 0.69, 95% CI 0.54 to 0.89; 6 studies, 1364 infants), but little or no effect on CLD (RR 0.88, 95% CI 0.75 to 1.04; 4 studies, 1236 infants); death or CLD (RR 0.92, 95% CI 0.79 to 1.08; 3 studies, 1070 infants); or severe IVH (RR 0.78, 95% CI 0.55 to 1.10; 4 studies, 1162 infants), all moderate-certainty. One study reported there might be no difference in ND (RR 0.88, 95% CI 0.35 to 2.16; 1 study, 72 infants; low-certainty). nHFV versus nIPPV following initial non-invasive RS failure nHFV may have little or no effect on mortality before hospital discharge (RR 1.44, 95% CI 0.10 to 21.33); or ET intubation (RR 1.23, 95% CI 0.51 to 2.98); or CLD (RR 1.01, 95% CI 0.70 to 1.47); or severe IVH (RR 0.47, 95% CI 0.02 to 10.87); 1 study, 39 participants, all low- or very low-certainty. Other deaths or CLD and ND were not reported.

AUTHORS' CONCLUSIONS

For initial RS, we are very uncertain if using nHFV compared to invasive respiratory therapy affects clinical outcomes. However, nHFV may reduce intubation when compared to nCPAP. For planned extubation, nHFV may reduce the risk of reintubation compared to nCPAP and nIPPV. nHFV may reduce the risk of CLD when compared to nCPAP. Following initial non-invasive respiratory support failure, nHFV when compared to nIPPV may result in little to no difference in intubation. Large trials, particularly in high-income settings, are needed to determine the role of nHFV in initial RS and following the failure of other non-invasive respiratory support. Also, the optimal settings of nHVF require further investigation.

Vein of Galen Aneurysmal Malformation: A Case Report

Vein of Galen aneurysmal malformation is a relatively rare disease in which failure of the median prosencephalic vein of Markowski to involute early in gestation leads to a grossly dilated deep cerebral vein with multiple arterial feeders, causing a large arteriovenous shunt which leads to high-output cardiac failure. We describe a case of a term neonate who presented to a tertiary neonatal centre on day one of life with history, symptoms, and signs consistent with perinatal asphyxia; however, in the context of worsening multi-organ dysfunction and cardiomegaly, the infant was found to have a severe vein of Galen aneurysmal dilatation leading to high-output cardiac failure. The patient was transferred to a tertiary paediatric hospital and underwent a total of four coiling procedures to embolise the multiple feeder arteries supplying the aneurysmal malformation. This case highlights the difficulties in diagnosing this relatively uncommon condition, particularly in the context of a possible perinatal insult.

Postoperative pain and pain management following selective dorsal rhizotomy

BACKGROUND

Selective dorsal rhizotomy (SDR) is a neurosurgical procedure that reduces lower limb spasticity, performed in some children with spastic diplegic cerebral palsy. Effective pain management after SDR is essential for early rehabilitation. This study aimed to describe the anaesthetic and early pain management, pain and adverse events in children following SDR.

METHODS

This was a retrospective cohort study. Participants were all children who underwent SDR at a single Australian tertiary hospital between 2010 and 2020. Electronic medical records of all children identified were reviewed. Data collected included demographic and clinical data (pain scores, key clinical outcomes, adverse events and side effects) and medications used during anaesthesia and postoperative recovery.

RESULTS

22 children (n=8, 36% female) had SDR. The mean (SD) age at surgery was 6 years and 6 months (1 year and 4 months). Common intraoperative medications used were remifentanil (100%), ketamine (95%), paracetamol (91%) and sevoflurane (86%). Postoperatively, all children were prescribed opioid nurse-controlled analgesia (morphine, 36%; fentanyl, 36%; and oxycodone, 18%) and concomitant ketamine infusion. Opioid doses were maximal on the day after surgery. The mean (SD) daily average pain score (Wong-Baker FACES scale) on the day after surgery was 1.4 (0.9), decreasing to 1.0 (0.5) on postoperative day 6 (POD6). Children first attended the physiotherapy gym on median day 7 (POD8, range 7-8). Most children experienced mild side effects or adverse events that were managed conservatively. Common side effects included constipation (n=19), nausea and vomiting (n=18), and pruritus (n=14). No patient required return to theatre, ICU admission or prolonged inpatient stay.

CONCLUSIONS

Most children achieve good pain management following SDR with opioid and ketamine infusions. Adverse events, while common, are typically mild and managed with medication or therapy. This information can be used as a baseline to improve postoperative care and to support families' understanding of SDR before surgery.

Laryngeal mask airway surfactant administration for prevention of morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome

BACKGROUND

Laryngeal mask airway surfactant administration (S-LMA) has the potential benefit of surfactant administration whilst avoiding endotracheal intubation and ventilation, ventilator-induced lung injury and bronchopulmonary dysplasia (BPD).

OBJECTIVES

To evaluate the benefits and harms of S-LMA either as prophylaxis or treatment (rescue) compared to placebo, no treatment, or intratracheal surfactant administration via an endotracheal tube (ETT) with the intent to rapidly extubate (InSurE) or extubate at standard criteria (S-ETT) or via other less-invasive surfactant administration (LISA) methods on morbidity and mortality in preterm infants with or at risk of respiratory distress syndrome (RDS).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and three trial registries in December 2022.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster- or quasi-RCTs of S-LMA compared to placebo, no treatment, or other routes of administration (nebulised, pharyngeal instillation of surfactant before the first breath, thin endotracheal catheter surfactant administration or intratracheal surfactant instillation) on morbidity and mortality in preterm infants at risk of RDS. We considered published, unpublished and ongoing trials.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and extracted data. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included eight trials (seven new to this update) recruiting 510 newborns. Five trials (333 infants) compared S-LMA with surfactant administration via ETT with InSurE. One trial (48 infants) compared S-LMA with surfactant administration via ETT with S-ETT, and two trials (129 infants) compared S-LMA with no surfactant administration. We found no studies comparing S-LMA with LISA techniques or prophylactic or early S-LMA. S-LMA versus surfactant administration via InSurE S-LMA may have little or no effect on the composite outcome of death or BPD at 36 weeks' postmenstrual age (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.27 to 8.34, I 2 = not applicable (NA) as 1 study had 0 events; risk difference (RD) 0.02, 95% CI -0.07 to 0.10; I 2 = 0%; 2 studies, 110 infants; low-certainty evidence). There may be a reduction in the need for mechanical ventilation at any time (RR 0.53, 95% CI 0.36 to 0.78; I 2 = 27%; RD -0.14, 95% CI -0.22 to -0.06, I 2 = 89%; number needed to treat for an additional beneficial outcome (NNTB) 7, 95% CI 5 to 17; 5 studies, 333 infants; low-certainty evidence). However, this was limited to four studies (236 infants) using analgesia or sedation for the InSurE group. There was little or no difference for air leak during first hospitalisation (RR 1.39, 95% CI 0.65 to 2.98; I 2 = 0%; 5 studies, 333 infants (based on 3 studies as 2 studies had 0 events); low-certainty evidence); BPD among survivors to 36 weeks' PMA (RR 1.28, 95% CI 0.47 to 3.52; I 2 = 0%; 4 studies, 264 infants (based on 3 studies as 1 study had 0 events); low-certainty evidence); or death (all causes) during the first hospitalisation (RR 0.28, 95% CI 0.01 to 6.60; I 2 = NA as 2 studies had 0 events; 3 studies, 203 infants; low-certainty evidence). Neurosensory disability was not reported. Intraventricular haemorrhage ( IVH) grades III and IV were reported among the study groups (1 study, 50 infants). S-LMA versus surfactant administration via S-ETT No study reported death or BPD at 36 weeks' PMA. S-LMA may reduce the use of mechanical ventilation at any time compared with S-ETT (RR 0.47, 95% CI 0.31 to 0.71; RD -0.54, 95% CI -0.74 to -0.34; NNTB 2, 95% CI 2 to 3; 1 study, 48 infants; low-certainty evidence). We are very uncertain whether S-LMA compared with S-ETT reduces air leak during first hospitalisation (RR 2.56, 95% CI 0.11 to 59.75), IVH grade III or IV (RR 2.56, 95% CI 0.11 to 59.75) and death (all causes) during the first hospitalisation (RR 0.17, 95% CI 0.01 to 3.37) (1 study, 48 infants; very low-certainty evidence). No study reported BPD to 36 weeks' PMA or neurosensory disability. S-LMA versus no surfactant administration Rescue surfactant could be used in both groups. There may be little or no difference in death or BPD at 36 weeks (RR 1.65, 95% CI 0.85 to 3.22; I 2 = 58%; RD 0.08, 95% CI -0.03 to 0.19; I 2 = 0%; 2 studies, 129 infants; low-certainty evidence). There was probably a reduction in the need for mechanical ventilation at any time with S-LMA compared with nasal continuous positive airway pressure without surfactant (RR 0.57, 95% CI 0.38 to 0.85; I 2 = 0%; RD -0.24, 95% CI -0.40 to -0.08; I 2 = 0%; NNTB 4, 95% CI 3 to 13; 2 studies, 129 infants; moderate-certainty evidence). There was little or no difference in air leak during first hospitalisation (RR 0.65, 95% CI 0.23 to 1.88; I 2 = 0%; 2 studies, 129 infants; low-certainty evidence) or BPD to 36 weeks' PMA (RR 1.65, 95% CI 0.85 to 3.22; I 2 = 58%; 2 studies, 129 infants; low-certainty evidence). There were no events in either group for death during the first hospitalisation (1 study, 103 infants) or IVH grade III and IV (1 study, 103 infants). No study reported neurosensory disability.

AUTHORS' CONCLUSIONS

In preterm infants less than 36 weeks' PMA, rescue S-LMA may have little or no effect on the composite outcome of death or BPD at 36 weeks' PMA. However, it may reduce the need for mechanical ventilation at any time. This benefit is limited to trials reporting the use of analgesia or sedation in the InSurE and S-ETT groups. There is low- to very-low certainty evidence for no or little difference in neonatal morbidities and mortality. Long-term outcomes are largely unreported. In preterm infants less than 32 weeks' PMA or less than 1500 g, there are insufficient data to support or refute the use of S-LMA in clinical practice. Adequately powered trials are required to determine the effect of S-LMA for prevention or early treatment of RDS in extremely preterm infants. S-LMA use should be limited to clinical trials in this group of infants.

Editorial for Special Issue "Maternal, Fetal and Neonatal Health"

The maternal, foetal, and neonatal health field has witnessed remarkable advancements in recent years, driven by cutting-edge research and innovative technologies [...].

Language outcomes at 4 years of linguistically diverse children born very preterm: an Australian retrospective single-centre study

BACKGROUND

Very preterm children are at increased risk of language delays. Concerns have been raised about the utility of standardised English language tools to diagnose language delay in linguistically diverse children. Our study investigated the incidence of language delay at 4 years in linguistically diverse very preterm children.

METHODS

Very preterm children born in South Western Sydney, Australia, between 2012 and 2016, were assessed with the Clinical Evaluation of Language Fundamentals Preschool-2 (CELF-P2) tool at 4 years of age. We sought to determine the incidence of language delay in this cohort using language scores from the CELF-P2 assessment tool, and explore potential predictors associated with language delay.

RESULTS

One hundred and sixty very preterm children attended the 4-year assessment out of the included 270 long-term survivors. At 4 years, 76 (52%) very preterm children had language delay diagnosed using the CELF-P2 assessment tool. Children who preferred a language other than English had lower average core language scores on the CELF-P2 assessment tool (75.1±14.4) compared with children that preferred English (86.5±17.9); p=0.002. Very preterm children growing up in households that preferenced a language other than English and those who were born from multiple births had higher odds of language delay at 4 years (AOR 10.30 (95% CI 2.82 to 38.28); p<0.001 and AOR 2.93 (95% CI 1.20 to 7.14); p=0.018, respectively). Assessing these children using an English language tool may have affected language scores at 4 years.

CONCLUSIONS

In this metropolitan setting, very preterm children from linguistically diverse backgrounds were found to be vulnerable to language delays at 4 years. Further large-scale studies evaluating the language outcomes of linguistically diverse preterm children with more culturally appropriate tools are warranted. We question the utility of standardised English language tools to assess language outcomes of linguistically diverse populations.

Variation in hospital morbidities in an Australian neonatal intensive care unit network

OBJECTIVE

There is an expectation among the public and within the profession that the performance and outcome of neonatal intensive care units (NICUs) should be comparable between centres with a similar setting. This study aims to benchmark and audit performance variation in a regional Australian network of eight NICUs.

DESIGN

Cohort study using prospectively collected data.

SETTING

All eight perinatal centres in New South Wales and the Australian Capital Territory, Australia.

PATIENTS

All live-born infants born between 23⁺⁰ and 31⁺⁶ weeks gestation admitted to one of the tertiary perinatal centres from 2007 to 2020 (n=12 608).

MAIN OUTCOME MEASURES

Early and late confirmed sepsis, intraventricular haemorrhage, medically and surgically treated patent ductus arteriosus, chronic lung disease (CLD), postnatal steroid for CLD, necrotising enterocolitis, retinopathy of prematurity (ROP), surgery for ROP, hospital mortality and home oxygen.

RESULTS

NICUs showed variations in maternal and neonatal characteristics and resources. The unadjusted funnel plots for neonatal outcomes showed apparent variation with multiple centres outside the 99.8% control limits of the network values. The hierarchical model-based risk-adjustment accounting for differences in patient characteristics showed that discharged home with oxygen is the only outcome above the 99.8% control limits.

CONCLUSIONS

Hierarchical model-based risk-adjusted estimates of morbidity rates plotted on funnel plots provide a robust and straightforward visual graphical tool for presenting variations in outcome performance to detect aberrations in healthcare delivery and guide timely intervention. We propose using hierarchical model-based risk adjustment and funnel plots in real or near real-time to detect aberrations and start timely intervention.

Outcomes of neonatal congenital diaphragmatic hernia in a non-ECMO center in a middle-income country: a retrospective cohort study

BACKGROUND

Most studies examining survival of neonates with congenital diaphragmatic hernia (CDH) are in high-income countries. We aimed to describe the management, survival to hospital discharge rate, and factors associated with survival of neonates with unilateral CDH in a middle-income country.

METHODS

We retrospectively reviewed the medical notes of neonates with unilateral CDH admitted to a pediatric intensive care unit (PICU) in a tertiary referral center over a 15-year period, from 2003-2017. We described the newborns' respiratory care pathways and then compared baseline demographic, hemodynamic, and respiratory indicators between survivors and non-survivors. The primary outcome measure was survival to hospital discharge.

RESULTS

Altogether, 120 neonates were included with 43.3% (52/120) diagnosed antenatally. Stabilization occurred in 38.3% (46/120) with conventional ventilation, 13.3% (16/120) with high-frequency intermittent positive-pressure ventilation, and 22.5% (27/120) with high frequency oscillatory ventilation. Surgical repair was possible in 75.0% (90/120). The overall 30-day survival was 70.8% (85/120) and survival to hospital discharge was 66.7% (80/120). Survival to hospital discharge tended to improve over time (p > 0.05), from 56.0% to 69.5% before and after, respectively, a service reorganization. For those neonates who could be stabilized and operated on, 90.9% (80/88) survived to hospital discharge. The commonest post-operative complication was infection, occurring in 43.3%. The median survivor length of stay was 32.5 (interquartile range 18.8-58.0) days. Multiple logistic regression modelling showed vaginal delivery (odds ratio [OR] = 4.8; 95% confidence interval [CI] [1.1-21.67]; p = 0.041), Apgar score [Formula: see text] 7 at 5 min (OR = 6.7; 95% CI [1.2-36.3]; p = 0.028), and fraction of inspired oxygen (FiO₂) < 50% at 24 h (OR = 89.6; 95% CI [10.6-758.6]; p < 0.001) were significantly associated with improved survival to hospital discharge.

CONCLUSIONS

We report a survival to hospital discharge rate of 66.7%. Survival tended to improve over time, reflecting a greater critical volume of cases and multi-disciplinary care with early involvement of the respiratory team resulting in improved transitioning from PICU. Vaginal delivery, Apgar score [Formula: see text] 7 at 5 min, and FiO₂ < 50% at 24 h increased the likelihood of survival to hospital discharge.

Detection of Dengue Virus From Aedes aegypti (Diptera, Culicidae) in Field-Caught Samples From Makkah Al-Mokarramah, Kingdom of Saudi Arabia, Using RT-PCR

Dengue fever (DF) is endemic to Makkah and Jeddah, the Kingdom of Saudi Arabia (KSA). However, until recently, the circulation of dengue virus (DENV) in Aedes mosquitoes in these areas was unknown. Serological surveillance of DENV in Ae aegypti is a powerful tool for early detection of dengue outbreaks and essential for developing effective control strategies. Therefore, this research aimed to examine a sample of adult Ae aegypti mosquitoes from Makkah, KSA, to detect DENV. In total, 1295 Ae aegypti mosquitoes were collected from the field from target areas of Makkah with a high incidence and prevalence of DF. The samples were divided into 259 coded pools (five mosquitoes in each) and preserved in 1.5 mL plastic tubes. The tubes were labeled, capped, and stored at-86°C until use. RT-PCR was used to detect DENV in the samples. All positive pools were confirmed by RT-PCR. The RT-PCR products were analyzed by gel electrophoresis (1.5% agarose in Tris-acetate EDTA buffer), stained with ethidium bromide, and visualized. DENV was isolated from six female Ae Aegypti collected from six pools (out of 259 pools). No other viruses were detected. Only five of the nine target localities had positive pools. Samples from the remaining four localities yielded negative results. Four DENV-positive mosquitoes were collected at the aquatic stages, and two were collected at the adult stage. These results show the circulation of DENV in adult mosquitoes and offspring, indicating vertical transmission of DENV. In conclusion, this study found that, in Makkah, DENV is circulating in dengue vectors with a high significance rate, suggesting the possibility of a dengue outbreak in the future; therefore, a sensitive surveillance system is vital to predict the outbreak and for early intervention and control.

Are we enrolling representative cohorts of premature infants in our clinical trials?

OBJECTIVE

To compare the difference in outcomes in a subset population of infants "eligible but not enrolled; ENE" vs those who were "eligible and enrolled, EE" in The Australian Placental Transfusion Study (APTS).

STUDY DESIGN

Population-based multicentre retrospective cohort study.

RESULTS

A total of 535 (17.7%) infants were categorized as EE and 2489 (82.3%) ENE. ENE infants were significantly more premature (mean gestation 27.0 vs 28.0 weeks) but otherwise of similar anthropometric measures compared to EE infants. ENE infants had significantly higher incidences of low Apgar scores <7 at 5 min, CLD, IVH and PDA requiring treatment. Using a multivariate adjusted-analysis, ENE were at a greater risk for mortality (OR 1.86; 95% CI, 1.30-2.67, p < 0.001).

CONCLUSION

Antenatal consenting may lead to biased population representation, which may affect trial results' generalizability. Retrospective consent or waiver of consent may improve the generalizability of neonatal and emergency clinical trials.

Surfactant therapy via thin catheter in preterm infants with or at risk of respiratory distress syndrome

BACKGROUND

Non-invasive respiratory support is increasingly used for the management of respiratory dysfunction in preterm infants. This approach runs the risk of under-treating those with respiratory distress syndrome (RDS), for whom surfactant administration is of paramount importance. Several techniques of minimally invasive surfactant therapy have been described. This review focuses on surfactant administration to spontaneously breathing infants via a thin catheter briefly inserted into the trachea.

OBJECTIVES

Primary objectives In non-intubated preterm infants with established RDS or at risk of developing RDS to compare surfactant administration via thin catheter with: 1. intubation and surfactant administration through an endotracheal tube (ETT); or 2. continuation of non-invasive respiratory support without surfactant administration or intubation. Secondary objective 1. To compare different methods of surfactant administration via thin catheter Planned subgroup analyses included gestational age, timing of intervention, and use of sedating pre-medication during the intervention.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 30 September 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials.

SELECTION CRITERIA

We included randomised trials comparing surfactant administration via thin catheter (S-TC) with (1) surfactant administration through an ETT (S-ETT), or (2) continuation of non-invasive respiratory support without surfactant administration or intubation. We also included trials comparing different methods/strategies of surfactant administration via thin catheter. We included preterm infants (at < 37 weeks' gestation) with or at risk of RDS.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed study quality and risk of bias and extracted data. Authors of all studies were contacted regarding study design and/or missing or unpublished data. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 16 studies (18 publications; 2164 neonates) in this review. These studies compared surfactant administration via thin catheter with surfactant administration through an ETT with early extubation (Intubate, Surfactant, Extubate technique - InSurE) (12 studies) or with delayed extubation (2 studies), or with continuation of continuous positive airway pressure (CPAP) and rescue surfactant administration at pre-specified criteria (1 study), or compared different strategies of surfactant administration via thin catheter (1 study). Two trials reported neurosensory outcomes of of surviving participants at two years of age. Eight studies were of moderate certainty with low risk of bias, and eight studies were of lower certainty with unclear risk of bias. S-TC versus S-ETT in preterm infants with or at risk of RDS Meta-analyses of 14 studies in which S-TC was compared with S-ETT as a control demonstrated a significant decrease in risk of the composite outcome of death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.48 to 0.73; risk difference (RD) -0.11, 95% CI -0.15 to -0.07; number needed to treat for an additional beneficial outcome (NNTB) 9, 95% CI 7 to 16; 10 studies; 1324 infants; moderate-certainty evidence); the need for intubation within 72 hours (RR 0.63, 95% CI 0.54 to 0.74; RD -0.14, 95% CI -0.18 to -0.09; NNTB 8, 95% CI; 6 to 12; 12 studies, 1422 infants; moderate-certainty evidence); severe intraventricular haemorrhage (RR 0.63, 95% CI 0.42 to 0.96; RD -0.04, 95% CI -0.08 to -0.00; NNTB 22, 95% CI 12 to 193; 5 studies, 857 infants; low-certainty evidence); death during first hospitalisation (RR 0.63, 95% CI 0.47 to 0.84; RD -0.02, 95% CI -0.10 to 0.06; NNTB 20, 95% CI 12 to 58; 11 studies, 1424 infants; low-certainty evidence); and BPD among survivors (RR 0.57, 95% CI 0.45 to 0.74; RD -0.08, 95% CI -0.11 to -0.04; NNTB 13, 95% CI 9 to 24; 11 studies, 1567 infants; moderate-certainty evidence). There was no significant difference in risk of air leak requiring drainage (RR 0.58, 95% CI 0.33 to 1.02; RD -0.03, 95% CI -0.05 to 0.00; 6 studies, 1036 infants; low-certainty evidence). None of the studies reported on the outcome of death or survival with neurosensory disability. Only one trial compared surfactant delivery via thin catheter with continuation of CPAP, and one trial compared different strategies of surfactant delivery via thin catheter, precluding meta-analysis.

AUTHORS' CONCLUSIONS

Administration of surfactant via thin catheter compared with administration via an ETT is associated with reduced risk of death or BPD, less intubation in the first 72 hours, and reduced incidence of major complications and in-hospital mortality. This procedure had a similar rate of adverse effects as surfactant administration through an ETT. Data suggest that treatment with surfactant via thin catheter may be preferable to surfactant therapy by ETT. Further well-designed studies of adequate size and power, as well as ongoing studies, will help confirm and refine these findings, clarify whether surfactant therapy via thin tracheal catheter provides benefits over continuation of non-invasive respiratory support without surfactant, address uncertainties within important subgroups, and clarify the role of sedation.

Characteristics and causes of death in children with neonatal abstinence syndrome

AIM

To determine characteristics of death in children with neonatal abstinence syndrome (NAS).

METHODS

A population-based linkage study of children from birth to 13 years of age in New South Wales (NSW), Australia, born 1 July 2000 to 31 December 2011. Infants with an International Statistical Classification of Diseases and Related Problems, Australian modification coding of NAS (P96.1, n = 3842) were compared to infants (n = 1 018 421) without NAS by birth, hospitalisation and death records linkage.

RESULTS

Forty-five (1.2%) children with NAS died, compared to 3665 (0.4%) other children. Most deaths (n = 30, 66%) in NAS children occurred between 1 month and 1 year. Risk of death was independently increased in full-term children (hazard ratio 2.34, 95% confidence interval 1.63-3.35; P < 0.001) from lower socio-economic groups (1.23, 1.12-1.35; P < 0.001), most commonly from ill-defined or external causes, including assault and accidents (P < 0.001).

CONCLUSIONS

Children with NAS, especially those of term gestation and from lower socio-economic groups, are more likely to die, especially from external causes.

The effect of lactoferrin supplementation on death or major morbidity in very low birthweight infants (LIFT): a multicentre, double-blind, randomised controlled trial

BACKGROUND

Very low birthweight or preterm infants are at increased risk of adverse outcomes including sepsis, necrotising enterocolitis, and death. We assessed whether supplementing the enteral diet of very low-birthweight infants with lactoferrin, an antimicrobial protein, reduces all-cause mortality or major morbidity.

METHODS

We did a multicentre, double-blind, pragmatic, randomised superiority trial in 14 Australian and two New Zealand neonatal intensive care units. Infants born weighing less than 1500 g and aged less than 8 days, were eligible and randomly assigned (1:1) using minimising web-based randomisation to receive once daily 200 mg/kg pasteurised bovine lactoferrin supplements or no lactoferrin supplement added to breast or formula milk until 34 weeks' post-menstrual age (or for 2 weeks, if longer), or until discharge from the study hospital if that occurred first. Designated nurses preparing the daily feeds were not masked to group assignment, but other nurses, doctors, parents, caregivers, and investigators were unaware. The primary outcome was survival to hospital discharge or major morbidity (defined as brain injury, necrotising enterocolitis, late-onset sepsis at 36 weeks' post-menstrual age, or retinopathy treated before discharge) assessed in the intention-to-treat population. Safety analyses were by treatment received. We also did a prespecified, PRISMA-compliant meta-analysis, which included this study and other relevant randomised controlled trials, to estimate more precisely the effects of lactoferrin supplementation on late-onset sepsis, necrotising enterocolitis, and survival. This trial is registered with the Australian and New Zealand Clinical Trials Registry, ACTRN12611000247976.

FINDINGS

Between June 27, 2014, and Sept 1, 2017, we recruited 1542 infants; 771 were assigned to the intervention group and 771 to the control group. One infant who had consent withdrawn before beginning lactoferrin treatment was excluded from analysis. In-hospital death or major morbidity occurred in 162 (21%) of 770 infants in the intervention group and in 170 (22%) of 771 infants in the control group (relative risk [RR] 0·95, 95% CI 0·79-1·14; p=0·60). Three suspected unexpected serious adverse reactions occurred; two in the lactoferrin group, namely unexplained late jaundice and inspissated milk syndrome, but were not attributed to the intervention and one in the control group had fatal inspissated milk syndrome. Our meta-analysis identified 13 trials completed before Feb 18, 2020, including this Article, in 5609 preterm infants. Lactoferrin supplements significantly reduced late-onset sepsis (RR 0·79, 95% CI 0·71-0·88; p<0·0001; I²=58%), but not necrotising enterocolitis or all-cause mortality.

INTERPRETATION

Lactoferrin supplementation did not improve death or major morbidity in this trial, but might reduce late-onset sepsis, as found in our meta-analysis of over 5000 infants. Future collaborative studies should use products with demonstrated biological activity, be large enough to detect moderate and clinically important effects reliably, and assess greater doses of lactoferrin in infants at increased risk, such as those not exclusively receiving breastmilk or infants of extremely low birthweight.

FUNDING

Australian National Health and Medical Research Council.

Safety attitudes in hospital emergency departments: a systematic review

PURPOSE

The purpose of this paper is to perform and report a systematic review of published research on patient safety attitudes of health staff employed in hospital emergency departments (EDs).

DESIGN/METHODOLOGY/APPROACH

An electronic search was conducted of PsychINFO, ProQuest, MEDLINE, EMBASE, PubMed and CINAHL databases. The review included all studies that focussed on the safety attitudes of professional hospital staff employed in EDs.

FINDINGS

Overall, the review revealed that the safety attitudes of ED health staff are generally low, especially on teamwork and management support and among nurses when compared to doctors. Conversely, two intervention studies showed the effectiveness of team building interventions on improving the safety attitudes of health staff employed in EDs.

RESEARCH LIMITATIONS/IMPLICATIONS

Six studies met the inclusion criteria, however, most of the studies demonstrated low to moderate methodological quality.

ORIGINALITY/VALUE

Teamwork, communication and management support are central to positive safety attitudes. Teamwork training can improve safety attitudes. Given that EDs are the "front-line" of hospital care and patients within EDs are especially vulnerable to medical errors, future research should focus on the safety attitudes of medical staff employed in EDs and its relationship to medical errors.

A pilot randomised clinical trial of 670 nm red light for reducing retinopathy of prematurity

BACKGROUND

Photobiomodulation by 670 nm red light in animal models reduced severity of ROP and improved survival. This pilot randomised controlled trial aimed to provide data on 670 nm red light exposure for prevention of ROP and survival for a larger randomised trial.

METHODS

Neonates <30 weeks gestation or <1150 g at birth were randomised to receive 670 nm for 15 min (9 J/cm²) daily until 34 weeks corrected age.

DATA COLLECTED

placental pathology, growth, days of respiratory support and oxygen, bronchopulmonary dysplasia, patent ductus arteriosus, necrotising enterocolitis, sepsis, worst stage of ROP, need for laser treatment, and survival.

RESULTS

Eighty-six neonates enrolled-45 no red light; 41 red light. There was no difference in severity of ROP (<27 weeks-p = 0.463; ≥27 weeks-p = 0.558) or requirement for laser treatment (<27 weeks-p = 1.00; ≥27 weeks-no laser treatment in either group). Survival in 670 nm red light treatment group was 100% (41/41) vs 89% (40/45) in untreated infants (p = 0.057).

CONCLUSION

Randomisation to receive 670 nm red light within 24-48 h after birth is feasible. Although no improvement in ROP or survivability was observed, further testing into the dosage and delivery for this potential therapy are required.

Attitudes of Doctors and Nurses toward Patient Safety within Emergency Departments of a Saudi Arabian Hospital: A Qualitative Study

Background: The attitudes of doctors and nurses toward patient safety representa significant contributing factor to hospital safety climates and medical error rates. Yet, there are very few studies of patient safety attitudes in Saudi hospitals and none conducted in hospital emergency departments. Aims: The current study aims to investigate and compare the patient safety attitudes of doctors and nurses in a Saudi hospital emergency department. Materials and Method: The study employed a qualitative research design via semi-structured interviews with Saudi and non-Saudi doctors and nurses working in a Saudi hospital emergency department to determine their attitudes and experiences about the patient safety climate. Results: Findings revealed doctors and nurses held some similar safety attitudes; however, nurses reported issues with doctors with respect to their teamwork, communication, and patient safety attitudes. Moreover, several barriers to the patient safety climate were identified, including limits to resources, teamwork, communication, and incident reporting. Conclusion: The findings provide one of the few research contributions to knowledge regarding the patient safety attitudes of Saudi and non-Saudi doctors and nurses and suggest the application of such knowledge would enhance positive patient outcomes in emergency departments.

Long-term outcomes after group B streptococcus infection: a cohort study

OBJECTIVE

To describe the risk of death and hospitalisation until adolescence of children after group B streptococcus (GBS) infection during infancy.

DESIGN

Population-based cohort study.

SETTING

New South Wales, Australia.

PATIENTS

All registered live births from 2000 to 2011.

INTERVENTIONS

Comparison of long-term outcomes in children with the International Statistical Classification of Diseases and Related Health Problems-10th Revision discharge codes corresponding to GBS infections and those without.

MAIN OUTCOME MEASURES

Death and hospitalisation.

RESULTS

A total of 1206 (0.1%) children (936 (77.6%)≥37 weeks' gestation) were diagnosed with GBS infection. Over the study period, infection rates decreased from 2.1 (95% CI 1.8 to 2.4) to 0.7 (95% CI 0.5 to 0.9) per 1000 live births. Infants with GBS infection were born at lower gestation (mean 37.6 vs 39.0 weeks), were more likely very low birth weight (<1500 g, OR 9.1(95% CI 7.4 to 11.3)), born premature (OR 3.9(95% CI 3.4 to 4.5)) and have 5 min Apgar scores ≤5 (OR 6.7(95% CI 5.1 to 8.8)). Children with GBS had three times the adjusted odds of death (adjusted OR (AOR) 3.0(95% CI 2.1 to 4.3)) or rehospitalisations (AOR 3.1(95% CI 2.7 to 3.5)). Thirty-six (3.0%) with GBS died, with >50% of deaths occurring <28 days. Children with GBS were hospitalised more frequently (median 2 vs 1), for longer duration (mean 3.7 vs 2.2 days) and were at higher risk for problems with genitourinary (OR 3.1(95% CI 2.8 to 3.5)) and nervous (OR 2.0 (95% CI1.7 to 2.3)) systems.

CONCLUSIONS

Despite decreasing GBS rates, the risk of poor health outcomes for GBS-infected children remains elevated, especially during the first 5 years. Survivors continue to be at increased risk of death and chronic conditions requiring hospitalisations, such as cerebral palsy and epilepsy.

Barriers to screening pregnant women for alcohol or other drugs: A narrative synthesis

BACKGROUND

Maternal alcohol or other drug use during pregnancy is associated with a range of adverse health outcomes for mothers and their unborn child. The antenatal period presents an opportunity for health professionals to offer routine screening for alcohol or other drugs, to then provide intervention and referral for treatment and/or specialised support services. However, literature indicates that limited screening practices currently exist in maternity care settings.

AIM

To identify barriers to screening pregnant women for alcohol or other drugs in maternity care settings, from the perspectives of healthcare professionals.

METHODS

A comprehensive literature search was conducted in October 2017 to identify relevant studies. Seven databases that index health and social sciences literature, and google scholar, were searched. Eligible articles were subjected to critical appraisal. Extracted data from the eligible studies were synthesised using narrative synthesis.

FINDINGS

Nine studies were eligible for this review. The review identified seven key barriers to screening for alcohol or other drugs in pregnancy, namely competing priorities and time constraint; lack of adequate screening skills and clear protocol; relationship between healthcare providers and pregnant women; healthcare providers' perceptions; under-reporting or none/false disclosure; inconclusive evidence regarding the risk of alcohol or other drug use in pregnancy; and concerns about guilt and anxiety.

CONCLUSIONS

The narrative review revealed a range of barriers to screening for alcohol or other drugs in pregnancy. Further research in minimising the barriers is required to establish women-centred, evidence-base screening practices.

Attitudes of doctors and nurses toward patient safety within emergency departments of two Saudi Arabian hospitals

Background

A hospital culture that promotes and insures patient safety is a critical aspect for the effective delivery of hospital services and patient care. Yet there are significant patient health and safety issues in hospitals worldwide. This study aims to investigate doctors’ and nurses’ attitudes toward patient safety in the emergency departments (ED) of two Saudi hospitals.

Method

A cross-sectional survey using a validated Safety Attitudes Questionnaire (SAQ) was used. Total of 503 ED doctors and nurses completed SAQ. Correlation analysis, using Spearman’s Rho, was performed between the number of incidents reported and each dimension of the SAQ.

Results

The mean score of each SAQ dimension was < 75%, indicating that nurses and doctors generally had less than a positive safety attitudes. This was especially prominent with dimensions of stress recognition (58.1%) and perceptions of hospital management (56.9%). Furthermore, nurses reported significantly lower on the teamwork climate dimension than doctors (p < .01), whereas doctors reported significantly lower on the hospital work conditions dimension than nurses (p < .01). There was a significant negative correlation between the number of errors reported and teamwork climate, job satisfaction, and work conditions.

Conclusion

Safety attitudes of doctors and nurses employed in EDs of Saudi hospitals are less than positive and correlate with the number of reported errors. Safety training interventions and management support would appear to be the most likely avenues to improve the safety attitudes and performance within Saudi ED’s.

Mode of delivery and outcomes of infants with gastroschisis: a meta-analysis of observational studies

BACKGROUND

There is controversy among the literature for electing caesarean section (CS) delivery for infants with gastroschisis in an attempt to reduce mortality and morbidity.

OBJECTIVE

This meta-analysis investigates whether there is enough evidence to support CS delivery over vaginal delivery.

DATA SOURCES

We conducted our search in April 2017. We searched Cochrane, Medline, Premedline, Embase, CINAHL, GoogleScholar and Web of Science. We also searched conferences for abstracts online. Additional studies were retrieved by reviewing reference lists.

STUDY SELECTION

Observational studies, excluding case series, were eligible if data compared relevant outcomes of infants with gastroschisis in relation to mode of delivery.

DATA EXTRACTION

Relevant information were extracted and assessed the methodological quality of the retrieved records.

RESULTS

Thirty-eight studies were included. Evidence suggested that mode of delivery is not significantly associated with overall mortality (OR 0.82, 95% CI 0.57 to 1.18), primary repair (OR 0.82, 95% CI 0.57 to 1.18), neonatal mortality (OR 1.08, 95% CI 0.54 to 2.15), necrotising enterocolitis, secondary repair, sepsis, short gut syndrome, duration until enteral feeding and duration of hospital stay. Furthermore, sensitivity analyses based on economic status and quality of study showed no significant difference between the impact of mode of delivery for all investigated outcomes.

LIMITATIONS

Due to uncontrolled variables between and within studies, particularly regarding characteristics of delivery and postdelivery care, it is difficult to extract meaningful results from the literature.

CONCLUSIONS

There is insufficient evidence to advocate the use of CS over vaginal delivery for infants with gastroschisis.

Variation in hospital mortality in an Australian neonatal intensive care unit network

BACKGROUND

Studying centre-to-centre (CTC) variation in mortality rates is important because inferences about quality of care can be made permitting changes in practice to improve outcomes. However, comparisons between hospitals can be misleading unless there is adjustment for population characteristics and severity of illness.

OBJECTIVE

We sought to report the risk-adjusted CTC variation in mortality among preterm infants born <32 weeks and admitted to all eight tertiary neonatal intensive care units (NICUs) in the New South Wales and the Australian Capital Territory Neonatal Network (NICUS), Australia.

METHODS

We analysed routinely collected prospective data for births between 2007 and 2014. Adjusted mortality rates for each NICU were produced using a multiple logistic regression model. Output from this model was used to construct funnel plots.

RESULTS

A total of 7212 live born infants <32 weeks gestation were admitted consecutively to network NICUs during the study period. NICUs differed in their patient populations and severity of illness.The overall unadjusted hospital mortality rate for the network was 7.9% (n=572 deaths). This varied from 5.3% in hospital E to 10.4% in hospital C. Adjusted mortality rates showed little CTC variation. No hospital reached the +99.8% control limit level on adjusted funnel plots.

CONCLUSION

Characteristics of infants admitted to NICUs differ, and comparing unadjusted mortality rates should be avoided. Logistic regression-derived risk-adjusted mortality rates plotted on funnel plots provide a powerful visual graphical tool for presenting quality performance data. CTC variation is readily identified, permitting hospitals to appraise their practices and start timely intervention.

Patient Demographic and Clinician Factors in Antibiotic Prescribing for Upper Respiratory Tract Infections in the Australian Capital Territory from 2006-2015

INTRODUCTION

National antibiotic stewardship programs aim to mitigate rising antimicrobial resistance and associated healthcare costs by promoting safe and appropriate antibiotic prescribing.

AIM

This study aimed to analyse patient and clinician demographic factors that may influence antibiotic prescribing for Upper Respiratory Tract Infections (URTIs). Trends in antibiotic prescribing patterns were also analysed over the study period.

MATERIALS AND METHODS

This retrospective cross-sectional study analysed data from the Australian National University Medical School Clinical Audit Project database, comprising data collected by students during patient encounters over a two week period each April-May between 2006 and 2015 (excluding 2013). Data was collected via standardised survey in multiple healthcare settings and locations in the Australian Capital Territory (ACT) and Southeast New South Wales. (NSW) URTI diagnosis and symptomatology were defined using the International Classification of Disease (ICD-10) and International Classification of Primary Care, version 2 PLUS (ICPC-2+) criteria.

RESULTS

URTI accounted for 5.6% (n=698) of total patient encounters (n=12,468), and of these, 42.7% (n=289) were prescribed an antibiotic intervention. Antibiotics were significantly more likely to be prescribed in the hospital setting (44.2%; n=237) compared to community GP (32.1%; n=52; p<0.05) and for patients presenting with localised symptoms (65.9%; n=109) compared to generalised symptoms (33.7%; n=122; p<0.01). No significant association was observed for age, rurality, patient gender, clinical gender or Indigenous status. The most frequently prescribed antibiotic was penicillin (67.8%; n=196). Over the decade of study, antibiotic prescribing for URTIs showed decreasing trend both overall (R2=0.204) and with respect to all demographic factors assessed.

CONCLUSION

This study supports the effectiveness to-date of antibiotic stewardship programs in Australia. While continued efforts are required to further mitigate antibiotic resistance, this study suggests target areas may include improving clinician resistance to patient demand for antibiotics and increasing confidence in prescribing for special populations such as Indigenous peoples and the extremes of age.

Maternal hypertensive disorders are associated with increased use of respiratory support but not chronic lung disease or poorer neurodevelopmental outcomes in preterm neonates at <29 weeks of gestation

AIM

To assess whether maternal hypertensive disorders in pregnancies result in higher respiratory requirements, risk of chronic lung disease (CLD) and poorer neurodevelopmental outcome in <29-week premature neonates.

METHODS

This is a multicentre, retrospective cohort study, within a geographically defined area in Australia, served by a network of 10 neonatal intensive care units (NICUs), consisting of infants <29 weeks of gestational age who were admitted to NICUs between 1998 and 2004. Outcome measures included hospital survival, perinatal complications and functional disability at 2-3 years follow-up.

RESULTS

A total of 2549 mothers and infants were included in the study; 379 (14.9%) mothers had hypertensive disorders during pregnancy. Follow-up data were obtained for 1473 (74.8%) infants at 2-3 years. Infants exposed to pre-eclampsia had a higher need for supplemental surfactant therapy (odds ratio (OR): 2.004, 95% confidence interval (CI): 1.51-2.66), longer duration of mechanical ventilation (7.0 days vs. 4.0 days), were associated with a higher incidence of CLD (OR: 1.40, 95% CI: 1.12-1.76) and received post-natal steroids for CLD (OR: 1.82, 95% CI: 1.43-2.31) and home oxygen (OR: 1.47, 95% CI: 1.11-1.95). Multivariable analysis showed that hypertensive disease of pregnancy was not significantly associated with the development of CLD in this cohort (OR: 1.103, 95% CI: 0.845-1.441). Multivariable analysis of long-term neurodevelopmental data available for the 1473 follow-up infants showed no significant difference in outcomes with or without exposure to maternal hypertensive disease.

CONCLUSION

Maternal hypertensive disease of pregnancy does not increase the risk of CLD or long-term neurodevelopmental complications in infants born at <29 weeks of gestation.

Neonatal Abstinence Syndrome and High School Performance

BACKGROUND AND OBJECTIVES

Little is known of the long-term, including school, outcomes of children diagnosed with Neonatal abstinence syndrome (NAS) (International Statistical Classification of Disease and Related Problems [10th Edition], Australian Modification, P96.1).

METHODS

Linked analysis of health and curriculum-based test data for all children born in the state of New South Wales (NSW), Australia, between 2000 and 2006. Children with NAS (n = 2234) were compared with a control group matched for gestation, socioeconomic status, and gender (n = 4330, control) and with other NSW children (n = 598 265, population) for results on the National Assessment Program: Literacy and Numeracy, in grades 3, 5, and 7.

RESULTS

Mean test scores (range 0-1000) for children with NAS were significantly lower in grade 3 (359 vs control: 410 vs population: 421). The deficit was progressive. By grade 7, children with NAS scored lower than other children in grade 5. The risk of not meeting minimum standards was independently associated with NAS (adjusted odds ratio [aOR], 2.5; 95% confidence interval [CI], 2.2-2.7), indigenous status (aOR, 2.2; 95% CI, 2.2-2.3), male gender (aOR, 1.3; 95% CI, 1.3-1.4), and low parental education (aOR, 1.5; 95% CI, 1.1-1.6), with all Ps < .001.

CONCLUSIONS

A neonatal diagnostic code of NAS is strongly associated with poor and deteriorating school performance. Parental education may decrease the risk of failure. Children with NAS and their families must be identified early and provided with support to minimize the consequences of poor educational outcomes.

Population-based study shows that resuscitating apparently stillborn extremely preterm babies is associated with poor outcomes

AIM

This population-based study determined the delivery room management and outcomes of extremely preterm infants born with Apgar scores of 0.

METHODS

We linked birth, neonatal intensive care unit (NICU) and death records for babies who were born between 22 + 0 and 27 + 6 weeks of gestation with a one-minute Apgar score of 0, in New South Wales, Australia, between 1998 and 2011.

RESULTS

We classified 2173/2262 (96%) of infants with a one-minute Apgar score of 0 as stillborn. Resuscitation was provided for 48/89 (54%) live births and 40/2173 (2%) stillbirths. Cardiac massage was given to 44 infants, including three 22-week stillborn babies. Of the 13 live births admitted to an NICU, 11 survived to hospital discharge. Most (98%) of the 2212 deaths occurred on the first day of life. One baby who was classified as stillborn lived for 51 days. Resuscitation increased the mean (95% confidence interval) duration of survival from 1 (0-2) to 45 (0-104) hours (p < 0.001). No infant with a five-minute Apgar score of 0 survived.

CONCLUSION

Clinicians resuscitated extremely preterm infants without a detectable heartbeat, even at 22 weeks of gestation. No infant survived without resuscitation or if their heartbeat was not regained by five minutes.

Outcomes of infants with abdominal wall defects over 18years

BACKGROUND/PURPOSE

Infants with abdominal wall defects (AWD) are at risk of poor outcomes including prolonged hospitalization, infections and mortality. Our objective was to describe and compare the outcomes of infants admitted with gastroschisis and omphalocele over 18years.

METHODS

Population-based study of clinical data and outcomes of live-born infants with AWD admitted to all tertiary-level neonatal intensive care units in New South Wales and Australian Capital Territory from 1992 to 2009.

RESULT

There were 502 infants with AWD - 336 gastroschisis, 166 omphalocele. Infants with gastroschisis required a longer duration of total parenteral nutrition (19 vs 4days, p<0.05), longer hospitalization (28 vs 15days, p<0.05) and had a higher rate of systemic infection [23.5% vs 13.3%, OR 1.77 (1.15-2.74), p<0.05] compared to infants with omphalocele. Overall, omphalocele infants had higher mortality rate compared to gastroschisis infants [OR 2.77 (1.53, 5.04), p<0.05]. Gastroschisis mortality rates increased from epoch 1 to epoch 3 (4.2% to 8.8%).

CONCLUSION

Compared to infants with omphalocele, infants with gastroschisis required significantly longer hospitalization and parenteral nutrition with higher rates of infection. Infants with omphalocele had higher overall mortality rates. However, there has been an increase in the gastroschisis mortality rates but the cause for this is unclear.

Case report of neonatal near drowning associated with underwater birth

Water immersion of labouring women during the first stage and second stage of labour significantly reduces analgesia requirements and increases women’s reported satisfaction with pushing, without adversely affecting labour duration, operative delivery rates, or foetal wellbeing. However, immersion during the third stage of labour is associated with potential serious complications that are not seen with land-based birth. Here, we present a case report of a baby born via water birth. The report illustrates increased risk of significant perinatal morbidity associated with water birth.

Risk of neurodevelopmental impairment for outborn extremely preterm infants in an Australian regional network

OBJECTIVE

To compare neurodevelopmental outcomes at 2-3 years in extremely premature outborn and inborn infants.

DESIGN

Population-based retrospective cohort study.

SETTING

Geographically defined area of New South Wales (NSW) and the Australian Capital Territory (ACT) served by a network of 10 neonatal intensive care units (NICUs).

PATIENTS

All premature infants <29 weeks gestation born between 1998 and 2004 in the setting.

INTERVENTION

At 2-3 years, corrected age, 1473 children were assessed with either the Griffiths Mental Developmental Scales (GMDS) or the Bayley Scales of Infant Development (BSID-II).

MAIN OUTCOME MEASURE

Moderate/severe functional disability (FD) defined as: developmental delay (GMDS general quotient (GQ) or BSID-II mental developmental index (MDI)) > 2 standard deviations (SD) below the mean; cerebral palsy (CP) requiring aids; sensorineural or conductive deafness (requiring amplification); or bilateral blindness (visual acuity <6/60 in better eye).

RESULTS

At 2-3 years, moderate/severe functional disability does not appear to be significantly different between outborn and inborn infants (adjusted OR 0.782; 95% CI 0.424-1.443). However, there were a significant number of outborn infants lost to follow up (23.3% versus 42.9%).

CONCLUSION

In this cohort, at 2-3 years follow up neurodevelopmental outcome does not appear to be significantly different between outborn and inborn infants. These results should be interpreted with caution given the limitation of this study.

Epidemiological Evidence for a Decreasing Incidence of Neonatal Abstinence Syndrome, 2000-11

BACKGROUND

This study analyses the incidence of Neonatal Abstinence Syndrome (NAS) in a large geographically defined population in Australia.

METHOD

Database linkage analysis of all births between 2000 and 2011 in New South Wales (NSW), Australia. The diagnosis of NAS was derived from hospital coding P96.1, 'Neonatal withdrawal symptoms from maternal use of drugs of addiction'. Temporal trends were studied by comparing epoch 1 (2000-05) with epoch 2 (2006-11). The relationship with changes in maternal factors was further analysed.

RESULTS

The NAS was coded in 3842 of 1 022 263 live born infants (0.38%). NAS incidence peaked at 5.07 per 1000 live births in 2002, decreasing to 3.18 in 2011 and was negatively correlated with maternal age (r = -0.7). The rate of NAS in epoch 2 (3.4 per 1000 births, 95% CI 3.28, 3.58) was significantly lower than in epoch 1 (4.1 per 1000 births, 95% CI 3.96, 4.33). Epoch 2 mothers were significantly older (mean 29.8 years vs. 28.3 years), less likely to be multiparous (OR 0.7, 95% CI 0.6, 0.9) or smoke (OR 0.4, 95% CI 0.4, 0.5). They were more likely to engage in antenatal care earlier (mean first visit: 14.1 vs. 18.9 weeks). Most infants (~80%) were born at term (>37 weeks gestation).

CONCLUSION

The incidence of NAS as a discharge diagnosis has decreased in our population since 2002. Mothers are also older and engaging earlier in prenatal care. Whether these changes alter NAS presentation and diagnosis or whether pregnant women are using drugs that do not cause typical NAS (e.g. amphetamines) is uncertain and requires further study.

Childhood Health and Developmental Outcomes After Cesarean Birth in an Australian Cohort

BACKGROUND AND OBJECTIVES

Concerns have been raised about associations between cesarean delivery and childhood obesity and asthma. However, published studies have not examined the long-term neurodevelopmental outcomes or fully addressed confounding influences. We used data from the LSAC (Longitudinal Study of Australian Children) to explore the relationship between cesarean delivery and physical and socio-emotional outcomes from 0 to 7 years, taking into account confounding factors.

METHODS

Data were from 5 waves of LSAC representing 5107 children born in 2003 and 2004. Outcome measures included: global health, asthma, BMI, use of prescribed medication, general development, medical conditions and/or disabilities, special health care needs, and socio-emotional development. Models adjusted for birth factors, social vulnerability, maternal BMI, and breastfeeding.

RESULTS

Children born by cesarean delivery were more likely to have a medical condition at 2 to 3 years (odds ratio: 1.33; P = .03), use prescribed medication at 6 to 7 years (odds ratio: 1.26; P = .04), and have a higher BMI at 8 to 9 years (coefficient: 0.08; P = .05), although this last effect was mediated by maternal obesity. Parent-reported quality of life for children born by cesarean delivery was lower at 8 to 9 years (coefficient: -0.08; P = .03) but not at younger ages. Contrasting this finding, cesarean delivery was associated with better parent-reported global health at 2 to 3 years (odds ratio: 1.23; P = .05) and prosocial skills at age 6 to 7 years (coefficient: 0.09; P = .02).

CONCLUSIONS

Cesarean delivery was associated with a mix of positive and negative outcomes across early childhood, but overall there were few associations, and these were not consistent across the 5 waves. This study does not support a strong association between cesarean delivery and poorer health or neurodevelopmental outcomes in childhood.

Neurodevelopmental Outcomes of Premature Infants Treated for Patent Ductus Arteriosus: A Population-Based Cohort Study

OBJECTIVE

To compare neurodevelopmental outcomes of extremely preterm infants diagnosed with patent ductus arteriosus (PDA) who were treated medically or surgically and those who were not diagnosed with PDA or who did not undergo treatment for PDA.

STUDY DESIGN

This retrospective population-based cohort study used data from a geographically defined area in New South Wales and the Australian Capital Territory served by a network of 10 neonatal intensive care units. Patients included all preterm infants born at <29 completed weeks of gestation between 1998 and 2004. Moderate/severe functional disability at 2-3 years corrected age was defined as developmental delay, cerebral palsy requiring aids, sensorineural or conductive deafness (requiring bilateral hearing aids or cochlear implant), or bilateral blindness (best visual acuity of <6/60).

RESULTS

Follow-up information at age 2-3 years was available for 1473 infants (74.8%). Compared with infants not diagnosed with a PDA or who did not receive PDA treatment for PDA, those with medically treated PDA (aOR, 1.622; 95% CI, 1.199-2.196) and those with surgically treated PDA (aOR, 2.001; 95% CI, 1.126-3.556) were at significantly greater risk for adverse neurodevelopmental outcomes at age 2-3 years.

CONCLUSION

Our results demonstrate that treatment for PDA may be associated with a greater risk of adverse neurodevelopmental outcome at age 2-3 years. This was particularly so among infants born at <25 weeks gestation. These results may support permissive tolerance of PDAs; however, reasons for this association remain to be elucidated through carefully designed prospective trials.

Reasons for Rehospitalization in Children Who Had Neonatal Abstinence Syndrome

BACKGROUND AND OBJECTIVES

Neonatal abstinence syndrome (NAS) occurs after in utero exposure to opioids, but outcomes after the postnatal period are unclear. Our objectives were to characterize childhood hospitalization after NAS.

METHODS

Population-based linkage study of births, hospitalization, and death records of all children registered in New South Wales (NSW), Australia, between 2000 and 2011 to a maximum of 13 years. Infants with an International Statistical Classification of Disease and Related Problems, 10th Edition, Australian Modification, coding of NAS (P96.1, n = 3842) were compared with 1,018,421 live born infants without an NAS diagnosis.

RESULTS

Infants with NAS were more likely to be admitted into a nursery (odds ratio 15.6, 95% confidence interval: 14.5-16.8) and be hospitalized longer (10.0 vs 3.0 days). In childhood, they were more likely to be rehospitalized (1.6, 1.5-1.7), die during hospitalization (3.3, 2.1-5.1), and be hospitalized for assaults (15.2, 11.3-20.6), maltreatment (21.0, 14.3-30.9), poisoning (3.6, 2.6-4.8), and mental/behavioral (2.6, 2.1-3.2) and visual (2.9, 2.5-3.5) disorders. Mothers of infants with NAS were more likely to be Indigenous (6.4, 6.0-7.0), have no antenatal care (6.6, 5.9-7.4), and be socioeconomically deprived (1.6, 1.5-1.7). Regression analyses demonstrated that NAS was the most important predictor of admissions for maltreatment (odds ratio 4.5, 95% confidence interval: 3.4-6.1) and mental and behavioral disorders (2.3, 1.9-2.9), even after accounting for prematurity, maternal age, and Indigenous status.

CONCLUSIONS

Children with NAS are more likely to be rehospitalized during childhood for maltreatment, trauma, and mental and behavioral disorders even after accounting for prematurity. This continues to adolescence and emphasizes the critical need for continued support of this vulnerable group after resolution of NAS.

Neurodevelopmental outcome of extremely preterm infants born to rural and urban residents' mothers in Australia

BACKGROUND

Rural and remote residents in Australia have long experienced unfavourable health outcomes compared to their urban counterparts.

AIMS

To study neurodevelopmental outcome at 2-3 years of age, corrected for prematurity of extremely preterm infants admitted to a regional neonatal Australian network from rural and urban regions (based on usual location of maternal residence).

METHODS

A multicenter population-based cohort study in which surviving urban and rural infants <29 weeks of gestation born between 1998 and 2004 underwent neurodevelopmental assessment at 2-3 years of age, corrected for prematurity by a developmental assessment team. Moderate/severe functional disability was defined as developmental delay (GQ or MDI>2 SD below the mean), cerebral palsy (aided for walking), sensorineural or conductive deafness (requiring amplification), and bilateral blindness (visual acuity <6/60 in the better eye).

RESULTS

Of the 1970 infants alive at 2-3 years of age, 268 (63.8%) rural and 1205 (77.7%) urban infants were evaluated. Infants lost to follow-up were of slightly higher gestational age and birth weight. Both rural and urban assessed groups were comparable in gestation and birth weight percentile. In comparison to their urban counterparts, the rural group had more outborn infants (19.8% vs. 4.6%, p<0.001). They, however, did not have an increased risk of moderate/severe functional disability (OR 0.77, 95% CI 0.52-1.23, p=0.176). This finding was not significantly altered by limiting the analysis to different gestational ages.

CONCLUSION

Extremely premature surviving young children from rural areas of residence do not seem to have an increased risk for moderate/severe functional disability.

A safety and feasibility study of the use of 670 nm red light in premature neonates

OBJECTIVE

Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina affecting extremely preterm or low birth weight infants The aim of this study was to assess the feasibility and safety of 670 nm red light use in a neonatal intensive care unit.

STUDY DESIGN

Neonates <30 weeks gestation and <1150 g were enrolled within 48 h of birth. Data collected included cause of preterm delivery, Apgar scores and birthweight. 670 nm red light was administered for 15 min per day from a distance of 25 cm, delivering 9 J cm(-)(2), from the time of inclusion in the study until 34 weeks postmenstrual age. Infants were assessed daily for the presence of any skin burns or other adverse signs.

RESULT

Twenty-eight neonates were enrolled, seven 24 to 26 weeks and twenty-one 27 to 29 weeks gestation. The most common cause for preterm delivery was preterm labor (14/28) with five of these having evidence of chorioamnionitis. There were no skin burns or other documented adverse events. Entry into the study was readily achieved and treatment was well accepted by parents and nursing staff.

CONCLUSION

670 nm red light appears to be a safe and feasible treatment for further research in respect to ROP.

Prematurity reduces the severity and need for treatment of neonatal abstinence syndrome

AIM

This study determined the influence of prematurity on the manifestation and treatment of neonatal abstinence syndrome (NAS).

METHODS

This was a medical record review of Australian infants exposed to opiates in 2004 and 2007. Finnegan scores were obtained for 215 of 361 (59%) preterm infants under 37-week gestation and 694 of 1178 (59%) term infants.

RESULTS

The mean and standard deviation (SD) gestational ages were 34 (3) and 38 (3) weeks for preterm and term infants, respectively. Maternal daily methadone doses were similar for the preterm and term infants with a mean (SD) of 79 mg (39) versus 72 mg (38) (p = 0.06). Maximum Finnegan scores were significantly lower in preterm infants (10 versus 11, p = 0.01), scores were positively correlated with gestation and fewer preterm infants were medicated for NAS (40% versus 48% p = 0.05). Maximum median daily and interquartile range morphine doses were lower for preterm than term infants (0.5 mg/kg/day (0.3-0.6) versus 0.5 mg/kg/day (0.4-0.7), p = 0.02).

CONCLUSION

Preterm infants were just as likely to be monitored for withdrawal as term infants, but their Finnegan scores were lower and fewer preterm infants were treated for NAS. Whether this indicates decreased NAS severity or physiological immaturity is uncertain. Other means of evaluating NAS in preterm infants are warranted, especially long-term outcomes.

Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion

BACKGROUND

There are limited data to inform the choice between parental presence at clinical bedside rounds (PPCBR) and non-PPCBR in neonatal intensive care units (NICUs).

METHODS

We performed a single-centre, survey-based, crossed-over randomised trial involving parents of all infants who were admitted to NICU and anticipated to stay >11 days. Parents were randomly assigned using a computer-generated stratified block randomisation protocol to start with PPCBR or non-PPCBR and then crossed over to the other arm after a wash-out period. At the conclusion of each arm, parents completed the 'NICU Parental Stressor Scale' (a validated tool) and a satisfaction survey. After completion of the trial, we surveyed all healthcare providers who participated at least in one PPCBR rounding episode. We also offered all participating parents and healthcare providers the opportunity to partake in a focus group discussion regarding PPCBR.

RESULTS

A total of 72 parents were enrolled in this study, with 63 parents (87%) partially or fully completing the trial. Of the parents who completed the trial, 95% agreed that parents should be allowed to attend clinical bedside rounds. A total of 39 healthcare providers' surveys were returned and 35 (90%) agreed that parents should be allowed to attend rounds. Nine healthcare providers and 8 parents participated in an interview or focus group, augmenting our understanding of the ways in which PPCBR was beneficial.

CONCLUSIONS

Parents and healthcare providers strongly support PPCBR. NICUs should develop policies allowing PPCBR while mitigating the downsides and concerns of parents and healthcare providers such as decreased education opportunity and confidentiality concerns.

TRIAL REGISTRATION NUMBER

Australia and New Zealand Clinical Trials Register number, ACTRN12612000506897.

Neurodevelopmental outcomes of preterm singletons, twins and higher-order gestations: a population-based cohort study

OBJECTIVE

To study the neurodevelopmental outcomes of multiple (twins, triplets, quads) compared with singleton extremely preterm infants <29 weeks gestation.

DESIGN

Population-based retrospective cohort study.

SETTING

A network of 10 neonatal intensive care units in a geographically defined area of New South Wales and the Australian Capital territory.

PATIENTS

1473 infants <29 weeks gestation born between 1 January 1998 and 31 December 2004.

INTERVENTION

At 2-3 years of corrected age, a neurodevelopmental assessment was conducted using either the Griffiths Mental Developmental Scales or the Bayley Scales of Infant Development II.

MAIN OUTCOME MEASURE

Moderate-severe functional disability was defined as developmental delay (Griffiths Mental Developmental Scales General Quotient or Bayley Scales of Infant Development-II Mental Development Index >2 SDs below the mean), moderate cerebral palsy (unable to walk without aids), sensorineural or conductive deafness (requiring amplification) or bilateral blindness (visual acuity <6/60 in the better eye).

RESULTS

Of the 1081 singletons and 392 multiples followed-up, singletons demonstrated higher rates of systemic infections, steroid treatment for chronic lung disease and birth weight <10th percentile. Moderate-severe functional disability did not differ significantly between singletons and multiples (15.8% vs 17.6%, OR 1.14; 95% CI 0.84 to 1.54; p=0.464). Further subgroup analysis of twins, higher-order gestations, 1st-born multiples, 2nd or higher-born multiples, same and unlike gender multiples, did not demonstrate statistically higher rates of functional disability compared with singletons.

CONCLUSIONS

Premature infants from multiple gestation pregnancies appear to have comparable neurodevelopmental outcomes to singletons.

Do maternal opioids reduce neonatal regional brain volumes? A pilot study

OBJECTIVE

A substantial number of children exposed to gestational opioids have neurodevelopmental, behavioral and cognitive problems. Opioids are not neuroteratogens but whether they affect the developing brain in more subtle ways (for example, volume loss) is unclear. We aimed to determine the feasibility of using magnetic resonance imaging (MRI) to assess volumetric changes in healthy opioid-exposed infants.

STUDY DESIGN

Observational pilot cohort study conducted in two maternity hospitals in New South Wales, Australia. Maternal history and neonatal urine and meconium screens were obtained to confirm drug exposure. Volumetric analysis of MRI scans was performed with the ITK-snap program.

RESULT

Scans for 16 infants (mean (s.d.) gestational age: 40.9 (1.5) weeks, birth weight: 3022.5 (476.6) g, head circumference (HC): 33.7 (1.5 cm)) were analyzed. Six (37.5%) infants had HC <25th percentile. Fourteen mothers used methadone, four used buprenorphine and 11 used more than one opioid (including heroin, seven). All scans were structurally normal whole brain volumes (357.4 (63.8)) and basal ganglia (14.5 (3.5)) ml were significantly smaller than population means (425.4 (4.8), 17.1 (4.4) ml, respectively) but lateral ventricular volumes (3.5 (1.8) ml) were larger than population values (2.1(1.5)) ml.

CONCLUSION

Our pilot study suggests that brain volumes of opioid-exposed babies may be smaller than population means and that specific regions, for example, basal ganglia, that are involved in neurotransmission, may be particularly affected. Larger studies including correlation with neurodevelopmental outcomes are warranted to substantiate this finding.

Population study of neurodevelopmental outcomes of extremely premature infants admitted after office hours

AIM

The aim of the study was to compare neurodevelopmental outcomes of extremely preterm infants admitted during (OH) and after (AH) office hours.

METHODS

A retrospective review of the New South Wales and Australian Capital Territory Neonatal Intensive Care Units' (NICUs) Data Collection of all infants <29 weeks gestation admitted to New South Wales and Australian Capital Territory NICUs between January 1998 and December 2004 was conducted. The primary outcome was moderate/severe functional disability (FD) at 2-3 years follow-up defined as developmental delay (Griffiths Mental Developmental Scales general quotient or Bayley Scales of Infant Development-II mental developmental index >2 standard deviations below the mean), cerebral palsy (unable to walk without aids), deafness (requiring bilateral hearing aids) or blindness (visual acuity <6/60 in the better eye).

RESULTS

Mortality and age at follow-up were comparable between the AH and OH groups. Developmental outcome was evaluated in 972 (74.9%) infants admitted during AH and 501 (74.6%) admitted during OH. FD was not significantly different between the AH and OH groups (17.1% vs. 14.8%, adjusted odds ratio 1.131, 95% confidence interval 1.131 (0.839-1.523), P = 0.420). There were no significant differences between AH and OH infants with cerebral palsy (9.6% vs. 7.6%), developmental delay (5.4% vs. 5.0%) or any other component of FD.

CONCLUSION

There is little circadian variation in mortality and adverse neurodevelopmental outcomes in an NICU network with the current model of after hours staffing and support, and sharing of NICU workload within a network.

CeasIng Cpap At standarD criteriA (CICADA): impact on weight gain, time to full feeds and caffeine use

INTRODUCTION

In our previous randomised controlled trial (RCT), we have shown in preterm babies (PBs) <30 weeks gestation that CeasIng Cpap At standarD criteriA (CICADA (method 1)) compared with cycling off continuous positive airway pressure (CPAP) gradually (method 2) or cycling off CPAP gradually with low flow air/oxygen during periods off CPAP (method 3) reduces CPAP cessation time in PBs <30 weeks gestation.

METHOD

This retrospective study reviewed weight gain, time to reach full feeds and time to cease caffeine in PBs previously enrolled in the RCT.

RESULTS

Data were collected from 162 of the 177 PBs, and there was no significant difference in the projected weight gain between the three methods. Based on intention to treat, the time taken to reach full feeds for all three methods showed no significant difference. However, post hoc analysis showed the CICADA method compared with cycling off gradually just failed significance (30.3±1.6 vs 31.1±2.4 (weeks corrected gestational age (Wks CGA±SD)), p=0.077). Analysis of time to cease caffeine showed there was a significant difference between the methods with PBs randomised to the CICADA method compared with the cycling off method ceasing caffeine almost a week earlier (33.6±2.4 vs 34.5±2.8 (Wks CGA±SD), p=0.02).

CONCLUSIONS

This retrospective study provides evidence to substantiate the optimum method of ceasing CPAP; the CICADA method, does not adversely affect weight gain, time to reach full feeds and may reduce time to cease caffeine in PBs <30 weeks gestation.

Cannabis, the pregnant woman and her child: weeding out the myths

To review and summarise the literature reporting on cannabis use within western communities with specific reference to patterns of use, the pharmacology of its major psychoactive compounds, including placental and fetal transfer, and the impact of maternal cannabis use on pregnancy, the newborn infant and the developing child. Review of published articles, governmental guidelines and data and book chapters. Although cannabis is one of the most widely used illegal drugs, there is limited data about the prevalence of cannabis use in pregnant women, and it is likely that reported rates of exposure are significantly underestimated. With much of the available literature focusing on the impact of other illicit drugs such as opioids and stimulants, the effects of cannabis use in pregnancy on the developing fetus remain uncertain. Current evidence indicates that cannabis use both during pregnancy and lactation, may adversely affect neurodevelopment, especially during periods of critical brain growth both in the developing fetal brain and during adolescent maturation, with impacts on neuropsychiatric, behavioural and executive functioning. These reported effects may influence future adult productivity and lifetime outcomes. Despite the widespread use of cannabis by young women, there is limited information available about the impact perinatal cannabis use on the developing fetus and child, particularly the effects of cannabis use while breast feeding. Women who are using cannabis while pregnant and breast feeding should be advised of what is known about the potential adverse effects on fetal growth and development and encouraged to either stop using or decrease their use. Long-term follow-up of exposed children is crucial as neurocognitive and behavioural problems may benefit from early intervention aimed to reduce future problems such as delinquency, depression and substance use.

Perinatal outcomes of Australian buprenorphine-exposed mothers and their newborn infants

AIM

To determine the short-term outcomes of Australian buprenorphine-exposed mother/infant dyads.

METHODS

Retrospective record review of drug-exposed mothers and infants in Australia. Groups were based on drug exposure: buprenorphine (55, 3.8%), non-buprenorphine opiates (O, 686, 48.6%) and non-opiates (NO, 671, 47.5%).

RESULTS

More than 30% of buprenorphine mothers continued to use heroin (21, 38%) and benzodiazepines (16, 29%). They were more likely to have child at risk concerns (29, 52.7%, P = 0.019) and have previous children placed in out-of-home care (9, 16.3%, P = 049). Buprenorphine babies were less likely to be preterm (16% vs. 25% (O), P = 0.001 and 23% (NO), P = 0.004) and had higher birthweights (median: 3165 g vs. 2842.5 g (O), P < 0.001 and 2900 g (NO), P = 0.004). Buprenorphine and non-buprenorphine opioid babies had similar maximum Finnegan scores (median 10 vs. 11(O), P = 0.144). The number of babies needing abstinence treatment (45% vs. 51% (O), P = 0.411) and length of hospital stay (median days 9 vs. 11(O), P = 0.067) were similar, but buprenorphine infants required lower maximum morphine doses (mg/kg/day) (median 0.4 mg vs. 0.5 mg (O), P = 0.009).

CONCLUSIONS

Short-term medical outcomes of infants of buprenorphine-using mothers are similar to those of non-buprenorphine opiate-using mothers, but interpretation of these results is confounded by the high rates of polydrug exposure in the buprenorphine group. This and other social concerns noted in buprenorphine mothers and infants warrant further study.