1
|
Tomotaki S, Isayama T, Kobayashi T, Masutani S, Kawasaki H, Nakayama A, Ikeda T, Toyoshima K. Proactive Diagnosis and Tailor-Made Treatment of Patent Ductus Arteriosus in Very Preterm Infants with Routine Echocardiography in Japan: A post hoc Analysis of the PLASE Study. Neonatology 2024:1-9. [PMID: 38593757 DOI: 10.1159/000538363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/12/2024] [Indexed: 04/11/2024]
Abstract
INTRODUCTION A feature of the management of extremely preterm infants in Japan is proactive circulatory management using early routine echocardiography performed by neonatologists. METHODS This study was a post hoc analysis of the Patent ductus arteriosus and Left Atrial Size Evaluation in preterm infants (PLASE) study, which is a prospective cohort study including preterm infants admitted to 34 tertiary neonatal intensive care units in Japan between October 2015 and December 2016. We described the details of the treatment strategy of patent ductus arteriosus (PDA) based on early routine echocardiography. RESULTS In total, 613 preterm infants were included into the analysis. Twenty percent of infants with prophylactic indomethacin were switched to therapeutic cyclooxygenase inhibitor (COX-I) before the completion of the full prophylactic indomethacin course. Therapeutic COX-I was mostly administered based on echocardiographic findings before PDA became symptomatic or hemodynamically significant. Therapeutic COX-I was frequently discontinued after one or two doses before the full course (three doses) was completed. The proportion of infants requiring additional treatment (additional therapeutic COX-I course or surgical PDA closure) after discontinued COX-I courses (<3 doses) compared to infants after completed 3 doses course was significantly lower (after the first therapeutic COX-I course 46% vs. 68%, p < 0.001) or without a significant difference (after the second or third course). CONCLUSIONS The clinical management of PDA in Japan featured (1) COX-I administration based on echocardiographic findings before symptomatic or hemodynamically significant PDA appeared and (2) frequent discontinuation of therapeutic COX-I before completing the standard three doses course.
Collapse
Affiliation(s)
- Seiichi Tomotaki
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsuya Isayama
- Department of Neonatology, National Center for Child Health and Development, Setagaya, Japan
| | - Tohru Kobayashi
- Department of Data Science, Clinical Research Center, National Center for Child Health and Development, Setagaya, Japan
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Hidenori Kawasaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Atsushi Nakayama
- Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital, Nagoya, Japan
| | | | - Katsuaki Toyoshima
- Department of Neonatology, Kanagawa Children's Medical Center, Yokohama, Japan
| |
Collapse
|
2
|
Beauchene MS, Cunningham AM, Stanford AH, Bischoff AR, Dagle JM, Rios DR, Klein JM, Giesinger RE, McNamara PJ. Patent ductus arteriosus (PDA) and response to late surfactant treatment in premature infants. J Perinatol 2023; 43:1245-1251. [PMID: 37160976 DOI: 10.1038/s41372-023-01689-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 04/18/2023] [Accepted: 04/26/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE To determine the clinical/echocardiography (ECHO) phenotype of patients with hypoxic respiratory failure (HRF) and response to late surfactant, according to patent ductus arteriosus (PDA) status. STUDY DESIGN This retrospective study included infants ≤26+6 weeks gestation who received ≥1 surfactant dose after 6 postnatal days and where PDA status was available by ECHO. Response to surfactant was appraised based on change in respiratory severity score over 48 h. The relationship between PDA status and response to surfactant was evaluated via univariate analysis. RESULT We studied late surfactant (n = 71 doses) administration in 35 preterm infants born at a mean weight and GA at birth were 595 g (508, 696) and 23.3 (22.7, 25) weeks, respectively of whom 16 (46%) had a diagnosis of PDA. Positive response to late surfactant treatment was independently associated with absence of PDA [OR 26 (2, 334), p = 0.01] whereas presence of PDA was independently associated with negative response [OR 12 (1.1, 126), p = 0.04]. CONCLUSIONS In neonates ≤26+6 weeks gestation, with HRF, response to surfactant after postnatal day 6 is influenced by PDA status. Future trials should consider PDA status which may enhance diagnostic precision and refine patient selection for late surfactant treatment.
Collapse
Affiliation(s)
- Madeline S Beauchene
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Alison M Cunningham
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Amy H Stanford
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Adrianne R Bischoff
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - John M Dagle
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Danielle R Rios
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Jonathan M Klein
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Regan E Giesinger
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA
| | - Patrick J McNamara
- Stead Family Department of Pediatrics, The University of Iowa, Iowa City, IA, USA.
- Department of Internal Medicine, The University of Iowa, Iowa City, IA, USA.
| |
Collapse
|
3
|
Charpuria PJ, Ganampet NR, Kurian SM, Patel D, Chemudupati Parven PC, Parmar MP, Venugopal V. Unveiling the Silent Ductus: A Classical Presentation of Patent Ductus Arteriosus in an Asymptomatic 23-Year-Old Male. Cureus 2023; 15:e42678. [PMID: 37649951 PMCID: PMC10464548 DOI: 10.7759/cureus.42678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 07/30/2023] [Indexed: 09/01/2023] Open
Abstract
The patent ductus arteriosus (PDA) refers to the persistence of a connection between the descending aorta distal to the left subclavian artery and the pulmonary trunk beyond fetal life. Adult congenital heart disease is a rare condition, with asymptomatic cases being particularly uncommon. The following report presents the case of a young adult male, aged 23, who was discovered to possess a patent ductus arteriosus in an incidental manner. The patient presented with an acute chest complaint and was found to be asymptomatic upon examination at the hospital. Based on the preliminary medical information provided, a tentative diagnosis of a ventricular septal defect was established. However, a comprehensive echocardiographic examination revealed the presence of a patent ductus arteriosus (PDA).
Collapse
Affiliation(s)
- Poornima J Charpuria
- Internal Medicine, Osmania Medical College, Hyderabad, IND
- Internal Medicine, Chigateri General Hospital, Davanagere, IND
| | - Narendranath R Ganampet
- Internal Medicine, Kamineni Academy of Medical Science And Research Centre, Hyderabad, IND
- Internal Medicine, Chigateri General Hospital, Davangere, IND
| | - Shresta M Kurian
- Internal Medicine, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, IND
- Internal Medicine, Chigateri General Hospital, Davangere, IND
| | - Dirgha Patel
- Internal Medicine, Baroda Medical College, Vadodara, IND
- Internal Medicine, Chigateri General Hospital, Davangere, IND
| | - Praver C Chemudupati Parven
- Internal Medicine, Gandhi Medical College and Hospital, Hyderabad, IND
- Internal Medicine, Chigateri General Hospital, Davangere, IND
| | - Mihirkumar P Parmar
- Internal Medicine, Gujarat Medical Education & Research Society Medical College, Mehsana, IND
- Internal Medicine, Chigateri General Hospital, Davangere, IND
| | - Vishal Venugopal
- Internal Medicine, Bhaarath Medical College and Hospital, Chennai, IND
- Internal Medicine, Chigateri General Hospital, Davangere, IND
| |
Collapse
|
4
|
Gómez-Quintana S, Schwarz CE, Shelevytsky I, Shelevytska V, Semenova O, Factor A, Popovici E, Temko A. A Framework for AI-Assisted Detection of Patent Ductus Arteriosus from Neonatal Phonocardiogram. Healthcare (Basel) 2021; 9:healthcare9020169. [PMID: 33562544 PMCID: PMC7914824 DOI: 10.3390/healthcare9020169] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/24/2021] [Accepted: 02/03/2021] [Indexed: 11/16/2022] Open
Abstract
The current diagnosis of Congenital Heart Disease (CHD) in neonates relies on echocardiography. Its limited availability requires alternative screening procedures to prioritise newborns awaiting ultrasound. The routine screening for CHD is performed using a multidimensional clinical examination including (but not limited to) auscultation and pulse oximetry. While auscultation might be subjective with some heart abnormalities not always audible it increases the ability to detect heart defects. This work aims at developing an objective clinical decision support tool based on machine learning (ML) to facilitate differentiation of sounds with signatures of Patent Ductus Arteriosus (PDA)/CHDs, in clinical settings. The heart sounds are pre-processed and segmented, followed by feature extraction. The features are fed into a boosted decision tree classifier to estimate the probability of PDA or CHDs. Several mechanisms to combine information from different auscultation points, as well as consecutive sound cycles, are presented. The system is evaluated on a large clinical dataset of heart sounds from 265 term and late-preterm newborns recorded within the first six days of life. The developed system reaches an area under the curve (AUC) of 78% at detecting CHD and 77% at detecting PDA. The obtained results for PDA detection compare favourably with the level of accuracy achieved by an experienced neonatologist when assessed on the same cohort.
Collapse
Affiliation(s)
- Sergi Gómez-Quintana
- Electrical and Electronic Engineering, University College Cork, T12 K8AF Cork, Ireland; (O.S.); (E.P.); (A.T.)
- Correspondence:
| | - Christoph E. Schwarz
- Irish Centre for Maternal and Child Health Research, University College Cork, T12 K8AF Cork, Ireland;
| | - Ihor Shelevytsky
- Faculty of Information Technologies, Kryvyi Rih Institute of Economics, 50479 Kryvyi Rih, Ukraine;
| | - Victoriya Shelevytska
- Faculty of Postgraduate Education, Dnipropetrovsk Medical Academy of Health, 49098 Dnipro, Ukraine;
| | - Oksana Semenova
- Electrical and Electronic Engineering, University College Cork, T12 K8AF Cork, Ireland; (O.S.); (E.P.); (A.T.)
| | - Andreea Factor
- Department of Anatomy and Neuroscience, University College Cork, T12 K8AF Cork, Ireland;
| | - Emanuel Popovici
- Electrical and Electronic Engineering, University College Cork, T12 K8AF Cork, Ireland; (O.S.); (E.P.); (A.T.)
| | - Andriy Temko
- Electrical and Electronic Engineering, University College Cork, T12 K8AF Cork, Ireland; (O.S.); (E.P.); (A.T.)
| |
Collapse
|
5
|
Joye S, McNamara PJ, Giesinger RE, Tolsa JF, Sekarski N. Association of hemoglobin and spontaneous closure of the ductus arteriosus during the transitional period in very low birth weight infants. J Neonatal Perinatal Med 2021; 14:493-502. [PMID: 33523022 DOI: 10.3233/npm-200518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine the association between plasma hemoglobin (HB) at three time-points (birth, postnatal days 0-3 and 0-10) and spontaneous closure of the ductus arteriosus (sDAC). STUDY DESIGN A retrospective case-control study of preterm infants born (2013-2016) between 24 and 29 weeks of gestational age (GA) was conducted in a level three perinatal center in Switzerland. We collected hemoglobin at birth, between days 0-3 and 0-10 in two distinct groups: (i) patients treated for a PDA and (ii) patients with spontaneous closure of the ductus arteriosus (sDAC). Antenatal and postnatal demographic data and neonatal morbidity were collected. Bivariate analysis was performed and a stepwise logistic regression was done to investigate factors associated with sDAC. RESULTS We reviewed the medical chart of 184 premature infants of whom 146 (79.3%) satisfied eligibility criteria. Of these, 74 (51%) were classified as sDAC. Patients with sDAC were older (GA: 28 vs 27, p < 0.001), more stable (clinical risk index for babies score (CRIB score): 2 vs 5, p < 0.001) and had better clinical outcomes than patients who received treatment for a PDA. Infants in the sDAC group had a higher level of hemoglobin during the first ten postnatal days. Multiple logistic regression analysis revealed that lower HB level (day 0-10) were associated with failure of sDAC (p < 0.05). CONCLUSIONS This is one of the first studies to highlight a potential association between hemoglobin during the transitional period and sDAC. The biological nature of this observation requires prospective clarification.
Collapse
Affiliation(s)
- S Joye
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - P J McNamara
- Division of Neonatology, Stead family Children's Hospital, Iowa City, Iowa, USA.,Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - R E Giesinger
- Division of Neonatology, Stead family Children's Hospital, Iowa City, Iowa, USA.,Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - J-F Tolsa
- Clinic of Neonatology, Lausanne University Hospital, Lausanne, Switzerland
| | - N Sekarski
- Pediatric Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
6
|
Evans P, O'Reilly D, Flyer JN, Soll R, Mitra S. Indomethacin for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev 2021; 1:CD013133. [PMID: 33448032 PMCID: PMC8095061 DOI: 10.1002/14651858.cd013133.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Symptomatic patent ductus arteriosus (PDA) is associated with mortality and morbidity in preterm infants. In these infants, prophylactic use of indomethacin, a non-selective cyclooxygenase inhibitor, has demonstrated short-term clinical benefits. The effect of indomethacin in preterm infants with a symptomatic PDA remains unexplored. OBJECTIVES To determine the effectiveness and safety of indomethacin (given by any route) compared to placebo or no treatment in reducing mortality and morbidity in preterm infants with a symptomatic PDA. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 7), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions(R); and Cumulative Index to Nursing and Allied Health Literature (CINAHL), on 31 July 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included RCTs and quasi-RCTs that compared indomethacin (any dose, any route) versus placebo or no treatment in preterm infants. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal, with separate evaluation of trial quality and data extraction by at least two review authors. We used the GRADE approach to assess the certainty of evidence for the following outcomes: failure of PDA closure within one week of administration of the first dose of indomethacin; bronchopulmonary dysplasia (BPD) at 28 days' postnatal age and at 36 weeks' postmenstrual age; proportion of infants requiring surgical ligation or transcatheter occlusion; all-cause neonatal mortality; necrotizing enterocolitis (NEC) (≥ Bell stage 2); and mucocutaneous or gastrointestinal bleeding. MAIN RESULTS We included 14 RCTs (880 preterm infants). Four out of the 14 included studies were judged to have high risk of bias in one or more domains. Indomethacin administration was associated with a large reduction in failure of PDA closure within one week of administration of the first dose (risk ratio (RR) 0.30, 95% confidence interval (CI) 0.23 to 0.38; risk difference (RD) -0.52, 95% CI -0.58 to -0.45; 10 studies, 654 infants; high-certainty evidence). There may be little to no difference in the incidence of BPD (BPD defined as supplemental oxygen need at 28 days' postnatal age: RR 1.45, 95% CI 0.60 to 3.51; 1 study, 55 infants; low-certainty evidence; BPD defined as supplemental oxygen need at 36 weeks' postmenstrual age: RR 0.80, 95% CI 0.41 to 1.55; 1 study, 92 infants; low-certainty evidence) and probably little to no difference in mortality (RR 0.78, 95% CI 0.46 to 1.33; 8 studies, 314 infants; moderate-certainty evidence) with use of indomethacin for symptomatic PDA. No differences were demonstrated in the need for surgical PDA ligation (RR 0.66, 95% CI 0.33 to 1.29; 7 studies, 275 infants; moderate-certainty evidence), in NEC (RR 1.27, 95% CI 0.36 to 4.55; 2 studies, 147 infants; low-certainty evidence), or in mucocutaneous or gastrointestinal bleeding (RR 0.33, 95% CI 0.01 to 7.58; 2 studies, 119 infants; low-certainty evidence) with use of indomethacin compared to placebo or no treatment. Certainty of evidence for BPD, surgical PDA ligation, NEC, and mucocutaneous or gastrointestinal bleeding was downgraded for very serious or serious imprecision. AUTHORS' CONCLUSIONS High-certainty evidence shows that indomethacin is effective in closing a symptomatic PDA compared to placebo or no treatment in preterm infants. Evidence is insufficient regarding effects of indomethacin on other clinically relevant outcomes and medication-related adverse effects.
Collapse
Affiliation(s)
- Peter Evans
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Deirdre O'Reilly
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Jonathan N Flyer
- Division of Pediatric Cardiology, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Souvik Mitra
- Departments of Pediatrics, Community Health & Epidemiology, Dalhousie University & IWK Health Centre, Halifax, Canada
| |
Collapse
|
7
|
Patra A, Thakkar PS, Makhoul M, Bada HS. Objective Assessment of Physiologic Alterations Associated With Hemodynamically Significant Patent Ductus Arteriosus in Extremely Premature Neonates. Front Pediatr 2021; 9:648584. [PMID: 33718311 PMCID: PMC7946992 DOI: 10.3389/fped.2021.648584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Delay in closure of ductus arteriosus in postnatal life may lead to serious consequences and complications in an extremely premature neonate secondary to hemodynamic alterations in regional blood flow pattern in various organs. Despite the widespread recognition amongst neonatologists to identify a hemodynamically significant patent ductus arteriosus (hsPDA) early in the postnatal course, there is lack of consensus in its definition and thus the threshold to initiate treatment. Echocardiographic assessment of PDA shunt size and volume combined with neonatologists' impression of clinical significance is most frequently used to determine the need for treatment of PDA. Common clinical signs of hsPDA utilized as surrogate for decreased tissue perfusion may lag behind early echocardiographic signs. Although echocardiogram allows direct assessment of PDA shunt and hemodynamic alterations in the heart, it is limited by dependence on pediatric cardiologist availability, interobserver variation and isolated time point assessment. Electrical cardiometry (EC) is a non-invasive continuous real time measurement of cardiac output by applying changes in thoracic electrical impedance. EC has been validated in preterm newborns by concomitant transthoracic echocardiogram assessments and may be beneficial in studying changes in cardiac output in premature newborns with hsPDA. Alterations in perfusion index derived from continuous pulse oximetry monitoring has been used to study changes in cardiac performance and tissue perfusion in infants with PDA. Near infrared spectroscopy (NIRS) has been used to objectively and continuously assess variations in renal, mesenteric, and cerebral oxygen saturation and thus perfusion changes due to diastolic vascular steal from hsPDA in preterm neonates. Doppler ultrasound studies measuring resistive indices in cerebral circulation indicate disturbance in cerebral perfusion secondary to ductal steal. With recent trends of change in practice toward less intervention in care of preterm newborn, treatment strategy needs to be targeted for select preterm population most vulnerable to adverse hemodynamic effects of PDA. Integration of these novel ways of hemodynamic and tissue perfusion assessment in routine clinical care may help mitigate the challenges in defining and targeting treatment of hsPDA thereby improving outcomes in extremely premature neonates.
Collapse
Affiliation(s)
- Aparna Patra
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Pratibha S Thakkar
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Majd Makhoul
- Division of Pediatric Cardiology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, University of Kentucky, Lexington, KY, United States
| |
Collapse
|
8
|
Davidson JM, Ferguson J, Ivey E, Philip R, Weems MF, Talati AJ. A randomized trial of intravenous acetaminophen versus indomethacin for treatment of hemodynamically significant PDAs in VLBW infants. J Perinatol 2021; 41:93-99. [PMID: 32439957 DOI: 10.1038/s41372-020-0694-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/20/2020] [Accepted: 05/11/2020] [Indexed: 11/09/2022]
Abstract
Objective was to compare the rate of successful treatment of hsPDA based on echocardiogram criteria after use of IV acetaminophen or IV indomethacin in very low-birthweight infants. The study was a multi-center, randomized controlled trial. Infants born prior to 32 weeks with birthweight ≤ 1500 g were included if PDA treatment was indicated within the 21 days after birth. hsPDA was defined by strict echocardiogram criteria. Eligible infants were randomized to treatment with either IV acetaminophen or IV indomethacin. Of 86 eligible infants, 17 infants were randomized to acetaminophen and 20 to indomethacin. One (5.9%) hsPDA in the acetaminophen group had successful treatment compared to 11 (55%) in the indomethacin group (p = 0.002). Eight (47%) in the acetaminophen group and 3 (15%) in the indomethacin group received transcatheter PDA closure (p = 0.07). IV indomethacin was more effective than IV acetaminophen for treatment of hsPDAs. More infants in the acetaminophen group received transcatheter closure.
Collapse
Affiliation(s)
- J M Davidson
- University of Tennessee Health Science Center, Memphis, TN, USA. .,Regional One Health, Memphis, TN, USA. .,Lebonheur Children's Hospital, Memphis, TN, USA.
| | - J Ferguson
- University of Tennessee Health Science Center, Memphis, TN, USA.,Lebonheur Children's Hospital, Memphis, TN, USA
| | - E Ivey
- Mednax/Germantown Hospital, Germantown, TN, USA
| | - R Philip
- University of Tennessee Health Science Center, Memphis, TN, USA.,Lebonheur Children's Hospital, Memphis, TN, USA
| | - M F Weems
- University of Tennessee Health Science Center, Memphis, TN, USA.,Regional One Health, Memphis, TN, USA.,Lebonheur Children's Hospital, Memphis, TN, USA
| | - A J Talati
- University of Tennessee Health Science Center, Memphis, TN, USA.,Regional One Health, Memphis, TN, USA.,Lebonheur Children's Hospital, Memphis, TN, USA
| |
Collapse
|
9
|
Prince B, Hoffman S, Pietris N, Vashist S, Driscoll C, Chaves AH. Use of feedback and structured reporting improves neonatal provider satisfaction and reduces variation in echocardiogram reports of patent ductus arteriosus. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
10
|
Ohlsson A, Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2020; 1:CD004213. [PMID: 31985838 PMCID: PMC6984616 DOI: 10.1002/14651858.cd004213.pub5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) complicates the clinical course of preterm infants and increases the risk of adverse outcomes. Indomethacin has been the standard treatment to close a PDA but is associated with renal, gastrointestinal, and cerebral side effects. Ibuprofen has less effect on blood flow velocity to important organs. OBJECTIVES Primary objectives To determine the effectiveness and safety of ibuprofen compared to placebo/no intervention, or other cyclo-oxygenase inhibitor drugs in the prevention of PDA in preterm infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10), MEDLINE via PubMed (1966 to 17 October 2018), Embase (1980 to 17 October 2018), and CINAHL; 1982 to 17 October 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing ibuprofen with placebo/no intervention or other cyclo-oxygenase inhibitor drugs to prevent PDA in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted outcomes data including presence of PDA on day three or four of life (after 72 hours of treatment), need for surgical ligation or rescue treatment with cyclo-oxygenase inhibitors, mortality, cerebral, renal, pulmonary, and gastrointestinal complications. We performed meta-analyses and reported treatment estimates as typical mean difference (MD), risk ratio (RR), risk difference (RD) and, if statistically significant, number needed to treat to benefit (NNTB) or to harm (NNTH), along with their 95% confidence intervals (CI). We assessed between-study heterogeneity by the I-squared test (I²). We used the GRADE approach to assess the quality of evidence. MAIN RESULTS In this updated analysis, we included nine trials (N = 1070 infants) comparing prophylactic ibuprofen (IV or oral) with placebo/no intervention or indomethacin. Ibuprofen (IV or oral) probably decreases the risk of PDA on day 3 or 4 (typical RR 0.39, 95% CI 0.31 to 0.48; typical RD -0.26, 95% CI -0.31 to -0.21; NNTB 4, 95% CI 3 to 5; 9 trials; N = 1029) (moderate-quality evidence). In the control group, the spontaneous closure rate was 58% by day 3 to 4 of age. In addition, ibuprofen probably decreases the need for rescue treatment with cyclo-oxygenase inhibitors (typical RR 0.17, 95% CI 0.11 to 0.26; typical RD -0.27, 95% CI -0.32 to -0.22; NNTB 4; 95% CI 3 to 5),and the need for surgical ductal ligation (typical RR 0.46, 95% CI 0.22 to 0.96; typical RD -0.03, 95% CI -0.05 to -0.00; NNTB 33, 95% CI 20 to infinity; 7 trials; N = 925) (moderate-quality evidence). There was a possible decrease in the risk of grade 3 or 4 intraventricular haemorrhage (IVH) in infants receiving prophylactic ibuprofen (typical RR 0.67, 95% CI 0.45 to 1.00; I² = 34%; typical RD -0.04, 95% CI -0.08 to- 0.00; I² = 60%; 7 trials; N = 925) (moderate-quality evidence). High quality evidence showed increased risk for oliguria (typical RR 1.45, 95% CI 1.04 to 2.02; typical RD 0.06, 95% CI 0.01 to 0.11; NNTH 17, 95% CI 9 to 100; 4 trials; N = 747). Low quality results from four studies (N = 202) showed that administering oral ibuprofen may decrease the risk of PDA (typical RR 0.47, 95% CI 0.30 to 0.74) and may increase risk of gastrointestinal bleeding (NNTH 7, 95% CI 4 to 25). No evidence of a difference was identified for mortality, any intraventricular haemorrhage (IVH), or chronic lung disease. AUTHORS' CONCLUSIONS This review shows that prophylactic use of ibuprofen, compared to placebo or no intervention, probably decreases the incidence of patent ductus arteriosus, the need for rescue treatment with cyclo-oxygenase inhibitors, and for surgical ductal closure. Adverse effects associated with ibuprofen (IV or oral) included increased risks for oliguria, increase in serum creatinine levels, and increased risk of gastrointestinal haemorrhage. There was a reduced risk for intraventricular haemorrhage (grade III - IV) but no evidence of a difference in mortality, chronic lung disease, necrotising enterocolitis, or time to reach full feeds. In the control group, the patent ductus arteriosus had closed spontaneously by day 3 or 4 in 58% of neonates. Prophylactic treatment exposes a large proportion of infants unnecessarily to a drug that has important side effects without conferring any important short-term benefits. Current evidence does not support the use of ibuprofen for prevention of patent ductus arteriosus. Until long-term follow-up results of the trials included in this review have been published, no further trials of prophylactic ibuprofen are recommended. A new approach to patent ductus arteriosus management is an early targeted treatment based on echocardiographic criteria within the first 72 hours of life, that have a high sensitivity for diagnosing a patent ductus arteriosus that is unlikely to close spontaneously. Such trials are currently ongoing in many parts of the world. Results of such trials will be included in updates of our "Ibuprofen for treatment of PDA" review.
Collapse
Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and EvaluationTorontoCanada
| | - Sachin S Shah
- Surya Hospital for Women and ChildrenDepartment of PediatricsPuneIndia
| | | |
Collapse
|
11
|
Palpan Flores A, Saceda Gutiérrez J, Brin Reyes JR, Sierra Tamayo J, Carceller Benito F. Risk factors associated with conversion of an Ommaya reservoir to a permanent cerebrospinal fluid shunt in preterm posthemorrhagic hydrocephalus. J Neurosurg Pediatr 2020; 25:417-424. [PMID: 31952037 DOI: 10.3171/2019.11.peds19320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A considerable percentage of preterm infants with posthemorrhagic hydrocephalus initially managed with an Ommaya reservoir require a permanent CSF shunt. The objective of the study was to analyze possible risk factors associated with the need for converting an Ommaya reservoir to a permanent shunt. METHODS The authors retrospectively reviewed the clinical records of premature infants weighing 1500 g or less with posthemorrhagic hydrocephalus (Papile grades III and IV) managed with an Ommaya reservoir at their institution between 2002 and 2017. RESULTS Forty-six patients received an Ommaya reservoir. Five patients (10.9%) were excluded due to intraventricular infection during management with an Ommaya reservoir. Average gestational age and weight for the remaining 41 patients was 27 ± 1.8 weeks and 987 ± 209 grams, respectively. Thirty patients required a permanent shunt and 11 patients did not require a permanent shunt. The conversion rate from an Ommaya reservoir to a permanent shunt was 76.1%. Symptomatic persistent ductus arteriosus (PDA) was more frequent in the nonpermanent shunt group than in the shunt group (88.9% vs 50%, p = 0.04). The need for extraction of more than 10 ml/kg per day of CSF through the Ommaya reservoir was lower in the nonpermanent shunt group than in the shunt group (9.1% vs 51.7%, p = 0.015). CSF lactate was lower in the nonpermanent group than in the shunt group (mean 2.48 mg/dl vs 3.19 mg/dl; p = 0.004). A cutoff value of ≥ 2.8 mg/dl CSF lactate predicted the need for a permanent shunt with sensitivity and specificity of 82.4% and 80%, respectively. There were no significant differences in gestational age, sex, weight, Papile grade, ventricular index, or other biochemical markers. After the multivariate analysis, only CSF lactate ≥ 2.8 mg/dl was associated with a higher conversion rate to a permanent shunt. CONCLUSIONS This study showed that a high level of CSF lactate, absence of symptomatic PDA, and a higher CSF extraction requirement were associated with a higher likelihood of implanting a permanent CSF shunt. The authors believe these findings should be considered in future studies.
Collapse
Affiliation(s)
- Alexis Palpan Flores
- 1Department of Pediatric Neurosurgery, La Paz University Hospital, Madrid, Spain
| | | | - Juan Raúl Brin Reyes
- 2Department of Pediatric Neurosurgery, Omar Torrijos Herrera Hospital, Panama City, Panama; and
| | | | | |
Collapse
|
12
|
Patent ductus arteriosus in preterm infants: is early transcatheter closure a paradigm shift? J Perinatol 2019; 39:1449-1461. [PMID: 31562396 DOI: 10.1038/s41372-019-0506-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 08/05/2019] [Accepted: 08/12/2019] [Indexed: 12/13/2022]
Abstract
The optimal management approach of the patent ductus arteriosus (PDA) in premature infants remains uncertain owing the lack of evidence for long-term benefits and the limited analyses of the complications of medical and surgical interventions to date. In recent years, devices suitable to plug the PDA of premature infants (including extremely low birthweight, <1000 g) have become available and several trials have demonstrated successful and safe transcatheter PDA closure (TCPC) in this population. Whether TCPC represents a paradigm shift in PDA management that will result in improved short- and long-term outcomes, less bronchopulmonary dysplasia, improved neurodevelopment, or better long term renal function remains to be seen. Careful rigorous study of the potential benefits of TCPC in this highly vulnerable population in the context of well-designed adequately powered trials is needed prior to widespread adoption of this approach.
Collapse
|
13
|
Slaughter JL, Cua CL, Notestine JL, Rivera BK, Marzec L, Hade EM, Maitre NL, Klebanoff MA, Ilgenfritz M, Le VT, Lewandowski DJ, Backes CH. Early prediction of spontaneous Patent Ductus Arteriosus (PDA) closure and PDA-associated outcomes: a prospective cohort investigation. BMC Pediatr 2019; 19:333. [PMID: 31519154 PMCID: PMC6743099 DOI: 10.1186/s12887-019-1708-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/03/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA), the most commonly diagnosed cardiovascular condition in preterm infants, is associated with increased mortality and harmful long-term outcomes (chronic lung disease, neurodevelopmental delay). Although pharmacologic and/or interventional treatments to close PDA likely benefit some infants, widespread routine treatment of all preterm infants with PDA may not improve outcomes. Most PDAs close spontaneously by 44-weeks postmenstrual age; treatment is increasingly controversial, varying markedly between institutions and providers. Because treatment detriments may outweigh benefits, especially in infants destined for early, spontaneous PDA closure, the relevant unanswered clinical question is not whether to treat all preterm infants with PDA, but whom to treat (and when). Clinicians cannot currently predict in the first month which infants are at highest risk for persistent PDA, nor which combination of clinical risk factors, echocardiographic measurements, and biomarkers best predict PDA-associated harm. METHODS Prospective cohort of untreated infants with PDA (n=450) will be used to predict spontaneous ductal closure timing. Clinical measures, serum (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide) and urine (neutrophil gelatinase-associated lipocalin, heart-type fatty acid-binding protein) biomarkers, and echocardiographic variables collected during each of first 4 postnatal weeks will be analyzed to identify those associated with long-term impairment. Myocardial deformation imaging and tissue Doppler imaging, innovative echocardiographic techniques, will facilitate quantitative evaluation of myocardial performance. Aim1 will estimate probability of spontaneous PDA closure and predict timing of ductal closure using echocardiographic, biomarker, and clinical predictors. Aim2 will specify which echocardiographic predictors and biomarkers are associated with mortality and respiratory illness severity at 36-weeks postmenstrual age. Aim3 will identify which echocardiographic predictors and biomarkers are associated with 22 to 26-month neurodevelopmental delay. Models will be validated in a separate cohort of infants (n=225) enrolled subsequent to primary study cohort. DISCUSSION The current study will make significant contributions to scientific knowledge and effective PDA management. Study results will reduce unnecessary and harmful overtreatment of infants with a high probability of early spontaneous PDA closure and facilitate development of outcomes-focused trials to examine effectiveness of PDA closure in "high-risk" infants most likely to receive benefit. TRIAL REGISTRATION ClinicalTrials.gov NCT03782610. Registered 20 December 2018.
Collapse
Affiliation(s)
- Jonathan L Slaughter
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Clifford L Cua
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer L Notestine
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brian K Rivera
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Laura Marzec
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Erinn M Hade
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Nathalie L Maitre
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA
| | - Mark A Klebanoff
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA.,Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, Ohio, USA.,Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Megan Ilgenfritz
- Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA
| | - Vi T Le
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dennis J Lewandowski
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carl H Backes
- Center for Perinatal Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA. .,Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Way, Columbus, Ohio, 43205, USA. .,The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA. .,Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, Ohio, USA.
| |
Collapse
|
14
|
Ohlsson A, Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2019; 6:CD004213. [PMID: 31222841 PMCID: PMC6587108 DOI: 10.1002/14651858.cd004213.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) complicates the clinical course of preterm infants and increases the risk of adverse outcomes. Indomethacin has been the standard treatment to close a PDA but is associated with renal, gastrointestinal, and cerebral side effects. Ibuprofen has less effect on blood flow velocity to important organs. OBJECTIVES Primary objectivesTo determine the effectiveness and safety of ibuprofen compared to placebo/no intervention, or other cyclo-oxygenase inhibitor drugs in the prevention of PDA in preterm infants. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10), MEDLINE via PubMed (1966 to 17 October 2018), Embase (1980 to 17 October 2018), and CINAHL; 1982 to 17 October 2018). We searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing ibuprofen with placebo/no intervention or other cyclo-oxygenase inhibitor drugs to prevent PDA in preterm or low birth weight infants. DATA COLLECTION AND ANALYSIS We extracted outcomes data including presence of PDA on day three or four of life (after 72 hours of treatment), need for surgical ligation or rescue treatment with cyclo-oxygenase inhibitors, mortality, cerebral, renal, pulmonary, and gastrointestinal complications. We performed meta-analyses and reported treatment estimates as typical mean difference (MD), risk ratio (RR), risk difference (RD) and, if statistically significant, number needed to treat to benefit (NNTB) or to harm (NNTH), along with their 95% confidence intervals (CI). We assessed between-study heterogeneity by the I-squared test (I²). We used the GRADE approach to assess the quality of evidence. MAIN RESULTS In this updated analysis, we included nine trials (N = 1070 infants) comparing prophylactic ibuprofen (IV or oral) with placebo/no intervention or indomethacin. Ibuprofen (IV or oral) probably decreases the risk of PDA on day 3 or 4 (typical RR 0.39, 95% CI 0.31 to 0.48; typical RD -0.26, 95% CI -0.31 to -0.21; NNTB 4, 95% CI 3 to 5; 9 trials; N = 1029) (moderate-quality evidence). In the control group, the spontaneous closure rate was 58% by day 3 to 4 of age. In addition, ibuprofen probably decreases the need for rescue treatment with cyclo-oxygenase inhibitors (typical RR 0.17, 95% CI 0.11 to 0.26; typical RD -0.27, 95% CI -0.32 to -0.22; NNTB 4; 95% CI 3 to 5),and the need for surgical ductal ligation (typical RR 0.46, 95% CI 0.22 to 0.96; typical RD -0.03, 95% CI -0.05 to -0.00; NNTB 33, 95% CI 20 to infinity; 7 trials; N = 925) (moderate-quality evidence). There was a possible decrease in the risk of grade 3 or 4 intraventricular haemorrhage (IVH) in infants receiving prophylactic ibuprofen (typical RR 0.67, 95% CI 0.45 to 1.00; I² = 34%; typical RD -0.04, 95% CI -0.08 to- 0.00; I² = 60%; 7 trials; N = 925) (moderate-quality evidence). High quality evidence showed increased risk for oliguria (typical RR 1.45, 95% CI 1.04 to 2.02; typical RD 0.06, 95% CI 0.01 to 0.11; NNTH 17, 95% CI 9 to 100; 4 trials; N = 747). Low quality results from four studies (N = 202) showed that administering oral ibuprofen may decrease the risk of PDA (typical RR 0.47, 95% CI 0.30 to 0.74) and may increase risk of gastrointestinal bleeding (NNTH 7, 95% CI 4 to 25). No evidence of a difference was identified for mortality, any intraventricular haemorrhage (IVH), or chronic lung disease. AUTHORS' CONCLUSIONS This review shows that prophylactic use of ibuprofen, compared to placebo or no intervention, probably decreases the incidence of patent ductus arteriosus, the need for rescue treatment with cyclo-oxygenase inhibitors, and for surgical ductal closure. Adverse effects associated with ibuprofen (IV or oral) included increased risks for oliguria, increase in serum creatinine levels, and increased risk of gastrointestinal haemorrhage. There was a reduced risk for intraventricular haemorrhage (grade III - IV) but no evidence of a difference in mortality, chronic lung disease, necrotising enterocolitis, or time to reach full feeds. In the control group, the patent ductus arteriosus had closed spontaneously by day 3 or 4 in 58% of neonates. Prophylactic treatment exposes a large proportion of infants unnecessarily to a drug that has important side effects without conferring any important short-term benefits. Current evidence does not support the use of ibuprofen for prevention of patent ductus arteriosus. Until long-term follow-up results of the trials included in this review have been published, no further trials of prophylactic ibuprofen are recommended.A new approach to patent ductus arteriosus management is an early targeted treatment based on echocardiographic criteria within the first 72 hours of life, that have a high sensitivity for diagnosing a patent ductus arteriosus that is unlikely to close spontaneously. Such trials are currently ongoing in many parts of the world. Results of such trials will be included in updates of our "Ibuprofen for treatment of PDA" review.
Collapse
Affiliation(s)
- Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1X5
| | - Sachin S Shah
- Surya Hospital for Women and ChildrenDepartment of PediatricsPuneIndia
| | | |
Collapse
|
15
|
Evans P, O'Reilly D, Flyer JN, Mitra S, Soll R. Indomethacin for symptomatic patent ductus arteriosus in preterm infants. Hippokratia 2018. [DOI: 10.1002/14651858.cd013133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Peter Evans
- Children's Hospital of Philadelphia; Department of Pediatrics; 34th Street and Civic Center Boulevard Philadelphia Pennsylvania USA 19104
| | - Deirdre O'Reilly
- Larner College of Medicine at the University of Vermont; Division of Neonatal-Perinatal Medicine, Department of Pediatrics; Burlington Vermont USA 05401
| | - Jonathan N Flyer
- Larner College of Medicine at the University of Vermont; Division of Pediatric Cardiology, Department of Pediatrics; 111 Colchester Avenue Burlington Vermont USA
| | - Souvik Mitra
- Dalhousie University & IWK Health Care; Division of Neonatal Perinatal Medicine, Department of Pediatrics; G-2214, 5850/5980 University Avenue Halifax Nova Scotia Canada B3K 6R8
| | - Roger Soll
- Larner College of Medicine at the University of Vermont; Division of Neonatal-Perinatal Medicine, Department of Pediatrics; Burlington Vermont USA 05401
| |
Collapse
|
16
|
Kluckow M, Lemmers P. Hemodynamic assessment of the patent ductus arteriosus: Beyond ultrasound. Semin Fetal Neonatal Med 2018; 23:239-244. [PMID: 29730050 DOI: 10.1016/j.siny.2018.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Assessment and management of a patent ductus arteriosus (PDA) in premature infants remains problematic. The more immature the infant, the more likely a PDA is to be present, due to lower spontaneous PDA closure rates. Clinicians now recognize that not all PDAs require treatment and that selection of the group of infants with a more hemodynamically relevant PDA, often manifesting as an increasing systemic-to-pulmonary shunt, is increasingly important. Ultrasound is the mainstay of diagnosis and physiological assessment of the PDA; however, there are other methodologies used to assess hemodynamic importance of the PDA. These range from assessment of clinical signs through biomarkers and finally to physiological assessment of the end-organ effect of the PDA, using methods such as cerebral Doppler or near infra-red spectroscopy. Extended assessment of a PDA's physiological effect may lead to a more individualized approach to PDA treatment.
Collapse
Affiliation(s)
- M Kluckow
- Department of Neonatology, Royal North Shore Hospital, University of Sydney, Sydney, Australia.
| | - P Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, The Netherlands
| |
Collapse
|
17
|
Abstract
In many preterm infants, the ductus arteriosus remains patent beyond the first few days of life. This prolonged patency is associated with numerous adverse outcomes, but the extent to which these adverse outcomes are attributable to the hemodynamic consequences of ductal patency, if at all, has not been established. Different treatment strategies have failed to improve short-term outcomes, with a paucity of data on the correct diagnostic and pathophysiological assessment of the patent ductus arteriosus (PDA) in association with long-term outcomes. Echocardiography is the selected method of choice for detecting a PDA, assessing the impact on the preterm circulation and monitoring treatment response. PDA in a preterm infant can result in pulmonary overcirculation and systemic hypoperfusion, Therefore, echocardiographic assessment should include evaluation of PDA characteristics, indices of pulmonary overcirculation with left heart loading conditions, and indices of systemic hypoperfusion. In this review, we provide an evidence-based overview of the current and emerging ultrasound measurements available to identify and monitor a PDA in the preterm infant. We offer indications and limitations for using Neonatologist Performed Echocardiography to optimize the management of a neonate with a PDA.
Collapse
|
18
|
Adzikah S, Maletzki J, Rüegger C, Bassler D. Association of early versus late caffeine administration on neonatal outcomes in very preterm neonates. Acta Paediatr 2017; 106:518. [PMID: 28127826 DOI: 10.1111/apa.13691] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Stephanie Adzikah
- Department of Neonatology; University Hospital of Zurich; Zurich Switzerland
| | - Julia Maletzki
- Department of Neonatology; University Hospital of Zurich; Zurich Switzerland
| | - Christoph Rüegger
- Department of Neonatology; University Hospital of Zurich; Zurich Switzerland
| | - Dirk Bassler
- Department of Neonatology; University Hospital of Zurich; Zurich Switzerland
| |
Collapse
|
19
|
Kindler A, Seipolt B, Heilmann A, Range U, Rüdiger M, Hofmann SR. Development of a Diagnostic Clinical Score for Hemodynamically Significant Patent Ductus Arteriosus. Front Pediatr 2017; 5:280. [PMID: 29312911 PMCID: PMC5743666 DOI: 10.3389/fped.2017.00280] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/12/2017] [Indexed: 11/13/2022] Open
Abstract
There is no consensus about the hemodynamic significance and, therefore, the need to treat a persistent ductus arteriosus in preterm newborns. Since the diagnosis of a hemodynamically significant persistent ductus arteriosus (hsPDA) is made by a summary of non-uniform echo-criteria in combination with the clinical deterioration of the preterm neonate, standardized clinical and ultrasound scoring systems are needed. The objective of this study was the development of a clinical score for the detection and follow-up of hsPDA. In this observational cohort study of 154 preterm neonates (mean gestational age 28.1 weeks), clinical signs for the development of hsPDA were recorded in a standardized score and compared to echocardiography. Analyzing the significance of single score parameters compared to the diagnosis by echocardiography, we developed a short clinical score (calculated sensitivity 84% and specificity 80%). In conclusion, this clinical diagnostic PDA score is non-invasive and quickly to implement. The continuous assessment of defined clinical parameters allows for a more precise diagnosis of hemodynamic significance of PDA and, therefore, should help to detect preterm neonates needing PDA-treatment. The score, therefore, allows a more targeted use of echocardiography in these very fragile preterm neonates.
Collapse
Affiliation(s)
- Annemarie Kindler
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Barbara Seipolt
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Antje Heilmann
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ursula Range
- Institute for Medical Informatics and Biometry, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mario Rüdiger
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Sigrun Ruth Hofmann
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
20
|
Jensen EA, Panitch H, Feng R, Moore PE, Schmidt B. Interobserver Reliability of the Respiratory Physical Examination in Premature Infants: A Multicenter Study. J Pediatr 2016; 178:87-92. [PMID: 27567413 PMCID: PMC5613665 DOI: 10.1016/j.jpeds.2016.07.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 06/28/2016] [Accepted: 07/26/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To measure the inter-rater reliability of 7 visual and 3 auscultatory respiratory physical examination findings at 36-40 weeks' postmenstrual age in infants born less than 29 weeks' gestation. Physicians also estimated the probability that each infant would remain hospitalized for 3 months after the examination or be readmitted for a respiratory illness during that time. STUDY DESIGN Prospective, multicenter, inter-rater reliability study using standardized audio-video recordings of respiratory physical examinations. RESULTS We recorded the respiratory physical examination of 30 infants at 2 centers and invited 32 physicians from 9 centers to review the examinations. The intraclass correlation values for physician agreement ranged from 0.73 (95% CI 0.57-0.85) for subcostal retractions to 0.22 (95% CI 0.11-0.41) for expiratory abdominal muscle use. Eight (27%) infants remained hospitalized or were readmitted within 3 months after the examination. The area under the receiver operating characteristic curve for prediction of this outcome was 0.82 (95% CI 0.78-0.86). Physician predictive accuracy was greater for infants receiving supplemental oxygen (0.90, 95% CI 0.86-0.95) compared with those breathing in room air (0.71, 95% CI 0.66-0.75). CONCLUSIONS Physicians often do not agree on respiratory physical examination findings in premature infants. Physician prediction of short-term respiratory morbidity was more accurate for infants receiving supplemental oxygen compared with those breathing in room air.
Collapse
Affiliation(s)
- Erik A Jensen
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Howard Panitch
- Department of Pediatrics, Division of Pulmonology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Rui Feng
- Department of Biostatistics and Epidemiology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Paul E Moore
- Department of Pediatrics, Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Barbara Schmidt
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
21
|
Pourarian S, Sharma D, Farahbakhsh N, Cheriki S, Bijanzadeh F. To evaluate the prevalence of symptomatic and non-symptomatic ductus arteriosus and accuracy of physical signs in diagnosing PDA in preterm infants using blinded comparison of clinical and echocardiographic findings during the first week of life: a prospective observational study from Iran. J Matern Fetal Neonatal Med 2016; 30:1666-1670. [PMID: 27494450 DOI: 10.1080/14767058.2016.1220532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS To evaluate the prevalence of symptomatic and non-symptomatic ductus arteriosus (PDA) and accuracy of physical signs in diagnosing PDA in preterm infants using blinded comparison of clinical and echocardiographic findings during the first week of life. METHODS AND MATERIAL This prospective observational cross-sectional study enrolled 200 preterm infants, who underwent echocardiography on 4th-7th postnatal day. The neonates who were diagnosed to have PDA on echo were observed for clinical features of PDA to label it symptomatic PDA. Symptomatic PDA was defined as detecting one or all of these symptoms in a neonate with PDA: bounding pulse, pericardial hyperactivity, systolic or continuous murmur. RESULTS Forty-five infants had PDA on echocardiography. 66.7% neonates with PDA were symptomatic and the most prevalent symptom in them was heart murmur (100%) either alone or combined with other clinical features. Isolated murmur was seen in 31.2%, murmur and hyperdynamic precordium was seen in 8.8%, murmur and bounding pulses were seen in 6.67% and all three features simultaneously were seen in 20% of infants. The sensitivity of murmur for diagnosing symptomatic PDA was highest. CONCLUSION Presence of murmur is the most important clinical feature for diagnosis of symptomatic PDA and has good specificity.
Collapse
Affiliation(s)
- Shahnaz Pourarian
- a Neonatal Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Deepak Sharma
- b NEOCLINIC, Plot number 3 & 4, Everest Vihar, Opposite Krishna Heart Hospital, TN Mishra Marg, Nirman Nagar , Jaipur , Rajasthan , India
| | - Nazanin Farahbakhsh
- c Department of Pediatrics , Shiraz University of Medical Sciences , Shiraz , Iran
| | - Sirous Cheriki
- d Department of Pediatric Cardiology , Shiraz University of Medical Sciences , Shiraz , Iran , and
| | - Farhad Bijanzadeh
- e Department of Orthopedics , Shiraz University of Medical sciences , Shiraz , Iran
| |
Collapse
|
22
|
Mukerji A, Diambomba Y, Lee SK, Jain A. Use of Targeted Neonatal Echocardiography and Focused Cardiac Sonography in Tertiary Neonatal Intensive Care Units: Time to Embrace It? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1579-91. [PMID: 27269001 DOI: 10.7863/ultra.15.06037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/02/2015] [Indexed: 05/28/2023]
Abstract
Focused cardiac sonography and targeted neonatal echocardiography refer to goal-directed cardiac imaging using ultrasound, typically by noncardiologic specialists. Although the former consists of a rapid qualitative assessment of cardiac function, which is usually performed by acute care practitioners, the latter refers to detailed functional echocardiography to obtain quantitative and qualitative indexes of pulmonary and systemic hemodynamics in sick neonates and is typically performed by neonatologists. Although the use of these modalities is increasing, they still remain unavailable in most North American centers providing acute care to neonates, partly because of limited data regarding their direct impact on patient care. Here we present a series of 5 cases from a large perinatal unit in which immediate availability of relevant expertise led to important and arguably life-saving clinical interventions. In 4 of these cases, focused cardiac sonography was sufficient to make the diagnosis, whereas in 1 case, clinical integration of detailed systemic hemodynamics measured on target neonatal echocardiography was required.
Collapse
Affiliation(s)
- Amit Mukerji
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Yenge Diambomba
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shoo K Lee
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amish Jain
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
23
|
Bhola K, Foster JP, Osborn DA. Chest shielding for prevention of a haemodynamically significant patent ductus arteriosus in preterm infants receiving phototherapy. Cochrane Database Syst Rev 2015; 2015:CD009816. [PMID: 26523368 PMCID: PMC9288670 DOI: 10.1002/14651858.cd009816.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is associated with mortality and morbidity in preterm infants. Phototherapy is a common treatment for jaundice in preterm infants. However, phototherapy has been associated with failure of closure of the ductus arteriosus in preterm infants. OBJECTIVES To determine if chest shielding of preterm infants receiving phototherapy reduces the incidence of clinically and/or haemodynamically significant PDA and reduces morbidity secondary to PDA. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE, CINAHL, previous reviews, cross-references, abstracts, proceedings of scientific meetings, and trial registries through March 2015. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, or quasi-RCTs of chest shielding during phototherapy compared to sham shielding or no shielding for the prevention of a haemodynamically or clinically significant PDA in preterm infants. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for eligibility and quality and extracted data. We defined a clinically significant PDA as the presence of a PDA with clinical signs of an effect on organ function attributable to the ductus arteriosus. We defined a haemodynamically significant PDA as clinical and/or echocardiographic signs of a significant ductus arteriosus effect on blood flow. MAIN RESULTS We included two small trials enrolling very preterm infants (Rosenfeld 1986; Travadi 2006). We assessed both as at high risk of bias. No study reported clinically significant PDA, defined as the presence of a PDA with clinical symptoms or signs attributable to the effect of a ductus arteriosus on organ function. Rosenfeld 1986 reported a non-significant reduction in haemodynamically significant PDA with left atrial to aortic root ratio greater than 1.2 (risk ratio (RR) 0.23, 95% confidence interval (CI) 0.05 to 1.01; 74 infants) but a statistically significant risk difference (RD -0.18, 95% CI -0.34 to -0.03; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 3 to 33). Rosenfeld 1986 reported a significant reduction in PDA detected by murmur (RR 0.50, 95% CI 0.29 to 0.88; RD -0.30, 95% CI -0.52 to -0.08; NNTB 3, 95% CI 2 to 12; 74 infants). Rosenfeld 1986 reported a significant reduction in treatment with indomethacin (RR 0.12, 95% CI 0.02 to 0.88; RD -0.21, 95% CI -0.35 to -0.06; NNTB 5, 95% CI 3 to 17; 74 infants), and only one infant had a ductal ligation in the no-shield group. There were no other significant outcomes, including mortality to discharge or 28 days, days in oxygen, days on mechanical ventilation, days in hospital, intraventricular haemorrhage, retinopathy of prematurity, or exchange transfusion. AUTHORS' CONCLUSIONS The available evidence is very low quality and insufficient to assess the safety or efficacy of chest shield during phototherapy for prevention of PDA in preterm infants. Further trials of chest shielding are warranted, particularly in settings where infants are not receiving prophylactic or early echocardiographic targeted cyclo-oxygenase inhibitors for PDA.
Collapse
Affiliation(s)
- Kavita Bhola
- Blacktown HospitalSpecial care Nursery5B‐1 Francis RoadArtarmonNSWAustralia22050
| | - Jann P Foster
- University of Western SydneySchool of Nursing & MidwiferyLocked Bag 1797Penrith DCNSWAustralia2751
| | - David A Osborn
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologySydneyNSWAustralia2050
| | | |
Collapse
|
24
|
Kim SJ, Shin JE, Lee SM, Eun HS, Park MS, Park KI, Namgung R. Risk Factors for Postoperative Cardiopulmonary Instability Following Ligation of Patent Ductus Arteriosus in Very Low Birth Weight Infants. NEONATAL MEDICINE 2015. [DOI: 10.5385/nm.2015.22.4.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Soo Jung Kim
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Eun Shin
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Seon Eun
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Park
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kook In Park
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Division of Neonatology, Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| |
Collapse
|
25
|
DeMauro SB, Cohen MS, Ratcliffe SJ, Abbasi S, Schmidt B. Serial echocardiography in very preterm infants: a pilot randomized trial. Acta Paediatr 2013; 102:1048-53. [PMID: 23952100 DOI: 10.1111/apa.12389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 11/28/2022]
Abstract
AIM To determine whether routine echocardiography increases diagnosis and treatment for patent ductus arteriosus (PDA) and whether randomized nondisclosure is a feasible strategy for studying PDA management. METHODS Two-centre, pilot randomized, controlled trial. 88 infants with birth weights ≤1250 grams and gestational ages ≤30 weeks were randomized to disclosure or nondisclosure of serial echocardiogram findings. Echocardiograms were performed at 3-5 and 7-10 days of life. The primary outcome was time to regain birth weight. RESULTS 100% of echocardiograms in the disclosure group were disclosed; 16% (echocardiogram #1) and 29% (echocardiogram #2) were disclosed in the nondisclosure group. There was a statistically nonsignificant decrease in drug therapy for PDA in the nondisclosure group (adjusted odds ratio [AOR] 0.56, 95% confidence interval [CI] 0.24-1.34). There was no difference in time to regain birth weight or in other important neonatal outcomes. However, infants in the nondisclosure group were more likely to demonstrate appropriate weight loss and then regain birth weight within 7-14 days (AOR 2.64, 95% CI 1.08-6.44). CONCLUSION Randomized nondisclosure of echocardiograms is a feasible strategy for evaluation of approaches to PDA management in very preterm infants. Avoidance of routine echocardiography may reduce drug therapy for PDA without adverse clinical effects.
Collapse
Affiliation(s)
- Sara B DeMauro
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | | | |
Collapse
|
26
|
Buddhe S, Dhuper S, Kim R, Weichbrod L, Mahdi E, Shah N, Kona S, Sokal M. NT-proBNP Levels Improve the Ability of Predicting a Hemodynamically Significant Patent Ductus Arteriosus in Very Low-Birth-Weight Infants. J Clin Neonatol 2013; 1:82-6. [PMID: 24027696 PMCID: PMC3743145 DOI: 10.4103/2249-4847.96758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: A hemodynamically significant Patent ductus arteriosus (HsPDA) in premature infants is known to be associated with significant morbidity. Recently brain natriuretic peptides and superior mesenteric artery (SMA)-resistive indices have been used to effectively diagnose HsPDA. Objective: To assess the sensitivity and specificity of N-terminal proBNP (NT-proBNP) in predicting an HsPDA diagnosed by clinical and echocardiographic criteria including pulsatility index (PI) of SMA. Materials and Methods: All preterm neonates <1500 g were evaluated with echocardiograms and NT-proBNP levels on the 3rd to 5th day of life and then every week until the echo showed either a closed PDA or non-HsPDA. Results: Sixty-nine babies with mean gestational age of 27 weeks were included in the study. NT-proBNP levels were significantly higher in the HsPDA group (n=22) with a mean±SEM of 24420±3190 compared to 3072±332 in the non-HsPDA group (n=47) (P<0.001). NT-pro BNP level of 5900 pg/ml had 96% sensitivity and 90% specificity of predicting HsPDA. Conclusions: With frequently changing hemodynamics in low-birth weight infants, including NT-proBNP and PI of SMA improve the ability of assessing the effects of a HsPDA and will help timing of intervention.
Collapse
Affiliation(s)
- Sujatha Buddhe
- Department of Pediatrics, Brookdale University Hospital and Medical Center; Childrens Hospital of Michigan, Pediatric Cardiology, MI, USA ; Department of Pediatrics, Childrens Hospital of Michigan, Pediatric Cardiology, MI, USA
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Ko SM, Yoon YC, Cho KH, Lee YH, Han IY, Park KT, Hwang YH, Jun HJ. Primary surgical closure should be considered in premature neonates with large patent ductus arteriosus. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2013; 46:178-84. [PMID: 23772404 PMCID: PMC3680602 DOI: 10.5090/kjtcs.2013.46.3.178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/23/2012] [Accepted: 10/25/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment for patent ductus arteriosus (PDA) in premature infants can consist of medical or surgical approaches. The appropriate therapeutic regimen remains contentious. This study evaluated the role of surgery in improving the survival of premature neonates weighing less than 1,500 g with PDA. MATERIALS AND METHODS From January 2008 to June 2011, 68 patients weighing less than 1,500 g with PDA were enrolled. The patients were divided into three groups: a group managed only by medical treatment (group I), a group requiring surgery after medical treatment (group II), and a group requiring primary surgical treatment (group III). RESULTS The rate of conversion to surgical methods due to failed medical treatment was 67.6% (25/37) in the patients with large PDA (≥2 mm in diameter). The number of patients who could be managed with medical treatment was nine which was only 20.5% (9/44) of the patients with large PDA. There was no surgery-related mortality. Group III displayed a statistically significantly low rate of development of bronchopulmonary dysplasia (BPD) (p=0.008). The mechanical ventilation time was significantly longer in group II (p=0.002). CONCLUSION Medical treatment has a high failure rate in infants weighing less than 1,500 g with PDA exceeding 2.0 mm. Surgical closure following medical treatment requires a longer mechanical ventilation time and increases the incidence of BPD. Primary surgical closure of PDA exceeding 2.0 mm in the infants weighing less than 1,500 g should be considered to reduce mortality and long-term morbidity events including BPD.
Collapse
Affiliation(s)
- Seong-Min Ko
- Department of Thoracic and Cardiovascular Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Korea
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Malviya MN, Ohlsson A, Shah SS. Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev 2013; 2013:CD003951. [PMID: 23543527 PMCID: PMC7027388 DOI: 10.1002/14651858.cd003951.pub3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A patent ductus arteriosus (PDA) with significant left to right shunt increases morbidity and mortality in preterm infants. Early closure of the ductus arteriosus may be achieved pharmacologically or by surgery. The preferred initial treatment of a symptomatic PDA, surgical ligation or treatment with indomethacin, is not clear. OBJECTIVES To compare the effect of surgical ligation of PDA versus medical treatment with cyclooxygenase inhibitors (indomethacin, ibuprofen or mefenamic acid), each used as the initial treatment, on neonatal mortality in preterm infants with a symptomatic PDA. SEARCH METHODS For this update we searched The Cochrane Library 2012, Issue 2, MEDLINE, EMBASE, CINAHL, Clinicaltrials.gov, Controlled-trials.com, Proceedings of the Annual Meetings of the Pediatric Academic Societies (2000 to 2011) (Abstracts2View(TM)) and Web of Science on 8 February 2012. SELECTION CRITERIA Randomised or quasi-randomised trials in preterm or low birth weight neonates with symptomatic PDA and comparing surgical ligation with medical treatment with cyclooxygenase inhibitors, each used as the initial treatment for closure of PDA. DATA COLLECTION AND ANALYSIS The authors independently assessed methodological quality and extracted data for the included trial. We used RevMan 5.1 for analyses of the data. MAIN RESULTS One study reporting on 154 neonates was found eligible. No significant difference between surgical closure and indomethacin treatment was found for in-hospital mortality, chronic lung disease, necrotising enterocolitis, sepsis, creatinine level or intraventricular haemorrhage. There was a significant increase in the surgical group in the incidence of pneumothorax (risk ratio (RR) 2.68; 95% confidence interval (CI) 1.45 to 4.93; risk difference (RD) 0.25; 95% CI 0.11 to 0.38; number needed to treat to harm (NNTH) 4 (95% CI 3 to 9)) and retinopathy of prematurity stage III and IV (RR 3.80; 95% CI 1.12 to 12.93; RD 0.11; 95% CI 0.02 to 0.20; NNTH 9 (95% CI 5 to 50)) compared to the indomethacin group. There was a statistically significant decrease in failure of ductal closure rate in the surgical group as compared to the indomethacin group (RR 0.04; 95% CI 0.01 to 0.27; RD -0.32; 95% CI -0.43 to -0.21, number needed to treat to benefit (NNTB) 3 (95% CI 2 to 4)). No new trials were identified for inclusion in the 2012 update. AUTHORS' CONCLUSIONS There are insufficient data to conclude whether surgical ligation or medical treatment with indomethacin is preferred as the initial treatment for symptomatic PDA in preterm infants.
Collapse
Affiliation(s)
- Manoj N Malviya
- Neonatal Intensive Care Unit, Nice Hospital for Children and Newborns, Shantinagar, Hyderabad, India.
| | | | | |
Collapse
|
29
|
Abstract
The current uncertainty in relation to treatment of the preterm patent ductus arteriosus reflects limitations to our understanding of the pathophysiology of ductal shunting, most particularly which ducts matter to which babies and when they matter. Doppler ultrasound offers a pragmatic tool with which to assess ductal patency and shunt significance and to allow prediction of spontaneous and therapeutic closure. Biomarkers, such as B-type natriuretic peptide, and clinical signs may have a diagnostic role where ultrasound is not available and also possibly as an adjunct to echocardiography in determining the pathophysiological impact of a ductal shunt in an individual baby.
Collapse
Affiliation(s)
- Nick Evans
- Department of Newborn Care, Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia.
| |
Collapse
|
30
|
Lai LS, McCrindle BW. Variation in the diagnosis and management of patent ductus arteriosus in premature infants. Paediatr Child Health 2011; 3:405-10. [PMID: 20401223 DOI: 10.1093/pch/3.6.405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To determine variations in neonatology practice regarding the diagnosis and management of patent ductus arteriosus (PDA) in premature infants. DESIGN Standardized telephone interview of preferences and practices. SUBJECTS Canadian neonatologists in active clinical practice. RESULTS Of 136 eligible Canadian neonatologists, 100 respondents (74%) estimated the proportion of infants with suspected PDA who have echocardiography to be a median of 80% (range 0% to 100%), with considerable variation both within and between centres. Only two centres had written guidelines. More recent medical school graduates were significantly more likely to use echocardiography. Increased use of echocardiography was also significantly related to increased availability. Fluid restriction and indomethacin was used as initial therapy by 89% of respondents, with the indomethacin dose standardized for 83%; surgical ligation was used when indomethacin therapy was contraindicated or had failed. Personal guidelines directed decisions regarding therapy for the majority of neonatologists. CONCLUSIONS Among Canadian neonatologists, there is considerable variation regarding practices related to the diagnosis and management of PDA in premature infants. This variation may potentially affect the cost effectiveness of care for these patients.
Collapse
Affiliation(s)
- L S Lai
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario
| | | |
Collapse
|
31
|
Ohlsson A, Shah SS. Ibuprofen for the prevention of patent ductus arteriosus in preterm and/or low birth weight infants. Cochrane Database Syst Rev 2011:CD004213. [PMID: 21735396 DOI: 10.1002/14651858.cd004213.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) complicates the clinical course of preterm infants and increases the risk of adverse outcomes. Indomethacin has been the standard treatment to close a PDA but is associated with renal, gastrointestinal and cerebral side-effects. Ibuprofen has less effect on blood flow velocity to important organs. OBJECTIVES To determine the effectiveness and safety of prophylactic ibuprofen compared to placebo/no intervention in the prevention of PDA in preterm infants. SEARCH STRATEGY Randomized controlled trials of prophylactic ibuprofen were identified by searching in The Cochrane Library, MEDLINE, CINAHL, EMBASE and trials registries in December 2010. SELECTION CRITERIA Randomized or quasi-randomised controlled trials comparing ibuprofen with placebo/no intervention or other cyclo-oxygenase inhibitor drugs to prevent PDA in preterm and/or low birth weight infants. DATA COLLECTION AND ANALYSIS Outcomes data including presence of PDA on day three, need for surgical ligation or rescue treatment with cyclo-oxygenase inhibitors, mortality, intraventricular haemorrhage (IVH), renal, pulmonary and gastrointestinal complications were extracted. Meta-analyses were performed and treatment estimates are reported as typical weighted mean difference, relative risk (RR), risk difference (RD) and, if statistically significant, number needed to treat to benefit (NNT) or number needed to treat to harm (NNH) along with their 95% confidence intervals (CI). MAIN RESULTS In this update, seven studies (n = 931) comparing prophylactic ibuprofen with placebo/no intervention are included. Ibuprofen decreased the incidence of PDA on day three [typical RR 0.36 (95% CI 0.29 to 0.46); typical RD -0.27 (95% CI -0.32 to -0.21); NNT 4 (95% CI 3 to 5)], decreased the need for rescue treatment with cyclo-oxygenase inhibitors and decreased the need for surgical ligation. Results from two studies administering oral ibuprofen had similar results, but showed an increased risk of gastrointestinal bleeding (NNH 4, 95% CI 2 to 17). In the control group the spontaneous closure rate was 58% by day three. Ibuprofen negatively affects renal function. No significant differences in mortality, IVH, chronic lung disease were found. AUTHORS' CONCLUSIONS Prophylactic use of ibuprofen decreased the incidence of PDA, decreased the need for rescue treatment with cyclo-oxygenase inhibitors and decreased the need for surgical closure. In the control group, the PDA closed spontaneously by day three in 58% of the neonates. Prophylactic treatment exposes many infants to a drug that has concerning renal and gastrointestinal side effects without conferring any important short-term benefits and is not recommended. Until long-term follow-up results are published from the trials included in this updated review, no further trials of prophylactic ibuprofen are recommended.
Collapse
Affiliation(s)
- Arne Ohlsson
- Departments of Paediatrics, Obstetrics and Gynaecology and Health Policy, Management and Evaluation, University of Toronto, 600 University Avenue, Toronto, Ontario, Canada, M5G 1X5
| | | |
Collapse
|
32
|
Brissaud O, Guichoux J. Patent ductus arteriosus in the preterm infant: a survey of clinical practices in French neonatal intensive care units. Pediatr Cardiol 2011; 32:607-14. [PMID: 21360267 DOI: 10.1007/s00246-011-9925-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 02/07/2011] [Indexed: 11/28/2022]
Abstract
Patent ductus arteriosus (PDA) is one of the most common problems in the care of premature infants, especially the extremely premature. There is no real consensus regarding the diagnostic criteria or treatment of a hemodynamically significant PDA. Its diagnosis, assessment, and treatment still remain challenges. Therefore, we investigated clinical practices in French tertiary neonatology centers regarding the management of PDA to compare their similarities and differences. We sent a questionnaire by email to the PDA specialist in every French tertiary neonatal intensive care unit. It contained 27 items regarding the unit's structure, method of diagnosing PDA, and treatment choices. The completed questionnaire were returned via email and analyzed blindly. The questionnaire response rate was 87.5%, which allowed us to draw some conclusions regarding French clinical practices in the care of neonates with PDA. Although the diagnostic criteria are quite similar, the therapeutic practices are rather different across neonatal care units. We highlight the great variability in French clinical practices when it comes to treating PDA and underscore the necessity for harmonization of these practices, which could be achieved using multicenter, randomized studies to identify the advantages of one approach compared with another.
Collapse
Affiliation(s)
- Olivier Brissaud
- Neonatal and Pediatric Intensive Care Unit, Bordeaux Teaching Hospital, 33076 Bordeaux Cedex, France
| | | |
Collapse
|
33
|
Han UJ, Cho HJ, Cho YK, Choi YY, Ma JS. Change in blood pressure and pulse pressure in preterm infants after treatment of patent ductus arteriosus with indomethacin. Korean Circ J 2011; 41:203-8. [PMID: 21607171 PMCID: PMC3098413 DOI: 10.4070/kcj.2011.41.4.203] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2010] [Accepted: 09/14/2010] [Indexed: 11/21/2022] Open
Abstract
Background and Objectives Patent ductus arteriosus (PDA) is associated with increased morbidity and mortality in premature infants. Therefore, an early diagnosis and treatment of a hemodynamically significant PDA are very important. A widened pulse pressure is considered to be a well known clinical sign of a PDA in older infants and children; however, whether this is also applicable in the case of preterm infants remains to be confirmed. The aims of this study were to investigate the change in blood pressure (BP) before and after medical treatment of a PDA with indomethacin and to evaluate if the change in the pulse pressure in preterm infants with a medically treated PDA could be used as a reliable clinical predictor of a hemodynamically significant PDA. Subjects and Methods Between January 2005 and June 2009, a retrospective analysis was performed in preterm infants with a hemodynamically significant PDA (PDA group, n=72) and preterm infants without a PDA (control group, n=72) at the Chonnam National University Hospital Neonatal Intensive Care Unit. The PDA was closed by treatment with indomethacin. The BP was compared between the two groups over the seven days after the first dose of indomethacin. Results In preterm infants with a hemodynamically significant PDA, the mean systolic (55.1±6.0 mmHg) and diastolic BPs (31.4±6.2 mmHg) were lower than those in the controls (mean systolic BP 58.0±6.4 mmHg, mean diastolic BP 34.7±6.0 mmHg) before indomethacin treatment. When the ductus arteriosus was successfully closed by indomethacin treatment, there was a gradual increase in both the systolic and diastolic BPs without any change in the pulse pressure. Conclusion The results of this study show that a widened pulse pressure is not a useful clinical sign of a hemodynamically significant PDA in preterm infants. However, low systolic and diastolic BPs may be useful clinical signs of a hemodynamically significant PDA in preterm infants. If the systolic and diastolic BP is low, a PDA should be considered and echocardiography should be performed for early diagnosis and treatment.
Collapse
Affiliation(s)
- Ui Joung Han
- Department of Pediatrics, Chonnam National University Medical School, Gwangju, Korea
| | | | | | | | | |
Collapse
|
34
|
Churchill R, Davies P, Caldwell D, Moore THM, Jones H, Lewis G, Hunot V. Humanistic therapies versus other psychological therapies for depression. Cochrane Database Syst Rev 2010; 2010:CD008700. [PMID: 25278809 PMCID: PMC4179874 DOI: 10.1002/14651858.cd007800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This is the protocol for a review and there is no abstract. The objectives are as follows: To examine the effectiveness and acceptability of all humanistic therapies compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of different humanistic therapy models (person-centred, gestalt, process-experiential, transactional analysis, existential and non-directive therapies) compared with all other psychological therapy approaches for acute depression.To examine the effectiveness and acceptability of all humanistic therapies compared with different psychological therapy approaches (psychodynamic, behavioural, humanistic, integrative, cognitive-behavioural) for acute depression.
Collapse
Affiliation(s)
- Rachel Churchill
- Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Philippa Davies
- Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Deborah Caldwell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Theresa HM Moore
- Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Hannah Jones
- Cochrane Schizophrenia Group, The University of Nottingham, Nottingham, UK
| | - Glyn Lewis
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Vivien Hunot
- Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK
| |
Collapse
|
35
|
Chiruvolu A, Punjwani P, Ramaciotti C. Clinical and echocardiographic diagnosis of patent ductus arteriosus in premature neonates. Early Hum Dev 2009; 85:147-9. [PMID: 19217224 DOI: 10.1016/j.earlhumdev.2008.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Accepted: 12/11/2008] [Indexed: 10/21/2022]
Abstract
The ductus arteriosus frequently fails to close in premature neonates. Considerable difference in opinion exists around what signifies a hemodynamically significant patent ductus arteriosus (PDA) and how reliable clinical signs are in determining the degree of the left-to-right shunting. Although reliance on clinical signs alone could delay the diagnosis of a PDA, there is insufficient evidence to suggest that early treatment improves outcome. Echocardiography is often used as the gold standard for diagnosing a PDA. A combination of echocardiographic measurements may assist in the early diagnosis of a PDA with a hemodynamically significant degree of left-to-right shunting, especially in extremely premature babies, where closure can be significantly delayed. Decision to treat PDA should be based on a combination of clinical signs and echocardiographic parameters. Monitoring B-type natriuretic peptide may be useful in the diagnosing neonates with symptomatic PDA.
Collapse
Affiliation(s)
- Arpitha Chiruvolu
- Department of Pediatrics, Division of Neonatology, Baylor University Medical Center, Dallas, Texas 75246, USA.
| | | | | |
Collapse
|
36
|
Nuntnarumit P, Khositseth A, Thanomsingh P. N-terminal probrain natriuretic peptide and patent ductus arteriosus in preterm infants. J Perinatol 2009; 29:137-42. [PMID: 19020527 DOI: 10.1038/jp.2008.185] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether plasma N-terminal probrain natriuretic peptide (NT-proBNP) in premature infants could identify hemodynamically significant patent ductus arteriosus (HsPDA) and to determine the correlation between serial plasma NT-proBNP and echocardiographic assessment of ductal shunting. STUDY DESIGN An observational study involving 35 preterm infants who underwent echocardiographic assessment for PDA on day 2, 4 and 7 of life with simultaneous blood sampling for determination of NT-proBNP concentrations. HsPDA was diagnosed by left-to-right ductal shunt on color Doppler, measuring diameter >1.5 mm on two-dimensional echocardiography plus > or =2 clinical features of PDA. RESULT Plasma NT-proNBP levels on day 2 in the HsPDA group (n=12) were significantly higher than in non-HsPDA group (n=23) with a median of 16,353 pg ml(-1) (interquartile range (IQR), 12,360-33,459; range, 10,316-104,998) vs 3914 pg ml(-1) (IQR, 2601-5782; range, 1535-19,516) (P<0.001), respectively. Eight infants (67%) in the HsPDA group responded to an initial course of indomethacin or ibuprofen and their NT-proBNP levels significantly decreased within 48 h after treatment compared with non-responders (P=0.007). NT-proBNP concentrations were significantly correlated with left atrial to aortic root ratio. A cut-off NT-proBNP on day 2 of 10,180 pg ml(-1) offered the best predictive values for HsPDA with a sensitivity of 100% and a specificity of 91%. CONCLUSION Plasma NT-proBNP on day 2 was found as a sensitive marker for predicting HsPDA in preterm infants. Successful closure of PDA was also correspondent with the decline in plasma NT-proBNP.
Collapse
Affiliation(s)
- P Nuntnarumit
- Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
| | | | | |
Collapse
|
37
|
Clinical assessment for diagnosing congenital heart disease in newborn infants with Down syndrome. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2008. [DOI: 10.1002/14651858.cd007486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
38
|
Alfaleh K, Smyth JA, Roberts RS, Solimano A, Asztalos EV, Schmidt B. Prevention and 18-month outcomes of serious pulmonary hemorrhage in extremely low birth weight infants: results from the trial of indomethacin prophylaxis in preterms. Pediatrics 2008; 121:e233-8. [PMID: 18245398 DOI: 10.1542/peds.2007-0028] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES A patent ductus arteriosus is a risk factor for pulmonary hemorrhage; however, despite halving the incidence of patent ductus arteriosus, indomethacin prophylaxis did not reduce the rate of pulmonary hemorrhage in the Trial of Indomethacin Prophylaxis in Preterms. Inclusion of mild bleeds after trauma to the upper airways may have masked a beneficial drug effect. Using the Trial of Indomethacin Prophylaxis in Preterms database, we studied the effect of prophylactic indomethacin on the prevention of serious hemorrhages in extremely low birth weight infants. We also compared the 18-month outcomes of infants with and without a serious pulmonary bleed. METHODS Pulmonary hemorrhage was classified as serious when it was treated with increased ventilator support, a higher concentration of oxygen, or transfusion of blood products. The cumulative risk for serious pulmonary hemorrhage was estimated for the first week of life and for the entire NICU stay. Poor outcome at a corrected age of 18 months was death or survival with cerebral palsy, cognitive delay, blindness, and/or deafness. RESULTS A total of 123 (10.2%) of 1202 infants developed a serious pulmonary hemorrhage. During week 1, prophylactic indomethacin reduced the risk for serious pulmonary hemorrhage by 35%; however, during the entire NICU stay, the risk for such hemorrhages was decreased by only 23%. A reduced risk for patent ductus arteriosus explained 80% of the beneficial effect of prophylactic indomethacin on serious pulmonary bleeds. The risks for death or for survival with neurosensory impairment were doubled after a serious pulmonary hemorrhage. CONCLUSIONS Extremely low birth weight infants with serious pulmonary hemorrhage have an increased risk for poor long-term outcome. Prophylactic indomethacin reduces the rate of early serious pulmonary hemorrhage, mainly through its action on patent ductus arteriosus. Prophylactic indomethacin is less effective in preventing serious pulmonary hemorrhages that occur after the first week of life.
Collapse
Affiliation(s)
- Khalid Alfaleh
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
39
|
Malviya M, Ohlsson A, Shah S. Surgical versus medical treatment with cyclooxygenase inhibitors for symptomatic patent ductus arteriosus in preterm infants. Cochrane Database Syst Rev 2008:CD003951. [PMID: 18254035 DOI: 10.1002/14651858.cd003951.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patent ductus arteriosus (PDA) with significant left to right shunt in preterm infants increases morbidity and mortality. Early closure of the ductus arteriosus may be achieved pharmacologically using cyclooxygenase inhibitors or by surgery. The efficacy of both treatment modalities is well established. However, the preferred initial treatment of a symptomatic PDA in a preterm infant, surgical ligation or treatment with indomethacin, has not been well established. OBJECTIVES To compare the effect of surgical ligation of PDA vs. medical treatment with cyclooxygenase inhibitors (using indomethacin, ibuprofen, or mefenamic acid), each used as the initial treatment, on neonatal mortality in preterm infants with a symptomatic PDA. SEARCH STRATEGY The standard search strategy of the Cochrane Neonatal Review Group was used. This included search of electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - July 2007), CINAHL (1982 - July 2007), EMBASE (1980 - July 2007); and hand search of abstracts of Pediatric Academic Societies annual meetings published in Pediatric Research (1990 - April 2002) or on line from May 2002 -July 2007. No language restrictions were applied. SELECTION CRITERIA All trials 1) using randomized or quasi-randomized patient allocation, 2) in preterm infants < 37 weeks gestational age or low-birth-weight infants (< 2500 grams) with symptomatic PDA in the neonatal period (< 28 days) and 3) comparing surgical ligation with medical treatment with cyclooxygenase inhibitors, each used as the initial treatment for closure of PDA. DATA COLLECTION AND ANALYSIS Assessment of methodological quality and extraction of data for included trials was undertaken independently by the authors. RevMan 4.1 was used for analysis of the data. MAIN RESULTS Only one study, trial B in the report of Gersony 1983, was found eligible. No additional studies were identified in the literature searches performed in July 2007. The trial compared the effect of surgical ligation of PDA vs. medical treatment with indomethacin, each used as the primary treatment. No trials comparing surgery to other cyclooxygenase inhibitors (ibuprofen, mefenamic acid) were found. Trial B of Gersony 1983 enrolled 154 infants. The study found no statistically significant difference between surgical closure and indomethacin treatment in mortality during hospital stay, chronic lung disease, other bleeding, necrotizing enterocolitis, sepsis, creatinine level, or intraventricular hemorrhage. There was a statistically significant increase in the surgical group in incidence of pneumothorax [RR 2.68 (95% CI 1.45, 4.93); RD 0.25 (95% CI 0.11, 0.38); NNH 4 (95% CI 3, 9)] and retinopathy of prematurity stage III and IV [RR 3.80 (95% CI 1.12, 12.93); RD 0.11 (95% CI 0.02, 0.20), NNH 9 (95% CI 5, 50] compared to the indomethacin group. There was as expected a statistically significant decrease in failure of ductal closure rate in the surgical group as compared to the indomethacin group: [RR 0.04 (95% CI 0.01, 0.27); RD -0.32 (95% CI -0.43, -0.21), NNT 3 (95% CI 2, 4)]. AUTHORS' CONCLUSIONS The data regarding net benefit/harm are insufficient to make a conclusion as to whether surgical ligation or medical treatment with indomethacin is preferred as initial treatment for symptomatic PDA in preterm infants. It should be noted that three recent observational studies indicated an increased risk for one or more of the following outcomes associated with PDA ligation; chronic lung disease, retinopathy of prematurity and neurosensory impairment . It is possible that the duration of the "waiting-time" and transport to another facility with surgical capacity to have the PDA ligated could adversely affect outcomes, as could the perioperative care.
Collapse
Affiliation(s)
- M Malviya
- University of Toronto, Division of Neonatology, Department of Paediatrics, 600 University Avenue, Rm 775a, Toronto, Ontario, Canada, M5G 1X5.
| | | | | |
Collapse
|
40
|
Lee HC, Silverman N, Hintz SR. Diagnosis of patent ductus arteriosus by a neonatologist with a compact, portable ultrasound machine. J Perinatol 2007; 27:291-6. [PMID: 17363908 DOI: 10.1038/sj.jp.7211693] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training. STUDY DESIGN Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist. RESULTS There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%). CONCLUSION A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.
Collapse
Affiliation(s)
- H C Lee
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, CA 94304, USA
| | | | | |
Collapse
|
41
|
Koch J, Hensley G, Roy L, Brown S, Ramaciotti C, Rosenfeld CR. Prevalence of spontaneous closure of the ductus arteriosus in neonates at a birth weight of 1000 grams or less. Pediatrics 2006; 117:1113-21. [PMID: 16585305 DOI: 10.1542/peds.2005-1528] [Citation(s) in RCA: 261] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Ductus arteriosus (DA) closure occurs within 96 hours in >95% of neonates >1500 g in birth weight (BW). The prevalence and postnatal age of spontaneous ductal closure in neonates < or =1000 g in BW (extremely low birth weight [ELBW] neonates) remain unclear, as does the incidence of failure to close with indomethacin. Therefore, we prospectively examined the prevalence, postnatal age, and clinical variables associated with spontaneous DA closure, occurrence of persistent patent DA, and indomethacin failure in ELBW neonates. METHODS Neonates delivered at Parkland Memorial Hospital from February 2001 through December 2003 were studied. Those with congenital heart defects or death <10 days postnatally were excluded. Echocardiograms were performed 48 to 72 hours postnatal and every 48 hours until 10 days postnatally. RESULTS We studied 122 neonates with BW of 794 +/- 118 (SD) g and estimated gestational age (EGA) of 26 +/- 2 weeks. Spontaneous permanent DA closure occurred in 42 (34%) neonates at 4.3 +/- 2 days postnatally, with 100% closure by 8 days. These neonates were more mature, less likely to have received antenatal steroids or have hyaline membrane disease (HMD; 52% vs 79%), and more likely to be growth restricted (31% vs 5%) and delivered of hypertensive women. Using regression analysis, EGA and absence of antenatal steroids and HMD predicted ductal closure. Ten (8%) neonates with early DA closure reopened and required medical/surgical closure. Eighty neonates had persistent patent DA; 7 were surgically ligated, and 5 remained asymptomatic, with 4 of 5 closing after 10 days postnatally. Sixty-eight (85%) received indomethacin at 6.2 +/- 4 days postnatally; 41% failed therapy and had no distinguishing characteristics. CONCLUSIONS Spontaneous permanent DA closure occurs in >34% of ELBW neonates and is predicted by variables related to maturation, for example, EGA and an absence of HMD, whereas indomethacin failure could not be predicated.
Collapse
Affiliation(s)
- Josh Koch
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | | | | | | | | | | |
Collapse
|
42
|
Sanjeev S, Pettersen M, Lua J, Thomas R, Shankaran S, L'Ecuyer T. Role of plasma B-type natriuretic peptide in screening for hemodynamically significant patent ductus arteriosus in preterm neonates. J Perinatol 2005; 25:709-13. [PMID: 16222347 DOI: 10.1038/sj.jp.7211383] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND B-type natriuretic peptide (BNP) is a hormone secreted by the ventricles under hemodynamic stress and congestive failure. OBJECTIVE The objective of the present study was to evaluate whether BNP can be used as a valid screening test for the presence of a hemodynamically significant patent ductus arteriosus (hsPDA) in the preterm neonate. MATERIALS AND METHODS This was a prospective blinded study involving preterm neonates with birth weights <or=1500 g and gestational age <or=34 weeks. Each enrolled neonate underwent the initial echocardiogram for a clinical suspicion of patent ductus arteriosus (PDA) and BNP assay within 3 hours of each other. Those neonates who did not have a PDA or who were not treated underwent a repeat echo and BNP measurement 48 to 72 hours after the first echo. In patients who received treatment for a PDA, an echo and BNP were repeated 48 to 72 hours after completion of treatment. RESULTS A total of 29 newborns with a median birth weight of 870 g (560 to 1325 g) and a median gestation of 26 weeks (24 to 31 weeks) were enrolled at a median age of 7 days (2 to 28 days). BNP levels were significantly higher in neonates with hsPDA (n=14) compared to those without (n=15) (508.5+/-618.2 vs 59.5+/-69.9 pg/ml, p<0.005). At a cutoff value of 70 pg/ml, BNP had a sensitivity of 92.9%, specificity of 73.3%, positive likelihood ratio of 3.5 and negative likelihood ratio of 0.09 for detection of hsPDA. BNP levels dropped significantly after medical or surgical closure of hsPDA (n=12), (404.9+/-159.2 to 25.1+/-4.1 pg/ml, p=0.03). CONCLUSIONS Elevation of plasma BNP accurately detects the presence of hsPDA in premature infants. Successful closure is reflected by a corresponding decrease in BNP. At a cutoff of 70 pg/ml, BNP is a useful screening tool for diagnosis and for monitoring efficacy of treatment of hsPDA.
Collapse
Affiliation(s)
- Sanjeev Sanjeev
- Division of Pediatric Cardiology, Children's Hosptial of Michigan, Detroit, MI 48201, USA
| | | | | | | | | | | |
Collapse
|
43
|
|
44
|
Alagarsamy S, Chhabra M, Gudavalli M, Nadroo AM, Sutija VG, Yugrakh D. Comparison of clinical criteria with echocardiographic findings in diagnosing PDA in preterm infants. J Perinat Med 2005; 33:161-4. [PMID: 15843268 DOI: 10.1515/jpm.2005.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The purpose of our study was to compare clinical criteria with echocardiographic findings in diagnosing hemodynamically significant patent ductus arteriosus (PDA) in preterm infants. METHODS We evaluated 25 preterm infants born at 24-32 weeks of gestation with birth weight from 500 to 1700 g for tachycardia, heart murmur, hyperdynamic chest, presence of dorsalis pedis pulse, hypotension, and worsening of the respiratory status at 48-72 h of life. A pediatric cardiologist blinded to clinical findings performed the echocardiograms. Infants with congenital anomalies and conditions, sepsis, IVH, and necrotizing enterocolitis were excluded. RESULTS Out of 25 preterm infants, 12 infants had hemodynamically significant PDA with left-to-right shunt. Two infants had small PDA and in 11 infants the ductus arteriosus was not patent. PDA infants had lower gestational age (P = 0.02) and birth weight (P = 0.03). Their Apgar scores (1 min) were lower (P = 0.03). The heart rate between the two groups differed, but was clinically within normal limits. Systolic (P = 0.05) and mean blood pressures (P = 0.04) were lower in the PDA group. A poor association between heart murmur, hyperdynamic chest and dorsalis pedis pulse, and the presence of PDA was revealed. CONCLUSION Echocardiogram is required for early diagnosis of PDA in preterm infants, as clinical signs are not reliable in the first few days of life.
Collapse
Affiliation(s)
- Sukirtha Alagarsamy
- Department of Pediatrics, New York Methodist Hospital, Brooklyn, New York 11215, USA.
| | | | | | | | | | | |
Collapse
|
45
|
Freeman-Ladd M, Cohen JB, Carver JD, Huhta JC. The hemodynamic effects of neonatal patent ductus arteriosus shunting on superior mesenteric artery blood flow. J Perinatol 2005; 25:459-62. [PMID: 15815707 DOI: 10.1038/sj.jp.7211294] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine if the ratio of the pulsatility index (PI) of the left pulmonary artery to the PI of the descending aorta, the Rp/Rs index, correlates with the degree of ductal steal from the intestine in neonates with a patent ductus arteriosus (PDA). STUDY DESIGN Echocardiograms and Doppler studies of the superior mesenteric artery (SMA) were performed in 41 neonates less than 35 weeks gestational age with a hemodynamically significant PDA (hsPDA). RESULTS There was a significant negative correlation between the Rp/Rs index and the SMA PI after controlling for ductal size (r=-0.476, p<0.008). CONCLUSIONS The Rp/Rs index can be used as an indicator of ductal steal on intestinal blood flow. The Rp/Rs index may be a useful adjunct to existing and new techniques for improving early assessment and treatment of hsPDA, and for evaluating the effects of hsPDA on systemic organs.
Collapse
MESH Headings
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/physiopathology
- Blood Flow Velocity/physiology
- Ductus Arteriosus, Patent/physiopathology
- Humans
- Infant, Low Birth Weight
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/physiopathology
- Mesenteric Artery, Superior/diagnostic imaging
- Mesenteric Artery, Superior/physiopathology
- Pulmonary Artery/diagnostic imaging
- Pulmonary Artery/physiopathology
- Pulse
- Regional Blood Flow/physiology
- Retrospective Studies
- Severity of Illness Index
- Ultrasonography
Collapse
Affiliation(s)
- Mayra Freeman-Ladd
- Department of Pediatrics, University of South Florida College of Medicine, Tampa, FL 33606, USA
| | | | | | | |
Collapse
|
46
|
Flynn PA, da Graca RL, Auld PAM, Nesin M, Kleinman CS. The use of a bedside assay for plasma B-type natriuretic peptide as a biomarker in the management of patent ductus arteriosus in premature neonates. J Pediatr 2005; 147:38-42. [PMID: 16027692 DOI: 10.1016/j.jpeds.2005.03.040] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the utility of the bedside plasma concentration of B-type natriuretic peptide (BNP) assay as a screen for patent ductus arteriosus (PDA) in premature neonates. STUDY DESIGN Newborn infants admitted to the neonatal intensive care unit (NICU) had paired echocardiography and BNP measurements at enrollment and every 4 to 5 days. RESULTS Twenty neonates (gestational age approximately 28.6 weeks and birth weight approximately 1161 g) had 81 paired echocardiography and BNP determinations. BNP ranged from 5 to 3900 pg/mL. Fifty-six of 81 echocardiograms showed PDA. Significant correlations were found between BNP and ductal size and degree of shunting. Correlation was greater in infants >2 days of age. BNP >300 pg/mL predicted significant PDA, whereas BNP <105 pg/mL predicted absence of significant PDA. CONCLUSION Bedside measurement of BNP correlates with magnitude of PDA in premature newborns, particularly beyond day 2, and may be useful in guiding diagnostic and management strategies.
Collapse
Affiliation(s)
- Patrick A Flynn
- Division of Pediatric Cardiology, Weill-Cornell Children's Hospital, New York, NY, USA.
| | | | | | | | | |
Collapse
|
47
|
Fonseca B, Chang RK, Senac M, Knight G, Sklansky MS. Chest radiography and the evaluation of the neonate for congenital heart disease. Pediatr Cardiol 2005; 26:367-72. [PMID: 16374686 DOI: 10.1007/s00246-005-8649-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We assessed the utility of the chest film as a screening tool for term and preterm neonates with suspected structural heart disease. Three independent observers, blinded to patient diagnosis, retrospectively evaluated the initial chest film for each of 128 consecutive neonates with suspected heart disease (gestational age, 23-42 weeks; birth weight, 500-4,621 g) who had undergone both chest radiography and echocardiography. These evaluations were subsequently compared with the results of the respective echocardiograms, read by board-certified pediatric cardiologists blinded to the chest film and chest film interpretation. Kappa statistics demonstrated moderate correlation (0.42-0.48) among different observers in their interpretation of the chest films but poor correlation (0.15-0.34) between chest radiography and echocardiography. The chest film had a low sensitivity for structural heart disease (26-59%), with a negative predictive value of 46-52%. Among neonates less than 2 kg or younger than 35 weeks of gestation, the chest film had still lower sensitivity for detecting heart disease. Despite agreement among observers in chest film interpretation, the chest film does not function as a screening test for neonates with suspected heart disease, particularly in small or premature neonates. In neonates with suspected heart disease, echocardiography should be considered, even in patients with chest films that do not suggest congenital heart disease.
Collapse
Affiliation(s)
- B Fonseca
- Department of Pediatrics, University of California, San Diego, UCSD Medical Center, 200 W. Arbor, CA 92103, USA
| | | | | | | | | |
Collapse
|
48
|
Choi BM, Lee KH, Eun BL, Yoo KH, Hong YS, Son CS, Lee JW. Utility of rapid B-type natriuretic peptide assay for diagnosis of symptomatic patent ductus arteriosus in preterm infants. Pediatrics 2005; 115:e255-61. [PMID: 15687418 DOI: 10.1542/peds.2004-1837] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE In preterm infants, the rapid and accurate determination of the presence of a hemodynamically significant patent ductus arteriosus (PDA) is extremely important, but this is often difficult. Plasma B-type natriuretic peptide (BNP) measurement has been reported to be a helpful aid in the diagnosis of hemodynamically significant PDA in preterm infants. The aim of our study was to investigate the usefulness of a rapid BNP assay as a diagnostic marker of symptomatic PDA (sPDA) in preterm infants. METHODS Sixty-six preterm infants, ranging from 25 to 34 gestational weeks of age, underwent clinical and echocardiographic examinations for PDA every other day from the third day of life until the disappearance of ductal flow. Blood samples were collected and plasma BNP concentrations were measured simultaneously using a commercial kit, (Triage BNP test kit; Biosite Diagnositics, San Diego, CA). When > or =2 clinically significant features of PDA were noted, and a large ductal flow was confirmed by color Doppler echocardiography, sPDA was diagnosed and treated with indomethacin. RESULTS On the third day after birth, the mean BNP concentration in the sPDA group (n = 23) was significantly higher than in the control group (n = 43) (2896 +/- 1627 vs 208 +/- 313 pg/mL). Seventeen infants (74%) in the sPDA group became asymptomatic after an initial course of indomethacin and their BNP levels concomitantly decreased. Moreover, BNP concentrations were significantly correlated with the magnitudes of the ductal shunt, such as the ratio of left atrial to aortic root diameter and the diastolic flow velocity of the left pulmonary artery (r = 0.726 and 0.877). The area under the receiver operator characteristic curve for the detection of sPDA was high: 0.997 (95% confidence interval: 0.991-1.004). The best cutoff of BNP concentration for the diagnosis of sPDA was determined to be 1110 pg/mL (sensitivity: 100%; specificity: 95.3%). CONCLUSION In preterm infants, the circulating BNP levels correlated well with the clinical and echocardiographic assessments of PDA. Although not a stand-alone test, the rapid BNP assay provides valuable information for the detection of infants with sPDA that require treatment. Moreover, serial BNP measurements may be of value in determining the clinical course of PDA in preterm infants.
Collapse
Affiliation(s)
- Byung Min Choi
- Department of Pediatrics, College of Medicine, Korea University, Seoul, Korea
| | | | | | | | | | | | | |
Collapse
|
49
|
Laughon MM, Simmons MA, Bose CL. Patency of the ductus arteriosus in the premature infant: is it pathologic? Should it be treated? Curr Opin Pediatr 2004; 16:146-51. [PMID: 15021192 DOI: 10.1097/00008480-200404000-00005] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW The ductus arteriosus is a vessel that connects the pulmonary artery to the aorta and provides a pulmonary-to-systemic diversion during fetal life. In the vast majority of infants, the ductus arteriosus closes by 3 days of life. In some infants, especially preterm infants with lung disease, there is delayed closure of the ductus arteriosus. There has been controversy as to whether or when the ductus arteriosus should be closed by either pharmacologic or surgical methods. RECENT FINDINGS There have been several epidemiologic studies describing an association between a patent ductus arteriosus and the development of morbidities, such as chronic lung disease. These associations have suggested to some that a causal relationship exists between patency of the ductus arteriosus and chronic lung disease and other morbidities. However, recent metaanalyses of randomized, controlled trials of the use of indomethacin for the prevention and treatment of the patent ductus arteriosus have not documented a decrease in the incidence of these morbidities after treatment, despite success in closure of the patent ductus arteriosus. SUMMARY In preterm infants, patency of the ductus arteriosus may represent a normal physiologic adaptation to allow shunting from either systemic-to-pulmonary circulation (eg, in the first day of life) or from pulmonary-to-systemic circulation (eg, in the presence of severe lung disease). Therapies designed to close the ductus arteriosus are contraindicated in some settings and should not be considered a standard of care at any time until these therapies are proven to decrease long-term clinical morbidities in randomized, placebo-controlled trials.
Collapse
Affiliation(s)
- Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7596, USA.
| | | | | |
Collapse
|
50
|
Evans N. CURRENT CONTROVERSIES IN THE DIAGNOSIS AND TREATMENT OF PATENT DUCTUS ARTERIOSUS IN PRETERM INFANTS. Adv Neonatal Care 2003; 3:168-77. [PMID: 14502524 DOI: 10.1016/s1536-0903(03)00143-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This article presents common misconceptions about the physiologic significance of early ductal shunting and reviews the evidence regarding the preferential use of echocardiography rather than reliance on clinical signs to diagnose patent ductus arteriosus. The rationale for the treatment of symptomatic versus presymptomatic versus prophylactic is compared and contrasted. Finally, a novel but untested treatment approach, using early echocardiographic findings to direct treatment decisions, is proposed as a direction for future research.
Collapse
Affiliation(s)
- Nick Evans
- Department of Neonatal Medicine, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia.
| |
Collapse
|