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Letzkus L, Fairchild K, Lyons G, Pyata H, Ratcliffe S, Lake D. Heart Rate and Pulse Oximetry Dynamics in the First Week after Birth in Neonatal Intensive Care Unit Patients and the Risk of Cerebral Palsy. Am J Perinatol 2024; 41:e528-e535. [PMID: 36174590 PMCID: PMC10050229 DOI: 10.1055/s-0042-1756335] [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] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Infants in the neonatal intensive care unit (NICU) are at high risk of adverse neuromotor outcomes. Atypical patterns of heart rate (HR) and pulse oximetry (SpO2) may serve as biomarkers for risk assessment for cerebral palsy (CP). The purpose of this study was to determine whether atypical HR and SpO2 patterns in NICU patients add to clinical variables predicting later diagnosis of CP. STUDY DESIGN This was a retrospective study including patients admitted to a level IV NICU from 2009 to 2017 with archived cardiorespiratory data in the first 7 days from birth to follow-up at >2 years of age. The mean, standard deviation (SD), skewness, kurtosis and cross-correlation of HR and SpO2 were calculated. Three predictive models were developed using least absolute shrinkage and selection operator regression (clinical, cardiorespiratory and combined model), and their performance for predicting CP was evaluated. RESULTS Seventy infants with CP and 1,733 controls met inclusion criteria for a 3.8% population prevalence. Area under the receiver operating characteristic curve for CP prediction was 0.7524 for the clinical model, 0.7419 for the vital sign model, and 0.7725 for the combined model. Variables included in the combined model were lower maternal age, outborn delivery, lower 5-minute Apgar's score, lower SD of HR, and more negative skewness of HR. CONCLUSION In this study including NICU patients of all gestational ages, HR but not SpO2 patterns added to clinical variables to predict the eventual diagnosis of CP. Identification of risk of CP within the first few days of life could result in improved therapy resource allocation and risk stratification in clinical trials of new therapeutics. KEY POINTS · SD and skewness of HR have some added predictive value of later diagnosis of CP.. · SpO2 measures do not add to CP prediction.. · Combining clinical variables with early HR measures may improve the prediction of later CP..
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Affiliation(s)
- Lisa Letzkus
- University of Virginia School of Medicine; Department of Pediatrics; Neurodevelopmental and Behavioral Pediatrics, UVA Children’s, Charlottesville, Virginia, USA
| | - Karen Fairchild
- University of Virginia School of Medicine; Department of Pediatrics; Neonatology, UVA Children’s, Charlottesville, Virginia, USA
| | - Genevieve Lyons
- University of Virginia School of Medicine; Department of Public Health Sciences; Charlottesville, Virginia, USA
| | - Harshini Pyata
- University of North Carolina at Chapel Hill; Department of Pediatrics
| | - Sarah Ratcliffe
- University of Virginia School of Medicine; Department of Public Health Sciences; Charlottesville, Virginia, USA
| | - Doug Lake
- University of North Carolina at Chapel Hill; Department of Pediatrics
- University of Virginia School of Medicine; Department of Cardiovascular Medicine; Charlottesville, Virginia, USA
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Duport O, Rolle VL, Guerrero G, Beuchée A, Hernández AI. Parametric analysis of an integrated cardio-respiratory model in preterm newborns during apnea. Comput Biol Med 2024; 173:108343. [PMID: 38513388 DOI: 10.1016/j.compbiomed.2024.108343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/16/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Abstract
The analysis of the complex interactions involved in the acute physiological response to apnea-bradycardia events in preterm newborns remains a challenging task. This paper presents a novel integrated model of cardio-respiratory interactions, adapted to preterm newborns. A sensitivity analysis, based Morris' screening method, was applied to study the effects of physiological parameters on heart rate and desaturation, during the simulation of a 15-seconds apnea-bradycardia episode. The most sensitive parameters are associated with fundamental, integrative physiological mechanisms involving: (i) respiratory mechanics (intermediate airways and lung compliance), (ii) fraction of inspired oxygen, (iii) metabolic rates (oxygen consumption rate), (iv) heart rate regulation and (v) chemoreflex (gain). Results highlight the relevant influence of physiological variables, involved in preterm apnea-bradycardia events.
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Affiliation(s)
- Orlane Duport
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Virginie Le Rolle
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France.
| | - Gustavo Guerrero
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Alain Beuchée
- Univ Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
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Rabienia Haratbar S, Chen L, Cheng Q, Singh D, Fathi F, Mohtasebi M, Liu X, Patwardhan A, Bhandary P, Bada HS, Yu G, Abu Jawdeh EG. The impact of intermittent hypoxemia on type 1 retinopathy of prematurity in preterm infants. Pediatr Res 2024:10.1038/s41390-024-03169-5. [PMID: 38600299 DOI: 10.1038/s41390-024-03169-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Intermittent hypoxemia (IH) may influence retinopathy of prematurity (ROP) development in preterm infants, however, previous studies had mixed results. This study tests the hypothesis that increased IH is associated with Type 1 ROP; a stage beyond which treatment is indicated. METHODS IH was quantified by continuously monitoring oxygen saturation (SpO2) using high-resolution pulse oximeters during the first 10 weeks of life. Statistical analyses assessed the relationship and predictive ability of weekly and cumulative IH for Type 1 ROP development. RESULTS Most analyses showed no association between IH and Type 1 ROP adjusting for gestational age (GA) and birth weight (BW). However, cumulative IH of longer duration during weeks 5-10, 6-10, and 7-10 were significantly associated with Type 1 ROP adjusting for GA and BW, e.g., the adjusted odds ratio of Type 1 ROP was 2.01 (p = 0.03) for every 3.8 seconds increase in IH duration from week 6-10. IH did not provide statistically significant added predictive ability above GA and BW. CONCLUSIONS For most analyses there was no significant association between IH and Type 1 ROP adjusting for GA and BW. However, infants with longer IH duration during the second month of life had higher risk for Type 1 ROP. IMPACT The relationship and predictive ability of intermittent hypoxemia (IH) on retinopathy of prematurity (ROP) is controversial. This study shows no significant association between IH events and Type 1 ROP after adjusting for gestational age (GA) and birth weight (BW), except for cumulative IH of longer duration in the second month of life. In this cohort, IH does not provide a statistically significant improvement in ROP prediction over GA and BW. This study is the first to assess the cumulative impact of IH measures on Type 1 ROP. Interventions for reducing IH duration during critical postnatal periods may improve ROP outcomes.
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Affiliation(s)
| | - Li Chen
- Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Qiang Cheng
- Institute for Biomedical Informatics, Department of Internal Medicine and Department of Computer Science, Lexington, Kentucky, USA
| | - Dara Singh
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Faraneh Fathi
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Mehrana Mohtasebi
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Xuhui Liu
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Abhijit Patwardhan
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA
| | - Prasad Bhandary
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky, Lexington, Kentucky, USA.
| | - Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA.
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Kausch SL, Lake DE, Di Fiore JM, Weese-Mayer DE, Claure N, Ambalavanan N, Vesoulis ZA, Fairchild KD, Dennery PA, Hibbs AM, Martin RJ, Indic P, Travers CP, Bancalari E, Hamvas A, Kemp JS, Carroll JL, Moorman JR, Sullivan BA. Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Infants Born Extremely Preterm. J Pediatr 2024; 271:114042. [PMID: 38570031 DOI: 10.1016/j.jpeds.2024.114042] [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: 11/10/2023] [Revised: 03/21/2024] [Accepted: 03/26/2024] [Indexed: 04/05/2024]
Abstract
OBJECTIVE The objective of this study was to examine the association of cardiorespiratory events, including apnea, periodic breathing, intermittent hypoxemia (IH), and bradycardia, with late-onset sepsis for extremely preterm infants (<29 weeks of gestational age) on vs off invasive mechanical ventilation. STUDY DESIGN This is a retrospective analysis of data from infants enrolled in Pre-Vent (ClinicalTrials.gov identifier NCT03174301), an observational study in 5 level IV neonatal intensive care units. Clinical data were analyzed for 737 infants (mean gestational age: 26.4 weeks, SD 1.71). Monitoring data were available and analyzed for 719 infants (47 512 patient-days); of whom, 109 had 123 sepsis events. Using continuous monitoring data, we quantified apnea, periodic breathing, bradycardia, and IH. We analyzed the relationships between these daily measures and late-onset sepsis (positive blood culture >72 hours after birth and ≥5-day antibiotics). RESULTS For infants not on a ventilator, apnea, periodic breathing, and bradycardia increased before sepsis diagnosis. During times on a ventilator, increased sepsis risk was associated with longer events with oxygen saturation <80% (IH80) and more bradycardia events before sepsis. IH events were associated with higher sepsis risk but did not dynamically increase before sepsis, regardless of ventilator status. A multivariable model including postmenstrual age, cardiorespiratory variables (apnea, periodic breathing, IH80, and bradycardia), and ventilator status predicted sepsis with an area under the receiver operator characteristic curve of 0.783. CONCLUSION We identified cardiorespiratory signatures of late-onset sepsis. Longer IH events were associated with increased sepsis risk but did not change temporally near diagnosis. Increases in bradycardia, apnea, and periodic breathing preceded the clinical diagnosis of sepsis.
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Affiliation(s)
- Sherry L Kausch
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA.
| | - Douglas E Lake
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Debra E Weese-Mayer
- Division of Autonomic Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Providence, RI
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - Colm P Travers
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Division of Neonatology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James S Kemp
- Division of Pediatric Pulmonology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - J Randall Moorman
- Division of Cardiology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
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Weese-Mayer DE, Di Fiore JM, Lake DE, Hibbs AM, Claure N, Qiu J, Ambalavanan N, Bancalari E, Kemp JS, Zimmet AM, Carroll JL, Martin RJ, Krahn KN, Hamvas A, Ratcliffe SJ, Krishnamurthi N, Indic P, Dormishian A, Dennery PA, Moorman JR. Maturation of cardioventilatory physiological trajectories in extremely preterm infants. Pediatr Res 2024; 95:1060-1069. [PMID: 37857848 DOI: 10.1038/s41390-023-02839-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/14/2023] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND In extremely preterm infants, persistence of cardioventilatory events is associated with long-term morbidity. Therefore, the objective was to characterize physiologic growth curves of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants during the first few months of life. METHODS The Prematurity-Related Ventilatory Control study included 717 preterm infants <29 weeks gestation. Waveforms were downloaded from bedside monitors with a novel sharing analytics strategy utilized to run software locally, with summary data sent to the Data Coordinating Center for compilation. RESULTS Apnea, periodic breathing, and intermittent hypoxemia events rose from day 3 of life then fell to near-resolution by 8-12 weeks of age. Apnea/intermittent hypoxemia were inversely correlated with gestational age, peaking at 3-4 weeks of age. Periodic breathing was positively correlated with gestational age peaking at 31-33 weeks postmenstrual age. Females had more periodic breathing but less intermittent hypoxemia/bradycardia. White infants had more apnea/periodic breathing/intermittent hypoxemia. Infants never receiving mechanical ventilation followed similar postnatal trajectories but with less apnea and intermittent hypoxemia, and more periodic breathing. CONCLUSIONS Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. IMPACT Physiologic curves of cardiorespiratory events in extremely preterm-born infants offer (1) objective measures to assess individual patient courses and (2) guides for research into control of ventilation, biomarkers and outcomes. Presented are updated maturational trajectories of apnea, periodic breathing, intermittent hypoxemia, and bradycardia in 717 infants born <29 weeks gestation from the multi-site NHLBI-funded Pre-Vent study. Cardioventilatory events peak during the first month of life but the actual postnatal trajectory is dependent on the type of event, race, sex and use of mechanical ventilation. Different time courses for apnea and periodic breathing suggest different maturational mechanisms.
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Affiliation(s)
- Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA.
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA.
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
| | - Douglas E Lake
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Nelson Claure
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jiaxing Qiu
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Namasivayam Ambalavanan
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James S Kemp
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Amanda M Zimmet
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, Division of Neonatology, UH Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Katy N Krahn
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Aaron Hamvas
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Division of Neonatology, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Sarah J Ratcliffe
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Narayanan Krishnamurthi
- Division of Autonomic Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital of Chicago and Stanley Manne Children's Research Institute, Chicago, IL, USA
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas Tyler, Tyler, TX, USA
| | - Alaleh Dormishian
- Division of Neonatology, Department of Pediatrics, Holtz Children's Hospital - Jackson Memorial Medical Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Phyllis A Dennery
- Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - J Randall Moorman
- Division of Cardiovascular Medicine, Center for Advanced Medical Analytics and Department of Internal Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, USA
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Varisco G, Peng Z, Kommers D, Cottaar EJE, Andriessen P, Long X, van Pul C. Detecting central apneas using multichannel signals in premature infants. Physiol Meas 2024; 45:025009. [PMID: 38271714 DOI: 10.1088/1361-6579/ad2291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 01/25/2024] [Indexed: 01/27/2024]
Abstract
Objective. Monitoring of apnea of prematurity, performed in neonatal intensive care units by detecting central apneas (CAs) in the respiratory traces, is characterized by a high number of false alarms. A two-step approach consisting of a threshold-based apneic event detection algorithm followed by a machine learning model was recently presented in literature aiming to improve CA detection. However, since this is characterized by high complexity and low precision, we developed a new direct approach that only consists of a detection model based on machine learning directly working with multichannel signals.Approach. The dataset used in this study consisted of 48 h of ECG, chest impedance and peripheral oxygen saturation extracted from 10 premature infants. CAs were labeled by two clinical experts. 47 features were extracted from time series using 30 s moving windows with an overlap of 5 s and evaluated in sets of 4 consecutive moving windows, in a similar way to what was indicated for the two-step approach. An undersampling method was used to reduce imbalance in the training set while aiming at increasing precision. A detection model using logistic regression with elastic net penalty and leave-one-patient-out cross-validation was then tested on the full dataset.Main results. This detection model returned a mean area under the receiver operating characteristic curve value equal to 0.86 and, after the selection of a FPR equal to 0.1 and the use of smoothing, an increased precision (0.50 versus 0.42) at the expense of a decrease in recall (0.70 versus 0.78) compared to the two-step approach around suspected apneic events.Significance. The new direct approach guaranteed correct detections for more than 81% of CAs with lengthL≥ 20 s, which are considered among the most threatening apneic events for premature infants. These results require additional verifications using more extensive datasets but could lead to promising applications in clinical practice.
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Affiliation(s)
- Gabriele Varisco
- Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Zheng Peng
- Applied Physics, Eindhoven University of Technology, Eindhoven, The Netherlands
- Clinical Physics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Deedee Kommers
- Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | | | - Peter Andriessen
- Applied Physics, Eindhoven University of Technology, Eindhoven, The Netherlands
- Pediatrics, Máxima Medical Center, Veldhoven, The Netherlands
| | - Xi Long
- Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carola van Pul
- Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
- Clinical Physics, Máxima Medical Center, Veldhoven, The Netherlands
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7
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Kausch SL, Lake DE, Di Fiore JM, Weese-Mayer DE, Claure N, Ambalavanan N, Vesoulis ZA, Fairchild KD, Dennery PA, Hibbs AM, Martin RJ, Indic P, Travers CP, Bancalari E, Hamvas A, Kemp JS, Carroll JL, Moorman JR, Sullivan BA. Apnea, Intermittent Hypoxemia, and Bradycardia Events Predict Late-Onset Sepsis in Extremely Preterm Infants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.26.24301820. [PMID: 38343825 PMCID: PMC10854335 DOI: 10.1101/2024.01.26.24301820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Objectives Detection of changes in cardiorespiratory events, including apnea, periodic breathing, intermittent hypoxemia (IH), and bradycardia, may facilitate earlier detection of sepsis. Our objective was to examine the association of cardiorespiratory events with late-onset sepsis for extremely preterm infants (<29 weeks' gestational age (GA)) on versus off invasive mechanical ventilation. Study Design Retrospective analysis of data from infants enrolled in Pre-Vent (ClinicalTrials.gov identifier NCT03174301), an observational study in five level IV neonatal intensive care units. Clinical data were analyzed for 737 infants (mean GA 26.4w, SD 1.71). Monitoring data were available and analyzed for 719 infants (47,512 patient-days), of whom 109 had 123 sepsis events. Using continuous monitoring data, we quantified apnea, periodic breathing, bradycardia, and IH. We analyzed the relationships between these daily measures and late-onset sepsis (positive blood culture >72h after birth and ≥5d antibiotics). Results For infants not on a ventilator, apnea, periodic breathing, and bradycardia increased before sepsis diagnosis. During times on a ventilator, increased sepsis risk was associated with longer IH80 events and more bradycardia events before sepsis. IH events were associated with higher sepsis risk, but did not dynamically increase before sepsis, regardless of ventilator status. A multivariable model predicted sepsis with an AUC of 0.783. Conclusion We identified cardiorespiratory signatures of late-onset sepsis. Longer IH events were associated with increased sepsis risk but did not change temporally near diagnosis. Increases in bradycardia, apnea, and periodic breathing preceded the clinical diagnosis of sepsis.
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Affiliation(s)
- Sherry L Kausch
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Juliann M Di Fiore
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Debra E Weese-Mayer
- Department of Pediatrics, Division of Autonomic Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nelson Claure
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Namasivayam Ambalavanan
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO
| | - Karen D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
| | - Phyllis A Dennery
- Department of Pediatrics, Brown University School of Medicine, Department of Pediatrics, Providence, RI
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Department of Pediatrics, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Premananda Indic
- Department of Electrical Engineering, University of Texas at Tyler, Tyler, TX
| | - Colm P Travers
- Department of Pediatrics, Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Eduardo Bancalari
- Department of Pediatrics, Division of Neonatology, University of Miami Miller School of Medicine, Miami, FL
| | - Aaron Hamvas
- Department of Pediatrics, Division of Neonatology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - James S Kemp
- Department of Pediatrics, Division of Pediatric Pulmonology, Washington University School of Medicine, St. Louis, MO
| | - John L Carroll
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AK
| | - J Randall Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Brynne A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA
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8
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Arwehed S, Axelin A, Björklund LJ, Thernström Blomqvist Y, Heiring C, Jonsson B, Klingenberg C, Metsäranta M, Ågren J, Lehtonen L. Nordic survey showed wide variation in discharge practices for very preterm infants. Acta Paediatr 2024; 113:48-55. [PMID: 37540833 DOI: 10.1111/apa.16934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/06/2023]
Abstract
AIM We aimed to describe clinical practices and criteria for discharge of very preterm infants in Nordic neonatal units. METHODS Medical directors of all 89 level-2 and level-3 units in Denmark, Finland, Iceland, Norway and Sweden were invited by e-mail to complete a web-based multiple-choice survey with the option to make additional free-text comments. RESULTS We received responses from 83/89 units (93%). In all responding units, discharge readiness was based mainly on clinical assessment with varying criteria. In addition, 36% used formal tests of cardiorespiratory stability and 59% used criteria related to infant weight or growth. For discharge with feeding tube, parental ability to speak the national language or English was mandatory in 45% of units, with large variation among countries. Post-discharge home visits and video-consultations were provided by 59% and 51%, respectively. In 54% of units, parental preparation for discharge were not initiated until the last two weeks of hospital stay. CONCLUSION Discharge readiness was based mainly on clinical assessment, with criteria varying among units despite similar population characteristics and care structures. This variation indicates a lack of evidence base and may unnecessarily delay discharge; further studies of this matter are needed. Earlier parental preparation and use of interpreters might facilitate earlier discharge.
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Affiliation(s)
- Sofia Arwehed
- Department of Women's and Children's Health, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Anna Axelin
- Department of Women's and Children's Health, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
- Department of Nursing Science, University of Turku, Turku, Finland
| | - Lars J Björklund
- Department of Clinical Sciences, Lund, Paediatrics, Lund University and Skåne University Hospital, Lund, Sweden
| | - Ylva Thernström Blomqvist
- Department of Women's and Children's Health, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Christian Heiring
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Marjo Metsäranta
- Department of Pediatrics, University of Helsinki and Helsinki University Hospital (HUH), Helsinki, Finland
| | - Johan Ågren
- Department of Women's and Children's Health, Uppsala University and Uppsala University Hospital, Uppsala, Sweden
| | - Liisa Lehtonen
- Department of Paediatrics and Adolescent Medicine, Turku University, Hospital and University of Turku, Turku, Finland
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9
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Poets CF, Quante M. Rethinking the Pathophysiology of Cardiorespiratory Events in Infants Born Preterm. J Pediatr 2023; 262:113651. [PMID: 37527701 DOI: 10.1016/j.jpeds.2023.113651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/26/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Christian F Poets
- Department of Neonatology, Tübingen University Hospital, Tübingen, Germany.
| | - Mirja Quante
- Department of Neonatology, Tübingen University Hospital, Tübingen, Germany
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10
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Yee AK, Siriwardhana LS, Nixson GM, Walter LM, Wong FY, Horne RSC. Developmental consequences of short apneas and periodic breathing in preterm infants. J Perinatol 2023; 43:1420-1428. [PMID: 37558750 PMCID: PMC10615736 DOI: 10.1038/s41372-023-01748-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/12/2023] [Accepted: 08/01/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE We investigated the relationship between respiratory events experienced before and after hospital discharge and developmental outcomes at 6 months corrected age (CA). STUDY DESIGN Preterm infants born between 28-32 weeks gestational age (GA) were studied at 32-36 weeks postmenstrual age (PMA), 36-40 weeks PMA, 3- and 6-months CA. Percentage total sleep time (%TST) with respiratory events (isolated apneas, sequential apneas and periodic breathing (PB)) at each study was calculated. Stepwise multiple linear regressions determined significant predictors of developmental outcomes at 6 months. RESULT %TST with respiratory events at term were significant predictors of language (R2 = 0.165, β = -0.416) and motor (R2 = 0.180, β = -0.485) composite scores of the Bayley Scales of Infant Development at 6 months, independent of GA, birth weight and sex. CONCLUSIONS In clinically stable very preterm infants at term equivalent age, time spent having respiratory events, was related to a reduction in language and motor outcomes at 6 months.
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Affiliation(s)
- Alicia K Yee
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | | | - Gillian M Nixson
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Melbourne Children's Sleep Centre, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Lisa M Walter
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Flora Y Wong
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Rosemary S C Horne
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia.
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11
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Haratbar SR, Chen L, Cheng Q, Singh D, Fathi F, Mohtasebi M, Liu X, Patwardhan A, Bhandary P, Bada HS, Yu G, Abu Jawdeh EG. The Impact of Intermittent Hypoxemia on Type 1 Retinopathy of Prematurity in Preterm Infants. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.25.23295922. [PMID: 37808800 PMCID: PMC10557831 DOI: 10.1101/2023.09.25.23295922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Intermittent hypoxemia (IH) may influence retinopathy of prematurity (ROP) development in preterm infants, however, previous studies had mixed results. This study aims to assess the influence and evaluate the predictive ability of IH measures on Type 1 ROP, a stage beyond which ROP treatment is indicated. Methods IH was quantified by continuously monitoring oxygen saturation (SpO2) using high-resolution pulse oximeters during the first 10 weeks of life. Statistical analyses assessed the relationship and predictive ability of weekly and cumulative IH variables for Type 1 ROP development. Results Univariate analyses suggested that IH measures are greater in infants with Type 1 ROP and are predictive of Type 1 ROP development. Multivariable logistic regression analyses revealed that cumulative IH of longer duration during certain postnatal periods are associated with Type 1 ROP development after adjusting for gestational age (GA) or birth weight (BW). Although area under the curve (AUC) analyses revealed added predictivity of cumulative IH variables above GA or BW, these increments in AUC were not statistically significant. Conclusions The duration of IH events was associated with Type 1 ROP development. Interventions for reducing the duration of IH events may potentially improve ROP outcomes.
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Affiliation(s)
| | - Li Chen
- Biostatistics and Bioinformatics Shared Resource Facility, Markey Cancer Center, University of Kentucky
| | - Qiang Cheng
- Institute for Biomedical Informatics, Department of Internal Medicine and Department of Computer Science
| | - Dara Singh
- Department of Biomedical Engineering, University of Kentucky
| | - Faraneh Fathi
- Department of Biomedical Engineering, University of Kentucky
| | | | - Xuhui Liu
- Department of Biomedical Engineering, University of Kentucky
| | | | - Prasad Bhandary
- Division of Neonatology, Department of Pediatrics, University of Kentucky
| | - Henrietta S. Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky
| | - Guoqiang Yu
- Department of Biomedical Engineering, University of Kentucky
| | - Elie G. Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky
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12
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Cardiorespiratory signature of neonatal sepsis: development and validation of prediction models in 3 NICUs. Pediatr Res 2023:10.1038/s41390-022-02444-7. [PMID: 36593281 DOI: 10.1038/s41390-022-02444-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/21/2022] [Accepted: 12/12/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Heart rate characteristics aid early detection of late-onset sepsis (LOS), but respiratory data contain additional signatures of illness due to infection. Predictive models using cardiorespiratory data may improve early sepsis detection. We hypothesized that heart rate (HR) and oxygenation (SpO2) data contain signatures that improve sepsis risk prediction over HR or demographics alone. METHODS We analyzed cardiorespiratory data from very low birth weight (VLBW, <1500 g) infants admitted to three NICUs. We developed and externally validated four machine learning models to predict LOS using features calculated every 10 m: mean, standard deviation, skewness, kurtosis of HR and SpO2, and cross-correlation. We compared feature importance, discrimination, calibration, and dynamic prediction across models and cohorts. We built models of demographics and HR or SpO2 features alone for comparison with HR-SpO2 models. RESULTS Performance, feature importance, and calibration were similar among modeling methods. All models had favorable external validation performance. The HR-SpO2 model performed better than models using either HR or SpO2 alone. Demographics improved the discrimination of all physiologic data models but dampened dynamic performance. CONCLUSIONS Cardiorespiratory signatures detect LOS in VLBW infants at 3 NICUs. Demographics risk-stratify, but predictive modeling with both HR and SpO2 features provides the best dynamic risk prediction. IMPACT Heart rate characteristics aid early detection of late-onset sepsis, but respiratory data contain signatures of illness due to infection. Predictive models using both heart rate and respiratory data may improve early sepsis detection. A cardiorespiratory early warning score, analyzing heart rate from electrocardiogram or pulse oximetry with SpO2, predicts late-onset sepsis within 24 h across multiple NICUs and detects sepsis better than heart rate characteristics or demographics alone. Demographics risk-stratify, but predictive modeling with both HR and SpO2 features provides the best dynamic risk prediction. The results increase understanding of physiologic signatures of neonatal sepsis.
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13
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Kodidhi A, Riley M, Vesoulis Z. The influence of late prematurity on the encephalopathy exam of infants with neonatal encephalopathy. J Neonatal Perinatal Med 2023; 16:693-700. [PMID: 38073399 PMCID: PMC10753960 DOI: 10.3233/npm-230041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023]
Abstract
BACKGROUND Late preterm (LPT) infants are increasingly treated for hypoxic-ischemic encephalopathy (HIE). However, neurodevelopmental differences of LPT infants may independently influence the neurologic exam and confound care. METHODS Perinatal and outcome characteristics were extracted along with the worst autonomic and state/neuromuscular/reflex Sarnat components in a cross-section of infants with moderate/severe HIE. Infants were classified as late preterm (LPT, 34-36 weeks) or term (>36 weeks). RESULTS 250 infants were identified, 55 were late preterm. LPT infants had lower mean gestational age and birthweight and greater length of stay (LOS). LPT infants had higher median scores for the Moro and respiratory autonomic components, but no difference in total score. CONCLUSIONS LPT infants had increased LOS, worse Moro reflex, and respiratory status, but no clinically or statistically significant differences in total Sarnat scores. Although it is important to note the impact of immaturity on the exam, it is unlikely to independently alter management.
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Affiliation(s)
- A Kodidhi
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - M Riley
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Z Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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14
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Sullivan BA, Kausch SL, Fairchild KD. Artificial and human intelligence for early identification of neonatal sepsis. Pediatr Res 2023; 93:350-356. [PMID: 36127407 DOI: 10.1038/s41390-022-02274-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
Artificial intelligence may have a role in the early detection of sepsis in neonates. Machine learning can identify patterns that predict high or increasing risk for clinical deterioration from a sepsis-like illness. In developing this potential addition to NICU care, careful consideration should be given to the data and methods used to develop, validate, and evaluate prediction models. When an AI system alerts clinicians to a change in a patient's condition that warrants a bedside evaluation, human intelligence and experience come into play to determine an appropriate course of action: evaluate and treat or wait and watch closely. With intelligently developed, validated, and implemented AI sepsis systems, both clinicians and patients stand to benefit. IMPACT: This narrative review highlights the application of AI in neonatal sepsis prediction. It describes issues in clinical prediction model development specific to this population. This article reviews the methods, considerations, and literature on neonatal sepsis model development and validation. Challenges of AI technology and potential barriers to using sepsis AI systems in the NICU are discussed.
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Affiliation(s)
- Brynne A Sullivan
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sherry L Kausch
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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15
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Dai HR, Guo HL, Hu YH, Xu J, Ding XS, Cheng R, Chen F. Precision caffeine therapy for apnea of prematurity and circadian rhythms: New possibilities open up. Front Pharmacol 2022; 13:1053210. [DOI: 10.3389/fphar.2022.1053210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/18/2022] [Indexed: 12/04/2022] Open
Abstract
Caffeine is the globally consumed psychoactive substance and the drug of choice for the treatment of apnea of prematurity (AOP), but its therapeutic effects are highly variable among preterm infants. Many of the molecular underpinnings of the marked individual response have remained elusive yet. Interestingly, the significant association between Clock gene polymorphisms and the response to caffeine therapy offers an opportunity to advance our understanding of potential mechanistic pathways. In this review, we delineate the functions and mechanisms of human circadian rhythms. An up-to-date advance of the formation and ontogeny of human circadian rhythms during the perinatal period are concisely discussed. Specially, we summarize and discuss the characteristics of circadian rhythms in preterm infants. Second, we discuss the role of caffeine consumption on the circadian rhythms in animal models and human, especially in neonates and preterm infants. Finally, we postulate how circadian-based therapeutic initiatives could open new possibilities to promote precision caffeine therapy for the AOP management in preterm infants.
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16
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Varisco G, Peng Z, Kommers D, Zhan Z, Cottaar W, Andriessen P, Long X, van Pul C. Central apnea detection in premature infants using machine learning. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 226:107155. [PMID: 36215858 DOI: 10.1016/j.cmpb.2022.107155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/13/2022] [Accepted: 09/23/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Apnea of prematurity is one of the most common diagnosis in neonatal intensive care units. Apneas can be classified as central, obstructive or mixed. According to the current international standards, minimal fluctuations or absence of fluctuations in the chest impedance (CI) suggest a central apnea (CA). However, automatic detection of reduced CI fluctuations leads to a high number of central apnea-suspected events (CASEs), the majority being false alarms. We aim to improve automatic detection of CAs by using machine learning to optimize detection of CAs among CASEs. METHODS Using an optimized algorithm for automated detection, all CASEs were detected in a population of 10 premature infants developing late-onset sepsis and 10 age-matched control patients. CASEs were inspected by two clinical experts and annotated as CAs or rejections in two rounds of annotations. A total of 47 features were extracted from the ECG, CI and oxygen saturation signals considering four 30 s-long moving windows, from 30 s before to 15 s after the onset of each CASE, using a moving step size of 5 s. Consecutively, new CA detection models were developed based on logistic regression with elastic net penalty, random forest and support vector machines. Performance was evaluated using both leave-one-patient-out and 10-fold cross-validation considering the mean area under the receiver-operating-characteristic curve (AUROC). RESULTS The CA detection model based on logistic regression with elastic net penalty returned the highest mean AUROC when features extracted from all four time windows were included, both using leave-one-patient-out and 10-fold cross-validation (mean AUROC of 0.88 and 0.90, respectively). Feature relevance was found to be the highest for features derived from the CI. A threshold for the false positive rate in the mean receiver-operating-characteristic curve equal to 0.3 led to a high percentage of correct detections for all CAs (78.2%) and even higher for CAs followed by a bradycardia (93.4%) and CAs followed by both a bradycardia and a desaturation (95.2%), which are more critical for the well-being of premature infants. CONCLUSIONS Models based on machine learning can lead to improved CA detection with fewer false alarms.
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Affiliation(s)
- Gabriele Varisco
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands.
| | - Zheng Peng
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Deedee Kommers
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Zhuozhao Zhan
- Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Ward Cottaar
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter Andriessen
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Pediatrics, Máxima Medical Center, Veldhoven, the Netherlands
| | - Xi Long
- Philips Research, Eindhoven, the Netherlands; Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.
| | - Carola van Pul
- Applied Physics, Eindhoven University of Technology, Eindhoven, the Netherlands; Clinical Physics, Máxima Medical Center, Veldhoven, the Netherlands
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17
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Lim K, Cramer SJE, Te Pas AB, Gale TJ, Dargaville PA. Sensory stimulation for apnoea mitigation in preterm infants. Pediatr Res 2022; 92:637-646. [PMID: 34819656 DOI: 10.1038/s41390-021-01828-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/09/2022]
Abstract
Apnoea, a pause in respiration, is ubiquitous in preterm infants and are often associated with physiological instability, which may lead to longer-term adverse neurodevelopmental consequences. Despite current therapies aimed at reducing the apnoea burden, preterm infants continue to exhibit apnoeic events throughout their hospital admission. Bedside staff are frequently required to manually intervene with different forms of stimuli, with the aim of re-establishing respiratory cadence and minimizing the physiological impact of each apnoeic event. Such a reactive approach makes apnoea and its associated adverse consequences inevitable and places a heavy reliance on human intervention. Different approaches to improving apnoea management in preterm infants have been investigated, including the use of various sensory stimuli. Despite studies reporting sensory stimuli of various forms to have potential in reducing apnoea frequency, non-invasive intermittent positive pressure ventilation is the only automated stimulus currently used in the clinical setting for infants with persistent apnoeic events. We find that the development of automated closed-looped sensory stimulation systems for apnoea mitigation in preterm infants receiving non-invasive respiratory support is warranted, including the possibility of stimulation being applied preventatively, and in a multi-modal form. IMPACT: This review examines the effects of various forms of sensory stimulation on apnoea mitigation in preterm infants, namely localized tactile, generalized kinesthetic, airway pressure, auditory, and olfactory stimulations. Amongst the 31 studies reviewed, each form of sensory stimulation showed some positive effects, although the findings were not definitive and comparative studies were lacking. We find that the development of automated closed-loop sensory stimulation systems for apnoea mitigation is warranted, including the possibility of stimulation being applied preventatively, and in a multi-modal form.
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Affiliation(s)
- Kathleen Lim
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Sophie J E Cramer
- Willem-Alexander Children's Hospital, Division of Neonatolog, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Willem-Alexander Children's Hospital, Division of Neonatolog, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Timothy J Gale
- School of Engineering, College of Science, Engineering and Technology, University of Tasmania, Hobart, TAS, Australia
| | - Peter A Dargaville
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia. .,Neonatal and Pediatric Intensive Care Unit, Department of Pediatrics, Royal Hobart Hospital, Hobart, TAS, Australia.
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18
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Judd RT, Mokhlesi B, Shogan A, Baroody FM. Improvement in Central Sleep Apnea Following Adenotonsillectomy in Children. Laryngoscope 2022; 132:478-484. [PMID: 34324202 DOI: 10.1002/lary.29784] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/29/2021] [Accepted: 07/20/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Previous studies examining changes in central sleep apnea (CSA) following adenotonsillectomy (T&A) performed for obstructive sleep apnea (OSA) in children have been limited by sample size and analysis of only certain populations. The aim of this study was to determine whether CSA improves following T&A and what factors mediate this change. METHODS This was a retrospective case series from 1994 to 2020 of children undergoing primary T&A for OSA (obstructive apnea-hypopnea index ≥1) with CSA (central apnea index [CAI] ≥1) and preoperative and postoperative polysomnograms within 12 months of T&A. Polysomnograms were analyzed for improvement in CSA, defined as: 1) if preoperative CAI >5, a postoperative CAI <5; or 2) if preoperative CAI <5, a postoperative CAI <1. RESULTS One hundred twenty-three patients were included. Median age was 5.5 years (interquartile range, 2.9-8.4). Most patients were overweight/obese (58.5%). Nineteen (15.4%) had a syndromic condition. Preoperative CAI was ≥5 in 21 (17.1%) patients. CAI significantly decreased following T&A (preoperative 2.1, postoperative 0.4; P < .001). Thirty-two (26.0%) patients had CSA postoperatively. Improvement in the microarousal index and older age were significantly associated with improvement in CSA. CONCLUSIONS T&A led to resolution of CSA in most children with OSA. Improvement in the microarousal index was associated with improvement in CAI, suggesting that preoperative central apneas may be postarousal and thus resolve following T&A. LEVEL OF EVIDENCE 4 Laryngoscope, 132:478-484, 2022.
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Affiliation(s)
- Ryan T Judd
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Babak Mokhlesi
- Department of Internal Medicine, Section of Pulmonary and Critical Care, University of Chicago Medicine, Chicago, Illinois, USA
| | - Andrea Shogan
- Department of Surgery, Section of Otolaryngology Head & Neck Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Fuad M Baroody
- Department of Surgery, Section of Otolaryngology Head & Neck Surgery, University of Chicago Medicine, Chicago, Illinois, USA.,Department of Pediatrics, University of Chicago Medicine, Chicago, Illinois, USA
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19
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Ventilatory control instability as a predictor of persistent periodic breathing in preterm infants. Pediatr Res 2022; 92:513-519. [PMID: 34716421 PMCID: PMC8555736 DOI: 10.1038/s41390-021-01816-9] [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: 05/11/2021] [Revised: 09/02/2021] [Accepted: 10/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Periodic breathing (PB) is common in preterm infants. We aimed to characterize the contribution of ventilatory control instability to the presence and persistence of PB longitudinally. METHODS Infants born between 28 and 32 weeks of gestation were studied using daytime polysomnography at: 32-36 weeks postmenstrual age (PMA) (N = 32), 36-40 weeks PMA (N = 20), 3 months corrected age (CA) (N = 18) and 6 months CA (N = 19). Loop gain, a measure of sensitivity of the ventilatory control system, was estimated by fitting a mathematical model to ventilatory patterns associated with spontaneous sighs. RESULTS The time spent in PB decreased from 32-36 weeks PMA to 6 months CA (P = 0.005). Across all studies, studies with PB (N = 62) were associated with higher loop gain compared to those without PB (N = 23) (estimated marginal mean ± SEM: 0.445 ± 0.01 vs 0.388 ± 0.02; P = 0.020). A threshold of loop gain >0.415 (measured at 32-36 weeks PMA) provided a sensitivity of 86% and a specificity of 75% to detect the presence of PB at 6 months CA. CONCLUSIONS The course of PB in preterm infants is related to changes in loop gain. Higher loop gain at 32-36 weeks PMA was associated with a greater risk of persistent PB at 6 months CA. IMPACT The developmental trajectory of periodic breathing and its relationship to ventilatory control instability is currently unclear. Unstable ventilatory control is a determinant of periodic breathing in preterm infants up to 6 months corrected age. Infants who display greater ventilatory control instability at 32-36 weeks postmenstrual age may be at increased risk of persistent periodic breathing at 6 months corrected age. Assessment of ventilatory control stability may assist in the early identification of infants at risk of persistent periodic breathing and its potential adverse effects.
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20
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Sullivan BA, Fairchild KD. Vital signs as physiomarkers of neonatal sepsis. Pediatr Res 2022; 91:273-282. [PMID: 34493832 DOI: 10.1038/s41390-021-01709-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
Neonatal sepsis accounts for significant morbidity and mortality, particularly among premature infants in the Neonatal Intensive Care Unit. Abnormal vital sign patterns serve as physiomarkers of sepsis and provide early warning of illness before overt clinical decompensation. The systemic inflammatory response to pathogens signals the autonomic nervous system, leading to changes in temperature, respiratory rate, heart rate, and blood pressure. In infants with comorbidities of prematurity, vital sign abnormalities often occur in the absence of infection, which confounds sepsis diagnosis. This review will cover the mechanisms of vital sign changes in neonatal sepsis, including the cholinergic anti-inflammatory pathway mediated by the vagus nerve, which is critical to the host response to infectious and inflammatory insults. We will also review the clinical implications of vital sign changes in neonatal sepsis, including their use in early warning scores and systems to direct clinicians to the bedside of infants with physiologic changes that might be due to sepsis. IMPACT: This manuscript summarizes and reviews the relevant literature on the physiological manifestations of neonatal sepsis and how we monitor and analyze these through vital signs and advanced analytics.
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Affiliation(s)
- Brynne A Sullivan
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Karen D Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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21
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AIM in Neonatal and Pediatric Intensive Care. Artif Intell Med 2022. [DOI: 10.1007/978-3-030-64573-1_309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Adjei T, Purdy R, Jorge J, Adams E, Buckle M, Evans Fry R, Green G, Patel C, Rogers R, Slater R, Tarassenko L, Villarroel M, Hartley C. New method to measure interbreath intervals in infants for the assessment of apnoea and respiration. BMJ Open Respir Res 2021; 8:8/1/e001042. [PMID: 34893521 PMCID: PMC8666899 DOI: 10.1136/bmjresp-2021-001042] [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] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/18/2021] [Indexed: 11/23/2022] Open
Abstract
Background Respiratory disorders, including apnoea, are common in preterm infants due to their immature respiratory control compared with term-born infants. However, our inability to accurately measure respiratory rate in hospitalised infants results in unreported episodes of apnoea and an incomplete picture of respiratory activity. Methods We develop, validate and use a novel algorithm to identify interbreath intervals (IBIs) and apnoeas in preterm infants. In 42 preterm infants (1600 hours of recordings), we assess IBIs from the chest electrical impedance pneumograph using an adaptive amplitude threshold for the detection of breaths. The algorithm is refined by comparing its accuracy with clinically observed breaths and pauses in breathing. We develop an automated classifier to differentiate periods of true apnoea from artefactually low amplitude signal. We assess the performance of this algorithm in the detection of morphine-induced respiratory depression. Finally, we use the algorithm to investigate whether retinopathy of prematurity (ROP) screening alters the IBI distribution. Results Individual breaths were detected with a false-positive rate of 13% and a false-negative rate of 12%. The classifier identified true apnoeas with an accuracy of 93%. As expected, morphine caused a significant shift in the IBI distribution towards longer IBIs. Following ROP screening, there was a significant increase in pauses in breathing that lasted more than 10 s (t-statistic=1.82, p=0.023). This was not reflected by changes in the monitor-derived respiratory rate and no episodes of apnoea were recorded in the medical records. Conclusions We show that our algorithm offers an improved method for the identification of IBIs and apnoeas in preterm infants. Following ROP screening, increased respiratory instability can occur even in the absence of clinically significant apnoeas. Accurate assessment of infant respiratory activity is essential to inform clinical practice.
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Affiliation(s)
- Tricia Adjei
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ryan Purdy
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - João Jorge
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Eleri Adams
- Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Miranda Buckle
- Department of Paediatrics, University of Oxford, Oxford, UK
| | - Ria Evans Fry
- Department of Paediatrics, University of Oxford, Oxford, UK
| | | | - Chetan Patel
- Department of Ophthalmology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard Rogers
- Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Lionel Tarassenko
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Mauricio Villarroel
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
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Persad E, Jost K, Honoré A, Forsberg D, Coste K, Olsson H, Rautiainen S, Herlenius E. Neonatal sepsis prediction through clinical decision support algorithms: A systematic review. Acta Paediatr 2021; 110:3201-3226. [PMID: 34432903 DOI: 10.1111/apa.16083] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/14/2021] [Accepted: 08/24/2021] [Indexed: 12/12/2022]
Abstract
AIM To systematically summarise the current evidence of employing clinical decision support algorithms (CDSAs) using non-invasive parameters for sepsis prediction in neonates. METHODS A comprehensive search in PubMed, CENTRAL and EMBASE was conducted. Screening, data extraction and risk of bias were performed by two authors. The certainty of the evidence was assessed using GRADE. PROSPERO ID CRD42020205143. RESULTS After abstract and full-text screening, 36 studies comprising 18,096 infants were included. Most CDSAs evaluated heart rate (HR)-based parameters. Two publications derived from one randomised-controlled trial assessing HR characteristics reported significant reduction in 30-day septicaemia-related mortality. Thirty-four non-randomised studies found promising yet inconclusive results. CONCLUSION Heart rate-based parameters are reliable components of CDSAs for sepsis prediction, particularly in combination with additional vital signs and demographics. However, inconclusive evidence and limited standardisation restricts clinical implementation of CDSAs outside of a controlled research environment. Further experimentation and comparison of parameter combinations and testing of new CDSAs are warranted.
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Affiliation(s)
- Emma Persad
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s HospitalKarolinska University Hospital Stockholm Sweden
- Karl Landsteiner University of Health Sciences Krems Austria
- Department of Evidence‐based Medicine and Evaluation Danube University Krems Krems Austria
| | - Kerstin Jost
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s HospitalKarolinska University Hospital Stockholm Sweden
| | - Antoine Honoré
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s HospitalKarolinska University Hospital Stockholm Sweden
- Division of Information Science and Engineering KTH Royal Institute of Technology Stockholm Sweden
| | - David Forsberg
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s HospitalKarolinska University Hospital Stockholm Sweden
| | - Karen Coste
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- CNRS INSERM GReD Université Clermont Auvergne Clermont‐Ferrand France
| | - Hanna Olsson
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
| | - Susanne Rautiainen
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s HospitalKarolinska University Hospital Stockholm Sweden
- Department of Global Public Health Karolinska Institutet Stockholm Sweden
| | - Eric Herlenius
- Department of Women's & Children’s Health Karolinska Institutet Stockholm Sweden
- Astrid Lindgren Children’s HospitalKarolinska University Hospital Stockholm Sweden
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Autism risk in neonatal intensive care unit patients associated with novel heart rate patterns. Pediatr Res 2021; 90:1186-1192. [PMID: 33603208 PMCID: PMC8371053 DOI: 10.1038/s41390-021-01381-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 12/30/2020] [Accepted: 12/31/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Neonatal intensive care unit (NICU) patients are at increased risk for autism spectrum disorder (ASD). Autonomic nervous system aberrancy has been described in children with ASD, and we aimed to identify heart rate (HR) patterns in NICU patients associated with eventual ASD diagnosis. METHODS This retrospective cohort study included NICU patients from 2009 to 2016 with archived HR data and follow-up beyond age 3 years. Medical records provided clinical variables and ASD diagnosis. HR data were compared in infants with and without ASD. RESULTS Of the 2371 patients, 88 had ASD, and 689,016 h of data were analyzed. HR skewness (HRskw) was significantly different between ASD and control infants. Preterm infants at early postmenstrual ages (PMAs) had negative HRskw reflecting decelerations, which increased with maturation. From 34 to 42 weeks PMA, positive HRskw toward accelerations was higher in males with ASD. In 931 males with at least 4 days of HR data, overall ASD prevalence was 5%, whereas 11% in the top 5th HRskw percentile had ASD. CONCLUSION High HRskw in NICU males, perhaps representing autonomic imbalance, was associated with increased ASD risk. Further study is needed to determine whether HR analysis identifies highest-risk infants who might benefit from earlier screening and therapies. IMPACT In a large retrospective single-center cohort of NICU patients, we found that high positive skewness of heart rate toward more accelerations was significantly associated with increased risk of eventual autism spectrum disorder diagnosis in male infants but not in females. Existing literature describes differences in heart rate characteristics in children, adolescents, and adults with autism spectrum disorders, but the finding from our study in NICU infants is novel. Heart rate analysis during the NICU stay might identify, among an inherently high-risk population, those infants with especially high risk of ASD who might benefit from earlier screening and therapies.
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Varisco G, Kommers D, Long X, Zhan Z, Nano MM, Cottaar W, Andriessen P, Pul CV. Optimized Detection of Central Apneas Preceding Late-Onset Sepsis in Premature Infants. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:5463-5468. [PMID: 34892362 DOI: 10.1109/embc46164.2021.9629528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In neonatal intensive care units, respiratory traces of premature infants developing late onset sepsis (LOS) may also show episodes of apneas. However, since clinical patient monitors often underdetect apneas, clinical experts are required to investigate patients' traces looking for these events. In this work we present a method to optimize an existing algorithm for central apnea (CA) detection and how we used it together with human annotations to investigate the occurrence of CAs preceding LOS.The algorithm was optimized by using a previously-annotated dataset consisting of 90 hours, extracted from 10 premature infants. This allowed to double precision (19.7% vs 9.3%, median values per patient) without affecting recall (90.5% vs 94.5%) compared to the original algorithm. This choice caused the missed identification of just 1 additional CA (4 vs 3) in the whole dataset. The optimized algorithm was then used to annotate a second dataset consisting of 480 hours, extracted from 10 premature infants diagnosed with LOS. Annotations were corrected by two clinical experts.A significantly higher number of CA annotations was found in the 6 hours prior to sepsis onset (p-value < 0.05). The use of the optimized algorithm followed by human annotations proved to be a suitable, time-efficient method to annotate CAs before sepsis in premature infants, enabling future use in large datasets.
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Mammel D, Kemp J. Prematurity, the diagnosis of bronchopulmonary dysplasia, and maturation of ventilatory control. Pediatr Pulmonol 2021; 56:3533-3545. [PMID: 34042316 DOI: 10.1002/ppul.25519] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/27/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022]
Abstract
Infants born before 32 weeks gestational age and receiving respiratory support at 36 weeks postmenstrual age (PMA) are diagnosed with bronchopulmonary dysplasia (BPD). This label suggests that their need for supplemental oxygen (O2 ) is primarily due to acquired dysplasia of airways and airspaces, and that the supplemental O2 is treating residual parenchymal lung disease. However, emerging evidence suggests that immature ventilatory control may also contribute to the need for supplemental O2 at 36 weeks PMA. In all newborns, maturation of ventilatory control continues ex utero and is a plastic process. Among premature infants, supplemental O2 mitigates the hypoxemic effects of delayed maturation of ventilatory control, as well as reduces the duration and frequency of periodic breathing events. Nevertheless, prematurity is associated with altered and occasionally aberrant maturation of ventilatory control. Infants born prematurely, with or without a diagnosis of BPD, are more prone to long-lasting effects of dysfunctional ventilatory control. This review addresses normal and abnormal maturation of ventilatory control and suggests how aberrant maturation complicates assigning the diagnosis of BPD. Greater awareness of the interaction between parenchymal lung disease and delayed maturation of ventilatory control is essential to understanding why a given premature infant requires and is benefitting from supplemental O2 at 36 weeks PMA.
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Affiliation(s)
- Daniel Mammel
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - James Kemp
- Department of Pediatrics, Allergy and Pulmonary Medicine, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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Nagraj VP, Lake DE, Kuhn L, Moorman JR, Fairchild KD. Central Apnea of Prematurity: Does Sex Matter? Am J Perinatol 2021; 38:1428-1434. [PMID: 32578186 DOI: 10.1055/s-0040-1713405] [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] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Apnea is common among infants in the neonatal intensive care unit (NICU). Our group previously developed an automated algorithm to quantitate central apneas with associated bradycardia and desaturation (ABDs). Sex differences in lung disease are well described in preterm infants, but the influence of sex on apnea has not been established. STUDY DESIGN This study includes infants < 34 weeks' gestation admitted to the University of Virginia NICU from 2009 to 2014 with at least 1 day of bedside monitor data available when not on mechanical ventilation. Waveform and vital sign data were analyzed using a validated algorithm to detect ABD events of low variance in chest impedance signal lasting at least 10 seconds with associated drop in heart rate to < 100 beats/minute and drop in oxygen saturation to < 80%. Male and female infants were compared for prevalence of at least one ABD event during the NICU stay, treatment with caffeine, occurrence of ABDs at each week of postmenstrual age, and number of events per day. RESULTS Of 926 infants studied (median gestational age 30 weeks, 53% male), median days of data analyzed were 19 and 22 for males and females, respectively. There was no sex difference in prevalence of at least one ABD event during the NICU stay (males 62%, females 64%, p = 0.47) or in the percentage of infants treated with caffeine (males 64%, females 67%, p = 0.40). Cumulative prevalence of ABDs from postmenstrual ages 24 to 36 weeks was comparable between sexes. Males had 18% more ABDs per day of data, but this difference was not statistically significant (p = 0.16). CONCLUSION In this large cohort of infants < 34 weeks' gestation, we did not detect a sex difference in prevalence of central ABD events. There was a nonsignificant trend toward a greater number of ABDs per day in male infants. KEY POINTS · Central apnea is pervasive among preterm infants in the NICU, but potential disparities between males and females have not been thoroughly studied.. · Identification of risk factors for central apnea can lead to improved treatment protocols.. · The rate and prevalence of central apnea events accompanied by bradycardia and desaturation does not significantly differ between male and female preterm infants..
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Affiliation(s)
| | - Douglas E Lake
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Louise Kuhn
- Gertrude H. Sergievsky Center, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, New York
| | - J Randall Moorman
- Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
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Lorato I, Stuijk S, Meftah M, Kommers D, Andriessen P, van Pul C, de Haan G. Automatic Separation of Respiratory Flow from Motion in Thermal Videos for Infant Apnea Detection. SENSORS (BASEL, SWITZERLAND) 2021; 21:6306. [PMID: 34577513 PMCID: PMC8472592 DOI: 10.3390/s21186306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 02/07/2023]
Abstract
Both Respiratory Flow (RF) and Respiratory Motion (RM) are visible in thermal recordings of infants. Monitoring these two signals usually requires landmark detection for the selection of a region of interest. Other approaches combine respiratory signals coming from both RF and RM, obtaining a Mixed Respiratory (MR) signal. The detection and classification of apneas, particularly common in preterm infants with low birth weight, would benefit from monitoring both RF and RM, or MR, signals. Therefore, we propose in this work an automatic RF pixel detector not based on facial/body landmarks. The method is based on the property of RF pixels in thermal videos, which are in areas with a smooth circular gradient. We defined 5 features combined with the use of a bank of Gabor filters that together allow selection of the RF pixels. The algorithm was tested on thermal recordings of 9 infants amounting to a total of 132 min acquired in a neonatal ward. On average the percentage of correctly identified RF pixels was 84%. Obstructive Apneas (OAs) were simulated as a proof of concept to prove the advantage in monitoring the RF signal compared to the MR signal. The sensitivity in the simulated OA detection improved for the RF signal reaching 73% against the 23% of the MR signal. Overall, the method yielded promising results, although the positioning and number of cameras used could be further optimized for optimal RF visibility.
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Affiliation(s)
- Ilde Lorato
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands; (S.S.); (G.d.H.)
| | - Sander Stuijk
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands; (S.S.); (G.d.H.)
| | - Mohammed Meftah
- Department of Family Care Solutions, Philips Research, 5656 AE Eindhoven, The Netherlands;
| | - Deedee Kommers
- Department of Neonatology, Máxima Medical Centre, 5504 DB Veldhoven, The Netherlands; (D.K.); (P.A.)
- Department of Applied Physics, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands;
| | - Peter Andriessen
- Department of Neonatology, Máxima Medical Centre, 5504 DB Veldhoven, The Netherlands; (D.K.); (P.A.)
- Department of Applied Physics, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands;
| | - Carola van Pul
- Department of Applied Physics, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands;
- Department of Clinical Physics, Máxima Medical Centre, 5504 DB Veldhoven, The Netherlands
| | - Gerard de Haan
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands; (S.S.); (G.d.H.)
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Sullivan B, Ahmad SM, Slevin CC, Sinkin RA, Nagraj VP, Fairchild KD. Major cardiorespiratory events do not increase after immunizations, eye exams, and other stressors in most very low birth weight infants. J Neonatal Perinatal Med 2021; 15:275-282. [PMID: 34459417 DOI: 10.3233/npm-210744] [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
BACKGROUND Increased cardiorespiratory events with bradycardia and oxygen desaturation have been reported in very low birthweight (VLBW) infants following stressors such as immunizations. These events are difficult to quantify and may be mild. Our group developed an automated algorithm to analyze bedside monitor data from NICU patients for events with bradycardia and prolonged oxygen desaturation (BDs) and used this to compare BDs 24 hours before and after potentially stressful interventions. METHODS We included VLBW infants from 2012-2017 with data available around at least one of four interventions: two-month immunizations, retinopathy of prematurity (ROP) examinations, ROP therapy, and inguinal hernia surgery. We used a validated algorithm to analyze electrocardiogram heart rate and pulse oximeter saturation data (HR, SpO2) to quantify BD events of HR < 100 beats/minute for≥4 seconds with oxygen desaturation < 80%SpO2 for≥10 seconds. BDs were analyzed 24 hours before and after interventions using Wilcoxon rank-sum tests. RESULTS In 354 of 493 (72%) interventions, BD frequency stayed the same or decreased in the 24 hours after the event. An increase of at least five BD's occurred in 17/146 (12%) after immunizations, 85/290 (29%) after ROP examinations, 4/33 (12%) after ROP therapy, and 3/25 (12%) after hernia surgery. Infants with an increase in BDs after interventions had similar demographics compared to those without. More infants with an increase in BDs following immunizations were on CPAP or caffeine than those without. CONCLUSIONS Most VLBW infants in our cohort had no increase in significant cardiorespiratory events in the 24 hours following potentially stressful interventions.
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Affiliation(s)
- B Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - S M Ahmad
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - C C Slevin
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - R A Sinkin
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - V P Nagraj
- Signature Science, LLC, Charlottesville, VA, USA
| | - K D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
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Zimmet AM, Sullivan BA, Fairchild KD, Moorman JR, Isler JR, Wallman-Stokes AW, Sahni R, Vesoulis ZA, Ratcliffe SJ, Lake DE. Vital sign metrics of VLBW infants in three NICUs: implications for predictive algorithms. Pediatr Res 2021; 90:125-130. [PMID: 33767372 PMCID: PMC8376742 DOI: 10.1038/s41390-021-01428-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Continuous heart rate (HR) and oxygenation (SpO2) metrics can be useful for predicting adverse events in very low birth weight (VLBW) infants. To optimize the utility of these tools, inter-site variability must be taken into account. METHODS For VLBW infants at three neonatal intensive care units (NICUs), we analyzed the mean, standard deviation, skewness, kurtosis, and cross-correlation of electrocardiogram HR, pulse oximeter pulse rate, and SpO2. The number and durations of bradycardia and desaturation events were also measured. Twenty-two metrics were calculated hourly, and mean daily values were compared between sites. RESULTS We analyzed data from 1168 VLBW infants from birth through day 42 (35,238 infant-days). HR and SpO2 metrics were similar at the three NICUs, with mean HR rising by ~10 beats/min over the first 2 weeks and mean SpO2 remaining stable ~94% over time. The number of bradycardia events was higher at one site, and the duration of desaturations was longer at another site. CONCLUSIONS Mean HR and SpO2 were generally similar among VLBW infants at three NICUs from birth through 6 weeks of age, but bradycardia and desaturation events differed in the first 2 weeks after birth. This highlights the importance of developing predictive analytics tools at multiple sites. IMPACT HR and SpO2 analytics can be useful for predicting adverse events in VLBW infants in the NICU, but inter-site differences must be taken into account in developing predictive algorithms. Although mean HR and SpO2 patterns were similar in VLBW infants at three NICUs, inter-site differences in the number of bradycardia events and duration of desaturation events were found. Inter-site differences in bradycardia and desaturation events among VLBW infants should be considered in the development of predictive algorithms.
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Affiliation(s)
- Amanda M. Zimmet
- Department of Medicine, University of Virginia, Charlottesville, VA
| | | | | | | | | | | | - Rakesh Sahni
- Department of Pediatrics, Columbia University, New York, NY
| | | | - Sarah J. Ratcliffe
- Department of Public Health Science, University of Virginia, Charlottesville, VA
| | - Douglas E. Lake
- Department of Medicine, University of Virginia, Charlottesville, VA,Sepsis Challenges Response Unit, University of Virginia, Charlottesville, VA
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Sullivan BA, Slevin CC, Ahmad SM, Sinkin RA, Fairchild KD. Achievement of maturational milestones among very low birth weight infants. J Neonatal Perinatal Med 2021; 15:155-163. [PMID: 33967061 DOI: 10.3233/npm-200698] [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
BACKGROUND Very low birth weight (VLBW) infants must achieve several maturational milestones to be discharged home from the NICU. OBJECTIVE Describe the timing of maturational milestones in VLBW infants and the impact of clinical variables and milestone achievement on postmenstrual age (PMA) at discharge. METHODS For VLBW infants without severe lung disease discharged home from a level IV NICU, we assessed PMA at the achievement of thermoregulation, cardiorespiratory stability, feeding, and discharge. RESULTS In 400 infants (median GA 28.4 weeks), lower birth weight, white race, and having multiple comorbidities of prematurity predicted later discharge PMA. The most common milestone sequence was CPAP discontinuation, caffeine discontinuation, thermoregulation, apnea resolution, and full oral feeds. PMA at apnea resolution and full oral feeds correlated highly with discharge PMA. CONCLUSIONS In a single-center VLBW cohort, comorbidities of prematurity impacted the timing of NICU discharge through delay in oral feeding and cardiorespiratory stability.
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Affiliation(s)
- B A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - C C Slevin
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - S M Ahmad
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - R A Sinkin
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - K D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
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32
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Sun Y, Kaur R, Gupta S, Paul R, Das R, Cho SJ, Anand S, Boutilier JJ, Saria S, Palma J, Saluja S, McAdams RM, Kaur A, Yadav G, Singh H. Development and validation of high definition phenotype-based mortality prediction in critical care units. JAMIA Open 2021; 4:ooab004. [PMID: 33796821 PMCID: PMC7991779 DOI: 10.1093/jamiaopen/ooab004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 12/02/2022] Open
Abstract
Objectives The objectives of this study are to construct the high definition phenotype (HDP), a novel time-series data structure composed of both primary and derived parameters, using heterogeneous clinical sources and to determine whether different predictive models can utilize the HDP in the neonatal intensive care unit (NICU) to improve neonatal mortality prediction in clinical settings. Materials and Methods A total of 49 primary data parameters were collected from July 2018 to May 2020 from eight level-III NICUs. From a total of 1546 patients, 757 patients were found to contain sufficient fixed, intermittent, and continuous data to create HDPs. Two different predictive models utilizing the HDP, one a logistic regression model (LRM) and the other a deep learning long–short-term memory (LSTM) model, were constructed to predict neonatal mortality at multiple time points during the patient hospitalization. The results were compared with previous illness severity scores, including SNAPPE, SNAPPE-II, CRIB, and CRIB-II. Results A HDP matrix, including 12 221 536 minutes of patient stay in NICU, was constructed. The LRM model and the LSTM model performed better than existing neonatal illness severity scores in predicting mortality using the area under the receiver operating characteristic curve (AUC) metric. An ablation study showed that utilizing continuous parameters alone results in an AUC score of >80% for both LRM and LSTM, but combining fixed, intermittent, and continuous parameters in the HDP results in scores >85%. The probability of mortality predictive score has recall and precision of 0.88 and 0.77 for the LRM and 0.97 and 0.85 for the LSTM. Conclusions and Relevance The HDP data structure supports multiple analytic techniques, including the statistical LRM approach and the machine learning LSTM approach used in this study. LRM and LSTM predictive models of neonatal mortality utilizing the HDP performed better than existing neonatal illness severity scores. Further research is necessary to create HDP–based clinical decision tools to detect the early onset of neonatal morbidities.
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Affiliation(s)
- Yao Sun
- Division of Neonatology, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Ravneet Kaur
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Shubham Gupta
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Rahul Paul
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Ritu Das
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
| | - Su Jin Cho
- Department of Pediatrics, College of Medicine, Ewha Womans University Seoul, Seoul, Korea
| | - Saket Anand
- Department of Computer Science, Indraprastha Institute of Information Technology, New Delhi, India
| | - Justin J Boutilier
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Wisconsin, USA
| | - Suchi Saria
- Machine Learning and Healthcare Lab, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Applied Math & Statistics, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Health Policy & Management, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Palma
- Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Satish Saluja
- Department of Neonatology, Sir Ganga Ram Hospital, New Delhi, India
| | - Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Avneet Kaur
- Department of Neonatology, Apollo Cradle Hospitals, New Delhi, India
| | - Gautam Yadav
- Department of Pediatrics, Kalawati Hospital, Rewari, India
| | - Harpreet Singh
- Research and Development, Child Health Imprints (CHIL) Pte. Ltd., Singapore
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Lorato I, Stuijk S, Meftah M, Kommers D, Andriessen P, van Pul C, de Haan G. Towards Continuous Camera-Based Respiration Monitoring in Infants. SENSORS (BASEL, SWITZERLAND) 2021; 21:2268. [PMID: 33804913 PMCID: PMC8036870 DOI: 10.3390/s21072268] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/19/2021] [Accepted: 03/21/2021] [Indexed: 02/06/2023]
Abstract
Aiming at continuous unobtrusive respiration monitoring, motion robustness is paramount. However, some types of motion can completely hide the respiration information and the detection of these events is required to avoid incorrect rate estimations. Therefore, this work proposes a motion detector optimized to specifically detect severe motion of infants combined with a respiration rate detection strategy based on automatic pixels selection, which proved to be robust to motion of the infants involving head and limbs. A dataset including both thermal and RGB (Red Green Blue) videos was used amounting to a total of 43 h acquired on 17 infants. The method was successfully applied to both RGB and thermal videos and compared to the chest impedance signal. The Mean Absolute Error (MAE) in segments where some motion is present was 1.16 and 1.97 breaths/min higher than the MAE in the ideal moments where the infants were still for testing and validation set, respectively. Overall, the average MAE on the testing and validation set are 3.31 breaths/min and 5.36 breaths/min, using 64.00% and 69.65% of the included video segments (segments containing events such as interventions were excluded based on a manual annotation), respectively. Moreover, we highlight challenges that need to be overcome for continuous camera-based respiration monitoring. The method can be applied to different camera modalities, does not require skin visibility, and is robust to some motion of the infants.
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Affiliation(s)
- Ilde Lorato
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands; (S.S.); (G.d.H.)
| | - Sander Stuijk
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands; (S.S.); (G.d.H.)
| | - Mohammed Meftah
- Department of Family Care Solutions, Philips Research, 5656 AE Eindhoven, The Netherlands;
| | - Deedee Kommers
- Department of Neonatology, Maxima Medical Centre, 5504 DB Veldhoven, The Netherlands; (D.K.); (P.A.)
- Department of Applied Physics, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands;
| | - Peter Andriessen
- Department of Neonatology, Maxima Medical Centre, 5504 DB Veldhoven, The Netherlands; (D.K.); (P.A.)
- Department of Applied Physics, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands;
| | - Carola van Pul
- Department of Applied Physics, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands;
- Department of Clinical Physics, Maxima Medical Centre, 5504 DB Veldhoven, The Netherlands
| | - Gerard de Haan
- Department of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands; (S.S.); (G.d.H.)
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Sullivan BA, Nagraj VP, Berry KL, Fleiss N, Rambhia A, Kumar R, Wallman-Stokes A, Vesoulis ZA, Sahni R, Ratcliffe S, Lake DE, Moorman JR, Fairchild KD. Clinical and vital sign changes associated with late-onset sepsis in very low birth weight infants at 3 NICUs. J Neonatal Perinatal Med 2021; 14:553-561. [PMID: 33523025 DOI: 10.3233/npm-200578] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In premature infants, clinical changes frequently occur due to sepsis or non-infectious conditions, and distinguishing between these is challenging. Baseline risk factors, vital signs, and clinical signs guide decisions to culture and start antibiotics. We sought to compare heart rate (HR) and oxygenation (SpO2) patterns as well as baseline variables and clinical signs prompting sepsis work-ups ultimately determined to be late-onset sepsis (LOS) and sepsis ruled out (SRO). METHODS At three NICUs, we reviewed records of very low birth weight (VLBW) infants around their first sepsis work-up diagnosed as LOS or SRO. Clinical signs prompting the evaluation were determined from clinician documentation. HR-SpO2 data, when available, were analyzed for mean, standard deviation, skewness, kurtosis, and cross-correlation. We used LASSO and logistic regression to assess variable importance and associations with LOS compared to SRO. RESULTS We analyzed sepsis work-ups in 408 infants (173 LOS, 235 SRO). Compared to infants with SRO, those with LOS were of lower GA and BW, and more likely to have a central catheter and mechanical ventilation. Clinical signs cited more often in LOS included hypotension, acidosis, abdominal distension, lethargy, oliguria, and abnormal CBC or CRP(p < 0.05). HR-SpO2 data were available in 266 events. Cross-correlation HR-SpO2 before the event was associated with LOS after adjusting for GA, BW, and postnatal age. A model combining baseline, clinical and HR-SpO2 variables had AUC 0.821. CONCLUSION In VLBW infants at 3-NICUs, we describe the baseline, clinical, and HR-SpO2 variables associated with LOS versus SRO.
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Affiliation(s)
- B A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA.,University of Virginia Center for Advanced Medical Analytics, Charlottesville, VA, USA
| | - V P Nagraj
- Department of Research Computing, University of Virginia School of Medicine, Charlottesville, VA, USA.,Signature Science, LLC, Charlottesville, Virginia, USA
| | - K L Berry
- University of Virginia School of Medicine, Charlottesville, VA, USA.,University of Virginia School of Public Health Sciences, Charlottesville, VA, USA
| | - N Fleiss
- Department of Pediatrics, Division of Neonatology, Columbia University, New York, NY, USA
| | - A Rambhia
- Department of Pediatrics, Division of Neonatology, Washington University School of Medicine, St. Louis, MO, USA
| | - R Kumar
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - A Wallman-Stokes
- Department of Pediatrics, Division of Neonatology, Columbia University, New York, NY, USA
| | - Z A Vesoulis
- Department of Pediatrics, Division of Neonatology, Washington University School of Medicine, St. Louis, MO, USA
| | - R Sahni
- Department of Pediatrics, Division of Neonatology, Columbia University, New York, NY, USA
| | - S Ratcliffe
- University of Virginia School of Public Health Sciences, Charlottesville, VA, USA.,University of Virginia Center for Advanced Medical Analytics, Charlottesville, VA, USA
| | - D E Lake
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, USA.,University of Virginia Center for Advanced Medical Analytics, Charlottesville, VA, USA
| | - J R Moorman
- Department of Medicine, Division of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, USA.,University of Virginia Center for Advanced Medical Analytics, Charlottesville, VA, USA
| | - K D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia School of Medicine, Charlottesville, VA, USA.,University of Virginia Center for Advanced Medical Analytics, Charlottesville, VA, USA
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Altamirano AE, Wilson CG. An overview of developmental dysregulation of autonomic control in infants. Birth Defects Res 2021; 113:864-871. [PMID: 33421331 DOI: 10.1002/bdr2.1855] [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: 11/14/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022]
Abstract
In this short review, we provide an overview of developmental disorders causing autonomic nervous system dysregulation. We briefly discuss perinatal conditions that adversely impact developmental outcomes including apnea of prematurity, sudden infant death syndrome, and Rett syndrome. We provide a brief clinical description, an overview of known or hypothesized mechanisms for the disorder, and current standard of practice for treatment of each condition. Additionally, we consider preventative measures and complications of these disorders to provide further insight into the pathogenesis of specific autonomic dysregulation in neonates. The goal of this short review is to provide an updated understanding of the impact of autonomic dysregulation on development of brainstem circuits and to briefly highlight promising future treatment options and controversies.
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Affiliation(s)
- Adulzir E Altamirano
- Center for Health Disparities, Loma Linda University, Loma Linda, California, USA.,Lawrence D. Longo, M.D. Center for Perinatal Biology, Loma Linda, California, USA
| | - Christopher G Wilson
- Lawrence D. Longo, M.D. Center for Perinatal Biology, Loma Linda, California, USA
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36
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AIM in Neonatal and Paediatric Intensive Care. Artif Intell Med 2021. [DOI: 10.1007/978-3-030-58080-3_309-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Immature control of breathing and apnea of prematurity: the known and unknown. J Perinatol 2021; 41:2111-2123. [PMID: 33712716 PMCID: PMC7952819 DOI: 10.1038/s41372-021-01010-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
This narrative review provides a broad perspective on immature control of breathing, which is universal in infants born premature. The degree of immaturity and severity of clinical symptoms are inversely correlated with gestational age. This immaturity presents as prolonged apneas with associated bradycardia or desaturation, or brief respiratory pauses, periodic breathing, and intermittent hypoxia. These manifestations are encompassed within the clinical diagnosis of apnea of prematurity, but there is no consensus on minimum criteria required for diagnosis. Common treatment strategies include caffeine and noninvasive respiratory support, but other therapies have also been advocated with varying effectiveness. There is considerable variability in when and how to initiate and discontinue treatment. There are significant knowledge gaps regarding effective strategies to quantify the severity of clinical manifestations of immature breathing, which prevent us from better understanding the long-term potential adverse outcomes, including neurodevelopment and sudden unexpected infant death.
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38
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Gross M, Poets A, Steinfeldt R, Urschitz MS, Böckmann K, Haase B, Poets CF. Randomized Longitudinal Study Comparing Three Nasal Respiratory Support Modes to Prevent Intermittent Hypoxia in Very Preterm Infants. CHILDREN 2020; 7:children7100168. [PMID: 33027941 PMCID: PMC7650757 DOI: 10.3390/children7100168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Abstract
Nasal continuous positive airway pressure (NCPAP) devices using variable (vf-) and continuous (cf-) flow or synchronized nasal intermittent positive pressure ventilation (s-NIPPV) are used to prevent or treat intermittent hypoxia (IH) in preterm infants. Results concerning which is most effective vary. We aimed to investigate the effect of s-NIPPV and vf-NCPAP compared to cf-NCPAP on the rate of IH episodes. Preterm infants with a gestational age of 24.9–29.7 weeks presenting with IH while being treated with cf-NCPAP were monitored for eight hours, then randomized to eight hours of treatment with vf-NCPAP or s-NIPPV. Data from 16 infants were analyzed. Due to an unexpectedly low sample size, the results were only reported descriptively. No relevant changes in the rate of IH events were detected between cf- vs. vf-NCPAP or between cf-NCPAP vs. s-NIPPV. Although limited by its small sample size, s-NIPPV, vf- and cf-NCPAP seemed to be similarly effective in the treatment of IH in these infants.
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Affiliation(s)
- Maximilian Gross
- Department of Neonatology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany; (M.G.); (A.P.); (K.B.); (B.H.)
| | - Anette Poets
- Department of Neonatology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany; (M.G.); (A.P.); (K.B.); (B.H.)
| | | | - Michael S. Urschitz
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg University Mainz, 55131 Mainz, Germany;
| | - Katrin Böckmann
- Department of Neonatology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany; (M.G.); (A.P.); (K.B.); (B.H.)
| | - Bianca Haase
- Department of Neonatology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany; (M.G.); (A.P.); (K.B.); (B.H.)
| | - Christian F. Poets
- Department of Neonatology, University Children’s Hospital Tübingen, 72076 Tübingen, Germany; (M.G.); (A.P.); (K.B.); (B.H.)
- Correspondence: ; Tel.: +49-707-1298-0895; Fax: +49-707-129-3969
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Kovatis KZ, Di Fiore JM, Martin RJ, Abbasi S, Chaundhary AS, Hoover S, Zhang Z, Kirpalani H. Effect of Blood Transfusions on Intermittent Hypoxic Episodes in a Prospective Study of Very Low Birth Weight Infants. J Pediatr 2020; 222:65-70. [PMID: 32423683 DOI: 10.1016/j.jpeds.2020.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 02/18/2020] [Accepted: 03/09/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To compare the number of intermittent hypoxia events before and after packed red blood cell (pRBC) and non-pRBC transfusions in very low birth weight infants, and to compare the time spent with saturations of ≤85% before and after transfusions in the same population. STUDY DESIGN This prospective observational study was conducted from April 2014 to August 2017. It included 92 transfusions (81 pRBC, 11 non-pRBC) from 41 very low birth weight infants between 230/7 and 286/7 weeks of gestation. The primary outcome was number of intermittent hypoxia events. Secondary outcomes included the percent time of Peripheral capillary oxygen saturation (SpO2)of ≤85%, ≤80%, and ≤75%. A mixed ANOVA model was used to examine the relationship between event rate and covariates. RESULTS The mean number of intermittent hypoxia events per hour decreased from 5.27 ± 5.02 events per hour before pRBC transfusion to 3.61 ± 3.17 per hour after pRBC transfusions (P < .01) and intermittent hypoxia did not change after non-RBC transfusions (before, 4.45 ± 3.19 vs after, 4.47 ± 2.78; P = NS). The percent time with saturations of ≤80% and ≤75% significantly decreased after pRBC transfusions (P = .01). The time with saturations of ≤85% did not significantly change after non-pRBC transfusion. CONCLUSIONS In very low birth weight infants with a hematocrit of 20%-42%, pRBC transfusions are associated with decreased frequency of intermittent hypoxia. No such diminution of intermittent hypoxia events was observed in infants who had received a non-pRBC transfusion. This finding suggests that the observed beneficial effects of RBC transfusions on apnea and its clinical manifestations of intermittent hypoxia are mediated through an enhanced oxygen carrying capacity.
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Affiliation(s)
- Kelley Z Kovatis
- Department of Neonatology, Christiana Care Health System, Newark, DE.
| | - Juliann M Di Fiore
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Richard J Martin
- Division of Neonatology, Case Western Reserve University, Cleveland, OH; Division of Neonatology, Rainbow Babies & Children's Hospital, Cleveland, OH
| | - Soraya Abbasi
- Division of Neonatology, Pennsylvania Hospital, Philadelphia, PA; Division of Neonatology, University of Pennsylvania, Philadelphia, PA
| | | | - Stephen Hoover
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Zugui Zhang
- Value Institute, Case Western Reserve University, Cleveland, OH
| | - Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA
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40
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Martini S, Frabboni G, Rucci P, Czosnyka M, Smielewski P, Galletti S, Vitali F, Faldella G, Austin T, Corvaglia L. Cardiorespiratory Events in Infants Born Preterm during the Transitional Period. J Pediatr 2020; 221:32-38.e2. [PMID: 32446489 DOI: 10.1016/j.jpeds.2020.02.037] [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: 11/27/2019] [Revised: 01/22/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate the features of cardiorespiratory events in infants born preterm during the transitional period, and to evaluate whether different neonatal characteristics may correlate with event type, duration, and severity. STUDY DESIGN Infants with gestational age (GA) <32 weeks and/or birth weight <1500 g were enrolled in this observational prospective study. Heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded continuously over the first 72 hours. Cardiorespiratory events of ≥10 seconds were clustered into isolated desaturation (SpO2 <85%), isolated bradycardia (HR <100 bpm or <70% of baseline), or combined desaturation/bradycardia and classified as mild, moderate, or severe. The daily incidences of isolated desaturation, isolated bradycardia, and combined desaturation and bradycardia were analyzed. The effects of relevant clinical variables on cardiorespiratory event type and severity were assessed using generalized estimating equations. RESULTS Among the 1050 events analyzed, isolated desaturations were the most frequent (n = 625) and isolated bradycardias the least common (n = 171). The number of cardiorespiratory events increased significantly from day 1 to day 2 (P = .028). One in 5 events had severe characteristics; event severity was highest for combined desaturation and bradycardia (P < .001). Compared with other event types, the incidence of combined desaturation and bradycardia was inversely correlated with GA (P = .029) and was higher with the use of continuous positive airway pressure (P = .002). The presence of a hemodynamically significant patent ductus arteriosus was associated with the occurrence of isolated desaturations (P = .001) and with a longer duration of cardiorespiratory events (P = .003). CONCLUSIONS Cardiorespiratory events during transition exhibit distinct types, duration, and severity. Neonatal characteristics are associated with the clinical features of these events, indicating that a tailored clinical approach may reduce the hypoxic burden in preterm infants aged 0-72 hours.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC).
| | - Giulia Frabboni
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Paola Rucci
- Division of Hygiene and Biostatistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Silvia Galletti
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
| | - Francesca Vitali
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
| | - Topun Austin
- Neonatal Intensive Care Unit, The Rosie Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Luigi Corvaglia
- Neonatal Intensive Care Unit, St Orsola-Malpighi University Hospital, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC)
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Beyeler SA, Hodges MR, Huxtable AG. Impact of inflammation on developing respiratory control networks: rhythm generation, chemoreception and plasticity. Respir Physiol Neurobiol 2020; 274:103357. [PMID: 31899353 DOI: 10.1016/j.resp.2019.103357] [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: 07/31/2019] [Revised: 11/17/2019] [Accepted: 12/02/2019] [Indexed: 10/25/2022]
Abstract
The respiratory control network in the central nervous system undergoes critical developmental events early in life to ensure adequate breathing at birth. There are at least three "critical windows" in development of respiratory control networks: 1) in utero, 2) newborn (postnatal day 0-4 in rodents), and 3) neonatal (P10-13 in rodents, 2-4 months in humans). During these critical windows, developmental processes required for normal maturation of the respiratory control network occur, thereby increasing vulnerability of the network to insults, such as inflammation. Early life inflammation (induced by LPS, chronic intermittent hypoxia, sustained hypoxia, or neonatal maternal separation) acutely impairs respiratory rhythm generation, chemoreception and increases neonatal risk of mortality. These early life impairments are also greater in young males, suggesting sex-specific impairments in respiratory control. Further, neonatal inflammation has a lasting impact on respiratory control by impairing adult respiratory plasticity. This review focuses on how inflammation alters respiratory rhythm generation, chemoreception and plasticity during each of the three critical windows. We also highlight the need for additional mechanistic studies and increased investigation into how glia (such as microglia and astrocytes) play a role in impaired respiratory control after inflammation. Understanding how inflammation during critical windows of development disrupt respiratory control networks is essential for developing better treatments for vulnerable neonates and preventing adult ventilatory control disorders.
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Affiliation(s)
- Sarah A Beyeler
- Department of Human Physiology, University of Oregon, Eugene, OR, 97403, United States
| | - Matthew R Hodges
- Department of Physiology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
| | - Adrianne G Huxtable
- Department of Human Physiology, University of Oregon, Eugene, OR, 97403, United States.
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Continuous vital sign analysis for predicting and preventing neonatal diseases in the twenty-first century: big data to the forefront. Pediatr Res 2020; 87:210-220. [PMID: 31377752 PMCID: PMC6962536 DOI: 10.1038/s41390-019-0527-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 07/20/2019] [Accepted: 07/25/2019] [Indexed: 01/03/2023]
Abstract
In the neonatal intensive care unit (NICU), heart rate, respiratory rate, and oxygen saturation are vital signs (VS) that are continuously monitored in infants, while blood pressure is often monitored continuously immediately after birth, or during critical illness. Although changes in VS can reflect infant physiology or circadian rhythms, persistent deviations in absolute values or complex changes in variability can indicate acute or chronic pathology. Recent studies demonstrate that analysis of continuous VS trends can predict sepsis, necrotizing enterocolitis, brain injury, bronchopulmonary dysplasia, cardiorespiratory decompensation, and mortality. Subtle changes in continuous VS patterns may not be discerned even by experienced clinicians reviewing spot VS data or VS trends captured in the monitor. In contrast, objective analysis of continuous VS data can improve neonatal outcomes by allowing heightened vigilance or preemptive interventions. In this review, we provide an overview of the studies that have used continuous analysis of single or multiple VS, their interactions, and combined VS and clinical analytic tools, to predict or detect neonatal pathophysiology. We make the case that big-data analytics are promising, and with continued improvements, can become a powerful tool to mitigate neonatal diseases in the twenty-first century.
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Lim K, Jiang H, Marshall AP, Salmon B, Gale TJ, Dargaville PA. Predicting Apnoeic Events in Preterm Infants. Front Pediatr 2020; 8:570. [PMID: 33042915 PMCID: PMC7525015 DOI: 10.3389/fped.2020.00570] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
Apnoea, a pause in respiration, is almost ubiquitous in preterm infants born before completing 30 weeks gestation. Apnoea often begets hypoxemia and/or bradycardia, and has the potential to result in adverse neurodevelopmental consequences. Our current inability to predict apnoeic events in preterm infants requires apnoea to first be detected by monitoring device/s in order to trigger an intervention by bedside (medical or nursing) staff. Such a reactive management approach is laborious, and makes the consequences of apnoeic events inevitable. Recent technological advances and improved signal processing have allowed the possibility of developing prediction models for apnoeic events in preterm infants. However, the development of such models has numerous challenges and is only starting to show potential. This paper identifies requisite components and current gaps in developing prediction models for apnoeic events, and reviews previous studies on predicting apnoeic events in preterm infants.
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Affiliation(s)
- Kathleen Lim
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia.,Neonatal and Pediatric Intensive Care Unit, Royal Hobart Hospital, Hobart, TAS, Australia
| | - Haimin Jiang
- School of Engineering, College of Science, Engineering and Technology, University of Tasmania, Hobart, TAS, Australia
| | - Andrew P Marshall
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia.,School of Engineering, College of Science, Engineering and Technology, University of Tasmania, Hobart, TAS, Australia
| | - Brian Salmon
- School of Engineering, College of Science, Engineering and Technology, University of Tasmania, Hobart, TAS, Australia
| | - Timothy J Gale
- School of Engineering, College of Science, Engineering and Technology, University of Tasmania, Hobart, TAS, Australia
| | - Peter A Dargaville
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia.,Neonatal and Pediatric Intensive Care Unit, Royal Hobart Hospital, Hobart, TAS, Australia
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McDonald FB, Dempsey EM, O'Halloran KD. The impact of preterm adversity on cardiorespiratory function. Exp Physiol 2019; 105:17-43. [PMID: 31626357 DOI: 10.1113/ep087490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 10/15/2019] [Indexed: 12/16/2022]
Abstract
NEW FINDINGS What is the topic of this review? We review the influence of prematurity on the cardiorespiratory system and examine the common sequel of alterations in oxygen tension, and immune activation in preterm infants. What advances does it highlight? The review highlights neonatal animal models of intermittent hypoxia, hyperoxia and infection that contribute to our understanding of the effect of stress on neurodevelopment and cardiorespiratory homeostasis. We also focus on some of the important physiological pathways that have a modulatory role on the cardiorespiratory system in early life. ABSTRACT Preterm birth is one of the leading causes of neonatal mortality. Babies that survive early-life stress associated with immaturity have significant prevailing short- and long-term morbidities. Oxygen dysregulation in the first few days and weeks after birth is a primary concern as the cardiorespiratory system slowly adjusts to extrauterine life. Infants exposed to rapid alterations in oxygen tension, including exposures to hypoxia and hyperoxia, have altered redox balance and active immune signalling, leading to altered stress responses that impinge on neurodevelopment and cardiorespiratory homeostasis. In this review, we explore the clinical challenges posed by preterm birth, followed by an examination of the literature on animal models of oxygen dysregulation and immune activation in the context of early-life stress.
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Affiliation(s)
- Fiona B McDonald
- Department of Physiology, School of Medicine, College of Medicine & Health, University College Cork, Cork, Ireland.,Irish Centre for Fetal and Neonatal Translational Research (INFANT) Research Centre, University College Cork, Cork, Ireland
| | - Eugene M Dempsey
- Irish Centre for Fetal and Neonatal Translational Research (INFANT) Research Centre, University College Cork, Cork, Ireland.,Department of Paediatrics & Child Health, School of Medicine, College of Medicine & Health, Cork University Hospital, Wilton, Cork, Ireland
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, College of Medicine & Health, University College Cork, Cork, Ireland.,Irish Centre for Fetal and Neonatal Translational Research (INFANT) Research Centre, University College Cork, Cork, Ireland
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Marshall AP, Lim K, Ali SK, Gale TJ, Dargaville PA. Physiological instability after respiratory pauses in preterm infants. Pediatr Pulmonol 2019; 54:1712-1721. [PMID: 31313528 DOI: 10.1002/ppul.24451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/18/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND The factors influencing the severity of apnea-related hypoxemia and bradycardia are incompletely characterized, especially in infants receiving noninvasive respiratory support. OBJECTIVES To identify the frequency and predictors of physiological instability (hypoxemia-oxygen saturation (SpO2 ) <80%, or bradycardia-heart rate (HR) < 100 bpm) following respiratory pauses in infants receiving noninvasive respiratory support. METHODS Respiratory pause duration, derived from capsule pneumography, was measured in 30 preterm infants of gestation 30 (24-32) weeks [median (interquartile range)] receiving noninvasive respiratory support and supplemental oxygen. For identified pauses of 5 to 29 seconds duration, we measured the magnitude and duration of SpO2 and HR reductions over a period starting at the pause onset and ending 60 seconds after resumption of breathing. Temporally clustered pauses (<60 seconds separation) were analyzed separately. The relative contribution of respiratory pauses to overall physiological instability was determined, and predictors of instability were sought in regression analysis, including demographic, clinical and situational variables as inputs. RESULTS In total, 17 105 isolated and 9180 clustered pauses were identified. Hypoxemia and bradycardia were more likely after longer duration and temporally-clustered pauses. However, the majority of such episodes occurred after 5 to 9 second pauses given their numerical preponderance, and short-lived pauses made a substantial contribution to physiological instability overall. Birth gestation, hemoglobin concentration, form of respiratory support, caffeine treatment, respiratory pause duration and temporal clustering were identified as predictors of instability. CONCLUSIONS Brief respiratory pauses, especially when clustered, contribute substantially to hypoxemia and bradycardia in preterm infants.
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Affiliation(s)
- Andrew P Marshall
- School of Engineering, College of Science Engineering and Technology, University of Tasmania, Hobart, Tasmania, Australia
| | - Kathleen Lim
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Sanoj K Ali
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Timothy J Gale
- School of Engineering, College of Science Engineering and Technology, University of Tasmania, Hobart, Tasmania, Australia
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
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Nagraj VP, Sinkin RA, Lake DE, Moorman JR, Fairchild KD. Recovery from bradycardia and desaturation events at 32 weeks corrected age and NICU length of stay: an indicator of physiologic resilience? Pediatr Res 2019; 86:622-627. [PMID: 31272102 PMCID: PMC6851471 DOI: 10.1038/s41390-019-0488-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/13/2019] [Accepted: 06/16/2019] [Indexed: 11/13/2022]
Abstract
BACKGROUND Preterm very low birth weight (VLBW) infants experience physiologic maturation and transitions off therapies from 32 to 35 weeks postmenstrual age (PMA), which may impact episodic bradycardia and oxygen desaturation. We sought to characterize bradycardias and desaturations from 32 to 35 weeks PMA and test whether events at 32 weeks PMA are associated with NICU length of stay. METHODS For 265 VLBW infants from 32 to 35 weeks PMA, we quantified the number and duration of bradycardias (HR <100 for ≥4 s) and desaturations (SpO2 <80% for ≥10 s) and compared events around discontinuation of CPAP, caffeine, and supplemental oxygen. We modeled associations between clinical variables, bradycardias and desaturations at 32 weeks PMA, and discharge PMA. RESULTS Desaturations decreased from 60 to 41 per day at 32 and 35 weeks, respectively (p < 0.01). Duration of desaturations and number and duration of bradycardias decreased to a smaller extent (p < 0.05), and there was a non-significant trend toward increased desaturations after stopping CPAP and caffeine. Controlling for clinical variables, longer duration of bradycardias and desaturations at 32 weeks PMA was associated with later discharge PMA. CONCLUSION Delayed recovery from bradycardias and desaturations at 32 weeks PMA, perhaps reflecting less physiologic resilience, is associated with prolonged NICU stay for VLBW infants.
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Affiliation(s)
- V Peter Nagraj
- School of Medicine Research Computing, University of Virginia, Charlottesville, VA
| | - Robert A Sinkin
- Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Douglas E Lake
- Department of Medicine, University of Virginia, Charlottesville, VA
| | | | - Karen D Fairchild
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA.
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Oxygen desaturations in the early neonatal period predict development of bronchopulmonary dysplasia. Pediatr Res 2019; 85:987-993. [PMID: 30374050 PMCID: PMC6488465 DOI: 10.1038/s41390-018-0223-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND Bradycardia and oxygen desaturation episodes are common among preterm very low birth weight (VLBW) infants in the Neonatal Intensive Care Unit (NICU), and their association with adverse outcomes such as bronchopulmonary dysplasia (BPD) is unclear. METHODS For 502 VLBW infants we quantified bradycardias (HR < 100 for ≥ 4 s) and desaturations (SpO2 < 80% for ≥ 10 s), combined bradycardia and desaturation (BD) events, and percent time in events in the first 4 weeks after birth (32 infant-years of data). We tested logistic regression models of clinical risks (including a respiratory acuity score incorporating FiO2 and level of respiratory support) to estimate the risks of BPD or death and secondary outcomes. We then tested the additive value of the bradycardia and desaturation metrics for outcomes prediction. RESULTS BPD occurred in 187 infants (37%). The clinical risk model had ROC area for BPD of 0.874. Measures of desaturation, but not bradycardia, significantly added to the predictive model. Desaturation metrics also added to clinical risks for prediction of severe intraventricular hemorrhage, retinopathy of prematurity and prolonged length of stay in the NICU. CONCLUSIONS Oxygen desaturations in the first month of the NICU course are associated with risk of BPD and other morbidities in VLBW infants.
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Intermittent hypoxemia and oxidative stress in preterm infants. Respir Physiol Neurobiol 2019; 266:121-129. [PMID: 31100375 DOI: 10.1016/j.resp.2019.05.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/17/2019] [Accepted: 05/10/2019] [Indexed: 01/11/2023]
Abstract
Intermittent hypoxemia events (IH) are common in extremely preterm infants and are associated with many poor outcomes including retinopathy or prematurity, wheezing, bronchopulmonary dysplasia, cognitive or language delays and motor impairment. More recent data in animal and rodent models have suggested that specific patterns of IH may increase the risk for morbidity. The pathway by which these high risk patterns of IH initiate a pathological cascade is unknown but animal models suggest that oxidative stress may play a role. This review describes early postnatal patterns of IH in preterm infants, their relationship with morbidity, oxidative stress biomarkers relevant to the newborn infant and the relationship between IH and reactive oxygen species.
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Dennery PA, Di Fiore JM, Ambalavanan N, Bancalari E, Carroll JL, Claure N, Hamvas A, Hibbs AM, Indic P, Kemp J, Krahn KN, Lake D, Laposky A, Martin RJ, Natarajan A, Rand C, Schau M, Weese-Mayer DE, Zimmet AM, Moorman JR. Pre-Vent: the prematurity-related ventilatory control study. Pediatr Res 2019; 85:769-776. [PMID: 30733614 PMCID: PMC6503843 DOI: 10.1038/s41390-019-0317-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/10/2019] [Accepted: 01/16/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The increasing incidence of bronchopulmonary dysplasia in premature babies may be due in part to immature ventilatory control, contributing to hypoxemia. The latter responds to ventilation and/or oxygen therapy, treatments associated with adverse sequelae. This is an overview of the Prematurity-Related Ventilatory Control Study which aims to analyze the under-utilized cardiorespiratory continuous waveform monitoring data to delineate mechanisms of immature ventilatory control in preterm infants and identify predictive markers. METHODS Continuous ECG, heart rate, respiratory, and oxygen saturation data will be collected throughout the NICU stay in 500 infants < 29 wks gestation across 5 centers. Mild permissive hypercapnia, and hyperoxia and/or hypoxia assessments will be conducted in a subcohort of infants along with inpatient questionnaires, urine, serum, and DNA samples. RESULTS Primary outcomes will be respiratory status at 40 wks and quantitative measures of immature breathing plotted on a standard curve for infants matched at 36-37 wks. Physiologic and/or biologic determinants will be collected to enhance the predictive model linking ventilatory control to outcomes. CONCLUSIONS By incorporating bedside monitoring variables along with biomarkers that predict respiratory outcomes we aim to elucidate individualized cardiopulmonary phenotypes and mechanisms of ventilatory control contributing to adverse respiratory outcomes in premature infants.
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Affiliation(s)
- Phyllis A. Dennery
- Brown University, Warren Alpert School of Medicine, Hasbro Children’s Hospital, Providence, RI,Address for Correspondence Phyllis A. Dennery, MD, Department of Pediatrics, Warren Alpert School of Medicine at Brown University, Office of the Chair, Hasbro Children’s Hospital, 593 Eddy Street, Suite 125 / Providence, RI 02903, (401) 444-5648,
| | - Juliann M. Di Fiore
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Namasivayam Ambalavanan
- University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics Molecular and Cellular Pathology, and Cell, Developmental, and Integrative Biology, Birmingham, AL
| | - Eduardo Bancalari
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - John L. Carroll
- University of Arkansas for Medical Science, Department of Pediatrics, Little Rock, AR
| | - Nelson Claure
- University of Miami Miller School of Medicine, Holtz Children’s Hospital - Jackson Memorial Medical Center, Division of Neonatology, Department of Pediatrics, Miami, FL
| | - Aaron Hamvas
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Anna Maria Hibbs
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Premananda Indic
- University of Texas Tyler, Department of Electrical Engineering, University of Alabama at Birmingham School of Med, Div. of Neonatology, Dept. Pediatrics, Tyler, TX
| | - James Kemp
- Washington University School of Medicine in St. Louis, Department of Pediatrics, St. Louis, MO
| | - Katy N. Krahn
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Douglas Lake
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - Aaron Laposky
- National Institute of Health, National Center of Sleep Disorders Research, Bethesda, MD
| | - Richard J. Martin
- Case Western Reserve University, School of Medicine, Department of Pediatrics, University Hospitals: Rainbow Babies & Children’s Hospital, Division of Neonatology, Cleveland, OH
| | - Aruna Natarajan
- Division of Lung Diseases, National Heart Lung and Blood Institute, National Institute of Health, Bethesda, MD
| | - Casey Rand
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Molly Schau
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Debra E. Weese-Mayer
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Stanley Manne Children’s Research Institute, Chicago, IL
| | - Amanda M. Zimmet
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
| | - J. Randall Moorman
- University of Virginia School of Medicine, Division of Cardiovascular Medicine, Charlottesville, VA
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Massoud M, Kühlmann AYR, van Dijk M, Staals LM, Wijnen RMH, van Rosmalen J, Sloots CEJ, Keyzer-Dekker CMG. Does the Incidence of Postoperative Complications After Inguinal Hernia Repair Justify Hospital Admission in Prematurely and Term Born Infants? Anesth Analg 2019; 128:525-532. [DOI: 10.1213/ane.0000000000003386] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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