1
|
Cervera SB, Saeed S, Luu TM, Gorgos A, Beltempo M, Claveau M, Basso O, Lapointe A, Tremblay S, Altit G. Evaluation of the association between patent ductus arteriosus approach and neurodevelopment in extremely preterm infants. J Perinatol 2024; 44:388-395. [PMID: 38278962 DOI: 10.1038/s41372-024-01877-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Assess if unit-level PDA management correlates with neurodevelopmental impairment (NDI) at 18-24 months corrected postnatal age (CPA) in extremely preterm infants. STUDY DESIGN Retrospective analysis of infants born at <29 weeks (2014-2017) across two units having distinct PDA strategies. Site 1 utilized an echocardiography-based treatment strategy aiming for accelerated closure (control). Site 2 followed a conservative approach. PRIMARY ENDPOINT NDI, characterized by cerebral palsy, any Bayley-III composite score <85, sensorineural/mixed hearing loss, or at least unilateral visual impairment. RESULTS 377 infants were evaluated. PDA treatment rates remained unchanged in Site 1 but eventually reached 0% in Site 2. Comparable rates of any/significant NDI were seen across both sites (any NDI: 38% vs 36%; significant NDI: 13% vs 10% for Site 1 and 2, respectively). After adjustments, NDI rates remained similar. CONCLUSION PDA management strategies in extremely preterm newborns showed no significant impact on neurodevelopment outcomes at 18-24 months CPA.
Collapse
Affiliation(s)
- Soledad Belén Cervera
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada
| | - Sahar Saeed
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Thuy Mai Luu
- Neonatal Follow-Up, Department of Paediatrics, Université de Montréal, Montreal, QC, Canada
| | - Andrea Gorgos
- Neonatal Follow-Up, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Marc Beltempo
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Martine Claveau
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Olga Basso
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Anie Lapointe
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada
| | - Sophie Tremblay
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada
| | - Gabriel Altit
- Division of Neonatology, Department of Paediatrics, Sainte-Justine University Health Center, Montréal, QC, Canada.
| |
Collapse
|
2
|
Kaluarachchi DC, Rysavy MA, Carper BA, Chock VY, Laughon MM, Backes CH, Colaizy TT, Bell EF, McNamara PJ. Secular Trends in Patent Ductus Arteriosus Management in Infants Born Preterm in the National Institute of Child Health and Human Development Neonatal Research Network. J Pediatr 2024; 266:113877. [PMID: 38135028 PMCID: PMC10922632 DOI: 10.1016/j.jpeds.2023.113877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/12/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023]
Abstract
We evaluated changes in patent ductus arteriosus (PDA) diagnosis and treatment from 2012 through 2021 in a network of US academic hospitals. PDA treatment decreased among infants born at 26-28 weeks but not among infants born at 22-25 weeks. Rates of indomethacin use and PDA ligation decreased while acetaminophen use and transcatheter PDA closure increased.
Collapse
Affiliation(s)
| | - Matthew A Rysavy
- Department of Pediatrics, McGovern Medical School, UTHealth Houston, Houston, TX
| | - Benjamin A Carper
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC
| | - Valerie Y Chock
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Matthew M Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC
| | - Carl H Backes
- Department of Pediatrics, Ohio State University and Nationwide Children's Hospital, Columbus, OH
| | | | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | | |
Collapse
|
3
|
Bischoff AR, Kennedy KF, Backes CH, Sathanandam S, McNamara PJ. Percutaneous Closure of the Patent Ductus Arteriosus in Infants ≤2 kg: IMPACT Registry Insights. Pediatrics 2023; 152:e2023061460. [PMID: 37529882 DOI: 10.1542/peds.2023-061460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2023] [Indexed: 08/03/2023] Open
Abstract
OBJECTIVES Percutaneous patent ductus arteriosus (PDA) closure is becoming the standard of care for definitive closure in progressively smaller and younger neonates. The objective of this study was to assess safety and feasibility of percutaneous PDA closure in patients ≤2 kg. METHODS This was a cohort study using the IMPACT Registry (Improving Pediatric and Adult Congenital Treatments) from the American College of Cardiology Foundation's National Cardiovascular Data Registry. Patients who were ≤2 kg at the time of percutaneous PDA closure were included. The primary outcome was the composite of technical failure and/or major adverse event. RESULTS A total of 1587 attempted PDA closures were included, with a 3% incidence of technical failure and 5.5% incidence of the composite outcome. Major adverse events were observed in 3.8% of the patients; the most common events were device embolization requiring retrieval and unplanned cardiac or vascular surgery in 1.3% and 1.3% of cases, respectively. The incidence of the composite outcome was associated with the need for arterial access (P < .001) as well as annual hospital volume of percutaneous PDA closures in infants ≤2 kg (P = .001). The incidence of the composite outcome has decreased overtime, whereas median weight at the time of procedure has also diminished. CONCLUSIONS Percutaneous PDA closure appears to be safe and feasible procedures in infants ≤2 kg. The incidence of major adverse events has continued to decline over the years and seems to have a strong correlation with individual center case volumes and expertise.
Collapse
Affiliation(s)
| | | | - Carl H Backes
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Shyam Sathanandam
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Patrick J McNamara
- Department of Pediatrics, Division of Neonatology
- Department of Internal Medicine University of Iowa, Iowa City, Iowa
| |
Collapse
|
4
|
Jasani B, Weisz DE, Reese J, Jain A. Combination pharmacotherapy for patent ductus arteriosus: Rationale and evidence. Semin Perinatol 2023; 47:151720. [PMID: 36914507 DOI: 10.1016/j.semperi.2023.151720] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
While cyclooxygenase inhibitors have been the most common medications used to facilitate earlier closure of patent ductus arteriosus in preterm infants, adverse effects and low efficacy in extremely low gestational age neonates (ELGANs) have highlighted a need for alternative options. Combination therapy with acetaminophen and ibuprofen is a novel strategy for PDA treatment in ELGANs, as it may facilitate higher ductal closure rates via additive action on two separate pathways inhibiting prostaglandin production. Initial small observational studies and pilot randomized clinical trials indicate potentially higher efficacy of the combination regime to induce ductal closure in comparison to treatment with ibuprofen alone. In this review, we examine the potential clinical impact of treatment failure in ELGANs with significant PDA, highlight the biological rationale in support of studying combination therapy, and review the randomized and non-randomized studies to date. With the rising number of ELGANs receiving neonatal intensive care, who are vulnerable to PDA-related morbidities, there is an urgent need for adequately powered clinical trials to systematically investigate the efficacy and safety of combination therapy for PDA treatment.
Collapse
Affiliation(s)
- Bonny Jasani
- Division of Neonatology, Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Dany E Weisz
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amish Jain
- Department of Pediatrics, University of Toronto, Toronto, Canada; Department of Pediatrics, Mount Sinai Hospital, Toronto, Canada.
| |
Collapse
|
5
|
Does active treatment in infants born at 22-23 weeks correlate with outcomes of more mature infants at the same hospital? An analysis of California NICU data, 2015-2019. J Perinatol 2022; 42:1301-1305. [PMID: 35361887 PMCID: PMC9522931 DOI: 10.1038/s41372-022-01381-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To investigate whether hospital rates of active treatment for infants born at 22-23 weeks is associated with survival of infants born at 24-27 weeks. STUDY DESIGN We included all liveborn infants 22-27 weeks of gestation delivered at California Perinatal Quality Care Collaborative hospitals from 2015 to 2019. We assessed (1) the correlation of active treatment (e.g., endotracheal intubation, epinephrine) in 22-23 week infants and survival until discharge for 24-27 week infants and (2) the association of active treatment with survival using multilevel models. RESULT The 22-23 week active treatment rate was associated with infant outcomes at 22-23 weeks but not 24-27 weeks. A 10% increase in active treatment did not relate to 24-25 week (adjusted OR: 1.00 [95% CI: 0.95-1.05]), or 26-27 week survival (aOR: 1.02 [0.95-1.09]). CONCLUSION The hospital rate of active treatment for infants born at 22-23 weeks was not associated with improved survival for 24-27 week infants.
Collapse
|
6
|
Bischoff AR, Cavallaro Moronta S, McNamara PJ. Going Home with a Patent Ductus Arteriosus: Is it Benign? J Pediatr 2022; 240:10-13. [PMID: 34530023 DOI: 10.1016/j.jpeds.2021.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/02/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Adrianne Rahde Bischoff
- Department of Pediatrics, Division of Neonatology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Stephania Cavallaro Moronta
- Department of Pediatrics, Division of Neonatology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Patrick J McNamara
- Department of Pediatrics, Division of Neonatology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa.
| |
Collapse
|
7
|
Effects of prophylactic indomethacin on morbidity and mortality in infants <25 weeks' gestation: a protocol driven intention to treat analysis. J Perinatol 2022; 42:1662-1668. [PMID: 36310242 PMCID: PMC9712120 DOI: 10.1038/s41372-022-01547-7] [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: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine if prophylactic indomethacin (PINDO) decreases death or bronchopulmonary dysplasia-grades 2 and 3 (death/BPD) in newborns <25 weeks. STUDY DESIGN Intention-to-treat, cohort-controlled study of 106 infants admitted during three alternating epochs of PINDO or Expectant patent ductus arteriosus (PDA) management. RESULTS At 7-8 days 85% of Expectant Management epoch infants had a moderate/large PDA (median exposure was 23 days). Among PINDO epoch infants only 24% still had a PDA at 7-8 days. There were no significant differences in the incidence of death/BPD or of secondary outcomes (BPD, death, necrotizing enterocolitis/spontaneous perforations, or intraventricular hemorrhage (grades 3 or 4)) in either unadjusted or adjusted comparisons between infants born in a PINDO epoch and those born in the Expectant Management epoch. CONCLUSION Despite being at high risk for PDA-related morbidities, PINDO did not appear to alter the rates of our primary and secondary outcomes in infants <25 weeks.
Collapse
|
8
|
Covariation of changing patent ductus arteriosus management and preterm infant outcomes in Pediatrix neonatal intensive care units. J Perinatol 2021; 41:2526-2531. [PMID: 34354226 DOI: 10.1038/s41372-021-01170-y] [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: 02/22/2021] [Revised: 05/28/2021] [Accepted: 07/14/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To test the hypothesis that NICU-specific preterm infant outcomes co-vary with changes in local patent ductus arteriosus (PDA) management. STUDY DESIGN This retrospective multicenter study examined NICU-specific aggregated data for infants born 400-1499 g (VLBW) in the Pediatrix Clinical Data Warehouse. For each NICU and each year 2006-2016 we calculated proportion of infants receiving cyclooxygenase inhibitor (COXI) and/or PDA ligation and determined NICU-specific changes in these therapies between consecutive years. We examined relationships between NICU-specific changes in COXI/ligation and concurrent changes in local adjusted in-hospital outcomes. RESULTS In 5678 observations of change at 259 NICUs summarizing 78,105 infants, between-year decreases in NICU-specific proportion treated with COXI/ligation were associated with concurrent increases in local mortality and decreases in BPD among infants 400-749 g, and with decreased pulmonary hemorrhage in larger infants. CONCLUSIONS NICU-specific adjusted mortality, BPD, and pulmonary hemorrhage rates co-vary with changes in local COXI/ligation rates in some VLBW infant subgroups.
Collapse
|
9
|
Altit G, Saeed S, Beltempo M, Claveau M, Lapointe A, Basso O. Outcomes of Extremely Premature Infants Comparing Patent Ductus Arteriosus Management Approaches. J Pediatr 2021; 235:49-57.e2. [PMID: 33864797 DOI: 10.1016/j.jpeds.2021.04.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/14/2021] [Accepted: 04/08/2021] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To evaluate the change in the proportion of deaths/bronchopulmonary dysplasia (BPD) among premature infants (born <26 and 26-29 weeks of gestational age) following a policy change to a strict nonintervention approach, compared with standard treatment. STUDY DESIGN We examined 1249 infants (341 born <26 weeks of gestational age) at 2 comparable sites. Site 1 (control) continued medical treatment/ligation, and site 2 (exposed) changed to a nonintervention policy in late 2013. Using the difference-in-differences approach, which accounts for time-invariant differences between sites and secular trends, we assessed changes in death or BPD separately among infants born 26-29 weeks and <26 weeks of gestational age in 2 epochs (epoch 1: 2011-2013; epoch 2: 2014-2017). RESULTS Baseline characteristics were similar across sites and epochs. Medical treatment/ligation use remained stable at site 1 but declined progressively to 0% at site 2, indicating adherence to policy. We saw no difference in death/BPD among infants born at 26-29 weeks of gestational age (12%, 95% CI -1% to 24%). However, incidence of death/BPD increased by 31% among infants born <26 weeks of gestational age (95% CI 10%-51%) in site 2, whereas there was no change in outcomes in site 1. The Score for Neonatal Acute Physiology-Version II, used as a control outcome, did not change in either site, suggesting that our findings were not due to changes in patients' severity. CONCLUSIONS Adherence to a strict conservative policy did not impact death or BPD among 26 weeks but was associated with a significant rise in infants born <26 weeks.
Collapse
Affiliation(s)
- Gabriel Altit
- Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Sahar Saeed
- Department of Epidemiology, Washington University, St. Louis, MO
| | - Marc Beltempo
- Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada
| | - Martine Claveau
- Division of Neonatology, McGill University Health Center, Montreal Children's Hospital, Department of Pediatrics, McGill University, Montreal, Quebec, Canada; Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Anie Lapointe
- Department of Neonatology, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Olga Basso
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada; Department of Obstetrics and Gynecology, McGill University Health Center; Montreal, Quebec, Canada
| |
Collapse
|
10
|
Villosis MFB, Barseghyan K, Ambat MT, Rezaie KK, Braun D. Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle. JAMA Netw Open 2021; 4:e2114140. [PMID: 34181013 PMCID: PMC8239950 DOI: 10.1001/jamanetworkopen.2021.14140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019). INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURES The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTS The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCE A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.
Collapse
Affiliation(s)
- Maria Fe B. Villosis
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Karine Barseghyan
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Ma. Teresa Ambat
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Kambiz K. Rezaie
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - David Braun
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| |
Collapse
|
11
|
Godin R, Rodriguez JC, Kahn DJ. Oral Versus Intravenous Medications for Treatment of Patent Ductus Arteriosus in Preterm Neonates: A Cost-Saving Initiative. J Pediatr Pharmacol Ther 2021; 26:291-299. [PMID: 33833632 DOI: 10.5863/1551-6776-26.3.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 10/18/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The purpose of the study was to quantify cost savings after promoting oral pharmacotherapy for the treatment of hemodynamically significant patent ductus arteriosus (hsPDA). METHODS This was a retrospective before-and-after time series quality improvement study. Oral ibuprofen and acetaminophen use criteria were developed and recommended, rather than the more costly intravenous equivalents. There were 24-month medication use reports generated for both the pre-criteria (Era-1) and the post-criteria (Era-2) implementation phases to identify neonates prescribed hsPDA medications in order to assess cost differences. RESULTS Era-1 had 190 treatment courses in 110 neonates for a total medication cost of $171,260.70. Era-2 had 210 courses in 109 patients for a total medication cost of $47,461.49, yielding savings of $123,799.21 ($61,899.61 annually) after criteria implementation. The reduction in intravenous ibuprofen use in Era-2 accounted for all the savings. CONCLUSION Preferentially prescribing lower-cost oral medications to treat hsPDA led to significant cost savings.
Collapse
|
12
|
Gillam-Krakauer M, Slaughter JC, Cotton RB, Robinson BE, Reese J, Maitre NL. Outcomes in infants < 29 weeks of gestation following single-dose prophylactic indomethacin. J Perinatol 2021; 41:109-118. [PMID: 32948814 PMCID: PMC7499931 DOI: 10.1038/s41372-020-00814-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/05/2020] [Accepted: 09/02/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Prophylactic indomethacin (3 doses) decreases patent ductus arteriosus (PDA) and intraventricular hemorrhage (IVH) in preterm infants. The study aim was to determine whether single-dose indomethacin (SD-INDO) decreases PDA, IVH, and improves motor function. METHODS A retrospective cohort (2007-2014) compared infants born < 29 weeks who did (n = 299) or did not (n = 85) receive SD-INDO and estimated outcomes association with ordinal logistic regression, adjusting for multiple variables using propensity scores. RESULTS Infants who received SD-INDO were more premature (p < 0.001) but had lower odds of PDA (OR 0.26 [0.15, 0.44], p < 0.005), PDA receiving treatment (OR 0.12 [0.03, 0.47], p < 0.005), death (OR 0.41 [0.20, 0.86], p = 0.02), and CP severity (OR 0.33 [0.12, 0.89], p = 0.03). There was less IVH (OR 0.58 [0.36, 0.94], p = 0.03) when adjusted for gestational age. CONCLUSIONS SD-INDO is associated with decreased PDA and CP severity and improved survival.
Collapse
Affiliation(s)
- Maria Gillam-Krakauer
- Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - James C. Slaughter
- grid.412807.80000 0004 1936 9916Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Robert B. Cotton
- grid.412807.80000 0004 1936 9916Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA
| | - Blaine E. Robinson
- grid.412807.80000 0004 1936 9916Vanderbilt University Medical Center, Nashville, TN USA
| | - Jeff Reese
- grid.412807.80000 0004 1936 9916Mildred T. Stahlman Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN USA ,grid.412807.80000 0004 1936 9916Department of Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, TN USA
| | - Nathalie L. Maitre
- grid.240344.50000 0004 0392 3476Department of Pediatrics Nationwide Children’s Hospital, Columbus, OH USA ,grid.412807.80000 0004 1936 9916Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, TN USA
| |
Collapse
|
13
|
Does crossover treatment of control subjects invalidate results of randomized trials of patent ductus arteriosus treatment? J Perinatol 2020; 40:1863-1870. [PMID: 33024260 DOI: 10.1038/s41372-020-00848-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/14/2020] [Accepted: 09/24/2020] [Indexed: 02/07/2023]
Abstract
Optimal management of patent ductus arteriosus (PDA) in extremely preterm infants remains controversial. There is paucity of evidence on the benefits of PDA treatment in reducing mortality and morbidities in extremely preterm infants. Failure of randomized clinical trials to demonstrate beneficial effects of PDA treatment on outcomes has often been attributed to open treatment of control subjects. This perspective examines the PDA treatment trials to date, with specific focus on rates of and ages of subjects at open rescue treatment. Although these trials demonstrate that ductal closure is significantly increased with treatment, that does not translate to a significant decrease in major morbidities or mortality in premature infants, even when trials with high rates of rescue treatment of controls are excluded. Trials in which enrollment occurred after 7 days of age include insufficient numbers of subjects to evaluate this relationship.
Collapse
|
14
|
Hamrick SEG, Sallmon H, Rose AT, Porras D, Shelton EL, Reese J, Hansmann G. Patent Ductus Arteriosus of the Preterm Infant. Pediatrics 2020; 146:e20201209. [PMID: 33093140 PMCID: PMC7605084 DOI: 10.1542/peds.2020-1209] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2020] [Indexed: 02/07/2023] Open
Abstract
Postnatal ductal closure is stimulated by rising oxygen tension and withdrawal of vasodilatory mediators (prostaglandins, nitric oxide, adenosine) and by vasoconstrictors (endothelin-1, catecholamines, contractile prostanoids), ion channels, calcium flux, platelets, morphologic maturity, and a favorable genetic predisposition. A persistently patent ductus arteriosus (PDA) in preterm infants can have clinical consequences. Decreasing pulmonary vascular resistance, especially in extremely low gestational age newborns, increases left-to-right shunting through the ductus and increases pulmonary blood flow further, leading to interstitial pulmonary edema and volume load to the left heart. Potential consequences of left-to-right shunting via a hemodynamically significant patent ductus arteriosus (hsPDA) include increased risk for prolonged ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis or focal intestinal perforation, intraventricular hemorrhage, and death. In the last decade, there has been a trend toward less aggressive treatment of PDA in preterm infants. However, there is a subgroup of infants who will likely benefit from intervention, be it pharmacologic, interventional, or surgical: (1) prophylactic intravenous indomethacin in highly selected extremely low gestational age newborns with PDA (<26 + 0/7 weeks' gestation, <750 g birth weight), (2) early targeted therapy of PDA in selected preterm infants at particular high risk for PDA-associated complications, and (3) PDA ligation, catheter intervention, or oral paracetamol may be considered as rescue options for hsPDA closure. The impact of catheter-based closure of hsPDA on clinical outcomes should be determined in future prospective studies. Finally, we provide a novel treatment algorithm for PDA in preterm infants that integrates the several treatment modalities in a staged approach.
Collapse
Affiliation(s)
- Shannon E G Hamrick
- Divisions of Neonatology and
- Cardiology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Hannes Sallmon
- Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany
| | | | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Elaine L Shelton
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Jeff Reese
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| |
Collapse
|
15
|
Ruoss JL, Bazacliu C, Giesinger RE, McNamara PJ. Patent ductus arteriosus and cerebral, cardiac, and gut hemodynamics in premature neonates. Semin Fetal Neonatal Med 2020; 25:101120. [PMID: 32513596 DOI: 10.1016/j.siny.2020.101120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patent ductus arteriosus is associated with multiple comorbidities in premature infants, however a causal link or strategy to decrease these morbidities has not been found. The association between the patent ductus arteriosus and morbidities has biologic plausibility as, like any cardiac mixing lesion, a significant systemic to pulmonic shunt may lead to pulmonary over-circulation and systemic hypoperfusion. Understanding the underlying pathophysiology of associated morbidities in the setting of a patent ductus arteriosus may aid in risk stratifying infants and offer a patient targeted approach to infants with a pathological ductal shunt. While the deleterious impact of increased pulmonary blood flow maybe easier to identify, the impact on end-organ perfusion is more challenging. In this review, we will discuss the pathophysiology of a hemodynamically significant patent ductus arteriosus in premature infants, impact on end-organ perfusion and associated morbidities, and novel modalities to assess shunt volume and effect on end-organ perfusion.
Collapse
Affiliation(s)
- J L Ruoss
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - C Bazacliu
- Division of Neonatology, Department of Pediatrics, University of Florida, 1600 SW Archer Rd, Gainesville, FL, 32608, USA
| | - R E Giesinger
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - P J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA; Department of Internal Medicine, University of Iowa, 8803 John Pappajohn Pavillion 200 Hawkins Drive, Iowa City, IA, 52242, USA.
| |
Collapse
|
16
|
Sung SI, Lee MH, Ahn SY, Chang YS, Park WS. Effect of Nonintervention vs Oral Ibuprofen in Patent Ductus Arteriosus in Preterm Infants: A Randomized Clinical Trial. JAMA Pediatr 2020; 174:755-763. [PMID: 32539121 PMCID: PMC7296457 DOI: 10.1001/jamapediatrics.2020.1447] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
IMPORTANCE Persistent patent ductus arteriosus (PDA) in preterm infants is associated with increased mortality and respiratory morbidities, including bronchopulmonary dysplasia (BPD). Despite recent increasing use of noninterventional approaches, no study to our knowledge has yet directly compared the nonintervention vs pharmacologic treatment for mediating PDA closure for decreasing mortality and preventing BPD. OBJECTIVE To determine the noninferiority of nonintervention vs oral ibuprofen treatment for PDA in decreasing BPD incidence or death in very preterm infants. DESIGN, SETTING, AND PARTICIPANTS A randomized, double-blind, placebo-controlled, noninferiority clinical trial was conducted on preterm infants (gestational age [GA] 23-30 weeks) with hemodynamically significant PDA (ductal size >1.5 mm plus respiratory support) diagnosed between postnatal days 6 and 14. Participants included 383 infants screened between July 24, 2014, and March 15, 2019. INTERVENTIONS Infants were stratified by GA and randomly assigned (1:1) to receive either oral ibuprofen (initial dose of 10 mg/kg followed by a 5-mg/kg dose after 24 hours and a second 5-mg/kg dose after 48 hours) or placebo. MAIN OUTCOMES AND MEASURES The primary outcome was BPD or death; the secondary outcomes included major morbidities and ductal closure rates. Per-protocol analysis was used. RESULTS Among 383 infants screened for participation, 146 infants were randomly assigned, with 72 in the nonintervention and 70 in the ibuprofen treatment group in the final analyses. The PDA closure rate at 1 week after randomization was significantly higher with ibuprofen (11 [34%]) than nonintervention (2 [7%]) in infants at GA 27 to 30 weeks (P = .007); however, the findings were not significant at GA 23 to 26 weeks (ibuprofen, 3 [8%] vs nonintervention, 1 [2%], P = .34). In addition, the ductal closure rates before hospital discharge (ibuprofen, 62 [89%] vs nonintervention, 59 [82%], P = .27) and device closure (ibuprofen, 2 [3%] vs nonintervention, 4 [6%], P = .40) were not significantly different between the 2 groups. The nonintervention approach was noninferior to ibuprofen treatment in terms of BPD incidence or death (nonintervention, 44%; ibuprofen, 50%; 95% CI, -0.11 to 0.22; noninferiority margin -0.2; P = .51). One infant in the ibuprofen arm received oral ibuprofen backup rescue treatment owing to cardiopulmonary compromise refractory to conservative management, and another infant in the ibuprofen group received surgical ligation; none of the infants in the placebo group received backup treatment. CONCLUSIONS AND RELEVANCE Nonintervention showed noninferiority compared with ibuprofen treatment in closing of hemodynamically significant PDA and reduction of BPD or death. The noninferiority of nonintervention over ibuprofen might be attributable to the low efficacy of oral ibuprofen for closing PDA, especially in infants born at 23 to 26 weeks' gestation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02128191.
Collapse
Affiliation(s)
- Se In Sung
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung Hee Lee
- Statistics and Data Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Yoon Ahn
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Samsung Medical Center, Department of Pediatrics, Sungkyunkwan University School of Medicine, Seoul, Korea
| |
Collapse
|
17
|
Benitz WE. Unwinding old habits: deimplementation of treatment regimens for patent ductus arteriosus in preterm infants. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
|
18
|
Benitz WE. Unwinding old habits: deimplementation of treatment regimens for patent ductus arteriosus in preterm infants. J Pediatr (Rio J) 2020; 96:138-141. [PMID: 30550757 PMCID: PMC9431994 DOI: 10.1016/j.jped.2018.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- William E Benitz
- Stanford University School of Medicine, Department of Pediatrics, Division of Neonatal and Developmental Medicine, Palo Alto, United States.
| |
Collapse
|
19
|
Yan H, Ma F, Li Y, Zhou K, Hua Y, Wan C. The optimal timing of surgical ligation of patent ductus arteriosus in preterm or very-low-birth-weight infants: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e19356. [PMID: 32118777 PMCID: PMC7478603 DOI: 10.1097/md.0000000000019356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patent ductus arteriosus (PDA) is a particularly common problem in preterm infants. Although surgical ligation is rarely performed in many contemporary neonatal intensive care units, it remains a necessary treatment option for preterm infants with a large hemodynamically significant PDA under strict clinical criteria, and it can reduce mortality in preterm infants. However, the optimal timing of surgical ligation is still controversial. We conducted this systematic review and meta-analysis to compare the mortality and morbidity of early and late surgical ligation of PDA in preterm or very-low-birth-weight (VLBW) infants. METHODS This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019133686). We searched the databases of PubMed, Embase, the Cochrane Central Register of Controlled Trials, and the World Health Organization International Clinical Trials Registry Platform up to May 2019. RESULTS This review included 6 retrospective studies involving 397 premature or VLBW infants with PDA. Pooled analysis showed that compared with the late ligation group, the early ligation group had a lower fraction of inspired oxygen (FiO2) at 24 hours postoperatively (mean difference [MD] -6.34, 95% confidence interval [CI] -9.45 to -3.22), fewer intubation days (MD -19.69, 95% CI -29.31 to -10.07), earlier date of full oral feeding (MD -22.98, 95% CI -28.63 to -17.34) and heavier body weight at 36 weeks of conceptional age (MD 232.08, 95% CI 57.28 to 406.88). No significant difference in mortality or other complications was found between the early and late groups. CONCLUSION Our meta-analysis implies that compared with late surgical ligation, early ligation might have a better respiratory outcome and nutritional status for PDA in preterm or VLBW infants. There was no difference in mortality or postoperative complications between early and late ligation. A randomized prospective clinical trial with a possible large sample size is urgently needed to reinvestigate this conclusion. PROSPERO REGISTRATION NUMBER CRD42019133686.
Collapse
Affiliation(s)
- Hualin Yan
- Department of Medical Ultrasound, West China Hospital, Sichuan University
- West China School of Medicine, Sichuan University
| | - Fan Ma
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yifei Li
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Kaiyu Zhou
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yimin Hua
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Chaomin Wan
- West China School of Medicine, Sichuan University
- Department of Pediatrics
- Ministry of Education Key Laboratory of Women and Children's Diseases and Birth Defects, West China Second University Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
20
|
Ibrahim T, Abdul Haium AA, Tapawan SJ, Dela Puerta R, Allen JC, Chandran S, Chua MC, Rajadurai VS. Selective Treatment of PDA in High-Risk VLBW Infants With Birth Weight ≤800 g or <27 Weeks and Short-Term Outcome: A Cohort Study. Front Pediatr 2020; 8:607772. [PMID: 33585364 PMCID: PMC7877482 DOI: 10.3389/fped.2020.607772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/30/2020] [Indexed: 12/15/2022] Open
Abstract
Background: Patent ductus arteriosus (PDA) causing significant left to right shunt can increase key morbidities in preterm infants. Yet, treatment does not improve outcomes and spontaneous closure is the natural course of PDA. The Impact of PDA on 23-26-week gestation infants is uncertain. Selective treatment of such infants would likely balance outcomes. Objective: To test the hypothesis that treatment of PDA in high-risk VLBW infants [birth weight ≤800 g or gestation <27 weeks, hemodynamically significant, ductal diameter (DD, ≥1.6 mm), and mechanical ventilation] and expectant management in low-risk infants will reduce the need for treatment and surgical ligation, without altering short term morbidities. Methods: This prospective observational study was initiated subsequent to the introduction of a new treatment protocol in 2016. The 12-months before and after protocol introduction were, respectively, defined as standard and early selective treatment periods. In the early selective treatment cohort, PDA was treated with indomethacin, maximum of two courses, 1 week apart. Surgical ligation was considered after 30 days of age if indicated (DD ≥2 mm, mechanical ventilation). Primary outcomes were need for treatment and rate of ligation. Protocol compliance and secondary outcomes were documented. Results: 415 infants were studied, 202 and 213 in the standard treatment and early selective treatment cohorts, respectively. Numbers treated (per protocol) in the standard treatment and early selective treatment cohorts were 27.7 and 19.3% (56/202 and 41/213) (p = 0.049), and the respective ligation rates were 7.54 and 2.96% (P = 0.045). Secondary outcomes were comparable. Conclusion: The early selective treatment protocol reduced the rates of treatment and surgical ligation of PDA, without altering key morbidities. Further studies under a randomized control trial setting is warranted.
Collapse
Affiliation(s)
- Thowfique Ibrahim
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Neonatology, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Abdul Alim Abdul Haium
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Neonatology, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Sarah Jane Tapawan
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Rowena Dela Puerta
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - Suresh Chandran
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Neonatology, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Mei Chien Chua
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Neonatology, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| | - Victor Samuel Rajadurai
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore.,Duke-NUS Medical School, Singapore, Singapore.,Department of Neonatology, National University of Singapore, Singapore, Singapore.,Lee Kong Chian School of Medicine, Singapore, Singapore
| |
Collapse
|
21
|
Sung SI, Chang YS, Ahn SY, Jo HS, Yang M, Park WS. Conservative Non-intervention Approach for Hemodynamically Significant Patent Ductus Arteriosus in Extremely Preterm Infants. Front Pediatr 2020; 8:605134. [PMID: 33425816 PMCID: PMC7786118 DOI: 10.3389/fped.2020.605134] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/07/2020] [Indexed: 12/15/2022] Open
Abstract
While persistent patent ductus arteriosus (PDA) in preterm infants has been known to be associated with increased mortality and morbidities including bronchopulmonary dysplasia, and necrotizing enterocolitis, there is minimal evidence supporting their causal relationships, and most traditional medical and/or surgical treatments have failed to show improvements in these outcomes. As such, the pendulum has swung toward the conservative non-intervention approach for the management of persistent PDA during the last decade; however, the benefits and risks of this approach are unclear. In this mini review, we focused on whom, when, and how to apply the conservative non-intervention approach for persistent PDA, especially in extremely preterm infants.
Collapse
Affiliation(s)
- Se In Sung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - So Yoon Ahn
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Heui Seung Jo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Misun Yang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
22
|
Pharmacological closure of the patent ductus arteriosus: when treatment still makes sense. J Perinatol 2019; 39:1439-1441. [PMID: 31591487 PMCID: PMC7055580 DOI: 10.1038/s41372-019-0518-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 01/30/2023]
|
23
|
Liebowitz M, Katheria A, Sauberan J, Singh J, Nelson K, Hassinger DC, Aucott SW, Kaempf J, Kimball A, Fernandez E, Carey WA, Perez J, Serize A, Wickremasinghe A, Dong L, Derrick M, Wolf IS, Heuchan AM, Sankar M, Bulbul A, Clyman RI. Lack of Equipoise in the PDA-TOLERATE Trial: A Comparison of Eligible Infants Enrolled in the Trial and Those Treated Outside the Trial. J Pediatr 2019; 213:222-226.e2. [PMID: 31255386 PMCID: PMC6765426 DOI: 10.1016/j.jpeds.2019.05.049] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 04/16/2019] [Accepted: 05/20/2019] [Indexed: 01/14/2023]
Abstract
The PDA: TO LEave it alone or Respond And Treat Early trial compared the effects of 2 strategies for treatment of patent ductus arteriosus (PDA) in infants <280/7 weeks of gestation; however 137 potentially eligible infants were not recruited and received treatment of their PDA outside the PDA-TOLERATE trial due to "lack-of-physician-equipoise" (LPE). Despite being less mature and needing more respiratory support, infants with LPE had lower rates of mortality than enrolled infants. Infants with LPE treated before day 6 had lower rates of late respiratory morbidity than infants with LPE treated ≥day 6. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01958320.
Collapse
Affiliation(s)
- Melissa Liebowitz
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Anup Katheria
- Department of Pediatrics, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | - Jason Sauberan
- Department of Pediatrics, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA
| | - Jaideep Singh
- Department of Pediatrics, University of Chicago, Chicago, IL
| | - Kelly Nelson
- Department of Pediatrics, University of Chicago, Chicago, IL
| | | | - Susan W. Aucott
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD
| | - Joseph Kaempf
- Department of Pediatrics, Providence St. Vincent Medical Center, Portland, OR
| | - Amy Kimball
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital, San Diego, CA
| | - Erika Fernandez
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital, San Diego, CA
| | | | - Jorge Perez
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
| | - Arturo Serize
- Department of Pediatrics, South Miami Hospital/Baptist Health South Florida, Miami, FL
| | | | - Lawrence Dong
- Department of Pediatrics, Kaiser Permanente Medical Center, Santa Clara, CA
| | - Matthew Derrick
- Department of Pediatrics, Northshore University Health System, Evanston, IL
| | - Ilene Sue Wolf
- Department of Pediatrics, Northshore University Health System, Evanston, IL
| | - Anne Marie Heuchan
- Department of Pediatrics, University of Glasgow, Royal Hospital for Sick Children, Glasgow, Scotland, UK
| | - Meera Sankar
- Department of Pediatrics, Mednax Medical Group, Good Samaritan Hospital, San Jose, CA
| | - Ali Bulbul
- Department of Pediatrics, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Ronald I. Clyman
- Department of Pediatrics, University of California San Francisco, San Francisco, CA,Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | | |
Collapse
|
24
|
Hierarchical Data Structures and Multilevel Modeling. J Pediatr 2019; 212:250-251. [PMID: 31262528 DOI: 10.1016/j.jpeds.2019.05.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/30/2019] [Accepted: 05/15/2019] [Indexed: 11/21/2022]
|
25
|
Regional tissue oxygenation monitoring in the neonatal intensive care unit: evidence for clinical strategies and future directions. Pediatr Res 2019; 86:296-304. [PMID: 31247635 DOI: 10.1038/s41390-019-0466-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 12/19/2022]
Abstract
Near-infrared spectroscopy (NIRS)-based monitoring of regional tissue oxygenation (rSO2) is becoming more commonplace in the neonatal intensive care unit (NICU). While increasing evidence supports rSO2 monitoring, actual standards for applying this noninvasive bedside technique continue to evolve. This review highlights the current strengths and pitfalls surrounding practical NIRS-based monitoring in the neonatal population. The physiologic background of rSO2 monitoring is discussed, with attention to understanding oxygen delivery/consumption mismatch and its effects on tissue oxygen extraction. The bedside utility of both cerebral and peripheral rSO2 monitoring in the NICU is then explored from two perspectives: (1) disease/event-specific "responsive" monitoring and (2) "routine," continuous monitoring. Recent evidence incorporating both monitoring approaches is summarized with emphasis on practical applicability in the NICU. Finally, a future paradigm for a broad-based NIRS monitoring strategy is presented, with attention towards improving personalization of neonatal care and ultimately enhancing long-term outcomes.
Collapse
|
26
|
Rooney SR, Shelton EL, Aka I, Shaffer CM, Clyman RI, Dagle JM, Ryckman K, Lewis TR, Reese J, Van Driest SL, Kannankeril PJ. CYP2C9*2 is associated with indomethacin treatment failure for patent ductus arteriosus. Pharmacogenomics 2019; 20:939-946. [PMID: 31486736 PMCID: PMC6817966 DOI: 10.2217/pgs-2019-0079] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
Aims: To identify clinical andgenetic factors associated with indomethacin treatment failure in preterm neonates with patent ductus arteriosus (PDA). Patients & Methods: This is a multicenter cohort study of 144 preterm infants (22-32 weeks gestational age) at three centers who received at least one treatment course of indomethacin for PDA. Indomethacin failure was defined as requiring subsequent surgical intervention. Results: In multivariate analysis, gestational age (AOR 0.76, 95% CI 0.60-0.96), surfactant use (AOR 9.77, 95% CI 1.15-83.26), and CYP2C9*2 (AOR 3.74; 95% CI 1.34-10.44) were each associated with indomethacin failure. Conclusion: Age, surfactant use, and CYP2C9*2 influence indomethacin treatment outcome in preterm infants with PDA. This combination of clinical and genetic factors may facilitate targeted indomethacin use for PDA.
Collapse
Affiliation(s)
- Sydney R Rooney
- Vanderbilt University School of Medicine, UCSF, Nashville, TN 37232, USA
| | - Elaine L Shelton
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ida Aka
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Christian M Shaffer
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Ronald I Clyman
- Department of Pediatrics & Cardiovascular Research Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - John M Dagle
- Department of Pediatrics, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Kelli Ryckman
- Department of Epidemiology, University of Iowa, Iowa City, UMKC, IA 52242, USA
| | - Tamorah R Lewis
- Department of Pediatrics, University of Missouri Kansas City School of Medicine, Kansas City, MO 64110, USA
| | - Jeff Reese
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Sara L Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
- Department of Medicine, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| | - Prince J Kannankeril
- Department of Pediatrics, Vanderbilt University Medical Center, UCSF, Nashville, TN 37232, USA
| |
Collapse
|
27
|
Medikal Tedaviye Yanıtsız Duktus Arteriosuslu Preterm İnfantların Tedavisinde Güvenli Bir Yöntem: Yatakbaşı Cerrahi ligasyon. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.568276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
28
|
Lee JA. Practice for preterm patent ductus arteriosus; focusing on the hemodynamic significance and the impact on the neonatal outcomes. KOREAN JOURNAL OF PEDIATRICS 2019; 62:245-251. [PMID: 30999726 PMCID: PMC6642924 DOI: 10.3345/kjp.2018.07213] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 04/06/2019] [Indexed: 12/11/2022]
Abstract
Hemodynamically significant preterm patent ductus arteriosus (PDA) affects mortality; comorbidities such as necrotizing enterocolitis, intraventricular hemorrhage, and bronchopulmonary dysplasia; and adverse long-term neurodevelopmental outcomes in preterm infants, particularly in very low birth weight infants. However, recent studies have indicated that there is no consensus on the causal relationship between PDA and neonatal outcomes, the benefit of PDA treatment, the factors guiding the need for treatment, and optimal treatment strategies. Such uncertainty has resulted in wide variations in practice for treating preterm PDA between units, regions, and nations. Nowadays, there has been a paradigm shift to more conservative treatment for preterm PDA, and suggestions regarding selective management of preterm PDA considering risk factors and hemodynamic significance are increasing. Neonatologist-performed echocardiography and advances in modalities to assess hemodynamic significance such as biologic markers and near-infrared spectroscopy also help improve the efficacy of selective treatment of preterm PDA.
Collapse
Affiliation(s)
- Jin A Lee
- Division of Neonatology, Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea.,Division of Neonatology, Department of Pediatrics, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| |
Collapse
|