A Meta-Analysis of the Risk Factors of Persistent Pulmonary Hypertension in Newborns

Urban environment and children's health: An umbrella review of exposure response functions for health impact assessment

BACKGROUND

Urban settlements have become the main living environment. Understanding the impact of urban exposures on human health has therefore become a growing area of research. Up-to-date knowledge about the influence of urban exposures on pregnant women's and children's health is especially relevant, as they are particularly vulnerable to certain external influences.

AIM

This review aims to provide a synthesis of systematic reviews with meta-analyses reporting on an association between the urban environmental risk factors and health outcomes in pregnancy, infants, children and adolescents.

METHODS

We conducted an umbrella review, methodically analysing systematic reviews with meta-analyses, published between January 2016 and December 2022 in PubMed or Scopus. Adhering to the PRISMA checklist, we searched for free text using Medical Subject Headings (MeSH) terms related to air pollution, noise pollution, temperature, green space exposure, built and food environment, health outcomes, children (aged 0-18 years), pregnancy and systematic reviews with meta-analyses. We extracted key characteristics of each included study and assessed the quality of the included studies via the R-AMSTAR 2 tool.

RESULTS

Twenty-four studies met our inclusion criteria and identified 104 associations including 15 exposures and 60 health outcomes. The most frequently studied associations were related to air pollutants, followed by the built and food environment and noise. Birth outcomes (including low birth weight, pre-term birth or stillbirth) were the most commonly affected health outcomes, followed by respiratory outcomes such as asthma or respiratory infections. A total of 45 exposure-response function were reported to be statistically significant, including 10 exposures and 23 health effects.

CONCLUSION

This umbrella review provides an overview of the evidence and availability of exposure response functions between selected urban exposures and child health outcomes. This helps to identify research gaps and to build the basis for health impact assessment.

Milrinone in persistent pulmonary hypertension of newborn: a scoping review

Persistent pulmonary hypertension of the newborn (PPHN) is a common neonatal condition in newborns admitted to the neonatal intensive care units (NICUs). PPHN has still a high mortality and morbidity. Inhaled nitric oxide (iNO) is the first line vasodilator therapy for PPHN in high income countries. In low-to-middle income countries (LMICs), availability of iNO remains scarce and expensive. The purpose of this scoping review was to evaluate the current existing literature for milrinone therapy in PPHN and to identify the knowledge gaps in milrinone use in infants with PPHN. The available evidence for milrinone remains limited both as monotherapy and as an adjuvant to iNO. The studies were heterogeneous, conducted in different settings, with different populations and more importantly the endpoints of these trials were short-term outcomes such as changes in oxygenation and blood pressure. Large prospective studies investigating long-term outcomes, mortality, and the need for Extracorporeal membrane oxygenation (ECMO) are warranted. Randomized controlled trials with milrinone as monotherapy are needed in LMICs where iNO availability remains limited. IMPACT: Milrinone has a potential role in the management of PPHN both as an adjuvant to iNO as well as a monotherapy. This scoping review identified the problems existing in the published literature on milrinone and the barriers to generalization of these results. Multi-centre randomized controlled trials on milrinone, especially involving centers from low- and middle-income countries are needed, where it can be evaluated as first-line pulmonary vasodilator therapy.

A Nomogram Prediction Model for Persistent Pulmonary Hypertension of the Newborn in Neonates Hospitalized for the First Time After Birth

OBJECTIVE

Persistent pulmonary hypertension of the newborn (PPHN) is one of the critical neonatal diseases associated with high morbidity and mortality. This study attempted to conduct a nomogram prediction model for performing early identification of PPHN and providing effective information for clinical practice.

METHODS

A total of 456 newborns who first admitted to the hospital after birth were included in the analysis, including 138 newborns with PPHN and 318 newborns without PPHN (as controls). The optimal predictive variables selection was performed based on LASSO (least absolute shrinkage and selection operator) regression and multivariate logistic regression. Using the selected variables, a nomogram prediction model was developed. To validate the model, the model was assessed using the receiver operating characteristic curve, calibration plot, and clinical impact curve.

RESULTS

Six predictors, namely, gestational age, neonatal respiratory distress syndrome, the levels of hemoglobin and creatine kinase-MB, gestational thyroid dysfunction, and Pa o2 , were identified by LASSO and multivariate logistic regression analysis from the original 30 variables studied. The constructed model, using these predictors, exhibited favorable predictive ability for PPHN, with an area under the receiver operating characteristic of 0.897 (sensitivity = 0.876, specificity = 0.785) in the training set and 0.871 (sensitivity = 0.902, specificity = 0.695) in the validation set, and was well calibrated, as indicated by the PHosmer-Lemeshow test values of 0.233 and 0.876 for the training and validation sets, respectively.

CONCLUSIONS

The model included gestational age, neonatal respiratory distress syndrome, the levels of hemoglobin and creatine kinase-MB, gestational thyroid dysfunction, and Pa o2 had good prediction performance for predicting PPHN among newborns first admitted to the hospital after birth.

Interdisciplinary fetal-neonatal neurology training applies neural exposome perspectives to neurology principles and practice

An interdisciplinary fetal-neonatal neurology (FNN) program over the first 1,000 days teaches perspectives of the neural exposome that are applicable across the life span. This curriculum strengthens neonatal neurocritical care, pediatric, and adult neurology training objectives. Teaching at maternal-pediatric hospital centers optimally merges reproductive, pregnancy, and pediatric approaches to healthcare. Phenotype-genotype expressions of health or disease pathways represent a dynamic neural exposome over developmental time. The science of uncertainty applied to FNN training re-enforces the importance of shared clinical decisions that minimize bias and reduce cognitive errors. Trainees select mentoring committee participants that will maximize their learning experiences. Standardized questions and oral presentations monitor educational progress. Master or doctoral defense preparation and competitive research funding can be goals for specific individuals. FNN principles applied to practice offer an understanding of gene-environment interactions that recognizes the effects of reproductive health on the maternal-placental-fetal triad, neonate, child, and adult. Pre-conception and prenatal adversities potentially diminish life-course brain health. Endogenous and exogenous toxic stressor interplay (TSI) alters the neural exposome through maladaptive developmental neuroplasticity. Developmental disorders and epilepsy are primarily expressed during the first 1,000 days. Communicable and noncommunicable illnesses continue to interact with the neural exposome to express diverse neurologic disorders across the lifespan, particularly during the critical/sensitive time periods of adolescence and reproductive senescence. Anomalous or destructive fetal neuropathologic lesions change clinical expressions across this developmental-aging continuum. An integrated understanding of reproductive, pregnancy, placental, neonatal, childhood, and adult exposome effects offers a life-course perspective of the neural exposome. Exosome research promises improved disease monitoring and drug delivery starting during pregnancy. Developmental origins of health and disease principles applied to FNN practice anticipate neurologic diagnoses with interventions that can benefit successive generations. Addressing health care disparities in the Global South and high-income country medical deserts require constructive dialogue among stakeholders to achieve medical equity. Population health policies require a brain capital strategy that reduces the global burden of neurologic diseases by applying FNN principles and practice. This integrative neurologic care approach will prolong survival with an improved quality of life for persons across the lifespan confronted with neurological disorders.

Methods for establishing animal models of persistent pulmonary hypertension of the newborn: A systematic literature analysis

OBJECTIVES

Persistent pulmonary hypertension of the newborn (PPHN) is a complex disease with poorly understood mechanisms and risk factors. Developing animal models that reflect the pathophysiological characteristics of PPHN is critical for studying its pathogenesis and treatment strategies. This study aims to analyze the applications, methodologies, and evaluation criteria of PPHN animal models through systematic literature analysis, and to provide guidelines for establishing scientific, cost-effective, and reproducible models.

METHODS

Relevant studies published until March 2023 were retrieved from Chinese databases (CNKI, Wanfang, VIP, and SinoMed) and English databases (PubMed, Web of Science, and Embase). Data were extracted on the applications, species, modeling methods and their principles, specific procedures, species and ages of animals used, and time to model establishment, and criteria for evaluating successful model establishment. A database was created and statistical analyses were performed using Excel 2021, with results presented as charts.

RESULTS

A total of 1 157 studies were identified, and 174 met the inclusion criteria. PPHN animal models were primarily used for pathophysiological and mechanistic research (47.70%). The species used including sheep, pigs, rats, cows, and mice, ranked by frequency of use. Modeling methods were categorized into 4 types: Hypoxia exposure (44.69%), prenatal ductus arteriosus (DA) constriction (41.34%), pharmacological induction (8.94%), and combined induction (hypoxia and indomethacin, 5.03%). Each method was associated with specific species and ages. Prenatal DA constriction was exclusively performed in fetal sheep. The time to model establishment varied: Hypoxia exposure typically required >3 days, prenatal DA constriction had a median of 8.5 days, and combined induction took 3 days. Criteria for evaluating successful model establishment were categorized into 5 dimensions: Anatomical structure, histological features, hemodynamic parameters, blood gas analysis, and other physiological indicators. The most common criteria were "right ventricular hypertrophy" and "significant pulmonary arterial pressure elevation".

CONCLUSIONS

Current methods for modeling PPHN in animals are diverse, each with its strengths and limitations. Researchers should select the method most suitable for their study objectives and budget. Further exploration is needed to develop scientifically robust, cost-effective, and reproducible animal models for PPHN.

Recent Advances in Pediatric Pulmonary Hypertension: Implications for Diagnosis and Treatment

PURPOSE

Pediatric pulmonary hypertension (PH) is a condition characterized by elevated pulmonary arterial pressure, which has the potential to be life-limiting. The etiology of pediatric PH varies. When compared with adult cohorts, the etiology is often multifactorial, with contributions from prenatal, genetic, and developmental factors. This review aims to provide an up-to-date overview of the causes and classification of pediatric PH, describe current therapeutics in pediatric PH, and discuss upcoming and necessary research in pediatric PH.

METHODS

PubMed was searched for articles relating to pediatric pulmonary hypertension, with a particular focus on articles published within the past 10 years. Literature was reviewed for pertinent areas related to this topic.

FINDINGS

The evaluation and approach to pediatric PH are unique when compared with that of adults, in large part because of the different, often multifactorial, causes of the disease in children. Collaborative registry studies have found that the most common disease causes include developmental lung disease and subsets of pulmonary arterial hypertension, which includes genetic variants and PH associated with congenital heart disease. Treatment with PH-targeted therapies in pediatrics is often guided by extrapolation of adult data, small clinical studies in pediatrics, and/or expert consensus opinion. We review diagnostic considerations and treatment in some of the more common pediatric subpopulations of patients with PH, including developmental lung diseases, congenital heart disease, and trisomy 21.

IMPLICATIONS

The care of pediatric patients with PH requires consideration of unique pediatric-specific factors. With significant variability in disease etiology, ongoing efforts are needed to optimize treatment strategies based on disease phenotype and guide evidence-based practices.

Comparison of the efficacy of inhaled versus infused milrinone in the management of persistent pulmonary hypertension of the newborn in resource-limited settings: A randomized clinical trial

BACKGROUND

The standard treatment for persistent pulmonary hypertension of the newborn (PPHN) is inhaled nitric oxide (iNO), which is not available in Iran. Consequently, other drugs, such as milrinone, are prescribed. So far, no study has investigated the effectiveness of inhaled milrinone in the management of PPHN. The present study aimed to improve the management of PPHN in the absence of iNO.

METHODS

In this randomized clinical trial, neonates with PPHN, admitted to the neonatal intensive care unit of Hazrat Ali-Asghar and Akbar-Abadi hospitals, were treated with intravenous dopamine infusion and randomly divided into two groups, receiving milrinone through inhalation or infusion rout. The neonates were evaluated by Doppler echocardiography, clinical examinations, and oxygen demand test. The neonates were also evaluated for the clinical symptoms and mortality in the follow-up.

RESULTS

A total of 31 infants, with a median age of 2 days (interquartile range = 4), were included in this study. There was a significant decrease in the peak systolic and mean pulmonary arterial pressure in both inhalation and infusion groups following milrinone administration, with no significant difference between the groups (p = 0.584 and p = 0.147, respectively). There was no significant difference between the two groups regarding the mean systolic blood pressure before and after treatment. Additionally, diastolic blood pressure was significantly lower in the infusion group after treatment (p = 0.020); however, the amount of reduction was not significantly different between the groups (p = 0.928). Overall, 83.9% of the participants achieved full recovery, 75% of whom were in the infusion group and 93.3% in the inhalation group (p = 0.186).

CONCLUSION

Milrinone inhalation can have similar effects to milrinone infusion as an adjunct treatment in the management of PPHN. Also, infusion and inhalation of milrinone showed similar safety.