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Ozer Bekmez B, Kanmaz Kutman HG, Oguz Y, Uygur D, Elbayiyev S, Canpolat FE, Oguz SS, Tayman C. Antenatal Neuroprotective Magnesium Sulfate in Very Preterm Infants and Its Association With Feeding Intolerance. J Pediatr Gastroenterol Nutr 2023; 77:597-602. [PMID: 37580867 DOI: 10.1097/mpg.0000000000003912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
INTRODUCTION/OBJECTIVE Magnesium sulfate (MgSO 4 ) treatment is widely used for fetal neuroprotection despite the controversy concerning the side effects. There is limited data regarding the impact of various cumulative maternal doses and neonatal serum magnesium (Mg) levels on short-term neonatal morbidity and mortality. We opted to carry out a study to determine the impact of neonatal serum Mg levels on neonatal outcomes. METHOD We conducted this prospective observational study between 2017 and 2021. Antenatal MgSO 4 was used for neuroprotective purpose only during the study period. Inborn preterm infants delivered between 23 and 31 6/7 weeks of gestation were enrolled consecutively. Babies who underwent advanced resuscitation in the delivery room, inotropic treatment due to hemodynamic instability in the first 7 days of life, >12 hours since the discontinuation of maternal MgSO 4 treatment, severe anemia, and major congenital/chromosomal anomalies were excluded from the study. The subgroup of babies with serum Mg level at the 6th hour of life underwent an analysis. A neonatal Mg concentration of 2.5 mg/dL was used to classify MgSO 4 -exposed patients into 2 groups (<2.5 mg/dL and ≥2.5 mg/dL). Another analysis was performed between babies whose mothers were exposed to MgSO 4 and those not exposed. Finally, the groups' neonatal outcomes were compared. RESULTS Of the 584 babies, 310 received antenatal MgSO 4 . The birth weights were significantly lower in the MgSO 4 exposed group (1113 ± 361 g vs 1202 ± 388 g, P = 0.005). Antenatal corticosteroid usage and intrauterine growth restriction were also noted to be higher. The MgSO 4 group was more likely to have bronchopulmonary dysplasia, prolonged invasive ventilation, necrotizing enterocolitis, delayed enteral nutrition, and feeding intolerance ( P < 0.05). MgSO 4 treatment was shown as an independent risk factor for feeding intolerance when corrected for confounders (odds ratio 2.13, 95% confidence interval: 1.4-3.1, P = 0.001). Furthermore, serum Mg level significantly correlated with feeding intolerance ( r = 0.21, P = 0.002). CONCLUSION This study highlighted the effect of MgSO 4 treatment and the potential superiority of serum Mg level as a predictor of immediate neonatal outcomes, particularly delayed enteral nutrition and feeding intolerance. Further studies are warranted to ascertain the optimal serum Mg concentration of preterm infants in early life to provide maximum benefit with minimal side effects.
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MESH Headings
- Female
- Humans
- Infant, Newborn
- Pregnancy
- Fetal Growth Retardation/drug therapy
- Infant, Newborn, Diseases/drug therapy
- Infant, Premature
- Infant, Premature, Diseases/drug therapy
- Infant, Premature, Diseases/prevention & control
- Infant, Premature, Diseases/chemically induced
- Magnesium Sulfate/therapeutic use
- Neuroprotection
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Affiliation(s)
- Buse Ozer Bekmez
- From the Division of Neonatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Hayriye Gozde Kanmaz Kutman
- From the Division of Neonatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Yuksel Oguz
- the Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Dilek Uygur
- the Department of Obstetrics and Gynecology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Sarkhan Elbayiyev
- From the Division of Neonatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Fuat Emre Canpolat
- From the Division of Neonatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Serife Suna Oguz
- From the Division of Neonatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Cuneyt Tayman
- From the Division of Neonatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Neonatal magnesium levels are safe after maternal MgSO 4 administration: a comparison between unexposed preterm neonates and neonates exposed for fetal neuroprotection or maternal eclampsia prevention-a cohort study. Eur J Pediatr 2022; 181:2971-2980. [PMID: 35595861 DOI: 10.1007/s00431-022-04507-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/18/2022] [Accepted: 05/14/2022] [Indexed: 12/29/2022]
Abstract
UNLABELLED To objective of this study was to compare neonatal magnesemia in the first 15 days of neonatal life between three groups: a control group not exposed to MgSO4, a neuroprotection group, and an eclampsia prevention group, and to explore its associations with child outcomes. A retrospective single-centre cohort study was performed in a tertiary care setting. Infants admitted at the neonatal intensive care unit born between 24 and 32 weeks' gestation, regardless of etiology of preterm birth, were included. The mean outcome measure was neonatal magnesemia (mmol/L). Linear mixed regression of neonatal magnesemia on exposure group and day of life was done. Generalised estimating equation models of child outcomes on neonatal magnesemia according to exposure group and day of life were made. The analyses showed that in neonatal magnesemia is significantly higher in the preeclampsia group compared to the control and neuroprotection groups. On the day of birth, this is irrespective of maternal magnesemia (preeclampsia vs control groups), and the maternal total dose or duration of MgSO4 administration (preeclampsia vs neuroprotection group). No differences were found in short-term composite outcome between the three groups. CONCLUSION We found mean differences in neonatal magnesemia between children not exposed to MgSO4 antenatally, children exposed for fetal neuroprotection, and children exposed for maternal eclampsia prevention. A 4-g loading and 1-g/h maintenance doses, for fetal neuroprotection and eclampsia prevention, appear to be safe on the short term for the neonate. WHAT IS KNOWN • Magnesium sulphate is a valuable medicine in obstetrics. The main indications are prevention of eclampsia and fetal neuroprotection. The most used dosage is a 4- or 6-g loading dose and a 1- or 2-g per h maintenance dose. It reduces neuromotor disabilities in extreme-to-moderate preterm born children. WHAT IS NEW • Maternal concentrations are supraphysiological and the maternal total dose can be high. Concentrations in neonates appear to remain in safe ranges. A dosage of 4-g loading and 1 g/h seems safe for the preterm neonate on the short term.
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Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
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Galinsky R, Dean JM, Lingam I, Robertson NJ, Mallard C, Bennet L, Gunn AJ. A Systematic Review of Magnesium Sulfate for Perinatal Neuroprotection: What Have We Learnt From the Past Decade? Front Neurol 2020; 11:449. [PMID: 32536903 PMCID: PMC7267212 DOI: 10.3389/fneur.2020.00449] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/28/2020] [Indexed: 12/14/2022] Open
Abstract
There is an important unmet need to improve long term outcomes of encephalopathy for preterm and term infants. Meta-analyses of large controlled trials suggest that maternal treatment with magnesium sulfate (MgSO4) is associated with a reduced risk of cerebral palsy and gross motor dysfunction after premature birth. However, to date, follow up to school age has found an apparent lack of long-term clinical benefit. Because of this inconsistency, it remains controversial whether MgSO4 offers sustained neuroprotection. We systematically reviewed preclinical and clinical studies reported from January 1 2010, to January 31 2020 to evaluate the most recent advances and knowledge gaps relating to the efficacy of MgSO4 for the treatment of perinatal brain injury. The outcomes of MgSO4 in preterm and term-equivalent animal models of perinatal encephalopathy were highly inconsistent between studies. None of the perinatal rodent studies that suggested benefit directly controlled body or brain temperature. The majority of the studies did not control for sex, study long term histological and functional outcomes or use pragmatic treatment regimens and many did not report controlling for potential study bias. Finally, most of the recent preterm or term human studies that tested the potential of MgSO4 for perinatal neuroprotection were relatively underpowered, but nevertheless, suggest that any improvements in neurodevelopment were at best modest or absent. On balance, these data suggest that further rigorous testing in translational preclinical models of perinatal encephalopathy is essential to ensure safety and best regimens for optimal preterm neuroprotection, and before further clinical trials of MgSO4 for perinatal encephalopathy at term are undertaken.
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Affiliation(s)
- Robert Galinsky
- Department of Obstetrics and Gynecology, The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, VIC, Australia.,Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Justin M Dean
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Ingran Lingam
- Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Nicola J Robertson
- Neonatology, Institute for Women's Health, University College London, London, United Kingdom
| | - Carina Mallard
- Department of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Laura Bennet
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Department of Physiology, University of Auckland, Auckland, New Zealand
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Shepherd E, Salam RA, Manhas D, Synnes A, Middleton P, Makrides M, Crowther CA. Antenatal magnesium sulphate and adverse neonatal outcomes: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002988. [PMID: 31809499 PMCID: PMC6897495 DOI: 10.1371/journal.pmed.1002988] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 11/06/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes. METHODS AND FINDINGS CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only. CONCLUSIONS Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.
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Affiliation(s)
- Emily Shepherd
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Rehana A. Salam
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Deepak Manhas
- University of British Columbia, Vancouver, British Columbia,
Canada
| | - Anne Synnes
- University of British Columbia, Vancouver, British Columbia,
Canada
| | - Philippa Middleton
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Maria Makrides
- South Australian Health and Medical Research Institute, Adelaide, South
Australia, Australia
| | - Caroline A. Crowther
- Robinson Research Institute, Discipline of Obstetrics and Gynaecology,
Adelaide Medical School, University of Adelaide, Adelaide, South Australia,
Australia
- Liggins Institute, University of Auckland, Auckland, New
Zealand
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Coskun Y, Isik S, Bayram T, Urgun K, Sakarya S, Akman I. A clinical scoring system to predict the development of intraventricular hemorrhage (IVH) in premature infants. Childs Nerv Syst 2018; 34:129-136. [PMID: 29026981 DOI: 10.1007/s00381-017-3610-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/04/2017] [Indexed: 11/24/2022]
Abstract
UNLABELLED OBJECTıVE: The aim of this study is to develop a scoring system for the prediction of intraventricular hemorrhage (IVH) in preterm infants in the first 7 days of life. METHODS A prospective, clinical study was conducted in Bahcesehir University, Medical Park Goztepe Hospital Neonatal Intensive Care Unit, with the enrollment of 144 preterm infants with gestational age between 24 and 34 weeks. All preterms were followed up for IVH after birth until the 4th week of life. The demographic characteristics and clinical risk factors were noted. Risk factors were analyzed. The score was established after logistic regression analysis, considering the impact of each variable on the occurrence of IVH within the first 7 days of life. The IVH scores were further applied prospectively to 89 preterm infants as validation cohort. RESULTS Low gestational age (GA), low Apgar score, and having bleeding diathesis were the most important risk factors for IVH. According to these risk factors, a scoring system was developed for IVH ranged from 0 to 5. According to the risk ratios (RR) obtained from the logistic regression model, low GA (≤ 28 gestational week), presence of bleeding diathesis within 7 days, and low Apgar score increased the risk of IVH (RR = 3.32 for GA ≤ 28 gestational week, RR = 6.7 for presence of bleeding diathesis in 7th day, RR = 3 for having low Apgar score). The score was validated successfully in 89 infants. The area under ROC curve was 0.85 for derivation cohort and 0.807 for validation cohort. The predictive ability of the IVH score for derivation and validation cohort was calculated. The negative predictive values of a score less than 4 were 96.4 and 59.1%. CONCLUSıON: Concerning IVH-related sequelae which continue to be a major public health problem, we have developed a feasible predictive model for evaluating the risk for developing IVH for preterm infants in the first 7 days of life.
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Affiliation(s)
- Yesim Coskun
- Department of Pediatrics, Goztepe Medical Park Hospital, Bahcesehir University School of Medicine, E5 Uzeri 23 Nisan Sokak No:17 34732 Merdivenkoy/Goztepe, Istanbul, Turkey.
| | - Semra Isik
- Department of Neurosurgery, Goztepe Medical Park Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Tevfik Bayram
- Department of Public Health, Marmara University School of Medicine, Istanbul, Turkey
| | - Kamran Urgun
- Department of Neurosurgery, Goztepe Medical Park Hospital, Bahcesehir University School of Medicine, Istanbul, Turkey
| | - Sibel Sakarya
- Department of Public Health, Marmara University School of Medicine, Istanbul, Turkey
| | - Ipek Akman
- Department of Pediatrics, Goztepe Medical Park Hospital, Bahcesehir University School of Medicine, E5 Uzeri 23 Nisan Sokak No:17 34732 Merdivenkoy/Goztepe, Istanbul, Turkey
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Rigo J, Pieltain C, Christmann V, Bonsante F, Moltu SJ, Iacobelli S, Marret S. Serum Magnesium Levels in Preterm Infants Are Higher Than Adult Levels: A Systematic Literature Review and Meta-Analysis. Nutrients 2017; 9:nu9101125. [PMID: 29035309 PMCID: PMC5691741 DOI: 10.3390/nu9101125] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 09/06/2017] [Accepted: 10/07/2017] [Indexed: 12/20/2022] Open
Abstract
Magnesium (Mg) is an essential mineral in the body, impacting the synthesis of biomacromolecules, bone matrix development, energy production, as well as heart, nerve, and muscle function. Although the importance of Mg is evident, reference values for serum Mg (sMg) in pediatric patients (more specifically, in neonates) are not well established. This systematic literature review and meta-analysis (using 47 eligible studies) aims to quantify normal and tolerable ranges of sMg concentrations during the neonatal period and to highlight the factors influencing Mg levels and the importance of regulating sMg levels during pregnancy and birth. In newborns without Mg supplementation during pregnancy, magnesium levels at birth (0.76 (95% CI: 0.52, 0.99) mmol/L) were similar to that of mothers during pregnancy (0.74 (95% CI: 0.43, 1.04) mmol/L), but increased during the first week of life (0.91 (95% CI: 0.55, 1.26) mmol/L) before returning to adult levels. This pattern was also seen in newborns with Mg supplementation during pregnancy, where the average was 1.29 (95% CI: 0.50, 2.08) mmol/L at birth and 1.44 (95% CI: 0.61, 2.27) mmol/L during the first week of life. Factors influencing these levels include prenatal Mg supplementation, gestational age, birth weight, renal maturity/function, and postnatal Mg intake. Elevated Mg levels (>2.5 mmol/L) have been associated with an increased risk of mortality, admission into intensive care, hypotonia, hypotension, and respiratory depression but sMg concentrations up to 2.0 mmol/L appear to be well tolerated in neonates, requiring adequate survey and minimal intervention.
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Affiliation(s)
- Jacques Rigo
- Department of Neonatology, Université de Liège, CHR Citadelle, 4000 Liège, Belgium.
| | - Catherine Pieltain
- Department of Neonatology, Université de Liège, CHR Citadelle, 4000 Liège, Belgium.
| | - Viola Christmann
- Radboudumc Amalia Children's Hospital, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands.
| | - Francesco Bonsante
- Centre d'Etudes Périnatales de l'Océan Indien (EA 7388), CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
- Réanimation Néonatale et Pédiatrique, Néonatologie, CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
| | - Sissel J Moltu
- Department of Neonatal Intensive Care, Oslo University Hospital, 0318 Oslo, Norway.
| | - Silvia Iacobelli
- Centre d'Etudes Périnatales de l'Océan Indien (EA 7388), CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
- Réanimation Néonatale et Pédiatrique, Néonatologie, CHU La Réunion-Site Sud Saint Pierre, BP 350 97448 Saint Pierre CEDEX, France.
| | - Stéphane Marret
- Department of Neonatal Pediatrics and Intensive Care and Neuropediatrics, Rouen University Hospital, and INSERM, Laboratoire NeoVasc ERI28, Normandy University, 76000 Rouen, France.
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Lecuyer M, Rubio M, Chollat C, Lecointre M, Jégou S, Leroux P, Cleren C, Leroux-Nicollet I, Marpeau L, Vivien D, Marret S, Gonzalez BJ. Experimental and clinical evidence of differential effects of magnesium sulfate on neuroprotection and angiogenesis in the fetal brain. Pharmacol Res Perspect 2017; 5. [PMID: 28805973 PMCID: PMC5684858 DOI: 10.1002/prp2.315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 01/05/2017] [Accepted: 01/10/2017] [Indexed: 01/25/2023] Open
Abstract
Clinical studies showed beneficial effects of magnesium sulfate regarding the risk of cerebral palsy. However, regimen protocols fluctuate worldwide and risks of adverse effects impacting the vascular system have been reported for human neonates, keeping open the question of the optimal dosing. Using clinically relevant concentrations and doses of magnesium sulfate, experiments consisted of characterizing, respectively, ex vivo and in vivo, the effects of magnesium sulfate on the nervous and vascular systems of mouse neonates by targeting neuroprotection, angiogenesis, and hemodynamic factors and in measuring, in human fetuses, the impact of a 4‐g neuroprotective loading dose of magnesium sulfate on brain hemodynamic parameters. Preclinical experiments using cultured cortical slices from mouse neonates showed that the lowest and highest tested concentrations of magnesium sulfate were equally potent to prevent excitotoxic‐induced cell death, cell edema, cell burst, and intracellular calcium increase, whereas no side effects were found regarding apoptosis. In contrast, in vivo data revealed that magnesium sulfate exerted dose‐dependent vascular effects on the fetal brain. In particular, it induced brain hypoperfusion, stabilization of Hif‐1α, long‐term upregulation of VEGF‐R2 expression, impaired endothelial viability, and altered cortical angiogenesis. Clinically, in contrast to 6‐g loading doses used in some protocols, a 4‐g bolus of magnesium sulfate did not altered fetal brain hemodynamic parameters. In conclusion, these data provide the first mechanistic evidence of double‐sword and dose‐dependent actions of magnesium sulfate on nervous and vascular systems. They strongly support the clinical use of neuroprotection protocols validated for the lowest (4‐g) loading dose of magnesium sulfate.
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Affiliation(s)
- Matthieu Lecuyer
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
| | - Marina Rubio
- INSERM U1237 unit "Serine proteases and Pathophysiology of the neurovascular Unit", Normandy University, Caen, France
| | - Clément Chollat
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France.,Department of Neonatal Paediatrics and Intensive Care, Rouen Hospital, Rouen, France.,Department of Neonatal Intensive Care, Port-Royal University Hospital, APHP, Paris, France
| | - Maryline Lecointre
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
| | - Sylvie Jégou
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
| | - Philippe Leroux
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
| | - Carine Cleren
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
| | - Isabelle Leroux-Nicollet
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
| | - Loic Marpeau
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France.,Department of Obstetrics, Rouen Hospital, Rouen, France
| | - Denis Vivien
- INSERM U1237 unit "Serine proteases and Pathophysiology of the neurovascular Unit", Normandy University, Caen, France
| | - Stéphane Marret
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France.,Department of Neonatal Paediatrics and Intensive Care, Rouen Hospital, Rouen, France
| | - Bruno J Gonzalez
- Normandie University, UNIROUEN, INSERM U1245 NeoVasc Team, Rouen University Hospital, IRIB, F76000 Normandy Centre for Genomic and Personalized Medicine, Rouen, France
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Downey LC, Cotten CM, Hornik CP, Laughon MM, Tolia VN, Clark RH, Smith PB. Association of in utero magnesium exposure and spontaneous intestinal perforations in extremely low birth weight infants. J Perinatol 2017; 37:641-644. [PMID: 28125094 PMCID: PMC5446291 DOI: 10.1038/jp.2016.274] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/03/2016] [Accepted: 11/23/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The objective of this study is to determine whether antenatal exposure to magnesium is associated with spontaneous intestinal perforation (SIP) in extremely low birth weight (ELBW) infants (⩽1000 g). STUDY DESIGN We identified all ELBW infants admitted to 1 of 323 neonatal intensive care units from 2007 to 2013. We used multivariable conditional logistic regression to compare outcomes in the first 21 days after birth between infants exposed and unexposed to magnesium in utero. RESULTS Of the 28 035 infants, 11 789 (42%) were exposed to antenatal magnesium (AM). There was no difference in the risk of SIP, odds ratio=1.08 (95% confidence interval; 0.91 to 1.29), between infants exposed and unexposed to AM. Mortality in the first 21 days after birth was lower in the magnesium-exposed infants, odds ratio=0.76 (0.70 to 0.83). CONCLUSION AM exposure in ELBW infants was not associated with increased risk of SIP.
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Affiliation(s)
- L. Corbin Downey
- Division of Neonatology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - C. Michael Cotten
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | - Christoph P. Hornik
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
| | - Matthew M. Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill
| | - Veeral N. Tolia
- Pediatrix Medical Group and Baylor University Medical Center, Dallas, TX
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - P. Brian Smith
- Department of Pediatrics, Duke Clinical Research Institute, Duke University, Durham, NC
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10
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Ostrander B, Bardsley T, Korgenski EK, Greene T, Bonkowsky JL. Neonatal Magnesium Levels Between 24 and 48 Hours of Life and Outcomes for Epilepsy and Motor Impairment in Premature Infants. Pediatr Neurol 2016; 59:41-6. [PMID: 27025188 PMCID: PMC4912928 DOI: 10.1016/j.pediatrneurol.2016.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 01/24/2016] [Accepted: 02/22/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Elevated rates of epilepsy and motor impairments including cerebral palsy are observed in children who were born prematurely. Maternal antenatal magnesium supplementation has been associated with decreased rates of cerebral palsy in infants born prematurely. Our objective was to determine whether the neonatal serum magnesium level between 24 and 48 hours after birth is associated with better long-term neurodevelopmental outcomes (epilepsy, motor impairment) in premature infants. METHODS We performed a retrospective cohort analysis in infants born less than 37-weeks gestation over a ten-year period. Prenatal, perinatal, and postnatal clinical and demographic information was collected. Crude and adjusted odds ratios were estimated under generalized linear models with generalized estimating equations to examine the association of the neonatal serum magnesium level between 24 and 48 hours after birth with the risk of epilepsy and/or motor impairment (spasticity; hypotonia; cerebral palsy). RESULTS The final cohort included 5461 infants born less than 37-weeks gestation from 2002 to 2011. The adjusted relative risk ratio for the combined outcomes of epilepsy and/or motor impairment, controlling for gestational age, current age, maternal magnesium supplementation, maternal steroid administration, five-minute Apgar score, neonatal infection, need for vasopressor use, and birth weight and with serum magnesium level as the main independent variable, was 0.85 (P = 0.24). Stratified analyses by gestational age less than 32 or greater than 32 weeks were not significantly associated with adverse neurodevelopmental outcome (risk ratio = 0.79 and 1.2, P = 0.12 and 0.49, respectively). A multivariate analysis for the risk of motor impairment alone had a risk ratio of 0.94 (P = 0.72). CONCLUSION This study demostrates that the neonatal magnesium level between 24 and 48 hours of life in premature infants is not significantly associated with the risk for developing epilepsy or motor impairment.
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Affiliation(s)
- Betsy Ostrander
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Tyler Bardsley
- Department of Biostatistics, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Tom Greene
- Department of Biostatistics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Joshua L. Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah,Address correspondence to: Josh Bonkowsky, Division of Pediatric Neurology, Department of Pediatrics, University of Utah Health Sciences Center, 295 Chipeta Way/Williams Building, Salt Lake City, Utah 84108, , Phone: 801-581-6756, Fax: 801-581-4233
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11
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Drassinower D, Friedman AM, Levin H, Običan SG, Gyamfi-Bannerman C. Does magnesium exposure affect neonatal resuscitation? Am J Obstet Gynecol 2015; 213:424.e1-5. [PMID: 26026919 DOI: 10.1016/j.ajog.2015.05.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/28/2015] [Accepted: 05/26/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Research on immediate neonatal resuscitation suggests that maternal magnesium exposure may be associated with increased risk of low Apgar scores, hypotonia, and neonatal intensive care unit admission. However, not all studies support these associations. Our objective was to determine whether exposure to magnesium at the time of delivery affects initial neonatal resuscitation. STUDY DESIGN This is a secondary analysis of the Randomized Controlled Trial of Magnesium Sulfate for the Prevention of Cerebral Palsy that evaluated whether the study drug (magnesium or placebo) that was administered at the time of delivery was associated with increased risk for a composite adverse neonatal resuscitation outcome (5-minute Apgar score <7, oxygen administration in the delivery room, intubation, chest compressions, hypotension, and hypotonicity). A subgroup analysis was performed among patients who delivered at ≥30 weeks of gestation. Log-linear regression was used to control for possible confounders. RESULTS Data for 1047 patients were analyzed, of whom 461 neonates (44%) were exposed to magnesium. There was no increased risk for the primary composite outcome associated with magnesium exposure. Individual adverse neonatal outcomes and other secondary short-term neonatal outcomes that were evaluated also did not demonstrate an association with magnesium exposure. CONCLUSION Exposure to magnesium sulfate did not affect neonatal resuscitation or other short-term outcomes. These findings may be useful in planning neonatal care and patient counseling.
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Weisz DE, Shivananda S, Asztalos E, Yee W, Synnes A, Lee SK, Shah PS. Intrapartum magnesium sulfate and need for intensive delivery room resuscitation. Arch Dis Child Fetal Neonatal Ed 2015; 100:F59-65. [PMID: 25232002 DOI: 10.1136/archdischild-2013-305884] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the association of intrapartum magnesium sulfate for fetal neuroprotection (MgSO4-FN) with the delivery room resuscitation and neonatal outcomes of preterm infants in an era of minimisation of invasive mechanical ventilation. DESIGN Retrospective cohort study. SETTING Neonatal intensive care units in the Canadian Neonatal Network. PATIENTS AND INTERVENTION Preterm infants (23(0) to 31(6) weeks gestational age) born in 2011 or 2012. Resuscitation requirements and neonatal outcomes were compared between infants exposed and unexposed to intrapartum MgSO4-FN. MAIN OUTCOME MEASURES The primary outcome was a composite outcome of 'intensive resuscitation', defined as the need for intubation and ventilation or chest compressions or epinephrine administration in the delivery room. Secondary outcomes included mortality and major neonatal morbidities. RESULTS Of 6015 eligible infants, 1387 (23.1%) were exposed to intrapartum MgSO4-FN. Significantly fewer MgSO4-FN infants (41.0% vs 44.6%, p=0.02) required intensive resuscitation. However, after adjustment for confounders, this difference was no longer significant (adjusted OR (AOR) 0.88; 95% CI 0.66 to 1.17). Infants exposed to MgSO4-FN had decreased odds of death (AOR 0.61; 95% CI 0.40 to 0.94), but there was no difference in neonatal morbidities compared with the unexposed infants. CONCLUSIONS Intrapartum MgSO4 for fetal neuroprotection was not associated with an increased need for intensive delivery room resuscitation in this cohort of preterm infants.
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Affiliation(s)
- Dany E Weisz
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sandesh Shivananda
- Department of Paediatrics, McMaster Children's Hospital, Hamilton, Canada
| | - Elizabeth Asztalos
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Canada Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Wendy Yee
- Department of Paediatrics, University of Calgary, Calgary, Canada
| | - Anne Synnes
- Department of Paediatrics, University of British Columbia, Vancouver, Canada
| | - Shoo K Lee
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Prakesh S Shah
- Department of Paediatrics, University of Toronto, Toronto, Canada Institute of HPME, University of Toronto, Toronto, Canada
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13
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Chang JJ, Mack WJ, Saver JL, Sanossian N. Magnesium: potential roles in neurovascular disease. Front Neurol 2014; 5:52. [PMID: 24782823 PMCID: PMC3995053 DOI: 10.3389/fneur.2014.00052] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 03/28/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Magnesium therapy has been studied extensively in pre-clinical and clinical trials in multiple organ systems. Cerebrovascular diseases may benefit from its neuroprotective properties. This review summarizes current studies of magnesium in a wide range of neurovascular diseases. METHODS We searched relevant terms in the National Library of Medicine PubMed database and selected research including basic science, translational reports, meta-analyses, and clinical studies. RESULTS Studies examining magnesium administration in ischemic stroke have failed to show any benefit in clinical outcome. Data on magnesium for intracerebral hemorrhage (ICH) are limited. Preliminary investigations in subarachnoid hemorrhage (SAH) were promising, but definitive studies did not reveal differences in clinical outcome between magnesium and placebo-treated groups. Studies examining magnesium administration in global ischemia following cardiac arrest suggest a trend toward improved clinical outcome. The strongest evidence for clinically relevant neuroprotection following magnesium administration derives from studies of pre-term infants and patients undergoing cardiac bypass and carotid endarterectomy procedures. Magnesium was found to have an excellent safety profile across all investigations. CONCLUSION Magnesium is easy to administer and possesses a favorable safety profile. Its utility as a neuroprotectant in cardiac surgery, carotid endarterectomy, and pre-term infant hypoxia remain promising. Value as a therapeutic agent in ischemic stroke, ICH, and SAH is unclear and appears to be limited by late administration. Ongoing clinical trials assessing magnesium administration in the first hours following symptom onset may help clarify the role of magnesium therapy in these disease processes.
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Affiliation(s)
- Jason J Chang
- Department of Neurology, University of Southern California , Los Angeles, CA , USA
| | - William J Mack
- Department of Neurosurgery, University of Southern California , Los Angeles, CA , USA ; The Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California , Los Angeles, CA , USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Stroke Center, University of California Los Angeles , Los Angeles, CA , USA
| | - Nerses Sanossian
- Department of Neurology, University of Southern California , Los Angeles, CA , USA ; The Roxanna Todd Hodges Comprehensive Stroke Clinic, University of Southern California , Los Angeles, CA , USA
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14
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Abstract
Intraventricular hemorrhage (IVH) is a major neurologic complication of prematurity. Pathogenesis of IVH is attributed to intrinsic fragility of germinal matrix vasculature and to the fluctuation in the cerebral blood flow. Germinal matrix exhibits rapid angiogenesis orchestrating formation of immature vessels. Prenatal glucocorticoid exposure remains the most effective means of preventing IVH. Therapies targeted to enhance the stability of the germinal matrix vasculature and minimize fluctuation in the cerebral blood flow might lead to more effective strategies in preventing IVH.
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Affiliation(s)
- Praveen Ballabh
- Department of Pediatrics, Cell Biology and Anatomy, Regional Neonatal Center, New York Medical College, Maria Fareri Children's Hospital, Westchester Medical Center, 100 Woods Road, Valhalla, NY 10595, USA.
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15
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Doll E, Wilkes J, Cook LJ, Korgenski EK, Faix RG, Yoder BA, Srivastava R, Sherwin CMT, Spigarelli MG, Clark EAS, Bonkowsky JL. Neonatal magnesium levels correlate with motor outcomes in premature infants: a long-term retrospective cohort study. Front Pediatr 2014; 2:120. [PMID: 25414842 PMCID: PMC4220726 DOI: 10.3389/fped.2014.00120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 10/22/2014] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Chronic neurological deficits are a significant complication of preterm birth. Magnesium supplementation has been suggested to have neuroprotective function in the developing brain. Our objective was to determine whether higher neonatal serum magnesium levels were associated with better long-term neurodevelopmental outcomes in very-low birth weight infants. STUDY DESIGN A retrospective cohort of 75 preterm infants (<1500 g, gestational age <27 weeks) had follow-up for the outcomes of abnormal motor exam and for epilepsy. Average total serum magnesium level in the neonate during the period of prematurity was the main independent variable assessed, tested using a Wilcoxon rank-sum test. RESULTS Higher average serum magnesium level was associated with a statistically significant decreased risk for abnormal motor exam (p = 0.037). A lower risk for epilepsy in the group with higher magnesium level did not reach statistical significance (p = 0.06). CONCLUSION This study demonstrates a correlation between higher neonatal magnesium levels and decreased risk for long-term abnormal motor exam. Larger studies are needed to evaluate the hypothesis that higher neonatal magnesium levels can improve long-term neurodevelopmental outcomes.
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Affiliation(s)
- Elizabeth Doll
- Division of Pediatric Neurology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Jacob Wilkes
- Intermountain Healthcare , Salt Lake City, UT , USA
| | - Lawrence J Cook
- Division of Critical Care Medicine, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | | | - Roger G Faix
- Division of Neonatology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Bradley A Yoder
- Division of Neonatology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Rajendu Srivastava
- Intermountain Healthcare , Salt Lake City, UT , USA ; Division of Inpatient Medicine, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Catherine M T Sherwin
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Michael G Spigarelli
- Division of Clinical Pharmacology, Department of Pediatrics, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Erin A S Clark
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, School of Medicine, University of Utah , Salt Lake City, UT , USA
| | - Joshua L Bonkowsky
- Division of Pediatric Neurology, School of Medicine, University of Utah , Salt Lake City, UT , USA
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16
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Treatment of intraventricular hemorrhages in premature infants: where is the evidence? Adv Neonatal Care 2013; 13:127-30. [PMID: 23532032 DOI: 10.1097/anc.0b013e31828ac82e] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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