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Callahan KP, Kielt MJ, Feudtner C, Barkman D, Bamat N, Fierro J, Fiest E, DeMauro SB. Ranking Future Outcomes Most Important to Parents of Children with Bronchopulmonary Dysplasia. J Pediatr 2023; 259:113455. [PMID: 37172804 PMCID: PMC10524943 DOI: 10.1016/j.jpeds.2023.113455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/06/2023] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To assess which potential future outcomes are most important to parents of children with bronchopulmonary dysplasia, a disease that affects future respiratory, medical, and developmental outcomes for children born preterm. STUDY DESIGN We recruited parents from 2 children's hospitals' neonatal follow-up clinics and elicited their importance rating for 20 different potential future outcomes associated with bronchopulmonary dysplasia. These outcomes were identified and selected through a literature review and discussions with panels of parents and clinician stakeholders, via a discrete choice experiment. RESULTS One hundred and 5 parents participated. Overall, parents ranked "Will my child be more vulnerable to other problems because of having lung disease?" as the most important outcome, with other respiratory health related outcomes also highly ranked. Outcomes related to child development and effects on the family were among the lowest ranked. Individually, parents rated outcomes differently, resulting in a broad distribution of importance scores for many of the outcomes. CONCLUSIONS The overall rankings suggest that parents prioritize future outcomes related to physical health and safety. Notably, for guiding research, some top-rated outcomes are not traditionally measured in outcome studies. For guiding individual counseling, the broad distribution of importance scores for many outcomes highlights the extent to which parents differ in their prioritization of outcomes.
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Affiliation(s)
- Katharine Press Callahan
- Children's Hospital of Philadelphia; Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA.
| | | | - Chris Feudtner
- Children's Hospital of Philadelphia; Philadelphia, PA; Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania; Philadelphia, PA
| | | | - Nicolas Bamat
- Children's Hospital of Philadelphia; Philadelphia, PA
| | - Julie Fierro
- Children's Hospital of Philadelphia; Philadelphia, PA
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Ethical considerations in the management of infants with severe intraventricular hemorrhage. Semin Perinatol 2022; 46:151599. [PMID: 35450739 DOI: 10.1016/j.semperi.2022.151599] [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: 11/22/2022]
Abstract
Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.
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Abstract
While medical advancements have led to improved survival of extremely premature infants, children remain at risk for brain injury and neurodevelopmental impairment. Brain imaging can offer insight into an infant's acute and long-term outcome; however, counseling parents about the results and implications of brain imaging remains challenging. The purpose of this article is to review the current literature and describe the challenges associated with counseling families of premature infants on neuroimaging findings. We propose a framework to guide clinicians in counseling parents about brain imaging results, informed by best practices in other disciplines: (FIGURE): 1) Formulate a plan 2) Identify parental needs and values 3) Give information 4) Acknowledge Uncertainty 5) Recognize and Respond to emotions 6) Discuss Expectations and Establish follow-up.
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Affiliation(s)
- Sarah M Bernstein
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | | | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University Medical Center, Duke-Margolis Center for Health Policy, DUMC 3936, Durham, NC 27710, United States.
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Lemmon ME, Wusthoff CJ, Boss RD, Rasmussen LA. Ethical considerations in the care of encephalopathic neonates treated with therapeutic hypothermia. Semin Fetal Neonatal Med 2021; 26:101258. [PMID: 34176763 PMCID: PMC8627487 DOI: 10.1016/j.siny.2021.101258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Engaging with ethical issues is central to the management of neonatal encephalopathy (NE). As treatment for these neonates evolves, new ethical issues will arise and many existing challenges will remain. We highlight three key ethical issues that arise in the care of neonates with NE treated with therapeutic hypothermia: facilitating shared decision making, understanding futility, and defining the boundaries between standard of care and research. Awareness of these issues will help clinicians counsel families in light of evolving treatments and outcomes.
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Affiliation(s)
- Monica E. Lemmon
- Division of Pediatric Neurology and Developmental Medicine, Departments of Pediatrics and Population Health Sciences, Duke University School of Medicine, DUMC 3936, Durham, NC, 27710, USA,Corresponding author. (M.E. Lemmon)
| | - Courtney J. Wusthoff
- Departments of Neurology and Pediatrics, Stanford University, Stanford, 750 Welch Road, Suite 317, Palo Alto, CA, 94304, USA
| | - Renee D. Boss
- Division of Neonatology, Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Berman Institute of Bioethics, 200 N. Wolfe St, Suite 2019, Baltimore, MD, 21287, United States
| | - Lisa Anne Rasmussen
- Division of Palliative Care, Department of Family Medicine, Department of Neurology, Department of Pediatrics, Larner College of Medicine, University of Vermont, UVM Medical Center Palliative Care, 111 Colchester Avenue, Main Campus, Smith 262, Burlington, VT, 05401-1473, USA.
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Inder TE, de Vries LS, Ferriero DM, Grant PE, Ment LR, Miller SP, Volpe JJ. Neuroimaging of the Preterm Brain: Review and Recommendations. J Pediatr 2021; 237:276-287.e4. [PMID: 34146549 DOI: 10.1016/j.jpeds.2021.06.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 06/08/2021] [Accepted: 06/10/2021] [Indexed: 12/26/2022]
Affiliation(s)
- Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Donna M Ferriero
- Department of Neurology, University of California San Francisco, San Francisco, CA; Department of Pediatrics, University of California San Francisco, San Francisco, CA; Weill Institute of Neurosciences, University of California San Francisco, San Francisco, CA
| | - P Ellen Grant
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Laura R Ment
- Department of Pediatrics, Yale School of Medicine, New Haven, CT; Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Steven P Miller
- Department of Pediatrics, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Joseph J Volpe
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Nataraj P, Svojsik M, Sura L, Curry K, Bliznyuk N, Rajderkar D, Weiss MD. Comparing head ultrasounds and susceptibility-weighted imaging for the detection of low-grade hemorrhages in preterm infants. J Perinatol 2021; 41:736-742. [PMID: 33318689 DOI: 10.1038/s41372-020-00890-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/08/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) is a complication of prematurity. Grades III and IV IVH lead to significant morbidity, but mounting evidence shows low-grade IVH (grades I-II) may be associated with adverse sequelae. Head ultrasounds (HUS) are used to screen infants for IVH but may miss low-grade IVH. Our study compared the results of HUS around 7 days of age to susceptibility-weighted imaging (SWI) obtained at term-corrected age in infants born at <30 wGA. STUDY DESIGN Infants <30 weeks gestational age (GA) with an HUS and MRI at admission to UF Health were identified by a retrospective chart review. Images were re-read by a pediatric neuroradiologist. RESULTS Ninety-four infants with a mean GA of 25.8 weeks were identified. Of those with normal HUS, 50% had low-grade IVH on the term-corrected MRI. CONCLUSIONS HUS are effective for screening for high-grade IVH. SWI is more sensitive in identifying low-grade IVH.
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Affiliation(s)
- Parvathi Nataraj
- Department of Pediatrics, University of Florida, Gainesville, FL, USA.
| | - Marcela Svojsik
- Department of Pediatrics, Baylor College of Medicine, San Antonio, TX, USA
| | - Livia Sura
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Kelly Curry
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
| | - Nikolay Bliznyuk
- Department of Agricultural and Biological Engineering, University of Florida, Gainesville, FL, USA
| | | | - Michael D Weiss
- Department of Pediatrics, University of Florida, Gainesville, FL, USA
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Neuroimaging at Term Equivalent Age: Is There Value for the Preterm Infant? A Narrative Summary. CHILDREN-BASEL 2021; 8:children8030227. [PMID: 33809745 PMCID: PMC8002329 DOI: 10.3390/children8030227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022]
Abstract
Advances in neuroimaging of the preterm infant have enhanced the ability to detect brain injury. This added information has been a blessing and a curse. Neuroimaging, particularly with magnetic resonance imaging, has provided greater insight into the patterns of injury and specific vulnerabilities. It has also provided a better understanding of the microscopic and functional impacts of subtle and significant injuries. While the ability to detect injury is important and irresistible, the evidence for how these injuries link to specific long-term outcomes is less clear. In addition, the impact on parents can be profound. This narrative summary will review the history and current state of brain imaging, focusing on magnetic resonance imaging in the preterm population and the current state of the evidence for how these patterns relate to long-term outcomes.
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Webbe J, Gale C. NICE guidelines on neonatal parenteral nutrition: a step towards standardised care but evidence is scarce. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:645-646. [DOI: 10.1016/s2352-4642(20)30179-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
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Lien R. Neurocritical care of premature infants. Biomed J 2020; 43:259-267. [PMID: 32333994 PMCID: PMC7424083 DOI: 10.1016/j.bj.2020.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/17/2022] Open
Abstract
Neurocritical care is an approach of comprehensive care through multidisciplinary coordination and implementation of neuroprotective strategies to reduce the risk of neurologic injury among critically ill patients. Premature infants are at a special risk of sustaining brain injury and having adverse neurodevelopmental outcome. The pathogenesis of “encephalopathy of prematurity” is tightly linked to hemodynamic instability during postnatal transition, immaturity of the cerebral vascular bed and nervous system, and the commonly encountered inflammation in an intensive care setting. Clinical assessment aided by renewed monitoring techniques, together with therapies supported by best available evidence may provide opportunities to salvage these vulnerable brains. Indeed, to promote optimal brain development and to ensure neurodevelopmental intact survival is of imperial priority in the modern care of preterm infants.
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Affiliation(s)
- Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Agut T, Alarcon A, Cabañas F, Bartocci M, Martinez-Biarge M, Horsch S. Preterm white matter injury: ultrasound diagnosis and classification. Pediatr Res 2020; 87:37-49. [PMID: 32218534 PMCID: PMC7098888 DOI: 10.1038/s41390-020-0781-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
White matter injury (WMI) is the most frequent form of preterm brain injury. Cranial ultrasound (CUS) remains the preferred modality for initial and sequential neuroimaging in preterm infants, and is reliable for the diagnosis of cystic periventricular leukomalacia. Although magnetic resonance imaging is superior to CUS in detecting the diffuse and more subtle forms of WMI that prevail in very premature infants surviving nowadays, recent improvement in the quality of neonatal CUS imaging has broadened the spectrum of preterm white matter abnormalities that can be detected with this technique. We propose a structured CUS assessment of WMI of prematurity that seeks to account for both cystic and non-cystic changes, as well as signs of white matter loss and impaired brain growth and maturation, at or near term equivalent age. This novel assessment system aims to improve disease description in both routine clinical practice and clinical research. Whether this systematic assessment will improve prediction of outcome in preterm infants with WMI still needs to be evaluated in prospective studies.
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Affiliation(s)
- Thais Agut
- Department of Neonatology, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain.
| | - Ana Alarcon
- 0000 0001 0663 8628grid.411160.3Department of Neonatology, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Fernando Cabañas
- 0000 0000 8970 9163grid.81821.32Department of Neonatology, Quironsalud Madrid University Hospital and Biomedical Research Foundation, La Paz University Hospital Madrid, Madrid, Spain
| | - Marco Bartocci
- Department of Women’s and Children’s Health, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Miriam Martinez-Biarge
- 0000 0001 2113 8111grid.7445.2Department of Paediatrics, Imperial College London, London, UK
| | - Sandra Horsch
- 0000 0000 8778 9382grid.491869.bDepartment of Neonatology, Helios Klinikum Berlin Buch, Berlin, Germany ,0000 0004 1937 0626grid.4714.6Department Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
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11
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Comparison of cranial ultrasound and MRI for detecting BRAIN injury in extremely preterm infants and correlation with neurological outcomes at 1 and 3 years. Eur J Pediatr 2019; 178:1053-1061. [PMID: 31065842 DOI: 10.1007/s00431-019-03388-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/23/2019] [Accepted: 04/23/2019] [Indexed: 10/26/2022]
Abstract
This study aimed to investigate the accuracy of different grades of brain injuries on serial and term equivalent age (TEA)-cranial ultrasound imaging (cUS) as compared to TEA magnetic resonance imaging (MRI) in extremely preterm infants < 28 weeks, and determine the predictive value of imaging abnormalities on neurodevelopmental outcome at 1 and 3 years. Seventy-five infants were included in the study. Severe TEA-cUS injury had high positive predictive value-PPV (100%) for predicting severe MRI injury compared to mild to moderate TEA-cUS injury or severe injury on worst cranial ultrasound scan. Absence of moderate to severe injury on TEA cUS or worst serial cUS was a good predictor of a normal MRI (negative predictive values > 93%). Severe grade 3 injuries on TEA-US had high predictive values in predicting abnormal neurodevelopment at both 1 and 3 years of age (PPV 100%). All grades of MRI and worst serial cUS injuries poorly predicted abnormal neurodevelopment at 1 and 3 years. Absence of an injury either on a cranial ultrasound or an MRI did not predict a normal outcome. Multiple logistic regression did not show a significant correlation between imaging injury and neurodevelopmental outcomes.Conclusion: This study demonstrates that TEA cUS can reliably identify severe brain abnormalities that would be seen on MRI imaging and positively predict abnormal neurodevelopment at both 1 and 3 years. Although MRI can pick up more subtle abnormalities that may be missed on cUS, their predictive value on neurodevelopmental impairment is poor. Normal cUS and MRI scan may not exclude abnormal neurodevelopment. Routine TEA-MRI scan provides limited benefit in predicting abnormal neurodevelopment in extremely preterm infants. What is Known: • Preterm neonates are at increased risk of white matter and other brain injuries, which may be associated with adverse neurodevelopmental outcome. • MRI is the most accurate method in detecting white matter injuries. What is New: • TEA-cUS can reliably detect severe brain injuries on MRI, but not mild/moderate lesions as well as abnormal neurodevelopment at 1 and 3 years. • TEA-MRI brain injury is poor in predicting abnormal neurodevelopment at 1 and 3 years and normal cUS or MRI brain injury may not guarantee normal neurodevelopment.
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Janvier A, Bourque CJ, Dahan S, Robson K, Barrington KJ. Integrating Parents in Neonatal and Pediatric Research. Neonatology 2019; 115:283-291. [PMID: 30799397 DOI: 10.1159/000492502] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 07/26/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Parents and their infants are the beneficiaries of neonatal and pediatric research, but in the past they have been excluded from most stages of research projects. As a result, many projects may fail to produce the most worthwhile information for parents and families. Lately, veteran resource parents and patients have been increasingly integrated in research initiatives. METHODS Benchmarking of neonatal and pediatric research initiatives where resource parents and/or ex neonatal patients have helped to optimize pediatric research. We review ways in which resource parents/patients can be involved in research, with examples and practical ideas of how to proceed. RESULTS Resource parents/patients can be collaborators in research and be integrated in many steps: prioritizing research projects, designing trials, determining the outcomes of interest, ethics review, developing and improving consent procedures, collection and interpretation of data, participation in data safety monitoring committees, publication of results, and presentation to peer groups. Some of the strategies for integration of stakeholders in clinical research are more complex, may involve risk and require more training than others. CONCLUSION We suggest that groups wanting to involve parents in their research endeavors start with simpler tasks that entail less risk and develop teams of resource parents who have differing interests and abilities. Quality control of programs is essential, such as frequently giving and obtaining feedback from resource parents/patients and researchers. In the future, integration of resource parents/patients into every step of clinical research will be essential to ensure that parent and family important outcomes are examined.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada, .,Division of Neonatology, Hôpital Sainte-Justine, Montréal, Québec, Canada, .,CHU Sainte-Justine Research Center, Montréal, Québec, Canada, .,Bureau de l'Éthique Clinique, Université de Montréal, Montréal, Québec, Canada, .,Unité d'Éthique Clinique, Hôpital Sainte-Justine, Montréal, Québec, Canada, .,Unité de Soins Palliatifs, Hôpital Sainte-Justine, Montréal, Québec, Canada, .,Unité de Recherche en Éthique Clinique et Partenariat Famille (UREPAF), Montréal, Québec, Canada,
| | - Claude Julie Bourque
- CHU Sainte-Justine Research Center, Montréal, Québec, Canada.,Unité d'Éthique Clinique, Hôpital Sainte-Justine, Montréal, Québec, Canada.,Unité de Recherche en Éthique Clinique et Partenariat Famille (UREPAF), Montréal, Québec, Canada
| | - Sonia Dahan
- Division of Neonatology, Hôpital Sainte-Justine, Montréal, Québec, Canada.,Unité d'Éthique Clinique, Hôpital Sainte-Justine, Montréal, Québec, Canada
| | - Kate Robson
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Keith James Barrington
- Department of Pediatrics, Université de Montréal, Montréal, Québec, Canada.,Division of Neonatology, Hôpital Sainte-Justine, Montréal, Québec, Canada.,CHU Sainte-Justine Research Center, Montréal, Québec, Canada
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Guttmann K, Flibotte J, DeMauro SB. Parental Perspectives on Diagnosis and Prognosis of Neonatal Intensive Care Unit Graduates with Cerebral Palsy. J Pediatr 2018; 203:156-162. [PMID: 30244983 DOI: 10.1016/j.jpeds.2018.07.089] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 07/18/2018] [Accepted: 07/26/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe how parents of neonatal intensive care unit (NICU) graduates with cerebral palsy (CP) perceive both the accuracy of prognoses provided in the NICU and the timing of their child's diagnosis of CP, and to assess the influence of functional outcome on these perceptions. STUDY DESIGN We surveyed parents of NICU graduates with CP about timing and benefit of diagnosis, accuracy of prognosis, and functional abilities of their children. After piloting and validation, CP parent support groups circulated the survey on social media, websites, and email lists. Bivariate relationships between categorical responses to survey questions were assessed with the χ2 test, and multivariable logistic regression was performed to identify independent factors associated with perceptions about the timing of diagnosis. RESULTS Parents of 463 children were included. Two-thirds (67%) of the children were diagnosed with CP before age 2 years, yet 40% of the respondents felt that diagnosis was made late, and only 11% categorized diagnosis as early. More than one-half (59%) perceived a benefit to diagnosis. There was a significant association between earlier age at diagnosis and greater functional limitations; 24% of parents who recalled being given a prognosis reported that their child functioned as predicted, and 46% reported that their child exceeded expectations. Parents were more likely to believe that children with fewer functional limitations had exceeded expectations. CONCLUSION Parents remember prognostic discussions about children who develop CP as underestimating functional outcome. Diagnosis is rarely seen as early and is associated with benefits. These observations suggest that clinicians should aim to diagnose CP early and to maintain guarded optimism about future outcomes. Tools for improved communication are urgently needed.
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Affiliation(s)
- Katherine Guttmann
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John Flibotte
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sara B DeMauro
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
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14
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Ibrahim J, Mir I, Chalak L. Brain imaging in preterm infants <32 weeks gestation: a clinical review and algorithm for the use of cranial ultrasound and qualitative brain MRI. Pediatr Res 2018; 84:799-806. [PMID: 30315272 DOI: 10.1038/s41390-018-0194-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 09/21/2018] [Accepted: 09/22/2018] [Indexed: 02/07/2023]
Abstract
The aim is to review the evidence about the utility of term-equivalent age (TEA) magnetic resonance imaging (MRI) in predicting neurodevelopmental outcomes for preterm neonates. Preterm birth accounts for ~12% of all deliveries in the United States and is the leading cause of neurologic disabilities in children. From the neonatologist perspective, it is critically important to identify preterm infants at risk of subsequent neurodevelopmental disability who may benefit from early intervention services. However "the choose wisely campaign" also emphasizes the need to have ongoing cost/benefit discussions regarding care of preterm newborns to avoid waste that comes from subjecting infants to procedures that do not help. We performed a MEDLINE EMBASE database review from 2000 to 2018 to account for the technical evolution in the cranial ultrasound machines and introduction of MRI imaging in the NICU. Studies were graded based on the strength of their design using the GRADE guidelines and summarized with respect to brain MRI vs. cranial US (1) detection of white matter injury; (2) cerebellar hemorrhage; (3) long-term neurodevelopmental outcomes and impact on parental anxiety. We conclude with a hospital-specific guideline algorithm for performing TEA MRI based on risk evaluations ≤32 weeks.
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Affiliation(s)
- John Ibrahim
- University of Texas Southwestern Medical Center Dallas, Dallas, TX, USA
| | - Imran Mir
- University of Texas Southwestern Medical Center Dallas, Dallas, TX, USA
| | - Lina Chalak
- University of Texas Southwestern Medical Center Dallas, Dallas, TX, USA.
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15
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van der Knoop BJ, Vermeulen RJ, Verbeke JIML, Pistorius LR, de Vries JIP. Fetal MRI, lower acceptance by women in research vs. clinical setting. J Perinat Med 2018; 46:983-990. [PMID: 29031020 DOI: 10.1515/jpm-2016-0360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 08/31/2017] [Indexed: 12/28/2022]
Abstract
AIM To determine acceptance of pregnant women to undergo fetal magnetic resonance imaging (MRI) examination in research and clinical setting. METHODS A prospective study included a research group [part of a study comparing brain ultrasound (US) to MRI in fetuses at risk for acquired brain damage] and a clinical group [fetuses with suspected (brain) anomalies after structural US examination] from 2011 to 2014. All women were advised to use sedatives. MRI declinations, use of sedation, MRI duration and imaging quality were compared between both groups. RESULTS Study participation was accepted in 57/104 (55%) research cases. Fetal MRI was performed in 34/104 (33%) research and 43/44 (98%) clinical cases. Reasons to decline study participation were MRI related in 41%, and participation was too burdensome in 46%. Acceptance was highest for indication infection and lowest in alloimmune thrombocytopenia and monochorionic twin pregnancy. Sedatives were used in 14/34 research and 43/43 clinical cases. Scan duration and quality were comparable (21 and 20 min in research and clinical cases, respectively, moderate/good quality in both groups). CONCLUSIONS Pregnant women consider MRI more burdensome than professionals realize. Two-third of women at risk for fetal brain damage decline MRI examination. Future studies should evaluate which information about fetal MRI is supportive.
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Affiliation(s)
- Bloeme J van der Knoop
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands, Tel.: +31 (0) 20 4443239 or +31 (0) 20 4444444, pager 6112, Fax: +31 (0) 20 4443333.,Neuroscience Campus, VU University, Amsterdam, The Netherlands
| | - Roland J Vermeulen
- Department of Child Neurology, VU University Medical Center, P.O. Box 7057,1007 MB Amsterdam, TheNetherlands
| | - Jonathan I M L Verbeke
- Department of Pediatric Radiology, VU University Medical Center, P.O. Box 7057,1007 MB Amsterdam, TheNetherlands
| | - Lourens R Pistorius
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, TheNetherlands
| | - Johanna I P de Vries
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057,1007 MB Amsterdam, TheNetherlands.,Research Institute MOVE, VU University, Amsterdam, TheNetherlands
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Vesoulis ZA, El Ters NM, Herco M, Whitehead HV, Mathur AM. A Web-Based Calculator for the Prediction of Severe Neurodevelopmental Impairment in Preterm Infants Using Clinical and Imaging Characteristics. CHILDREN-BASEL 2018; 5:children5110151. [PMID: 30441798 PMCID: PMC6262423 DOI: 10.3390/children5110151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/02/2018] [Accepted: 11/08/2018] [Indexed: 11/23/2022]
Abstract
Although the most common forms of brain injury in preterm infants have been associated with adverse neurodevelopmental outcomes, existing MRI scoring systems lack specificity, do not incorporate clinical factors, and are technically challenging to perform. The objective of this study was to develop a web-based, clinically-focused prediction system which differentiates severe neurodevelopmental outcomes from normal-moderate outcomes at two years. Infants were retrospectively identified as those who were born ≤30 weeks gestation and who had MRI imaging at term-equivalent age and neurodevelopmental testing at 18–24 months. Each MRI was scored on injury in three domains (intraventricular hemorrhage, white matter injury, and cerebellar hemorrhage) and clinical factors that were strongly predictive of an outcome were investigated. A binary logistic regression model was then generated from the composite of clinical and imaging components. A total of 154 infants were included (mean gestational age = 26.1 ± 1.8 weeks, birth weight = 889.1 ± 226.2 g). The final model (imaging score + ventilator days + delivery mode + antenatal steroids + retinopathy of prematurity requiring surgery) had strong discriminatory power for severe disability (AUC = 0.850), with a PPV (positive predictive value) of 76% and an NPV (negative predictive value) of 90%. Available as a web-based tool, it can be useful for prognostication and targeting early intervention services to infants who may benefit the most from such services.
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Affiliation(s)
- Zachary A Vesoulis
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Nathalie M El Ters
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Maja Herco
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Halana V Whitehead
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Amit M Mathur
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
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17
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Improving neonatal care with the help of veteran resource parents: An overview of current practices. Semin Fetal Neonatal Med 2018; 23:44-51. [PMID: 29111298 DOI: 10.1016/j.siny.2017.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Over the past decade, veteran parents who have lived a neonatal intensive care unit (NICU) experience have become increasingly involved as 'resource parents' to provide peer-to-peer support to "new" NICU parents. These parents can provide a unique form of support to new parents. They can also assume other roles in clinical care, research, administration and/or teaching, but those roles are rarely described in the literature. This article reviews many of the activities performed by resource parents in neonatology. These activities were identified/examined and classified according to the location of involvement (hospital or not), the presence/absence of direct interaction with families and providers, and the topic of involvement. We have also identified gaps in knowledge relative to recruitment and training, development and evaluation of programs, structuring of responsibilities, and remuneration of resource parents. Future research is needed to measure the impact of resource parents on neonatal care.
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18
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Webbe J, Brunton G, Ali S, Longford N, Modi N, Gale C. Parent, patient and clinician perceptions of outcomes during and following neonatal care: a systematic review of qualitative research. BMJ Paediatr Open 2018; 2:e000343. [PMID: 30397672 PMCID: PMC6203019 DOI: 10.1136/bmjpo-2018-000343] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Multiple outcomes can be measured in infants that receive neonatal care. It is unknown whether outcomes of importance to parents and patients differ from those of health professionals. Our objective was to systematically map neonatal care outcomes discussed in qualitative research by patients, parents and healthcare professionals and test whether the frequency with which outcomes are discussed differs between groups. DESIGN Systematic review of qualitative literature. The following databases were searched: Medline, CINAHL, EMBASE, PsycINFO and ASSIA from 1997 to 2017. Publications describing qualitative data relating to neonatal care outcomes, reported by former patients, parents or healthcare professionals, were included. Narrative text was analysed and outcomes grouped thematically by organ system. Permutation testing was applied to assess an association between the outcomes identified and stakeholder group. RESULTS Sixty-two papers containing the views of over 4100 stakeholders were identified; 146 discrete outcomes were discussed; 58 outcomes related to organ systems and 88 to other more global domains. Permutation testing provides evidence that parents, former patients and health professionals reported outcomes with different frequencies (p=0.037). CONCLUSIONS Parents, patients and health professionals focus on different outcomes when discussing their experience of neonatal care. A wide range of neonatal care outcomes are reported in qualitative research; many are global outcomes relating to the overall status of the infant. The views of former patients and parents should be taken into consideration when designing research; the development of a core outcomes set for neonatal research will facilitate this.
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Affiliation(s)
- James Webbe
- Neonatal Medicine, Imperial College London, London, UK
| | | | | | | | - Neena Modi
- Neonatal Medicine, Imperial College London, London, UK
| | - Chris Gale
- Neonatal Medicine, Imperial College London, London, UK
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19
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George JM, Fiori S, Fripp J, Pannek K, Bursle J, Moldrich RX, Guzzetta A, Coulthard A, Ware RS, Rose SE, Colditz PB, Boyd RN. Validation of an MRI Brain Injury and Growth Scoring System in Very Preterm Infants Scanned at 29- to 35-Week Postmenstrual Age. AJNR Am J Neuroradiol 2017; 38:1435-1442. [PMID: 28522659 DOI: 10.3174/ajnr.a5191] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/21/2017] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND PURPOSE The diagnostic and prognostic potential of brain MR imaging before term-equivalent age is limited until valid MR imaging scoring systems are available. This study aimed to validate an MR imaging scoring system of brain injury and impaired growth for use at 29 to 35 weeks postmenstrual age in infants born at <31 weeks gestational age. MATERIALS AND METHODS Eighty-three infants in a prospective cohort study underwent early 3T MR imaging between 29 and 35 weeks' postmenstrual age (mean, 32+2 ± 1+3 weeks; 49 males, born at median gestation of 28+4 weeks; range, 23+6-30+6 weeks; mean birthweight, 1068 ± 312 g). Seventy-seven infants had a second MR scan at term-equivalent age (mean, 40+6 ± 1+3 weeks). Structural images were scored using a modified scoring system which generated WM, cortical gray matter, deep gray matter, cerebellar, and global scores. Outcome at 12-months corrected age (mean, 12 months 4 days ± 1+2 weeks) consisted of the Bayley Scales of Infant and Toddler Development, 3rd ed. (Bayley III), and the Neuro-Sensory Motor Developmental Assessment. RESULTS Early MR imaging global, WM, and deep gray matter scores were negatively associated with Bayley III motor (regression coefficient for global score β = -1.31; 95% CI, -2.39 to -0.23; P = .02), cognitive (β = -1.52; 95% CI, -2.39 to -0.65; P < .01) and the Neuro-Sensory Motor Developmental Assessment outcomes (β = -1.73; 95% CI, -3.19 to -0.28; P = .02). Early MR imaging cerebellar scores were negatively associated with the Neuro-Sensory Motor Developmental Assessment (β = -5.99; 95% CI, -11.82 to -0.16; P = .04). Results were reconfirmed at term-equivalent-age MR imaging. CONCLUSIONS This clinically accessible MR imaging scoring system is valid for use at 29 to 35 weeks postmenstrual age in infants born very preterm. It enables identification of infants at risk of adverse outcomes before the current standard of term-equivalent age.
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Affiliation(s)
- J M George
- From the Queensland Cerebral Palsy and Rehabilitation Research Centre (J.M.G., R.N.B.), Centre for Children's Health Research, Faculty of Medicine
| | - S Fiori
- Stella Maris Scientific Institute (S.F., A.G.), Department of Developmental Neuroscience, Pisa, Italy
| | - J Fripp
- Health and Biosecurity (J.F., K.P., S.E.R.), The Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - K Pannek
- Health and Biosecurity (J.F., K.P., S.E.R.), The Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - J Bursle
- Department of Medical Imaging (J.B., A.C.)
| | - R X Moldrich
- University of Queensland Centre for Clinical Research (R.X.M., P.B.C.)
| | - A Guzzetta
- Stella Maris Scientific Institute (S.F., A.G.), Department of Developmental Neuroscience, Pisa, Italy
| | - A Coulthard
- Discipline of Medical Imaging (A.C.)
- Department of Medical Imaging (J.B., A.C.)
| | - R S Ware
- Queensland Centre for Intellectual and Developmental Disability (R.S.W.), The University of Queensland, Brisbane, Australia
- Menzies Health Institute Queensland (R.S.W.), Griffith University, Brisbane, Australia
| | - S E Rose
- Health and Biosecurity (J.F., K.P., S.E.R.), The Australian e-Health Research Centre, Commonwealth Scientific and Industrial Research Organisation, Brisbane, Australia
| | - P B Colditz
- University of Queensland Centre for Clinical Research (R.X.M., P.B.C.)
- Perinatal Research Centre (P.B.C.), Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - R N Boyd
- From the Queensland Cerebral Palsy and Rehabilitation Research Centre (J.M.G., R.N.B.), Centre for Children's Health Research, Faculty of Medicine
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20
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Abstract
Parents often ask neonatologists and neurologists to determine neurologic prognosis in the preterm and term infant after neonatal brain injury. Prognostication in these populations remains rather full of uncertainties. Knowledge of available diagnostic tests and their limitations allows the clinician to synthesize the most likely outcomes after neurologic injury. In this review, we describe the diagnostic tools available to the clinician, active areas of research, and challenges in neurologic prognostication of the neonate.
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Affiliation(s)
- Niranjana Natarajan
- Department of Neurology, University of Washington, Seattle Children׳s Hospital, Seattle, WA
| | - Andrea C Pardo
- Division of Neurology, Ann & Robert H. Lurie Children׳s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave, Box #51, Chicago, IL 60611.
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21
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Parikh NA. Advanced neuroimaging and its role in predicting neurodevelopmental outcomes in very preterm infants. Semin Perinatol 2016; 40:530-541. [PMID: 27863706 PMCID: PMC5951398 DOI: 10.1053/j.semperi.2016.09.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Up to 35% of very preterm infants survive with neurodevelopmental impairments (NDI) such as cognitive deficits, cerebral palsy, and attention deficit disorder. Advanced MRI quantitative tools such as brain morphometry, diffusion MRI, magnetic resonance spectroscopy, and functional MRI at term-equivalent age are ideally suited to improve current efforts to predict later development of disabilities. This would facilitate application of targeted early intervention therapies during the first few years of life when neuroplasticity is optimal. A systematic search and review identified 47 published studies of advanced MRI to predict NDI. Diffusion MRI and morphometry studies were the most commonly studied modalities. Despite several limitations, studies clearly showed that brain structural and metabolite biomarkers are promising independent predictors of NDI. Large representative multicenter studies are needed to validate these studies.
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Affiliation(s)
- Nehal A. Parikh
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH,Correspondence address: Cincinnati Children’s Hospital, Perinatal Institute, 3333 Burnet Ave., MLC 7009, Cincinnati, OH.
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22
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Harvey ME, Redshaw ME. Qualitative study of the clinician-parent interface in discussing prognosis following MRI and US imaging of preterm infants in the UK. BMJ Open 2016; 6:e011472. [PMID: 27678531 PMCID: PMC5051465 DOI: 10.1136/bmjopen-2016-011472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore communication and interaction between parents and clinicians following neonatal ultrasound (US) and MRI of the brain of babies born preterm. SETTING This qualitative study was undertaken as part of a larger UK study of neonatal brain imaging. 511 infants were cared for in 14 London neonatal units with MR and cerebral US imaging in a specialist centre. PARTICIPANTS Parents with infants born at <33 weeks gestation were randomised to receive prognostic information based on either MRI or US findings on their infants at term-corrected age. METHODS Discussions between parents and clinicians about the MRI or US result were audio recorded. Parents were told about the findings and their baby's predicted outcome. A topic guide ensured essential aspects were covered. Recordings were fully transcribed. Discussion of the scan results, the content and style of the interaction and parental response were analysed qualitatively in 36 recordings using NVivo V.10. OUTCOMES Key themes and subthemes were identified in the clinician-parent discussions. RESULTS The overarching theme of 'the communication interface' was identified with three key themes: 'giving information', 'managing the conversation' and 'getting it right' and further subthemes. A range of approaches were used to facilitate parental understanding and engagement. There were differences in the exchanges when information about an abnormal scan was given. The overall structure of the discussions was largely similar, though the language used varied. In all of the discussions, the clinicians talked more than the parents. CONCLUSIONS The discussions represent a difficult situation in which the challenge is to give and receive complex prognostic information in the context of considerable uncertainty. The study highlights the importance of being able to re-visit specific issues and any potential areas of misunderstanding, of making time to talk to parents appreciating their perspective and level of knowledge. TRIAL REGISTRATION NUMBER EudraCT 2009-013888-19; Pre-results.
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Affiliation(s)
- M E Harvey
- Department of Perinatal Imaging and Health, Division of Imaging and Biomedical Engineering, King's College, London, UK
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
| | - M E Redshaw
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
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23
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Redshaw ME, Harvey ME. Explanations and information-giving: clinician strategies used in talking to parents of preterm infants. BMC Pediatr 2016; 16:25. [PMID: 26863870 PMCID: PMC4750359 DOI: 10.1186/s12887-016-0561-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 01/30/2016] [Indexed: 11/10/2022] Open
Abstract
Background The study is part of a larger research programme on neonatal brain imaging in the trial element of which parents were randomised to receive prognostic information based upon either magnetic resonance imaging (MRI) or ultrasound findings (ePrime study). The aim of this study was to investigate the strategies used by clinicians in communicating with parents following imaging at term age of the brain of preterm infants born before 33 weeks gestation, focusing on explanations and information-giving about prognosis Method Audio recordings of discussions between parents and clinicians were made following MRI and ultrasound assessment. Parents were given the scan result and the baby’s predicted prognosis. A framework was developed based on preliminary analysis of the recordings and findings of other studies of information-giving in healthcare. Communication of scan results by the clinicians was further explored in qualitative analysis with 36 recordings using NVivo 10 and the specifically developed framework. Emerging themes and associated sub-themes were identified. Results The ways in which clinicians gave information and helped parents to understand were identified. Within the over-arching theme of clinician strategies a wide range of approaches were used to facilitate parental understanding. These included orienting, checking on previously acquired information, using analogies, explaining terminology, pacing the information, confirming understanding, inviting clarification, answering parents’ questions and recapping at intervals. Ultimately four key themes were identified: ‘Framing the information-giving’, ‘What we are looking at’, ‘Presenting the numbers and explaining the risk’ and ‘Appreciating the position of parents’. Conclusions The interviews represent a multifaceted situation in which there is a tension between the need to explain and inform and the inherent complexity of neurological development, potential problems following preterm birth and the technology used to investigate and monitor these. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0561-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M E Redshaw
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK.
| | - M E Harvey
- National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK. .,Department of Perinatal Imaging and Health, Division of Imaging and Biomedical Engineering, King's College, 4th Floor North Wing, St Thomas' Hospital, SE1 7EH, London, UK. .,Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK.
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24
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Janvier A, Farlow B. The ethics of neonatal research: An ethicist's and a parents' perspective. Semin Fetal Neonatal Med 2015; 20:436-41. [PMID: 26497942 DOI: 10.1016/j.siny.2015.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The ethics of neonatal research are complex because vulnerable new parents are asked to provide consent on behalf of their fragile baby. Whereas clinical neonatal care has evolved to value personalized and shared decision-making, the goal of research ethics is still to standardize the informed consent process and make it as complete and thorough as possible. Ethicists, lawyers and physicians have shaped the field of research ethics and consent for research. The goal of detailed informed consent is to protect participants from harm, but procedures were developed without input from the principal stakeholders: ex-neonatal intensive care unit parents/patients. Empirical investigations examining patient and parental perspectives on research and research ethics are lacking. Rigorous investigations are needed to determine how parents of sick neonates want their families to be protected, knowing that a lack of research is also harmful. Large randomized controlled multicenter trials will always be needed to improve neonatal outcomes. These trials are costly and time-consuming. Currently, the way in which research is funded and regulated and the way in which academic merit is recognized lead to inefficiency and a waste of precious resources. Following a review of the history of research ethics, this article examines and discusses the ethics of research in neonatology. In addition, challenges and opportunities are identified and ideas for future investigations are proposed.
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Affiliation(s)
- Annie Janvier
- Department of Pediatrics and Clinical Ethics, University of Montreal, Montreal, Canada; Sainte-Justine Hospital Research Center, Montreal, Quebec, Canada.
| | - Barbara Farlow
- The DeVeber Institute for Bioethics and Social Research, North York, Ontario, Canada; Patients for Patient Safety Canada, Canadian Patient Safety Institute, Canada
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25
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Ho T, Dukhovny D, Zupancic JA, Goldmann DA, Horbar JD, Pursley DM. Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value. Pediatrics 2015; 136:e482-9. [PMID: 26195536 PMCID: PMC9923615 DOI: 10.1542/peds.2015-0737] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The use of unnecessary tests and treatments contributes to health care waste. The "Choosing Wisely" campaign charges medical societies with identifying such items. This report describes the identification of 5 tests and treatments in newborn medicine. METHODS A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over 3 rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation (GRADE) literature summaries of the top 12 tests and treatments. RESULTS A total of 1648 candidate tests and 1222 treatments were suggested by 1047 survey respondents. After 3 Delphi rounds, the expert panel achieved consensus on the following top 5 items: (1) avoid routine use of antireflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants, (2) avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection, (3) avoid routine use of pneumograms for predischarge assessment of ongoing and/or prolonged apnea of prematurity, (4) avoid routine daily chest radiographs without an indication for intubated infants, and (5) avoid routine screening term-equivalent or discharge brain MRIs in preterm infants. CONCLUSIONS The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care.
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Affiliation(s)
- Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;,Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Institute for Healthcare Improvement, Cambridge, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Dmitry Dukhovny
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;,Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - John A.F. Zupancic
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;,Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Don A. Goldmann
- Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Institute for Healthcare Improvement, Cambridge, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Jeffrey D. Horbar
- Department of Pediatrics, University of Vermont, Burlington, Vermont; and,Vermont Oxford Network, Burlington, Vermont
| | - DeWayne M. Pursley
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts;,Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;,Address correspondence to DeWayne M. Pursley, MD, MPH, Department of Neonatology, Beth Israel Deaconess Medical Center, Rose 3, 330 Brookline Ave, Boston, MA 02215. E-mail:
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26
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Van't Hooft J, van der Lee JH, Opmeer BC, Aarnoudse-Moens CSH, Leenders AGE, Mol BWJ, de Haan TR. Predicting developmental outcomes in premature infants by term equivalent MRI: systematic review and meta-analysis. Syst Rev 2015; 4:71. [PMID: 25982565 PMCID: PMC4438620 DOI: 10.1186/s13643-015-0058-7] [Citation(s) in RCA: 81] [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: 03/26/2015] [Accepted: 05/05/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to determine the prognostic accuracy of term MRI in very preterm born (≤32 weeks) or low-birth-weight (≤1500 g) infants for long-term (>18 months) developmental outcomes. METHODS We performed a systematic review searching Central, Medline, Embase, and PsycInfo. Two independent reviewers performed study selection, data extraction, and quality assessment. We documented sensitivity and specificity for three different MRI findings (white matter abnormalities (WMA), brain abnormality (BA), and diffuse excessive high signal intensity (DEHSI)), related to developmental outcomes including cerebral palsy (CP), visual and/or hearing problems, motor, neurocognitive, and behavioral function. Using bivariate meta-analysis, we estimated pooled sensitivity and specificity and plotted summary receiver operating characteristic (sROC) curves for different cut-offs of MRI. RESULTS We included 20 papers published between 2000 and 2013. Quality of included studies varied. Pooled sensitivity and specificity values (95 % confidence interval (CI)) for prediction of CP combining the three different MRI findings (using normal/mild vs. moderate/severe cut-off) were 77 % (53 to 91 %) and 79 % (51 to 93 %), respectively. For prediction of motor function, the values were 72 % (52 to 86 %) and 62 % (29 to 87 %), respectively. Prognostic accuracy for visual and/or hearing problems, neurocognitive, and/or behavioral function was poor. sROC curves of the individual MRI findings showed that presence of WMA provided the best prognostic accuracy whereas DEHSI did not show any potential prognostic accuracy. CONCLUSIONS This study shows that presence of moderate/severe WMA on MRI around term equivalent age can predict CP and motor function in very preterm or low-birth-weight infants with moderate sensitivity and specificity. Its ability to predict other long-term outcomes such as neurocognitive and behavioral impairments is limited. Also, other white matter related tests as BA and DEHSI demonstrated limited prognostic value. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42013006362.
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Affiliation(s)
- Janneke Van't Hooft
- Department of Obstetrics and Gynecology, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Johanna H van der Lee
- Pediatric Clinical Research Office, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Brent C Opmeer
- Clinical Research Unit, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Cornelieke S H Aarnoudse-Moens
- Pediatric Psychosocial Department, Emma Children's Hospital, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Arnold G E Leenders
- Medical Library, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Ben Willem J Mol
- Robinson Research Institute, School of Pediatrics and Reproductive Health, University of Adelaide, Adelaide, 5000, SA, Australia.
| | - Timo R de Haan
- Department of Neonatology (H3-147), Emma Children's Hospital, Academical Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
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27
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Staub K, Baardsnes J, Hébert N, Hébert M, Newell S, Pearce R. Our child is not just a gestational age. A first-hand account of what parents want and need to know before premature birth. Acta Paediatr 2014; 103:1035-8. [PMID: 24920539 DOI: 10.1111/apa.12716] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/05/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Katharina Staub
- Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens; Sherwood Park AB Canada
| | - Jason Baardsnes
- Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens; Sherwood Park AB Canada
| | - Nina Hébert
- Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens; Sherwood Park AB Canada
| | - Michael Hébert
- Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens; Sherwood Park AB Canada
| | - Stephanie Newell
- Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens; Sherwood Park AB Canada
| | - Rebecca Pearce
- Canadian Premature Babies Foundation-Fondation pour Bébés Prématurés Canadiens; Sherwood Park AB Canada
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28
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Weinstein M, Ben Bashat D, Gross-Tsur V, Leitner Y, Berger I, Marom R, Geva R, Uliel S, Ben-Sira L. Isolated mild white matter signal changes in preterm infants: a regional approach for comparison of cranial ultrasound and MRI findings. J Perinatol 2014; 34:476-82. [PMID: 24651736 DOI: 10.1038/jp.2014.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 01/20/2014] [Accepted: 01/27/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare echogenicity detected using cranial ultrasound (cUS) and diffuse excessive high signal intensity (DEHSI) detected using magnetic resonance imaging (MRI) by identical region-based scoring criteria in preterm infants. To explore the association between these white matter (WM) signal changes with early neurobehavior. STUDY DESIGN Forty-nine pre-selected premature infants with only echogenicity on a first routine cUS1 underwent MRI and a repeated cUS2 at term equivalent age. Echogenicity and DEHSI were graded in various brain areas and diffusivity values were calculated. Neurobehavior was assessed using the Rapid Neonatal Neurobehavioral Assessment Procedure. RESULT WM signal changes were significantly higher on cUS1 than cUS2; and higher in MRI than cUS2 in posterior regions. Infants with DEHSI demonstrated reduced tissue integrity. Imaging findings were not correlated with early neurobehavior. CONCLUSION Echogenicity and DEHSI likely represent the same phenomenon. Reduction of over-interpretation of WM signal changes may help define criteria for the judicious use of imaging in routine follow-up of premature infants.
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Affiliation(s)
- M Weinstein
- 1] Functional Brain Center, Wohl Institute for Advanced Imaging, Tel-Aviv Sourasky Medical Center (TASMC), Tel-Aviv, Israel [2] Department of Psychology, Gonda Multidisciplinary Brain Research Center, Bar Ilan University, Ramat-Gan, Israel
| | - D Ben Bashat
- 1] Functional Brain Center, Wohl Institute for Advanced Imaging, Tel-Aviv Sourasky Medical Center (TASMC), Tel-Aviv, Israel [2] Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel [3] Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - V Gross-Tsur
- Department of Pediatric Neurology, Shaare-Zedek Medical Center, Jerusalem, Israel
| | - Y Leitner
- 1] Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel [2] Department of Pediatrics, Child Development Center, TASMC, Tel-Aviv, Israel
| | - I Berger
- 1] Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel [2] Department of Neonatology, Lis Maternity Hospital, TASMC, Tel-Aviv, Israel
| | - R Marom
- 1] Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel [2] Department of Neonatology, Lis Maternity Hospital, TASMC, Tel-Aviv, Israel
| | - R Geva
- Department of Psychology, Gonda Multidisciplinary Brain Research Center, Bar Ilan University, Ramat-Gan, Israel
| | - S Uliel
- Department of Pediatrics, Child Development Center, TASMC, Tel-Aviv, Israel
| | - L Ben-Sira
- 1] Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel [2] Department of Radiology, TASMC, Tel-Aviv, Israel
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Abstract
White matter injury and hemorrhage are common findings in extremely preterm infants. Large hemorrhages and extensive cystic lesions are identified with cranial ultrasound. MRI, which is more sensitive, is especially useful in the identification of small intraventricular hemorrhage; cerebellar hemorrhage; punctate lesion in the white matter and cerebellum; and diffuse, noncystic white matter injury. Imaging sequences such as diffusion-weighted, diffusion tensor, and susceptibility weighted imaging may improve recognition and prediction of outcome. These techniques improve understanding of the underlying pathophysiology of white matter injury and its effects on brain development and neurodevelopmental outcome.
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Mann PC, Woodrum DE, Wilfond BS. Fuzzy images: Ethical implications of using routine neuroimaging in premature neonates to predict neurologic outcomes. J Pediatr 2013; 163:587-92. [PMID: 23623529 DOI: 10.1016/j.jpeds.2013.03.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 02/07/2013] [Accepted: 03/19/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Paul C Mann
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Research Institute, Seattle, WA 98105, USA.
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31
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de Vries LS, Benders MJNL, Groenendaal F. Imaging the premature brain: ultrasound or MRI? Neuroradiology 2013; 55 Suppl 2:13-22. [PMID: 23839652 DOI: 10.1007/s00234-013-1233-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 06/27/2013] [Indexed: 12/12/2022]
Abstract
Neuroimaging of preterm infants has become part of routine clinical care, but the question is often raised on how often cranial ultrasound should be done and whether every high risk preterm infant should at least have one MRI during the neonatal period. An increasing number of centres perform an MRI either at discharge or around term equivalent age, and a few centres have access to a magnet in or adjacent to the neonatal intensive care unit and are doing sequential MRIs. In this review, we try to discuss when best to perform these two neuroimaging techniques and the additional information each technique may provide.
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Affiliation(s)
- Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, UMC Utrecht, Utrecht, The Netherlands.
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32
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Setänen S, Haataja L, Parkkola R, Lind A, Lehtonen L. Predictive value of neonatal brain MRI on the neurodevelopmental outcome of preterm infants by 5 years of age. Acta Paediatr 2013; 102:492-7. [PMID: 23398524 DOI: 10.1111/apa.12191] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 01/30/2013] [Accepted: 02/04/2013] [Indexed: 11/27/2022]
Abstract
AIM To study the prognostic value of MRI in preterm infants at term equivalent age for cognitive development at 5 years of age. METHODS A total of 217 very low birth weight/very low gestational age infants who all received brain MRI at term equivalent age were categorized into 4 groups based on the brain MRI findings. Cognitive development was assessed at 5 years of chronological age by using a short form of Wechsler Preschool and Primary Scale of Intelligence - Revised. This information was combined with neurosensory diagnoses by 2 years of corrected age. RESULTS Of all infants 31 (17.0%) had Full Scale Intelligence Quotient (FSIQ) <85, 14 (6.5%) had cerebral palsy and 4 (1.8%) had severe hearing impairment. A total of 41 (22.0%) infants had some neurodevelopmental impairment at 5 years of age. Considering cognitive outcome (FSIQ <85), the positive predictive value of several major MRI pathologies was 43.8%, and the negative predictive value of normal finding or minor pathologies was 92.0% and 85.7%, respectively. CONCLUSION The MRI of the brain at term equivalent age may be valuable in predicting neurodevelopmental outcome in preterm infants by 5 years of age. The findings should always be interpreted alongside the clinical information of the infant. Furthermore, MRI should not replace a long-term clinical follow-up for very preterm infants.
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Affiliation(s)
- Sirkku Setänen
- Department of Pediatric Neurology, Turku University Hospital, Turku, Finland.
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33
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Harvey ME, Nongena P, Gonzalez-Cinca N, Edwards AD, Redshaw ME. Parents' experiences of information and communication in the neonatal unit about brain imaging and neurological prognosis: a qualitative study. Acta Paediatr 2013; 102:360-5. [PMID: 23298288 DOI: 10.1111/apa.12154] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 10/19/2012] [Accepted: 01/03/2013] [Indexed: 11/27/2022]
Abstract
AIM To explore parental information and communication needs during their baby's care in the neonatal unit with a focus on brain imaging and neurological prognosis. METHODS Eighteen parents recruited from one neonatal unit in the United Kingdom participated in semi-structured qualitative interviews using a grounded theory approach. The topic guide focused on information received about neonatal brain imaging, diagnosis and prognosis, emotional impact and support. RESULTS Parents expressed different information needs influenced by their history, expectations, coping strategies and experiences. Most felt they initially were passive recipients of information and attempted to gain control of the information flow. Nurses were the main providers of information; doctors and other parents were also valuable. Attending ward rounds was important. Some parents felt accessing specific information such as the results of brain imaging could be difficult. Concerns about long-term developmental outcomes and the need for information did not diminish over time. The emotional impact of having a preterm baby had a negative effect on parents' ability to retain information, and all had an ongoing need for reassurance. CONCLUSION The findings provide insights about the needs and experiences of parents who have a continuing requirement for information about their infant's care, development and prognosis.
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Affiliation(s)
- Merryl E Harvey
- Centre for the Developing Brain; Imperial College London and MRC Clinical Sciences Centre; Hammersmith Hospital; London UK
| | - Phumza Nongena
- Centre for the Developing Brain; Imperial College London and MRC Clinical Sciences Centre; Hammersmith Hospital; London UK
| | - Nuria Gonzalez-Cinca
- Centre for the Developing Brain; Imperial College London and MRC Clinical Sciences Centre; Hammersmith Hospital; London UK
| | - A David Edwards
- Centre for the Developing Brain; Imperial College London and MRC Clinical Sciences Centre; Hammersmith Hospital; London UK
| | - Maggie E. Redshaw
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
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Janvier A, Barrington K. Trying to predict the future of ex-preterm infants: who benefits from a brain MRI at term? Acta Paediatr 2012; 101:1016-7. [PMID: 22804827 DOI: 10.1111/j.1651-2227.2012.02788.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Annie Janvier
- Department of Pediatrics, Université de Montréal, Hôpital Sainte-Justine, Montreal, Quebec.
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