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Branagan A, Yu I, Gurusamy K, Miletin J. Thresholds for surfactant use in preterm neonates: a network meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2022-324184. [PMID: 36600484 DOI: 10.1136/archdischild-2022-324184] [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: 03/24/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a network meta-analysis of randomised controlled trials of different surfactant treatment strategies for respiratory distress syndrome (RDS) to assess if a certain fraction of inspired oxygen (FiO2) is optimal for selective surfactant therapy. DESIGN Systematic review and network meta-analysis using Bayesian analysis of randomised trials of prophylactic versus selective surfactant for RDS. SETTING Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Science Citation Index Expanded. PATIENTS Randomised trials including infants under 32 weeks of gestational age. INTERVENTIONS Intratracheal surfactant, irrespective of type or dose. MAIN OUTCOME MEASURES Our primary outcome was neonatal mortality, compared between groups treated with selective surfactant therapy at different thresholds of FiO2. Secondary outcomes included respiratory morbidity and major complications of prematurity. RESULTS Of 4643 identified references, 14 studies involving 5298 participants were included. We found no statistically significant differences between 30%, 40% and 50% FiO2 thresholds. A sensitivity analysis of infants treated in the era of high antenatal steroid use and nasal continuous positive airway pressure as initial mode of respiratory support showed no difference in mortality, RDS or intraventricular haemorrhage alone but suggested an increase in the combined outcome of major morbidities in the 60% threshold. CONCLUSION Our results do not show a clear benefit of surfactant treatment at any threshold of FiO2. The 60% threshold was suggestive of increased morbidity. There was no advantage seen with prophylactic treatment. Randomised trials of different thresholds for surfactant delivery are urgently needed to guide clinicians and provide robust evidence. PROSPERO REGISTRATION NUMBER CRD42020166620.
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Affiliation(s)
- Aoife Branagan
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland .,Division of Surgery and Interventional Science, UCL, London, UK
| | - Ivan Yu
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,Division of Surgery and Interventional Science, UCL, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, UCL, London, UK.,Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moskva, Russian Federation
| | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic.,2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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Pulse Oximetry Saturation (Spo2) Monitoring in the Neonatal Intensive Care Unit (NICU): The Challenge for Providers: A Systematic Review. Adv Neonatal Care 2022; 22:231-238. [PMID: 34334676 DOI: 10.1097/anc.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the neonatal intensive care unit (NICU), maintaining an oxygenation level that avoids both hypoxemia and hyperoxemia is challenging. Pulse oximetry has become fundamental for noninvasive monitoring of saturation of peripheral oxygen (Spo2) in preterm newborns. PURPOSE The aim of this systematic review is to determine Spo2 target values in order to avoid hypoxemia or hyperoxemia and complications arising from these. METHOD AND SEARCH STRATEGY For this systematic review, articles were audited from 2010 to 2020 using the PRISMA guidelines. PubMed, MEDLINE, Google Scholar, and Scopus databases were used, and search terms were related to use of pulse oximetry in the NICU. RESULTS The result showed that 12 of 20 (60%) studies focused on target values but without a unanimous agreement on values, although 5 of 12 studies (41.66%) suggested a lower value target of 85% and 4 of 12 studies (33.33%) recommended 95% as the higher target value. Other authors showed no difference in the incidence of adverse events comparing different target values and focused the importance more on the fluctuation of the value than on the target value itself. IMPLICATION FOR PRACTICE Reaching a balance in the oxygen administration so as to avoid potential complications associated with hypoxemia or hyperoxemia is a challenge for the clinicians. IMPLICATION FOR RESEARCH Further studies on fluctuation of Spo2 comparing different starting targets could better clarify the role of fluctuations and the absolute target values.Video Abstract available at:https://journals.na.lww.com/advancesinneonatalcare/Pages/videogallery.aspx?autoPlay=false&videoId=49.
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Dhanireddy R, Scott PA, Barker B, Scott TA. Quality Initiative to Reduce Extrauterine Growth Restriction in Very Low Birth Weight Infants. Hosp Pediatr 2022; 12:173-181. [PMID: 35001101 DOI: 10.1542/hpeds.2021-006146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND We report a statewide quality improvement initiative aimed to decrease the incidence of extrauterine growth restriction among very low birth weight infants cared for in Tennessee NICUs. METHODS The cohort consisted of infants born appropriate for gestational age between May 2016 and December 2018 from 9 NICUs across Tennessee. The infants were 23 to 32 weeks gestation and 500 to 1499 g birth weight. The process measures were the hours of life (HOL) when parenteral protein and intravenous lipid emulsion were initiated, the number of days to first enteral feeding, and attainment of full enteral caloric intake (110-130 kcal/kg per day). The primary outcome was extrauterine growth restriction, defined as weight <10th percentile for weight at 36 weeks postmenstrual age. Statistical process control charts and the Shewhart control rules were used to find special cause variation. RESULTS Although special cause variation was not indicated in the primary outcome measure, it was indicated for the reduction in specific process measures: HOL when parenteral protein was initiated, HOL when intravenous lipid emulsion was initiated, and the number of days to attainment of full enteral caloric intake (among the hospitals considered regional perinatal centers). CONCLUSIONS A statewide quality improvement initiative led to earlier initiation of parenteral and enteral nutrition and improved awareness of the importance of postnatal nutrition.
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Affiliation(s)
- Ramasubbareddy Dhanireddy
- Division of Neonatology, Department of PediatricsUniversity of Tennessee Health Science Center Memphis Tennessee.,Tennessee Initiative for Perinatal Quality Care Nashville Tennessee
| | - Patricia A Scott
- Tennessee Initiative for Perinatal Quality Care Nashville Tennessee.,Vanderbilt University School of Nursing Nashville Tennessee; and
| | - Brenda Barker
- Tennessee Initiative for Perinatal Quality Care Nashville Tennessee.,Division of Neonatology, Vanderbilt University Medical Center Nashville Tennessee
| | - Theresa A Scott
- Tennessee Initiative for Perinatal Quality Care Nashville Tennessee.,Division of Neonatology, Vanderbilt University Medical Center Nashville Tennessee
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Salas AA, Carlo WA, Do BT, Bell EF, Das A, Van Meurs KP, Poindexter BB, Shankaran S, Younge N, Watterberg KL, Higgins RD. Growth Rates of Infants Randomized to Continuous Positive Airway Pressure or Intubation After Extremely Preterm Birth. J Pediatr 2021; 237:148-153.e3. [PMID: 34157349 PMCID: PMC8478787 DOI: 10.1016/j.jpeds.2021.06.026] [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: 02/12/2021] [Revised: 05/03/2021] [Accepted: 06/15/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate the effects of early treatment with continuous positive airway pressure (CPAP) on nutritional intake and in-hospital growth rates of extremely preterm (EPT) infants. STUDY DESIGN EPT infants (240/7-276/7 weeks of gestation) enrolled in the Surfactant Positive Airway Pressure and Pulse Oximetry Trial (SUPPORT) were included. EPT infants who died before 36 weeks of postmenstrual age (PMA) were excluded. The growth rates from birth to 36 weeks of PMA and follow-up outcomes at 18-22 months corrected age of EPT infants randomized at birth to either early CPAP (intervention group) or early intubation for surfactant administration (control group) were analyzed. RESULTS Growth data were analyzed for 810 of 1316 infants enrolled in SUPPORT (414 in the intervention group, 396 in the control group). The median gestational age was 26 weeks, and the mean birth weight was 839 g. Baseline characteristics, total nutritional intake, and in-hospital comorbidities were not significantly different between the 2 groups. In a regression model, growth rates between birth and 36 weeks of PMA, as well as growth rates during multiple intervals from birth to day 7, days 7-14, days 14-21, days 21-28, day 28 to 32 weeks PMA, and 32-36 weeks PMA did not differ between treatment groups. Independent of treatment group, higher growth rates from day 21 to day 28 were associated with a lower risk of having a Bayley-III cognitive score <85 at 18-22 months corrected age (P = .002). CONCLUSIONS EPT infants randomized to early CPAP did not have higher in-hospital growth rates than infants randomized to early intubation.
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Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Barbara T. Do
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Abhik Das
- Statistics and Epidemiology Unit, RTI International, Research Triangle Park, NC
| | - Krisa P. Van Meurs
- Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Brenda B. Poindexter
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA
| | | | - Noelle Younge
- Department of Pediatrics, Duke University, Durham, NC
| | | | - Rosemary D. Higgins
- National Institute of Child Health and Human Development, Bethesda, MD and Department of Global and Community Health, George Mason University, Fairfax, VA
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Salas AA, Bhatia A, Carlo WA. Postnatal growth of preterm infants 24 to 26 weeks of gestation and cognitive outcomes at 2 years of age. Pediatr Res 2021; 89:1804-1809. [PMID: 32942289 PMCID: PMC7965787 DOI: 10.1038/s41390-020-01158-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/25/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Weight z scores at 36 weeks of postmenstrual age (PMA) define postnatal growth failure (PGF) and malnutrition. This study aimed to determine weight z scores at 36 weeks PMA that are associated with adverse cognitive outcomes at 2 years of age. METHODS In this retrospective cohort study, 350 infants 24-26 weeks of gestation born between 2006 and 2014 and followed at 2 years were included. Weight z scores at birth and at 36 weeks PMA were calculated using the INTERGROWTH-21st growth curves. The primary outcome was cognitive delay at 2 years of age (Bayley-III cognitive score < 85). RESULTS Neither the traditional definition of PGF (z score below -1.3) nor the recently proposed definition of malnutrition (z score decline of 1.2 or greater) was associated with cognitive delay. Both a weight z score below -1.0 at 36 weeks PMA (RR: 1.65; 95% CI: 1.10-2.49; p < 0.05) and a decline below -1.0 in weight z score from birth to 36 weeks PMA (RR: 1.40; 95% CI: 1.00-1.94; p < 0.05) were associated with a higher risk of cognitive delay. CONCLUSION With optimal cutoffs, INTERGROWTH-21st weight z scores can predict the risk of cognitive delay. IMPACT New growth curves generated with longitudinal data could overcome some limitations of traditional growth curves generated with cross-sectional data. When these new growth curves are used to assess the growth of preterm infants, alternative definitions for postnatal growth alterations may be needed. This study examines the association between postnatal growth alterations defined by the INTEGROWTH-21st growth curves and adverse cognitive outcomes at 2 years of age. With alternative definitions of postnatal growth failure and malnutrition, the INTERGROWTH-21st growth curves can help establish the association between postnatal growth of extremely preterm infants and adverse neurodevelopmental outcomes in early childhood.
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Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Anisha Bhatia
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Salas AA, Jerome ML, Chandler-Laney P, Ambalavanan N, Carlo WA. Serial assessment of fat and fat-free mass accretion in very preterm infants: a randomized trial. Pediatr Res 2020; 88:733-738. [PMID: 32634820 PMCID: PMC7581604 DOI: 10.1038/s41390-020-1052-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians could modify dietary interventions during early infancy by monitoring fat and fat-free mass accretion in very preterm infants. METHODS Preterm infants were randomly assigned to either having reports on infant body composition available to the clinicians caring for them (intervention group) or not having reports available (control group). All infants underwent serial assessments of body composition by air-displacement plethysmography before 32 weeks of postmenstrual age (PMA) and at 36 weeks PMA. The primary outcome was percent body fat (%BF) at 3 months of corrected age (CA). RESULTS Fifty infants were randomized (median gestational age: 30 weeks; mean ± SD birth weight: 1387 ± 283 g). The mean %BF increased from 7 ± 4 before 32 weeks PMA to 20 ± 5 at 3 months CA. The differences in mean %BF between the intervention group and the control group were not statistically significant at 36 weeks PMA (14.5 vs. 13.6) or 3 months CA (20.8 vs. 19.4). Feeding practices and anthropometric measurements during hospitalization did not differ between groups. CONCLUSIONS Serial assessments of body composition in both intervention and control groups showed consistent increments in %BF. However, providing this information to clinicians did not influence nutritional practices or growth. IMPACT Serial assessments of body composition in preterm infants at 32 and 36 weeks postmenstrual age show consistent increments in % body fat up to 3 months of corrected age. However, providing this information to the clinician did not influence nutritional practices or growth.
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Affiliation(s)
- Ariel A. Salas
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249
| | - Maggie L. Jerome
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35249
| | - Paula Chandler-Laney
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL 35249
| | | | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL 35249
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Darlow BA, Binenbaum G. Oxygen, weight gain, IGF-1 and ROP: not a straight-forward equation. Acta Paediatr 2018; 107:732-733. [PMID: 29083092 DOI: 10.1111/apa.14114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Brian A. Darlow
- Department of Paediatrics; University of Otago; Christchurch New Zealand
| | - Gil Binenbaum
- Ophthalmology; The Children's Hospital of Philadelphia; Philadelphia PA USA
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Kennedy KA, Mintz-Hittner HA. Medical and developmental outcomes of bevacizumab versus laser for retinopathy of prematurity. J AAPOS 2018; 22:61-65.e1. [PMID: 29223789 PMCID: PMC5826862 DOI: 10.1016/j.jaapos.2017.10.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/09/2017] [Accepted: 10/17/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Infants with stage 3+ retinopathy of prematurity (ROP) in zone I or zone II posterior were randomized to initial treatment with bevacizumab or laser in a multicenter trial (BEAT-ROP). The purpose of this study was to assess the effects of bevacizumab on nonophthalmologic outcomes. METHODS At one study site, inborn infants of <27 weeks' gestational age underwent medical and standardized neurologic and developmental assessments at 18-22 months' corrected age (age after expected date of full-term delivery). RESULTS Of the 18 infants enrolled at our site, 16 (7 bevacizumab, 9 laser) were evaluated for medical and neurodevelopmental outcomes at 18-28 months' corrected age. For each of the groups, the medians and ranges of growth percentiles were low compared with norms for healthy infants. The ranges for Bayley III developmental scores were also low relative to expected norms for healthy infants. There were no significant differences between the bevacizumab and laser therapy groups in weight (median percentile: bevacizumab, 18; laser, 7), length, head circumference, cerebral palsy, or Bayley scores (median Cognitive Composite Score: bevacizumab, 85; laser, 65). There was a significant difference in length of hospital stay (median days, 98 vs 140 days) favoring the bevacizumab group. CONCLUSIONS In this patient cohort 2-year follow-up evaluation of infants treated with bevacizumab versus laser therapy for retinopathy of prematurity showed no adverse effects on medical or neurodevelopmental outcomes.
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Affiliation(s)
- Kathleen A Kennedy
- Department of Pediatrics, McGovern Medical School at The University of Texas Health Science Center at Houston.
| | - Helen A Mintz-Hittner
- Department of Ophthalmology and Visual Science, McGovern Medical School at The University of Texas Health Science Center at Houston
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Maas C, Franz AR, von Krogh S, Arand J, Poets CF. Growth and morbidity of extremely preterm infants after early full enteral nutrition. Arch Dis Child Fetal Neonatal Ed 2018; 103:F79-F81. [PMID: 28733478 DOI: 10.1136/archdischild-2017-312917] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/14/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To evaluate feasibility and consequences of accelerated feeding advancement on short-term outcomes in extremely low gestational age neonates (ELGANs) who stayed in our institution for >28 days. METHODS Retrospective single-centre cohort analysis covering the years 2011-2013. Data are presented as median (IQR). RESULTS Infants '(n=77) birth weight was 745 (640 to 960) g and gestational age at birth 26.7 (25.1 to 27.4) weeks. Full enteral feeds were attained by postnatal day 7 (5 to 11). Weight gain from birth to discharge was 14.3 (13.3 to 16.1) g/kg/day, change in SD score for weight -0.03 (-0.55 to 0.46) and 0.09 (-0.78 and 0.82) for head circumference. Rates of necrotising enterocolitis and spontaneous intestinal perforation in all ELGANs admitted during the study period were 3.1% and 9.4%, respectively. CONCLUSIONS This cohort of ELGANs showed good weight gain and head growth after early full enteral nutrition. The impact of this feeding practice on neonatal morbidity and long-term outcome remains to be tested in adequately powered randomised trials.
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Affiliation(s)
- Christoph Maas
- Department of Neonatology, University Children's Hospital, Eberhard-Karls University, Tübingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital, Eberhard-Karls University, Tübingen, Germany.,Center for Pediatric Clinical Studies, University Children's Hospital, Eberhard-Karls University, Tübingen, Germany
| | - Stefanie von Krogh
- Department of Neonatology, University Children's Hospital, Eberhard-Karls University, Tübingen, Germany
| | - Jörg Arand
- Department of Neonatology, University Children's Hospital, Eberhard-Karls University, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital, Eberhard-Karls University, Tübingen, Germany
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