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Korček P, Širc J, Berka I, Kučera J, Straňák Z. Does perinatal management have the potential to reduce the risk of intraventricular hemorrhage in preterm infants? Front Pediatr 2024; 12:1361074. [PMID: 38357510 PMCID: PMC10864433 DOI: 10.3389/fped.2024.1361074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/18/2024] [Indexed: 02/16/2024] Open
Abstract
Background Intraventricular hemorrhage (IVH) is an important cause of neurodevelopmental impairment in preterm infants. A number of risk factors for IVH have already been proposed; however, some controversies regarding optimal perinatal management persist. This study aimed to identify perinatal and neonatal attributes associated with IVH in a representative population of preterm infants. Methods Perinatal data on 1,279 very preterm infants (<32 weeks of gestation) admitted to a tertiary neonatal intensive care unit were analyzed. The records were assessed using univariate analysis and logistic regression model to evaluate the risk factors for any and high-grade IVH (grade III-IV according to the classification by Papile) within the first week after birth. Results The incidence of any IVH was 14.3% (183/1,279); the rate of low-grade (I-II) and high-grade (III-IV) IVH was 9.0% (115/1,279) and 5.3% (68/1,279), respectively. Univariate analysis revealed multiple factors significantly associated with intraventricular hemorrhage: lower gestational age and birth weight, absence of antenatal steroids, vaginal delivery, low Apgar score at 5 min, delivery room intubation, surfactant administration, high frequency oscillation, pulmonary hypertension, pulmonary hemorrhage, tension pneumothorax, persistent ductus arteriosus, hypotension and early onset sepsis. Logistic regression confirmed lower gestational age, vaginal delivery, ductus arteriosus and early onset sepsis to be independent predictors for any IVH. Pulmonary hemorrhage, tension pneumothorax and early onset sepsis were independent risk factors for high-grade IVH. Complete course of antenatal steroids was associated with a lower risk for any (odds ratio 0.58, 95% confidence interval 0.39-0.85; P = .006) and for high-grade intraventricular hemorrhage (odds ratio 0.36, 95% confidence interval 0.20-0.65; P < .001). Conclusion The use of antenatal steroids and mode of delivery are crucial in the prevention of IVH; however, our study did not confirm the protective effect of placental transfusion. Severe respiratory insufficiency and circulatory instability remain to be powerful contributors to the development of IVH. Early detection and management of perinatal infection may also help to reduce the rate of brain injury and improve neurodevelopment in high-risk newborns.
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Affiliation(s)
- Peter Korček
- Neonatal Intensive Care Unit, Institute for the Care of Mother and Child, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Širc
- Neonatal Intensive Care Unit, Institute for the Care of Mother and Child, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ivan Berka
- Neonatal Intensive Care Unit, Institute for the Care of Mother and Child, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jáchym Kučera
- Neonatal Intensive Care Unit, Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Zbyněk Straňák
- Neonatal Intensive Care Unit, Institute for the Care of Mother and Child, Prague, Czech Republic
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
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Jin D, Gu X, Jiang S, Wang Y, Yang T, Lu Y, Cao Y, Lee SK, Wu H. The Association between Evidence-Based Healthcare Practices and Outcomes among Preterm Births in China. Neonatology 2022; 119:26-32. [PMID: 34883485 DOI: 10.1159/000519846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Very preterm infants are at high risk of early death or severe brain injury, with potential for impaired long-term neurodevelopmental function and physical health. There are evidence-based healthcare practices that can reduce the incidence. MATERIALS AND METHODS Infants born at 24-316 weeks gestational age and admitted within 24 h to NICUs participating in the Chinese Neonatal Network in 2019 were included. We examined the association between 4 evidence-based practices: inborn (born in a tertiary hospital in the Chinese Neonatal Network), ACS (any antenatal corticosteroid), MgSO4 (prenatal magnesium sulfate), and NT (normothermic temperature [36.0-37.5°C] at admission) and early death and/or severe brain injury in the study population. RESULTS Of 6,035 eligible infants, the incidence of early death and/or severe brain injury was 10.6%. Exposure to ACS only was associated with significant lower incidence of death and/or severe brain injury than none (aOR, 0.71; 95% CI: 0.57-0.88), but not MgSO4 only (aOR, 0.97; 95% CI: 0.81-1.17), NT only (aOR, 0.91; 95% CI: 0.76-1.08), or inborn only (aOR, 0.91; 95% CI: 0.72-1.15). The association between number of practices and incidence of early death and/or severe brain injury is as follows: none = 23% (31/138), any 1 = 14% (84/592), any 2 = 12% (185/1,538), any 3 = 9% (202/2,285), and all 4 = 9% (140/1,482). DISCUSSION/CONCLUSION More comprehensive use of evidence-based practices was associated with improved survival without severe brain injury among very preterm infants born at <32 weeks gestational age.
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Affiliation(s)
- Di Jin
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China,
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yanchen Wang
- NHC Key Laboratory of Neonatal Diseases (Fudan University), Children's Hospital of Fudan University, Shanghai, China
| | - Tongling Yang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yulan Lu
- Center for Molecular Medicine, Pediatrics Research Institute, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Maternal-Infant Care Research Centre, Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Department of Obstetrics and Gynecology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Hui Wu
- Department of Neonatology, The First Hospital of Jilin University, Changchun, China
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Yue G, Wu Y, Zhao F, Zhang C, Zhao D, Lu J, Fang Q, Li X, Wei Y, Qian M, Yi L, Zheng S, Ba R, Luo L, Luo J, Zhao S, Lu J, Huang X, Wei G, Xi Y, Gao S, Hu X, Ju R. A 3-armed multicenter randomized controlled trial: Placental Transfusion in Very Preterm Infants (PT-VPI). Contemp Clin Trials 2021; 103:106337. [PMID: 33662589 DOI: 10.1016/j.cct.2021.106337] [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: 11/08/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022]
Abstract
Preterm infants constitute an important proportion of neonatal deaths and various complications, and very preterm infants (VPI) are more likely to develop severe complications, such as intraventricular hemorrhage (IVH), anemia, and sepsis. It has been confirmed that placental transfusion can supplement blood volume in infants and reduce preterm-associated complications, which is further conducive to the development of the nervous system and a better long-term prognosis. Based on these advantages, placental transfusion has been widely used in VPI. There are three main types of placental transfusion: delayed cord clamping (DCC), intact umbilical cord milking (I-UCM), and cut umbilical cord milking (C-UCM). However, the optimal method for PT-VPI remains controversial, and it is urgent to identify the best method of placental transfusion. We plan to fully evaluate the safety and effectiveness of these three placental transfusion methods in VPI in a 3-arm multicenter randomized controlled trial: Placental Transfusion in Very Preterm Infants (PT-VPI). Trial registration: chictr.org.cn, number ChiCTR2000030953.
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Affiliation(s)
- Guang Yue
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Yan Wu
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, PR China
| | - Fangping Zhao
- Neonatal Department, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, PR China
| | - Chunyi Zhang
- Neonatal Department, Guangdong Women and Children Hospital, Guangzhou, PR China
| | - Dan Zhao
- Neonatal Department, Maternity and Child-Care Hospital of Guangxi Zhuang Autonomous Region, Nanning, PR China
| | - Jingjie Lu
- Neonatal Department, Guiyang Maternal and Child Health Hospital, Guizhou, PR China
| | - Qiaoyan Fang
- Neonatal Department, Hunan Provincial Maternal and Child Healthcare Hospital, Changsha, PR China
| | - Xia Li
- Neonatal Department, Jinan Maternity and Child-Care Hospital, Jinan, PR China
| | - Yijun Wei
- Neonatal Department, Liuzhou Maternity and Child Healthcare Hospital, Liuzhou, PR China
| | - Miao Qian
- Neonatal Department, Nanjing Maternity and Child Health Care Hospital, Nanjing, PR China
| | - Lin Yi
- Neonatal Department, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, PR China
| | - Shan Zheng
- Neonatal Department, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjin, PR China
| | - Ruihua Ba
- Neonatal Department, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, PR China
| | - Liqian Luo
- Neonatal Department, Northwest Women's and Children's Hospital, Xi'an, PR China
| | - Jiping Luo
- Neonatal Department, Xichang People's Hospital, Xichang, PR China
| | - Shuai Zhao
- Neonatal Department, The Affiliated Hospital of Southwest Medical University, Luzhou, PR China
| | - Jiangyi Lu
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Xia Huang
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Guoqing Wei
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Yufeng Xi
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Shuqiang Gao
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Xuhong Hu
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China
| | - Rong Ju
- Neonatal Department, Chengdu Women's and Children's Central Hospital, School of Medicine, School of Medicine, University of Electronic Science and Technology of China, Chengdu, PR China.
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Balasubramanian H, Ananthan A, Jain V, Rao SC, Kabra N. Umbilical cord milking in preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2020; 105:572-580. [PMID: 32152192 DOI: 10.1136/archdischild-2019-318627] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/15/2020] [Accepted: 02/19/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of the efficacy and safety of umbilical cord milking in preterm infants. DESIGN Randomised controlled trials comparing umbilical cord milking with delayed cord clamping/immediate cord clamping in preterm infants were identified by searching databases, clinical trial registries and reference list of relevant studies in November 2019. Fixed effects model was used to pool the data on various clinically relevant outcomes. MAIN OUTCOME MEASURES Mortality and morbidities in preterm neonates. RESULTS Nineteen studies (2014 preterm infants) were included. Five studies (n=922) compared cord milking with delayed cord clamping, whereas 14 studies (n=1092) compared milking with immediate cord clamping. Cord milking, as opposed to delayed cord clamping, significantly increased the risk of intraventricular haemorrhage (grade III or more) (risk ratio (RR): 1.95 (95% CI 1.01 to 3.76), p=0.05). When compared with immediate cord clamping, cord milking reduced the need for packed RBC transfusions (RR:0.56 (95% CI 0.43 to 0.73), p<0.001). There was limited information on long-term neurodevelopmental outcomes. The grade of evidence was moderate or low for the various outcomes analysed. CONCLUSION Umbilical cord milking, when compared with delayed cord clamping, significantly increased the risk of severe intraventricular haemorrhage in preterm infants, especially at lower gestational ages. Cord milking, when compared with immediate cord clamping, reduced the need for packed RBC transfusions but did not improve clinical outcomes. Hence, cord milking cannot be considered as placental transfusion strategy in preterm infants based on the currently available evidence.
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Affiliation(s)
| | - Anitha Ananthan
- Department of Neonatology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Vaibhav Jain
- Department of Neonatology, Surya Hospitals, Mumbai, Maharashtra, India
| | - Shripada C Rao
- Department of Neonatology, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Nandkishor Kabra
- Department of Neonatology, Surya Hospitals, Mumbai, Maharashtra, India
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Pérez-Iranzo A, Jarque A, Toledo JD, Tosca R. Less invasive surfactant administration reduces incidence of severe intraventricular haemorrage in preterms with respiratory distress syndrome: a cohort study. J Perinatol 2020; 40:1185-1192. [PMID: 32546828 DOI: 10.1038/s41372-020-0702-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 04/25/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Less invasive surfactant administration (LISA) has proved to safely improve morbidity in extreme preterms with respiratory distress syndrome (RDS). Its effect regarding intraventricular hemorrhage (IVH) remains controversial between most recent systematic reviews. We aimed to evaluate its effect over incidence of severe IVH in this population. STUDY DESIGN We compared the incidence of IVH in a prospective cohort of consecutively born preterm infants <34 weeks' gestation receiving LISA (n = 108) with a historical cohort receiving surfactant delivery via tracheal tube and managed with mechanical ventilation (n = 100). RESULTS No significant differences regarding perinatal characteristics were observed between both groups. There was a significant reduction in the incidence of severe IVH in LISA group as compared with the historical group [OR = 0.054 (95% CI 0.01-0.2) p = 0.000. NNT 5]. In addition, a significant trend towards decreased mortality was also observed in the study group [OR = 0.2 (95% CI 0.04-0.9) p = 0.027, NNT 9]. Intervention group infants also showed lower oxygenation requirements during the first 72 h post surfactant administration and a reduced incidence of pneumothorax. They were less frequently intubated [31 infants (28.4%) vs. 100 [100%]; P < 0.001] and required fewer days of mechanical ventilation. However, no significant difference in bronchopulmonary dysplasia incidence was observed between both groups. CONCLUSIONS LISA approach effectively reduces severe IVH in very low and low birth weight (BW) preterms with RDS. In addition we observe a significant trend towards reduction in both need and duration of MV support, air leak, and overall mortality in the intervention group.
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Affiliation(s)
- A Pérez-Iranzo
- Division of Neonatology, General and University Hospital, Castellon, Spain.
| | - A Jarque
- Division of Neonatology, General and University Hospital, Castellon, Spain
| | - J D Toledo
- Division of Neonatology, General and University Hospital, Castellon, Spain
| | - R Tosca
- Division of Neonatology, General and University Hospital, Castellon, Spain
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Abstract
Although risk for necrotizing enterocolitis (NEC) is often presented from the perspective of a premature infant's vulnerability to nonmodifiable risk factors, in this paper we describe the evidence and present recommendations to manage modifiable risks that are amenable to clinical actions. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, we present recommendations in the context of their supporting evidence in a way that balances risks (e.g. potential harm, cost) and benefits. Across the prenatal, intrapartum, early and late clinical course, strategies to limit NEC risk in premature infants are presented. Our goal is to summarize modifiable NEC risk factors, grade the evidence to offer quality improvement (QI) targets for healthcare teams and offer a patient-family advocate's perspective on how to engage parents to recognize and reduce NEC risk.
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Lim J, Hagen E. Reducing Germinal Matrix-Intraventricular Hemorrhage: Perinatal and Delivery Room Factors. Neoreviews 2019; 20:e452-e463. [PMID: 31371554 DOI: 10.1542/neo.20-8-e452] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Germinal matrix hemorrhage-intraventricular hemorrhage (IVH) is the most common form of brain injury in preterm infants. Although severe IVH has declined over the years, it still affects approximately 6% of infants born before 32 weeks of gestation. Most IVH cases are detectable by the first 24 hours after birth; therefore interventions to prevent IVH should focus on antenatal management for pregnant women and delivery room management. Obstetrical interventions, including antenatal corticosteroids, maternal rather than infant transport, and possibly elective cesarean delivery have been associated with a decreased risk of IVH. Neonatal interventions in the delivery room, including delayed cord clamping or umbilical cord milking, maintaining normothermia, avoiding fluctuations in cerebral blood flow, and optimal ventilation management are associated with a decreased risk of IVH. Multiple clinical trials are under way to further identify IVH risk factors, ability to monitor or predict IVH, and ideally prevent IVH altogether. This discussion will focus on reviewing current obstetric and neonatal management practices and their associations with germinal matrix hemorrhage-IVH.
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Affiliation(s)
- Jina Lim
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, CA
| | - Eunice Hagen
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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Umbilical cord milking in preterm infants: time to act. J Perinatol 2019; 39:889-890. [PMID: 30952948 DOI: 10.1038/s41372-019-0377-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 11/08/2022]
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