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Wei Y, Zhang HL, Sun YZ, Yang JP, Li SJ. Correlation of vitamin A levels in umbilical cord blood with neonatal pulmonary diseases. Pediatr Neonatol 2024:S1875-9572(24)00036-6. [PMID: 38523015 DOI: 10.1016/j.pedneo.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/12/2023] [Accepted: 10/02/2023] [Indexed: 03/26/2024] Open
Abstract
OBJECTIVE To study the relationship between umbilical cord blood vitamin A (VA) and neonatal lung diseases and explore the impact of umbilical cord blood VA on neonatal lung diseases. METHOD Umbilical vein blood was collected at birth, and its VA content was measured. According to the VA levels in umbilical cord blood, a VA deficiency (VAD) group, a marginal deficiency group and a normal group were created and followed up until 28 days after birth. RESULTS The umbilical cord blood VA level in the neonatal group with lung disease was 0.13 ± 0.05 mg/L, while the result for the VA level in the non-lung disease group was 0.15 ± 0.05 mg/L. The umbilical cord blood VA levels in the neonatal lung disease group were significantly lower than those in the non-lung disease group. The incidence of neonatal pulmonary diseases was highest in the VAD group, and the incidence decreased as the level of VA in umbilical cord blood increased. Umbilical cord blood VAD and premature birth were found to be independent risk factors for neonatal respiratory disease. CONCLUSION Umbilical cord blood VAD and premature birth are independent risk factors for neonatal pulmonary diseases. The lower the level of VA in umbilical cord blood, the more susceptible infants will be to neonatal respiratory infections in the neonatal period.
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Affiliation(s)
- Yu Wei
- Department of Neonatology, Anyang People's Hospital, Xinxiang Medical University, Anyang, 455000, Henan province, China
| | - Hong-Liang Zhang
- Department of Neonatology, Anyang People's Hospital, Xinxiang Medical University, Anyang, 455000, Henan province, China
| | - Ya-Zhou Sun
- Department of Neonatology, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453100, Henan province, China
| | - Jin-Peng Yang
- Department of Neonatology, Anyang People's Hospital, Xinxiang Medical University, Anyang, 455000, Henan province, China
| | - Shu-Jun Li
- Department of Neonatology, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453100, Henan province, China.
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Kumar A, Anjankar A. A Narrative Review of Vitamin A Supplementation in Preterm and Term Infants. Cureus 2022; 14:e30242. [DOI: 10.7759/cureus.30242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/12/2022] [Indexed: 11/07/2022] Open
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Tong Y, Zuo J, Yue D. Application Prospects of Mesenchymal Stem Cell Therapy for Bronchopulmonary Dysplasia and the Challenges Encountered. Biomed Res Int 2021; 2021:9983664. [PMID: 33997051 DOI: 10.1155/2021/9983664] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 01/01/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a common chronic lung disease in premature babies, especially affecting those with very low or extremely low birth weights. Survivors experience adverse lung and neurological defects including cognitive dysfunction. This impacts the prognosis of children with BPD and may result in developmental delays. The currently available options for the treatment of BPD are limited owing to low efficacy or several side effects; therefore, there is a lack of effective treatments for BPD. The treatment for BPD must help in the repair of damaged lung tissue and promote further growth of the lung tissue. In recent years, the emergence of stem cell therapy, especially mesenchymal stem cell (MSC) therapy, has improved the treatment of BPD to a great extent. This article briefly reviews the advantages, research progress, and challenges faced with the use of MSCs in the treatment of BPD. Stem cell therapy is beneficial as it repairs damaged tissues by reducing inflammation, fibrosis, and by acting against oxidative stress damage. Experimental trials have also proven that MSCs provide a promising avenue for BPD treatment. However, there are challenges such as the possibility of MSCs contributing to tumorous growths, the presence of heterogeneous cell populations resulting in variable efficacy, and the ethical considerations regarding the use of this treatment in humans. Therefore, more research must be conducted to determine whether MSC therapy can be approved as a treatment option for BPD.
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Rakshasbhuvankar AA, Patole SK, Simmer K, Pillow J. Vitamin A supplementation for prevention of mortality and morbidity in moderate and late preterm infants. Hippokratia 2019. [DOI: 10.1002/14651858.cd013322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Abhijeet A Rakshasbhuvankar
- King Edward Memorial Hospital for Women; Department of Neonatal Paediatrics; 374 Bagot Road Subiaco WA Australia 6008
| | - Sanjay K Patole
- King Edward Memorial Hospital; School of Paediatrics and Child Health, School of Women's and Infants' Health, University of Western Australia; 374 Bagot Rd Subiaco Perth Western Australia Australia 6008
| | - Karen Simmer
- King Edward Memorial Hospital for Women and Princess Margaret Hospital for Children; Neonatal Care Unit; Bagot Road Subiaco WA Australia 6008
| | - Jane Pillow
- King Edward Memorial Hospital; School of Women's and Infant's Health, University of Western Australia; 374 Bagot Rd Subiaco Perth Western Australia Australia 6008
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5
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Abstract
Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease of infancy, which mostly affects premature infants with significant morbidity and mortality. Premature infants who require to be treated for conditions including respiratory distress syndrome have a higher risk of developing BPD. In spite of the improvement in clinical methods, the incidence of BPD has not reduced. In the present review, the pathogenesis of BPD is described along with the treatments available at present and the role of nursing in the management of BPD. Emerging preventive therapies for BPD are also discussed, including the use of recombinant human superoxide dismutase, which has been proven effective in reducing respiratory injury and its long-term effects.
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Affiliation(s)
- Asfia Banu Pasha
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Xiao-Qing Chen
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Guo-Ping Zhou
- Department of Pediatrics, The First Affiliated Hospital, School of International Education, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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6
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Cherukuri L, Gewirtz G, Osea K, Tayek JA. Vitamin A treatment for severe sepsis in humans; a prospective randomized double blind placebo-controlled clinical trial. Clin Nutr ESPEN 2018; 29:49-51. [PMID: 30661700 DOI: 10.1016/j.clnesp.2018.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/22/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To test the benefits of Vitamin A treatment in patients with sepsis on length of time in ICU, days on ventilator, days on intravenous blood pressure support and 28-day mortality. The trial was prospective, randomized and double-blind. As part of a larger sepsis trial, 63 patients with sepsis were randomized to receive either 100,000 IU of Vitamin A intramuscular or placebo over 7-days. Data analysis was by ANOVA with two tailed test and p < 0.05 as significant. RESULTS The mean age was 51 ± 2 (mean ± SEM) with 54% female. Groups were well matched with regards to APACHE III score, WBC count, and incidence of bacteremia. In addition, all patients had an ACTH stimulation test using 250 mcg of ACTH IV and serum cortisol was measured at time 0, 30 and 60 min. Baseline cortisol of 24.6 ± 1 mg/dl increased to 41 ± 2 mg/dl at 30 min and 49 ± 2 at 60 min. There was no significant difference between the groups. All cortisol responses were greater than 11.9 mg/dl. Serum Vitamin A level was below normal in 54% of the patients. After randomization, 100,000 IU of Vitamin A daily was given to 32 patients and blinded placebo was given daily to 32 patients for seven days. This was administered as a 1 cc injection of either medication or placebo and was blinded from all but the research pharmacist. The number of days in the ICU was slightly, but not significantly reduced (p = 0.39) by approximately 2 days in the Vitamin A treated patients. The average number of days on blood pressure agents and the day on ventilator were similar. The 28-day mortality rates were similar between the two groups (28 vs 34% placebo vs Vitamin A group). Seven days of high dose intramuscular Vitamin A treatment in patients with sepsis where approximately 50% were vitamin A deficient had no benefit in adults with sepsis.
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Affiliation(s)
- Lavanya Cherukuri
- David Geffen School of Medicine at UCLA, Department of Internal Medicine, Los Angeles BioMedical Research Institute (LaBioMed), Harbor-UCLA Medical Center, United States
| | - Gail Gewirtz
- David Geffen School of Medicine at UCLA, Department of Internal Medicine, Los Angeles BioMedical Research Institute (LaBioMed), Harbor-UCLA Medical Center, United States; NutritonDay US, Northbrook, IL, United States
| | - Kea Osea
- David Geffen School of Medicine at UCLA, Department of Internal Medicine, Los Angeles BioMedical Research Institute (LaBioMed), Harbor-UCLA Medical Center, United States
| | - John A Tayek
- David Geffen School of Medicine at UCLA, Department of Internal Medicine, Los Angeles BioMedical Research Institute (LaBioMed), Harbor-UCLA Medical Center, United States.
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7
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Abstract
Retinopathy of prematurity (ROP) is a leading cause of blindness in preterm infants around the world. Through the development of animal models and clinical trials our understanding of the pathophysiology of this disease and approach to therapy has evolved significantly since ROP was first described in the 1940s in the United States. The mainstay of treatment in ROP remains ablative laser therapy to the avascular retina but pharmacologic agents are being more and more commonly used with new targets for pharmacotherapy emerging. This paper summarizes our current understanding of the pathophysiology of ROP based on the data gleaned from animal models and discusses current approaches to pharmacotherapy.
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Dao DT, Anez-Bustillos L, Cho BS, Li Z, Puder M, Gura KM. Assessment of Micronutrient Status in Critically Ill Children: Challenges and Opportunities. Nutrients 2017; 9:nu9111185. [PMID: 29143766 PMCID: PMC5707657 DOI: 10.3390/nu9111185] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 10/19/2017] [Accepted: 10/20/2017] [Indexed: 02/06/2023] Open
Abstract
Micronutrients refer to a group of organic vitamins and inorganic trace elements that serve many functions in metabolism. Assessment of micronutrient status in critically ill children is challenging due to many complicating factors, such as evolving metabolic demands, immature organ function, and varying methods of feeding that affect nutritional dietary intake. Determination of micronutrient status, especially in children, usually relies on a combination of biomarkers, with only a few having been established as a gold standard. Almost all micronutrients display a decrease in their serum levels in critically ill children, resulting in an increased risk of deficiency in this setting. While vitamin D deficiency is a well-known phenomenon in critical illness and can predict a higher need for intensive care, serum concentrations of many trace elements such as iron, zinc, and selenium decrease as a result of tissue redistribution in response to systemic inflammation. Despite a decrease in their levels, supplementation of micronutrients during times of severe illness has not demonstrated clear benefits in either survival advantage or reduction of adverse outcomes. For many micronutrients, the lack of large and randomized studies remains a major hindrance to critically evaluating their status and clinical significance.
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Affiliation(s)
- Duy T Dao
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Lorenzo Anez-Bustillos
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Bennet S Cho
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Zhilling Li
- Department of Pharmacy, Shanghai Children's Hospital, Shanghai Jiao Tong University, 355 Luding Road, Shanghai 200062, China.
| | - Mark Puder
- Department of Surgery and Vascular Biology Program, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Kathleen M Gura
- Department of Pharmacy and the Division of Gastroenterology and Nutrition, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
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9
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Abstract
Preterm infants with lung disease present nutrition challenges to health care providers. Malnutrition is common, develops shortly after birth, and may continue into early childhood. Although there are many studies identifying the nutrient deficiencies in infants with chronic lung disease, few randomized trials have explored the effects of nutrition support on the prevention and treatment of chronic lung disease. The purpose of this article is to review current practices and ongoing controversies in the nutrition management of infants with chronic lung disease.
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Affiliation(s)
- Susan J Carlson
- Children's Hospital of Iowa at The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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10
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Quan M, Cai CL, Valencia GB, Aranda JV, Beharry KD. MnTBAP or Catalase Is More Protective against Oxidative Stress in Human Retinal Endothelial Cells Exposed to Intermittent Hypoxia than Their Co-Administration (EUK-134). React Oxyg Species (Apex) 2017; 3:47-65. [PMID: 29806034 PMCID: PMC5967656 DOI: 10.20455/ros.2017.801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Retinopathy of prematurity is a blinding disease that affects extremely low gestational age neonates. Its etiology is due to extrauterinehyperoxia in an immature antioxidant system culminating as oxidative stress on the retina. Our aim is to elucidate the role of pharmacological antioxidants in modulating the biochemical and molecular response of human retinal microvascular endothelial cells (HRECs) exposed to oxidative stress. HRECs were treated with MnTBAP [a superoxide dismutase (SOD) mimetic], catalase, EUK-134 (SOD + catalase), or saline prior to exposure to normoxia (Nx), hyperoxia (Hx), or intermittent hypoxia (IH). Media levels of SOD, catalase, glutathione peroxidase (GPx), 8-isoPGF2α, and H2O2; cellular SOD and catalase; cellular function (migration and tube formation); and antioxidant gene expression were assessed. Pharmacological antioxidants had delayed suppressive effect on 8-isoPGF2α. MnTBAP and catalase were more effective for H2O2 scavenging in the media than co-administration in the form of EUK-134. A delayed response was noted in SOD and catalase media activity in MnTBAP- and catalase-treated cells, respectively in 50% and IH. MnTBAP had progressively increased media GPx in all oxygen conditions. Antioxidants resulted in normal, but more abundant tubulogenesis in IH and Hx. The distinct temporal response to oxidative stress reflected the respective antioxidant's potency and catalytic properties. The cell permeability of the antioxidants limited the ability to scavenge intracellular free radicals. The results support that MnTBAP or catalase may be more effective for the prevention of oxidative stress in oxygen-induced retinopathy.
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Affiliation(s)
- Michelle Quan
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Charles L Cai
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Gloria B Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
| | - Jacob V Aranda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- SUNY Eye Institute, New York, NY, USA
| | - Kay D Beharry
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- Department of Ophthalmology, State University of New York, Downstate Medical Center, Brooklyn, NY, USA
- SUNY Eye Institute, New York, NY, USA
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11
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Abstract
BACKGROUND Vitamin A is necessary for normal lung growth and the integrity of respiratory tract epithelial cells. Preterm infants have low vitamin A status at birth and this has been associated with an increased risk of developing chronic lung disease. OBJECTIVES To evaluate supplementation with vitamin A on the incidence of death or neonatal chronic lung disease and long-term neurodevelopmental disability in very low birth weight (VLBW) infants compared with a control (placebo or no supplementation), and to consider the effect of the supplementation route, dose, and timing. SEARCH METHODS For the original review and subsequent updates, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, Science Citation Index, and the Oxford Database of Perinatal Trials. The reference lists of relevant trials, paediatric and nutrition journals, and conference abstracts and proceedings were handsearched up to 2010.For the 2016 update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1 May 2016), EMBASE (1 May 2016), and CINAHL (1 May 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised controlled trials comparing vitamin A supplementation with a control (placebo or no supplementation) or other dosage regimens in VLBW infants (birth weight ≤ 1500 grams or less than 32 weeks' gestation). DATA COLLECTION AND ANALYSIS Two review authors screened the search results, extracted data, and assessed the trials for risk of bias. Results were reported as risk ratios (RR), risk differences (RD), and number needed to treat to benefit (NNTB), all with 95% confidence intervals (CI). Trialists were contacted for additional data. MAIN RESULTS Eleven trials met the inclusion criteria. Ten trials (1460 infants) compared vitamin A supplementation with a control and one (120 infants) compared different regimens of vitamin A supplementation. Compared to the control group, vitamin A appeared to have a small benefit in reducing the risk of death or oxygen requirement at one month of age (typical RR 0.93, 95% CI 0.88 to 0.99; typical RD -0.05, 95% CI -0.10 to -0.01; NNTB 20, 95% CI 10 to 100; 6 studies, 1165 infants) and the risk of chronic lung disease (oxygen requirement) at 36 weeks' postmenstrual age (typical RR 0.87, 95% CI 0.77 to 0.99; typical RD -0.07, 95% CI -0.13 to -0.01; NNTB 11, 95% CI 6 to 100; 5 studies, 986 infants) (moderate-quality evidence). There was a marginal reduction of the combined outcome of death or chronic lung disease (typical RR 0.92, 95% CI 0.84 to 1.01; typical RD -0.05, 95% CI -0.11 to 0.01; 4 studies, 1089 infants). Neurodevelopmental assessment of 88% of the surviving infants in the largest trial showed no difference between the groups at 18 to 22 months of age, corrected for prematurity (low-quality evidence). There is no evidence to support different vitamin A dosing regimens. No adverse effects of vitamin A supplementation were reported, but it was noted that intramuscular injections of vitamin A were painful. AUTHORS' CONCLUSIONS Whether clinicians decide to utilise repeat intramuscular doses of vitamin A to prevent chronic lung disease may depend upon the local incidence of this outcome and the value attached to achieving a modest reduction in the outcome balanced against the lack of other proven benefits and the acceptability of the treatment. Information on long-term neurodevelopmental status suggests no evidence of either benefit or harm from the intervention.
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Affiliation(s)
- Brian A Darlow
- University of OtagoDepartment of PaediatricsChristchurchNew Zealand
| | - P J Graham
- Christchurch School of MedicineDepartment of Public Health and General PracticeChristchurchNew Zealand
| | - Maria Ximena Rojas‐Reyes
- Pontificia Universidad JaverianaDepartment of Clinical Epidemiology and Biostatistics, Faculty of MedicineCr. 7 #40‐62, 2nd floorBogotáDCColombia
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12
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Abstract
Retinopathy of prematurity (ROP), a significant morbidity in prematurely born infants, is the most common cause of visual impairment and blindness in children and persists till adulthood. Strict control of oxygen therapy and prevention of intermittent hypoxia are the keys in the prevention of ROP, but pharmacologic interventions have decreased risk of ROP. Various drug classes such as methylxanthines (caffeine), VEGF inhibitors, antioxidants, and others have decreased ROP occurrence. The timing of pharmacologic intervention remains unsettled, but early prevention rather than controlling disease progression may be preferred. These drugs act through different mechanisms, and synergistic approaches should be considered to maximize efficacy and safety.
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13
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Uberos J, Miras-Baldo M, Jerez-Calero A, Narbona-López E. Effectiveness of vitamin A in the prevention of complications of prematurity. Pediatr Neonatol 2014; 55:358-62. [PMID: 24582166 DOI: 10.1016/j.pedneo.2013.12.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 11/05/2013] [Accepted: 12/06/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND To assess the effectiveness of vitamin A supplementation in very low birth weight (VLBW) infants to prevent complications of prematurity. METHODS This was a retrospective cohort study to determine the effectiveness of vitamin A in preventing complications of prematurity in VLBW infants. Vitamin A was delivered intramuscularly at a dose of 5000 IU, three times weekly during the first 28 days of life. RESULTS Of the 187 eligible VLBW infants, we excluded from the analysis (due to death or transfer to another hospital), 16 infants weighing <1000 g and 17 weighing 1000-1500 g. Sixty VLBW infants received the vitamin supplement. We observed no differences between the groups in the duration of oxygen therapy or in the risk of bronchopulmonary dysplasia. The risk of sepsis was up to three times higher among the infants who were given the vitamin A supplement. CONCLUSION Given the increased risk of sepsis in patients weighing >1000 g, the risk associated with repeated intramuscular injections of vitamin A and the modest clinical results described, we do not believe the universal administration of vitamin A to VLBW infants to be justified as prophylaxis for bronchopulmonary dysplasia.
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Affiliation(s)
- J Uberos
- Unidad Neonatal, Servicio de Pediatría, Hospital Clínico San Cecilio, Avenida del Doctor Oloriz, 16, 18012 Granada, Spain.
| | - M Miras-Baldo
- Unidad Neonatal, Servicio de Pediatría, Hospital Clínico San Cecilio, Avenida del Doctor Oloriz, 16, 18012 Granada, Spain
| | - A Jerez-Calero
- Unidad Neonatal, Servicio de Pediatría, Hospital Clínico San Cecilio, Avenida del Doctor Oloriz, 16, 18012 Granada, Spain
| | - E Narbona-López
- Unidad Neonatal, Servicio de Pediatría, Hospital Clínico San Cecilio, Avenida del Doctor Oloriz, 16, 18012 Granada, Spain
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14
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Wu L, Ross AC. Inflammation induced by lipopolysaccharide does not prevent the vitamin A and retinoic acid-induced increase in retinyl ester formation in neonatal rat lungs. Br J Nutr 2013; 109:1739-45. [PMID: 22950813 PMCID: PMC3763729 DOI: 10.1017/s0007114512003790] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Vitamin A (VA) plays an important role in post-natal lung development and maturation. Previously, we have reported that a supplemental dose of VA combined with 10% of all-trans-retinoic acid (VARA) synergistically increases retinol uptake and retinyl ester (RE) storage in neonatal rat lung, while up-regulating several retinoid homeostatic genes including lecithin:retinol acyltransferase (LRAT) and the retinol-binding protein receptor, stimulated by retinoic acid 6 (STRA6). However, whether inflammation has an impact on the expression of these genes and thus compromises the ability of VARA to increase lung RE content is not clear. Neonatal rats, 7- to 8-d-old, were treated with VARA either concurrently with lipopolysaccharide (LPS; Expt 1) or 12 h after LPS administration (Expt 2); in both studies, lung tissue was collected 6 h after VARA treatment, when RE formation is maximal. Inflammation was confirmed by increased IL-6 and chemokine (C–C motif) ligand 2 (CCL2) gene expression in lung at 6 h and C-reactive protein in plasma at 18 h. In both studies, LPS-induced inflammation only slightly reduced, but did not prevent the VARA-induced increase in lung RE. Quantitative RT-PCR showed that co-administration of LPS with VARA slightly attenuated the VARA-induced increase of LRAT mRNA, but not of STRA6 or cytochrome P450 26B1, the predominant RA hydroxylase in lung. By 18 h post-LPS, expression had subsided and none of these genes differed from the level in the control group. Overall, the present results suggest that retinoid homeostatic gene expression is reduced modestly, if at all, by acute LPS-induced inflammation and that VARA is still effective in increasing lung RE under conditions of moderate inflammation.
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Affiliation(s)
- Lili Wu
- Department of Nutritional Sciences, 110 Chandlee Laboratory, Pennsylvania State University, University Park, PA 16802, USA
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15
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Smith PB, Ambalavanan N, Li L, Cotten CM, Laughon M, Walsh MC, Das A, Bell EF, Carlo WA, Stoll BJ, Shankaran S, Laptook AR, Higgins RD, Goldberg RN. Approach to infants born at 22 to 24 weeks' gestation: relationship to outcomes of more-mature infants. Pediatrics 2012; 129:e1508-16. [PMID: 22641761 PMCID: PMC3362905 DOI: 10.1542/peds.2011-2216] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to determine if a center's approach to care of premature infants at the youngest gestational ages (22-24 weeks' gestation) is associated with clinical outcomes among infants of older gestational ages (25-27 weeks' gestation). METHODS Inborn infants of 401 to 1000 g birth weight and 22 0/7 to 27 6/7 weeks' gestation at birth from 2002 to 2008 were enrolled into a prospectively collected database at 20 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Markers of an aggressive approach to care for 22- to 24-week infants included use of antenatal corticosteroids, cesarean delivery, and resuscitation. The primary outcome was death before postnatal day 120 for infants of 25 to 27 weeks' gestation. Secondary outcomes were the combined outcomes of death or a number of morbidities associated with prematurity. RESULTS Our study included 3631 infants 22 to 24 weeks' gestation and 5227 infants 25 to 27 weeks' gestation. Among the 22- to 24-week infants, use of antenatal corticosteroids ranged from 28% to 100%, cesarean delivery from 13% to 65%, and resuscitation from 30% to 100% by center. Centers with higher rates of antenatal corticosteroid use in 22- to 24-week infants had reduced rates of death, death or retinopathy of prematurity, death or late-onset sepsis, death or necrotizing enterocolitis, and death or neurodevelopmental impairment in 25- to 27-week infants. CONCLUSIONS This study suggests that physicians' willingness to provide care to extremely low gestation infants as measured by frequency of use of antenatal corticosteroids is associated with improved outcomes for more-mature infants.
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Affiliation(s)
- P. Brian Smith
- Department of Pediatrics, Duke University, Durham, North Carolina
| | | | - Lei Li
- RTI International, Research Triangle Park, North Carolina
| | | | - Matthew Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Michele C. Walsh
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, Ohio
| | - Abhik Das
- RTI International, Research Triangle Park, North Carolina
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine, and Department of Pediatrics, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, Michigan
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants’ Hospital, Brown University, Providence, Rhode Island; and
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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16
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Abstract
BACKGROUND Vitamin A is necessary for normal lung growth and the integrity of respiratory tract epithelial cells. Preterm infants have low vitamin A status at birth, and this has been associated with increased risk of developing chronic lung disease. OBJECTIVES To evaluate vitamin A supplementation on the incidence of death and/or neonatal chronic lung disease and long-term neurodevelopmental disability in very low birthweight infants (VLBW); and to consider the effect of the supplementation route, dose, and timing. SEARCH STRATEGY In August 2011, the Cochrane Central Regsiter of Controlled Trials (Central, The Cochrane Library), MEDLINE, Science Citation Index and the Oxford Database of Perinatal Trials were searched. The reference lists of relevant trials, paediatric and nutrition journals, and conference abstracts and proceedings were handsearched up to 2007. SELECTION CRITERIA Randomised controlled trials comparing vitamin A supplementation with a control (placebo or no supplementation) or other dosage regimens in VLBW infants (birthweight ≤ 1500 g or < 32 weeks' gestation). DATA COLLECTION AND ANALYSIS Both review authors screened the search results, extracted data, and assessed the trials' risk of bias. Results were reported as risk ratios (RR), risk differences (RD), and number needed to treat to benefit (NNTB), all with 95% confidence intervals (CI). Trialists were contacted for additional data. MAIN RESULTS Nine trials met the inclusion criteria, eight compared vitamin A supplementation with a control (1291 infants), and one compared different regimens (120 infants). Compared to the control group, vitamin A appears to be beneficial in reducing death or oxygen requirement at one month of age (RR 0.93, 95% CI 0.88 to 0.99; RD -0.05, 95% CI -0.10 to -0.01; NNTB 20, 95% CI 10 to 100; 1165 infants) and oxygen requirement at 36 weeks' postmenstrual age (RR 0.87, 95% CI 0.77 to 0.98; RD -0.08, 95% CI -0.14 to -0.01; NNTB 13, 95% CI 7 to 100; 824 infants). A trend towards a reduction in death or oxygen requirement at 36 weeks' postmenstrual age was also noted (RR 0.91, 95% CI 0.82 to 1.00; 1001 infants). Neurodevelopmental assessment of 88% of surviving infants in the largest trial showed no differences between the groups at 18 to 22 months of age, corrected for prematurity. The different dosage vitamin A regimens showed similar results. AUTHORS' CONCLUSIONS Whether clinicians decide to utilise repeat intramuscular doses of vitamin A to prevent chronic lung disease may depend upon the local incidence of this outcome and the value attached to achieving a modest reduction in this outcome, balanced against the lack of other proven benefits and the acceptability of treatment. Information on long-term neurodevelopmental status suggests no evidence of either benefit or harm from the intervention.
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Affiliation(s)
- Brian A Darlow
- Department of Paediatrics, Christchurch School of Medicine, PO Box 4345, CHRISTCHURCH, New Zealand
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Abstract
PURPOSE OF REVIEW Bronchopulmonary dysplasia (BPD) is a chronic lung disease of infancy affecting mostly premature infants with significant morbidity and mortality. Improved survival of very immature infants has led to increased numbers of infants with this disorder. Acute and chronic lung injury and impaired postnatal lung growth are thought to be responsible for the development of BPD. Whereas changes in clinical practice have improved the clinical course and outcomes for infants with BPD, over the past decade, the overall incidence of BPD has not changed. This review will describe the prenatal and postnatal factors that contribute to the pathogenesis of BPD as well as current and experimental therapies for treatment of BPD. RECENT FINDINGS The factors that contribute to the pathogenesis of BPD are well described; however, recent studies have better defined how these factors modulate lung growth. Inflammation, proinflammatory cytokines and altered angiogenic gene signaling contribute to lung injury and impair prenatal and postnatal lung growth resulting in BPD; however, to date no therapy has been identified that potently and consistently prevents or reverses their effects on lung growth. We will discuss the cell signaling pathways affected in BPD and current therapies available for modulating these pathways. SUMMARY Despite current advances in neonatal care, BPD remains a heavy burden on healthcare resources. New treatments directed at either reducing lung injury or improving lung growth are under study.
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Ambalavanan N, Walsh M, Bobashev G, Das A, Levine B, Carlo WA, Higgins RD. Intercenter differences in bronchopulmonary dysplasia or death among very low birth weight infants. Pediatrics 2011; 127:e106-16. [PMID: 21149431 PMCID: PMC3010091 DOI: 10.1542/peds.2010-0648] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine (1) the magnitude of clustering of bronchopulmonary dysplasia (36 weeks) or death (the outcome) across centers of the Eunice Kennedy Shriver National Institute of Child and Human Development National Research Network, (2) the infant-level variables associated with the outcome and estimate their clustering, and (3) the center-specific practices associated with the differences and build predictive models. METHODS Data on neonates with a birth weight of <1250 g from the cluster-randomized benchmarking trial were used to determine the magnitude of clustering of the outcome according to alternating logistic regression by using pairwise odds ratio and predictive modeling. Clinical variables associated with the outcome were identified by using multivariate analysis. The magnitude of clustering was then evaluated after correction for infant-level variables. Predictive models were developed by using center-specific and infant-level variables for data from 2001 2004 and projected to 2006. RESULTS In 2001-2004, clustering of bronchopulmonary dysplasia/death was significant (pairwise odds ratio: 1.3; P < .001) and increased in 2006 (pairwise odds ratio: 1.6; overall incidence: 52%; range across centers: 32%-74%); center rates were relatively stable over time. Variables that varied according to center and were associated with increased risk of outcome included lower body temperature at NICU admission, use of prophylactic indomethacin, specific drug therapy on day 1, and lack of endotracheal intubation. Center differences remained significant even after correction for clustered variables. CONCLUSION Bronchopulmonary dysplasia/death rates demonstrated moderate clustering according to center. Clinical variables associated with the outcome were also clustered. Center differences after correction of clustered variables indicate presence of as-yet unmeasured center variables.
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Affiliation(s)
| | - Michele Walsh
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | | | - Abhik Das
- RTI International, Research Triangle Park, North Carolina; and
| | - Burton Levine
- RTI International, Research Triangle Park, North Carolina; and
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Health and Development Neonatal Research Network, Bethesda, Maryland
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Fusch C, Bauer K, Böhles HJ, Jochum F, Koletzko B, Krawinkel M, Krohn K, Mühlebach S. Neonatology/Paediatrics - Guidelines on Parenteral Nutrition, Chapter 13. Ger Med Sci 2009; 7:Doc15. [PMID: 20049070 PMCID: PMC2795370 DOI: 10.3205/000074] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 12/30/2022]
Abstract
There are special challenges in implementing parenteral nutrition (PN) in paediatric patients, which arises from the wide range of patients, ranging from extremely premature infants up to teenagers weighing up to and over 100 kg, and their varying substrate requirements. Age and maturity-related changes of the metabolism and fluid and nutrient requirements must be taken into consideration along with the clinical situation during which PN is applied. The indication, the procedure as well as the intake of fluid and substrates are very different to that known in PN-practice in adult patients, e.g. the fluid, nutrient and energy needs of premature infants and newborns per kg body weight are markedly higher than of older paediatric and adult patients. Premature infants <35 weeks of pregnancy and most sick term infants usually require full or partial PN. In neonates the actual amount of PN administered must be calculated (not estimated). Enteral nutrition should be gradually introduced and should replace PN as quickly as possible in order to minimise any side-effects from exposure to PN. Inadequate substrate intake in early infancy can cause long-term detrimental effects in terms of metabolic programming of the risk of illness in later life. If energy and nutrient demands in children and adolescents cannot be met through enteral nutrition, partial or total PN should be considered within 7 days or less depending on the nutritional state and clinical conditions.
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Affiliation(s)
- C Fusch
- Dept. of Pediatrics, McMaster University, Hamilton, Canada
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Abstract
Often used interchangeably, chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) develops primarily in extremely low birth weight infants weighing <1000 g who receive prolonged oxygen therapy and or positive pressure ventilation. CLD, which occurs in as many as 30 percent of infants born weighing <1000 g, contributes significantly to the morbidity and mortality seen in very low birth weight infants. Despite extensive research aimed at identifying risk factors and devising preventative therapies, many questions about the etiology and pathogenesis of BPD remain. This article reviews the embryologic development of the lung and the pathogenesis of CLD or BPD. The authors discuss some of the measures that have been used in an attempt to both prevent and treat BPD.
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Abstract
The history of retinopathy of prematurity (ROP) gives a prime example of how dangerous the uncontrolled introduction of a new medical treatment--particularly in the field of neonatology--may be. The most important risk factors for the development of ROP are the immaturity of premature infants as well as uncontrolled and/or inadequate treatment with oxygen. In comparison to the fetus, the premature infant is exposed to a nonphysiologically high oxygen concentration. This hyperoxia leads to formation of aggressive oxygen radicals on the one hand and, on the other hand, to temporarily reduced production of growth factors such as vascular endothelial growth factor and erythropoietin, which both play an important role in the pathogenesis of ROP. The most important measure to prevent ROP is restrictive and carefully monitored oxygen treatment. Medical treatment to prevent ROP includes injection of D-penicillamine and retinol, but the available data are still limited, particularly with regard to the long-term effects of this treatment. A higher oxygenation in prethreshold ROP does not lead to recovery of ocular findings, but it increases the incidence of pulmonary complications. A reduction of light intensity in neonatal intensive care units proved not to be efficient for preventing ROP. To avoid blindness, standardized screening of the risk group is needed.
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Affiliation(s)
- L Pelken
- Zentrum für Kinder- und Jugendmedizin, Philipps-Universität Marburg, Baldingerstrasse, 35033 Marburg
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Abstract
Background Intramuscular injections of vitamin A decrease the risk of broncho-pulmonary dysplasia. Admixture of vitamin A with surfactant as a lipophilic vehicle might be a less invasive modality. Aim Test physical properties of surfactant + vitamin A. Methods Miscibility and surface activity were tested in surfactant supplemented with retinyl-acetate, -palmitate, 13-cis-, or all-trans-retinoic acid. Results Retinol acetate (5000 IU/mL) demonstrated miscibility with surfactant when premixing with ethanol. Its surface activity was 40% lower compared to surfactant alone. Conclusion These findings warrant preclinical studies to test whether administration of vitamin A in subjects requiring surfactant is associated with beneficial functional properties.
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Affiliation(s)
- Vadim Bronshtein
- Division of Neonatology, Children's and Women's Health Centre of British Columbia, University of British Columbia, 4480 Oak Street, Vancouver, BC, Canada
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Rojas MA, Lozano JM, Rojas MX, Laughon M, Bose CL, Rondon MA, Charry L, Bastidas JA, Perez LA, Rojas C, Ovalle O, Celis LA, Garcia-Harker J, Jaramillo ML. Very early surfactant without mandatory ventilation in premature infants treated with early continuous positive airway pressure: a randomized, controlled trial. Pediatrics 2009; 123:137-42. [PMID: 19117872 DOI: 10.1542/peds.2007-3501] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Chronic lung disease is one of the most frequent and serious complications of premature birth. Because mechanical ventilation is a major risk factor for chronic lung disease, the early application of nasal continuous positive airway pressure has been used as a strategy for avoiding mechanical ventilation in premature infants. Surfactant therapy improves the short-term respiratory status of premature infants, but its use is traditionally limited to infants being mechanically ventilated. Administration of very early surfactant during a brief period of intubation to infants treated with nasal continuous positive airway pressure may improve their outcome and further decrease the need for mechanical ventilation. OBJECTIVE Our goal was to determine if very early surfactant therapy without mandatory ventilation improves outcome and decreases the need for mechanical ventilation when used in very premature infants treated with nasal continuous positive airway pressure soon after birth. DESIGN/METHODS Eight centers in Colombia participated in this randomized, controlled trial. Infants born between 27 and 31 weeks' gestation with evidence of respiratory distress and treated with supplemental oxygen in the delivery room were randomly assigned within the first hour of life to intubation, very early surfactant, extubation, and nasal continuous positive airway pressure (treatment group) or nasal continuous airway pressure alone (control group). The primary outcome was the need for subsequent mechanical ventilation using predefined criteria. RESULTS From January 1, 2004, to December 31, 2006, 279 infants were randomly assigned, 141 to the treatment group and 138 to the control group. The need for mechanical ventilation was lower in the treatment group (26%) compared with the control group (39%). Air-leak syndrome occurred less frequently in the treatment group (2%) compared with the control group (9%). The percentage of patients receiving surfactant after the first hour of life was also significantly less in the treatment group (12%) compared with the control group (26%). The incidence of chronic lung disease (oxygen treatment at 36 weeks' postmenstrual age) was 49% in the treatment group compared with 59% in the control group. All other outcomes, including mortality, intraventricular hemorrhage, and periventricular leukomalacia were similar between the groups. CONCLUSIONS In premature infants treated with nasal continuous positive airway pressure early after birth, the addition of very early surfactant therapy without mandatory ventilation decreased the need for subsequent mechanical ventilation, decreased the incidence of air-leak syndrome, and seemed to be safe. Reduction in the need for mechanical ventilation is an important outcome when medical resources are limited and may result in less chronic lung disease in both developed and developing countries.
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Affiliation(s)
- Mario Augusto Rojas
- Vanderbilt University, Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Nashville, TN 37232-2370, USA.
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Brok J, Thorlund K, Wetterslev J, Gluud C. Apparently conclusive meta-analyses may be inconclusive--Trial sequential analysis adjustment of random error risk due to repetitive testing of accumulating data in apparently conclusive neonatal meta-analyses. Int J Epidemiol 2008; 38:287-98. [PMID: 18824466 DOI: 10.1093/ije/dyn188] [Citation(s) in RCA: 700] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Random error may cause misleading evidence in meta-analyses. The required number of participants in a meta-analysis (i.e. information size) should be at least as large as an adequately powered single trial. Trial sequential analysis (TSA) may reduce risk of random errors due to repetitive testing of accumulating data by evaluating meta-analyses not reaching the information size with monitoring boundaries. This is analogous to sequential monitoring boundaries in a single trial. METHODS We selected apparently conclusive (P </= 0.05) Cochrane neonatal meta-analyses. We applied heterogeneity-adjusted and unadjusted TSA on these meta-analyses by calculating the information size, the monitoring boundaries, and the cumulative Z-statistic after each trial. We identified the proportion of meta-analyses that did not reach the required information size and the proportion of these meta-analyses in which the Z-curve did not cross the monitoring boundaries. RESULTS Of 54 apparently conclusive meta-analyses, 39 (72%) did not reach the heterogeneity-adjusted information size required to accept or reject an intervention effect of 25% relative risk reduction. Of these 39, 19 meta-analyses (49%) were considered inconclusive, because the cumulative Z-curve did not cross the monitoring boundaries. The median number of participants required to reach the required information size was 1591 (range, 339-6149). TSA without heterogeneity adjustment largely confirmed these results. CONCLUSIONS Many apparently conclusive Cochrane neonatal meta-analyses may become inconclusive when the statistical analyses take into account the risk of random error due to repetitive testing.
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Affiliation(s)
- Jesper Brok
- The Copenhagen Trial Unit, Center for Clinical Intervention Research, Department 3344, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Brok J, Thorlund K, Gluud C, Wetterslev J. Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses. J Clin Epidemiol 2008; 61:763-9. [PMID: 18411040 DOI: 10.1016/j.jclinepi.2007.10.007] [Citation(s) in RCA: 776] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Revised: 06/29/2007] [Accepted: 10/01/2007] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate meta-analyses with trial sequential analysis (TSA). TSA adjusts for random error risk and provides the required number of participants (information size) in a meta-analysis. Meta-analyses not reaching information size are analyzed with trial sequential monitoring boundaries analogous to interim monitoring boundaries in a single trial. STUDY DESIGN AND SETTING We applied TSA on meta-analyses performed in Cochrane Neonatal reviews. We calculated information sizes and monitoring boundaries with three different anticipated intervention effects of 30% relative risk reduction (TSA(30%)), 15% (TSA(15%)), or a risk reduction suggested by low-bias risk trials of the meta-analysis corrected for heterogeneity (TSA(LBHIS)). RESULTS A total of 174 meta-analyses were eligible; 79 out of 174 (45%) meta-analyses were statistically significant (P<0.05). In the significant meta-analyses, TSA(30%) showed firm evidence in 61%. TSA(15%) and TSA(LBHIS) found firm evidence in 33% and 73%, respectively. The remaining significant meta-analyses had potentially spurious evidence of effect. In the 95 statistically nonsignificant (P>or=0.05) meta-analyses, TSA(30%) showed absence of evidence in 80% (insufficient information size). TSA(15%) and TSA(LBHIS) found that 95% and 91% had absence of evidence. The remaining nonsignificant meta-analyses had evidence of lack of effect. CONCLUSION TSA reveals insufficient information size and potentially false positive results in many meta-analyses.
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Affiliation(s)
- Jesper Brok
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Cochrane Hepato-Biliary Group, Dept. 3344, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Abstract
Chronic lung disease (CLD) or bronchopulmonary dysplasia (BPD) occurs in preterm infants who require respiratory support in the first few days of birth. Apart from prematurity, oxygen therapy and assisted ventilation, factors like intrauterine/postnatal infections, patent ductus arteriosus, and genetic polymorphisms also contribute to its pathogenesis. The severe form of BPD with extensive inflammatory changes is rarely seen nowadays; instead, a milder form characterized by decreased alveolar septation due to arrest in lung development is more common. A multitude of strategies, mainly pharmacological and ventilatory, have been employed for prevention and treatment of BPD. Unfortunately, most of them have not been proved to be beneficial. A comprehensive protocol for management of BPD based on the current evidence is discussed here.
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Cerny L, Torday JS, Rehan VK. Prevention and Treatment of Bronchopulmonary Dysplasia: Contemporary Status and Future Outlook. Lung 2008; 186:75-89. [DOI: 10.1007/s00408-007-9069-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2007] [Accepted: 12/27/2007] [Indexed: 01/06/2023]
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Abstract
BACKGROUND Vitamin A supplements are effective for preventing diarrhoea. There are theoretical reasons it might also be effective for acute lower respiratory tract infections (LRTIs), also very common in children, especially in low income countries. OBJECTIVES To assess the effectiveness and safety of vitamin A for preventing acute LRTIs in children up to seven years of age. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (1966 to July 2007); EMBASE (1974 to July 2007); and the Chinese Biomedicine Database (CBM) (1976 to July 2007). SELECTION CRITERIA Randomised controlled trials (RCTs) that assessed the effectiveness of vitamin A in the prevention of acute LRTI in children up to seven years of age. DATA COLLECTION AND ANALYSIS The review authors independently extracted data and assessed trial quality. Study authors were contacted for additional information. MAIN RESULTS Most studies found no significant effect of vitamin A on the incidence of acute LRTI, or prevalence of symptoms of acute LRTI. Vitamin A caused an increased incidence of acute LRTI in one study; an increase in cough and fever; and increased symptoms of cough and rapid breathing in two others. Three reported no differences and no protective effect of vitamin A. Two studies reported that vitamin A significantly reduced the incidence of acute LRTI with children with poor nutritional status or weight, but increased it in normal children. AUTHORS' CONCLUSIONS This unexpected result is outside our current understanding of the use of vitamin A for preventing acute LRTIs. Accordingly, vitamin A should not be given to all children to prevent acute LRTIs. There is evidence for vitamin A supplements to prevent acute LRTIs in children with low serum retinol or those with a poor nutritional status.
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Abstract
BACKGROUND Vitamin A is necessary for normal lung growth and the ongoing integrity of respiratory tract epithelial cells. Preterm infants have low vitamin A status at birth and this has been associated with increased risk of developing chronic lung disease. Several studies have been undertaken to assess whether vitamin A supplementation beyond that routinely given in multivitamin preparations can reduce the incidence of this outcome. OBJECTIVES To assess the benefit and risk of supplementation with vitamin A in very low birthweight infants. SEARCH STRATEGY Searches were made of the Oxford Database of Perinatal Trials, MEDLINE up to November 2006, Cochrane Central Register of Controlled Trials Register (CENTRAL, The Cochrane Library, Issue 4, 2006), and Science Citation Index. The reference lists of relevant trials, recent issues of paediatric and nutrition journals, abstracts and proceedings from relevant conferences in the English language were hand searched. SELECTION CRITERIA Randomised controlled trials which compared the effects of supplemental vitamin A with standard vitamin A regimes in infants with birthweight </= 1500 g and reported clinical outcomes (death, chronic lung disease or bronchopulmonary dysplasia, long-term neurodevelopmental status) and/or vitamin A concentrations were considered for the review, as were trials which compared vitamin A dosing regimes and reported biochemical outcomes (retinol concentrations at 28 days). DATA COLLECTION AND ANALYSIS Data on mortality, requirement for supplemental oxygen at one month of age and at 36 weeks postmenstrual age, retinopathy of prematurity, nosocomial sepsis and follow-up at 18 to 22 months, as well as retinol concentrations at 28 days in trials comparing dosage regimes, were excerpted by both reviewers independently. Data analysis was conducted according to the standards of the Cochrane Neonatal Review Group. MAIN RESULTS Eight eligible trials comparing vitamin A supplementation with standard regimes were identified, one having a much larger sample size than the others combined. The meta-analysis suggests supplementation with vitamin A is beneficial in reducing death or oxygen requirement at one month of age [typical RR 0.93 (95% CI 0.88, 0.99), RD -0.05 ( 95% CI -0.10, -0.01), NNT 20 (10, 100) and oxygen requirement at 36 weeks postmenstrual age [typical RR 0.87 (95% CI 0.77, 0.98), RD -0.08 ( 95% CI -0.14, -0.01), NNT 13 (7, 100)], and trends towards reduction in oxygen requirement in survivors at one month of age [typical RR 0.93 (95% CI 0.86, 1.01) and death or oxygen requirement at 36 weeks postmenstrual age [typical RR 0.91 (95% CI 0.82, 1.00)]. Meta-analysis of the three studies from which data on retinopathy of prematurity are available suggests a trend towards reduced incidence in vitamin A supplemented infants. Neurodevelopmental assessment of 85% of surviving infants participating in the largest trial showed no differences in outcome between supplementation and placebo groups at 18 to 22 months corrected age. AUTHORS' CONCLUSIONS Supplementing very low birthweight infants with vitamin A is associated with a reduction in death or oxygen requirement at one month of age and oxygen requirement among survivors at 36 weeks postmenstrual age, with this latter outcome being confined to infants with birthweight less than 1000 g. Whether clinicians decide to utilise repeat intramuscular doses of vitamin A to prevent chronic lung disease may depend upon the local incidence of this outcome and the value attached to achieving a modest reduction in this outcome, balanced against the lack of other proven benefits and the acceptability of treatment. Information on long-term neurodevelopmental status suggests no evidence of either benefit or harm from the intervention. The benefits, in terms of vitamin A status, safety and acceptability of delivering vitamin A in an intravenous emulsion compared with repeat intramuscular injections, should be assessed in a further trial.
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Affiliation(s)
- B A Darlow
- Christchurch School of Medicine, Department of Paediatrics, PO Box 4345, Christchurch, New Zealand.
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Ross AC, Li NQ. Lung retinyl ester is low in young adult rats fed a vitamin A deficient diet after weaning, despite neonatal vitamin A supplementation and maintenance of normal plasma retinol. J Nutr 2007; 137:2213-8. [PMID: 17885000 PMCID: PMC3843128 DOI: 10.1093/jn/137.10.2213] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Although it is understood that plasma retinol concentration is not proportional to the concentration of vitamin A stored in liver, plasma retinol still is often used as an indicator of vitamin A status. An aim of vitamin A supplementation strategies is to maintain plasma retinol concentration in a range considered adequate, generally >1.05 micromol/L in humans, with some adjustment for age. In the present study in rats, we addressed the following question: Does lung vitamin A increase postnatally, as is observed in rats fed a vitamin A-adequate diet, if plasma retinol is maintained at approximately 1 micromol/L by supplementation at neonatal age, but the weaning diet is deficient in vitamin A? We treated rats on postnatal d 6, 7, and 8 with placebo (oil), vitamin A, retinoic acid (RA), and a nutrient-metabolite combination of vitamin A and RA, VARA, after which tissues were analyzed on d 9. Other rats treated identically as neonates were fed a vitamin A-deficient diet from 3-9 wk of age, and in parallel, another group of rats was fed a vitamin A-adequate diet. Although supplementation with vitamin A or VARA elevated liver and lung retinyl esters (RE) on d 9 (P < 0.0001), and prevented the fall in plasma retinol to <1 micromol/L by 9 wk of age, when the diet was vitamin A-deficient, lung RE fell to 28% of the concentration present in the lungs of rats fed the vitamin A-adequate diet (P < 0.0001). We infer that the lungs depend, at least in part, on the uptake of dietary vitamin A, probably from chylomicrons, to develop RE stores in the postweaning growth period.
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Affiliation(s)
- A Catharine Ross
- Department of Nutritional Sciences, Pennsylvania State University, University Park, PA 16802, USA.
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Abstract
Oxidative stress plays an important role in causing organ injury in the compromised fetus and neonate. Recent experimental research and clinical studies have clarified important pathways in the production of reactive oxygen and nitrogen species. Free radicals are involved in causing cerebral damage after perinatal hypoxia-ischemia affecting membrane lipids, proteins, and DNA. Anti-oxidant strategies can be used as add-on neuroprotective therapy after perinatal oxidative stress. Selective inhibitors of neuronal and inducible nitric oxide synthase, allopurinol, melatonin, and erythropoietin are among the first compounds that are ready for clinical trials.
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Affiliation(s)
- Giuseppe Buonocore
- Department of Pediatrics, Obstetrics and Reproductive Medicine, University of Siena, viale Bracci 36, Siena, Italy.
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Abstract
Respiratory distress is the most common reason for admission to newborn intensive care units. Over the past two decades, we have witnessed a revolution in the therapies that are used to manage neonates who have pulmonary disorders. Multiple adjunctive agents have also been used in an attempt to mitigate the course of neonatal lung disease. The disorders we discuss include respiratory distress syndrome, chronic lung disease/bronchopulmonary dysplasia, persistent pulmonary hypertension of the newborn, meconium aspiration syndrome, and transient tachypnea of the newborn. We review the evidence that either supports or refutes the use of adjunctive therapies for these disorders.
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Affiliation(s)
- Thomas E Wiswell
- Center for Neonatal Care, Florida Hospital Orlando, 2718 North Orange Avenue, Suite B, Orlando, FL 32804, USA.
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Brok J, Greisen G, Jacobsen T, Gluud LL, Gluud C. Agreement between Cochrane Neonatal Group reviews and clinical guidelines for newborns at a Copenhagen University Hospital - a cross-sectional study. Acta Paediatr 2007; 96:39-43. [PMID: 17187601 DOI: 10.1111/j.1651-2227.2006.00035.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To assess the agreement between Cochrane Neonatal Group reviews and clinical guidelines of a University Neonatology Department, to evaluate the reasons for potential disagreements and to ascertain whether Cochrane reviews were considered for the guidelines development. METHODS The recommendations in the reviews and guidelines were compared and classified as being in 'agreement', 'partial agreement' or 'disagreement'. The guideline authors were interviewed for reasons about disagreement and whether Cochrane reviews were considered during the guideline development. RESULTS Agreement between reviews and guidelines was found for 133 interventions (77%), partial agreement for 31 interventions (18%) and disagreement for nine interventions (5%). Six interventions were recommended in the guidelines, but not in the reviews. Three interventions were recommended in the reviews, but not in the guidelines. Use of consensus statements, evidence on surrogate markers, observational studies, basic immunology and pathophysiological knowledge, expert opinion, economical constraints, reservations about the external validity and unawareness of reviews were reasons for disagreement. Cochrane reviews were rarely (22%) used during the guideline development. CONCLUSION We found agreement between more than three quarters of Cochrane reviews and neonatal guidelines. However, few important disagreements occurred. Reviews were only used for guideline development in about a fifth of cases.
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Affiliation(s)
- Jesper Brok
- The Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, H:S Rigshospitalet, Denmark.
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Ross AC, Li NQ, Wu L. The components of VARA, a nutrient-metabolite combination of vitamin A and retinoic acid, act efficiently together and separately to increase retinyl esters in the lungs of neonatal rats. J Nutr 2006; 136:2803-7. [PMID: 17056804 PMCID: PMC3843131 DOI: 10.1093/jn/136.11.2803] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Retinoic acid (RA), produced from vitamin A (VA, retinol), is required for normal lung development and postnatal lung maturation. The concentration of retinyl ester (RE), the major storage form of retinol, decreases in the lungs in the perinatal period. Previously, we tested VARA, a nutrient-metabolite combination of VA and RA (10:1 molar ratio), on lung RE formation in postnatal rats and showed that the components of VARA acted synergistically to increase lung RE, as compared with the effects of equal amounts of VA and RA given alone. In this study, we first determined the equivalency of orally administered VARA in comparison to a standard oral supplement of VA, with respect to lung and liver RE storage. In a dose-dilution study, VARA was 4 times as effective as the standard dose of VA (VARA-25% did not differ from VA-100%). The synergistic effect of VARA was selective for the lungs, compared with the liver, in which VA and VARA had equal effects. Secondly, we tested whether the 2 components of VARA must be coadministered to exert their synergistic effect on lung RE content. RA and VA and were administered separately and together as VARA. Although RA alone had no effect on lung RE in this 24-h experiment, RA synergized with VA administered either 12 h before RA or 12 h after RA, as well as when coadministered as VARA. We infer that VA and RA are both limiting for lung RE formation in neonates. Given the importance of bioactive retinoids in cell differentiation and lung development, assuring an adequate lung RE content postnatally could be of benefit for lung maturation.
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Affiliation(s)
- A Catharine Ross
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, PA 16801, USA.
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Payne NR, LaCorte M, Sun S, Karna P, Lewis-Hunstiger M, Goldsmith JP. Evaluation and development of potentially better practices to reduce bronchopulmonary dysplasia in very low birth weight infants. Pediatrics 2006; 118 Suppl 2:S65-72. [PMID: 17079625 DOI: 10.1542/peds.2006-0913b] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The objective of this study was to describe development and implementation of potentially better practices to reduce bronchopulmonary dysplasia in very low birth weight infants (birth weight: 501-1500 g). METHODS Results of Breathsavers Group meetings, conference calls and critically appraised topic summaries were used to construct potentially better practices. Implementation plans and experiences were reported by participants and collated. RESULTS The Breathsavers Group developed 13 potentially better practices, based on published evidence and expert opinion. Participants determined which potentially better practices to implement and implementation methods. Participating NICUs implemented an average of 5 potentially better practices (range: 3-9). The Breathsavers Group also developed a resource kit, identified common obstacles to implementation, and initiated research to define bronchopulmonary dysplasia better. CONCLUSIONS Multiinstitutional collaboration facilitated development and implementation of potentially better practices to reduce bronchopulmonary dysplasia.
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Affiliation(s)
- Nathaniel R Payne
- Division of Neonatology, Children's Hospitals and Clinics, 2525 Chicago Ave South, Minneapolis, MN 55404, USA.
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Abstract
BACKGROUND Preterm infants with bronchopulmonary dysplasia/chronic lung disease have nutritional deficits that may contribute to short and long term morbidity and mortality. Increasing the daily energy intake for these infants may improve their respiratory, growth and neurodevelopmental outcomes. OBJECTIVES To assess the effect of increased energy intake on mortality and respiratory, growth and neurodevelopmental outcomes for preterm infants with (or developing) CLD/BPD. Secondarily, the review examines any adverse effects associated with increased energy intake. SEARCH STRATEGY The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2006) , MEDLINE (accessed via Ovid), references cited in previous relevant Cochrane reviews and in other relevant studies, review articles, standard textbooks, and manuals of neonatal medicine. Hand search results of the Cochrane Neonatal Review Group were also assessed. SELECTION CRITERIA All randomized and quasi-randomized trials comparing the outcomes of preterm infants with (or developing) CLD/BPD who had either increased (> 135 kcal/kg/day) or standard energy intake (98 to 135 kcal/kg/day). Increasing energy intake might be achieved enterally and/or parenterally, enterally by increasing the energy content of the milk, increasing feed volume, or by nutrient supplementation with protein, carbohydrate or fat. The primary outcomes were the development of CLD and neonatal mortality; secondary outcomes included respiratory morbidities, growth, neurodevelopmental status and possible complications with increased energy intake. DATA COLLECTION AND ANALYSIS We planned to extract data using the standard methods of the Cochrane Neonatal Review Group. Relevant trials would be scrutinized for methodological quality independently by the reviewers to determine their eligibility for inclusion. Data of the included trials would be expressed as relative risk, risk difference, NNT and weighted mean difference where appropriate, using a fixed effect model. MAIN RESULTS No eligible trials were identified. Twelve studies that appeared to be relevant were excluded, as no study directly compared increased versus standard energy intakes in infants with CLD/BPD. However, two excluded trials provided some insights into the topic. One study showed that infants with CLD/BPD who were fed formula enriched with protein and minerals had improved growth parameters up until the cessation of the intervention at three months of corrected age. The other study compared different energy density of formula but identical energy intake by setting different feed volumes for both groups. It showed that both groups were unable to achieve the pre-designated feed volumes, and that there were no differences in growth, respiratory outcomes, oedema and the diuretic requirements. AUTHORS' CONCLUSIONS To date, no randomized controlled trials are available that examine the effects of increased versus standard energy intake for preterm infants with (or developing) CLD/BPD. Research should be directed at evaluating the effects of various levels of energy intake on this group of infants on clinically important outcomes like mortality, respiratory status, growth and neurodevelopment. The benefits and harms of various ways of increasing energy intake, including higher energy density of milk feed and/or fluid volume (clinically realistic target volume should be set), parenteral nutrition, and the use of various constituents of energy like carbohydrate, protein and fat for this purpose also need to be assessed.
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Affiliation(s)
- N M Lai
- International Medical University, Paediatrics, 12, Jalan Indah, Taman Sri Kenangan, Batu Pahat, Johor, Malaysia 83000.
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Abstract
Pharmacologic study is needed in the extremely immature newborns who currently survive. Study is needed of both the drug treatment previously established in more mature neonates and of novel drug therapy. Carefully controlled studies are needed to identify accurately both beneficial and harmful drug therapy and the mechanisms of that toxicity. Careful pharmacologic study of drug disposition and its mechanisms might lead to dosing paradigms or patient selection that minimize toxicity and maximize efficacy. In vivo, translational models of neonatal diseases are limited, but can be used to identify novel treatments and study mechanisms of established, successful therapy. Findings from such studies can generate hypotheses for study in humans leading to a continuing scientific interchange from bedside to bench to bedside. Similarly, clinical observations can generate hypotheses for study in translational models where more invasive analyses are possible. Specific areas of drug treatment should focus on neonatal disorders with long-term, adverse outcomes, such as chronic lung disease, that is amenable to translational study with animal models. National data show a progressive decrease in the clinician-scientist pool entering biomedical research. The future of neonatal pharmacology studies requires an increase in training programs for the physician-scientist whose clinical education in neonatology can be complemented by rigorous basic-science training. Success as a clinician-scientist will require collaboration with full-time basic scientists who can continue studies during periods of clinical work and provide critical study methodology to the overall study design. Such a work environment must be supported by academic institutions and may require more flexibility in the promotion and tenure schedule and process, such as the nature of what it rewards. To complement this, the NIH could modify its grant reporting process to identify co-investigators in studies who may provide unique input to the study concepts and design, such as clinical correlations or clinical investigations.
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Affiliation(s)
- R M Ward
- Pediatric Pharmacology Program, University of Utah Department of Pediatrics, Salt Lake City, 84108, USA.
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Abstract
BACKGROUND Recent improvements in the survival of extremely preterm infants have been accompanied by evolution in the pathogenesis and histopathology of bronchopulmonary dysplasia (BPD). Although oxygen and barotrauma-induced injury remain important contributing factors, pulmonary developmental arrest appears to play an equally important causal role in prolonged respiratory illness, especially among the most immature surviving preterm newborns. To date, clinical trials have failed to demonstrate a substantial benefit of a single treatment or preventive strategy for BPD. OBJECTIVES To evaluate the current evidence in favor of treatments that might prevent BPD. METHODS Review of clinical studies of preventive treatment strategies for BPD. RESULTS High frequency oscillatory ventilation, permissive hypercapnea, and inhaled nitric oxide might offer benefit to infants at risk of BPD. These and other potential preventive therapies for BPD, such as superoxide dismutase, inositol, and alpha(1)-proteinase inhibitor, deserve further study. CONCLUSIONS Although some current treatments offer promise, no preventive therapy for BPD has proven safe and effective, except for intramuscular vitamin A. Additional studies of respiratory technologies, management strategies, and protective molecules are needed.
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Affiliation(s)
- Linda J Van Marter
- Children's Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass., USA.
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Ross AC, Ambalavanan N, Zolfaghari R, Li NQ. Vitamin A combined with retinoic acid increases retinol uptake and lung retinyl ester formation in a synergistic manner in neonatal rats. J Lipid Res 2006; 47:1844-51. [PMID: 16685080 DOI: 10.1194/jlr.m600061-jlr200] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Vitamin A (VA) is stored in tissues predominantly as retinyl esters (REs), which provide substrate for the production of bioactive retinoids. Retinoic acid (RA), a principal metabolite, has been shown to induce postnatal lung development. To better understand lung RE storage, we compared VA (given as retinyl palmitate), RA, and a nutrient-metabolite combination, VARA, given orally on postnatal days 5-7, for their ability to increase lung RE in neonatal rats. VARA increased lung RE significantly [ approximately 14, 2.4, 2.1, and <1 nmol/g for VARA, VA, RA, and control (C), respectively; P < 0.001]; the increase by VARA was more than additive compared with the effects of VA and RA alone. Lung histology and morphometry were unchanged. In a 6 h metabolic study, providing [(3)H]retinol with VARA, compared with VA or C, increased the uptake of newly absorbed (3)H by 3-fold, indicating that VARA stimulated the uptake of [(3)H]retinol and its retention as [(3)H]RE in neonatal lungs. After cessation of VARA, lung RE remained increased for 9 d afterward, through the period of alveolar development. In conclusion, VARA, a 10:1 nutrient-metabolite combination, increased lung RE significantly compared with VA alone and could be a promising therapeutic option for enhancing the delivery of VA to the lungs.
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Affiliation(s)
- A Catharine Ross
- Department of Nutritional Sciences, Pennsylvania State University, University Park, 16802, USA.
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40
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Abstract
Retinopathy of prematurity is on the rise and a third epidemic has been identified. In spite of extensive research and progress in the understanding of this disease in recent years, 50 000 children worldwide are blinded by this condition each year. The relation between hyperoxia, low-gestational age, growth retardation, oxygen dependent growth factors, and oxidative stress are now being understood more clearly. We know that in the first phase of retinopathy of prematurity, hyperoxia inhibits vascular endothelial growth factor. In the second phase, vascular endothelial growth factor rises, and when insulin-like growth factor-1 reaches a threshold around 32 to 34 weeks postconceptional age, uncontrolled neovascularization may occur. It is not known whether this new knowledge will have implications for future therapy. However, by strictly avoiding hyperoxia, that is, SaO2>92-93% and avoiding fluctuations in SaO2, it is possible to control and prevent severe retinopathy of prematurity in most cases.
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Affiliation(s)
- O D Saugstad
- Department of Pediatric Research, Rikshospitalet University Hospital, University of Oslo, Oslo, Norway.
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41
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Abstract
Bronchopulmonary dysplasia is a chronic lung disease that affects premature babies and contributes to their morbidity and mortality. Improved survival of very immature infants has led to increased numbers of infants with this disorder. This increase puts a heavy burden on health resources since these infants need frequent re-admission to hospital in the first 2 years after birth and, even as adolescents, have lung-function abnormalities and persistent respiratory symptoms. Unlike the original description of the disease in 1967, premature infants can develop chronic oxygen dependency without severe, acute respiratory distress; this "new bronchopulmonary dysplasia" could be the result of impaired postnatal lung growth. Whether such infants subsequently have catch-up lung growth, especially if given corticosteroids postnatally, is unknown. No safe and effective preventive therapy has been identified, but promising new treatments directed either at reducing lung injury or improving lung growth are under study.
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Affiliation(s)
- John P Kinsella
- Department of Paediatrics, University of Colorado School of Medicine, Denver, USA.
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Poets CF. Prävention und Therapie der bronchopulmonalen Dysplasie. Monatsschr Kinderheilkd 2005; 153:1140-7. [DOI: 10.1007/s00112-005-1259-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
BACKGROUND Vitamin A deficiency reduces retinol binding protein (RBP) but not transthyretin (TTR), while inflammation reduces both RBP and TTR and increases C-reactive protein (CRP), an acute phase reactant. OBJECTIVE To estimate serum RBP, TTR, and CRP in ELBW infants to test the hypotheses that (a) TTR is a negative acute phase reactant and (b) a higher RBP/TTR ratio or CRP is associated with death/BPD by 36 weeks corrected age. DESIGN/METHODS Serum RBP, TTR, and CRP were measured in 79 ELBW infants at 28 days. Area under the curve (AUC) of receiver operating characteristic curve analysis evaluated the predictive value of TTR, the RBP/TTR ratio, and CRP for death/BPD at 36 weeks. RESULTS (1) TTR inversely correlated with CRP (r=-0.45, p<0.0001) consistent with TTR being a negative acute phase reactant. (2) The RBP/TTR ratio predicted death/BPD (AUC 0.68 (CI 0.57 to 0.78)). (3) CRP strongly predicted death/BPD (AUC 0.85 (CI 0.76 to 0.92)), even after exclusion of sepsis. CONCLUSIONS A higher CRP and RBP/TTR molar ratio on day 28 are associated with death/BPD at 36 weeks in ELBW infants. Lower TTR and maintained RBP/TTR ratios suggest inflammation rather than vitamin A deficiency as the cause for lower serum vitamin A levels in ELBW infants..
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Abstract
Vitamins are micronutrients not synthesised by the human body and should be provided by the nutrition. Liposoluble vitamins include vitamins A, E, D and K. Vitamins A and E are two potent antioxidant nutrients and play a significant role in immune function. Vitamin D plays a major role in intestinal calcium absorption and bone mineralization. Vitamin K intervenes in the synthesis of coagulation factors particularly in the prothrombin synthesis. Vitamin metabolism, placental transfer, vitamin status in newborns and infants are reported. Finally requirements of these vitamins are defined.
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Affiliation(s)
- B-L Salle
- Service de néonatologie, hôpital Edouard-Herriot, Arsonval, Lyon, France.
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45
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Ambalavanan N, Tyson JE, Kennedy KA, Hansen NI, Vohr BR, Wright LL, Carlo WA. Vitamin A supplementation for extremely low birth weight infants: outcome at 18 to 22 months. Pediatrics 2005; 115:e249-54. [PMID: 15713907 DOI: 10.1542/peds.2004-1812] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A National Institute of Child Health and Human Development Neonatal Research Network randomized trial showed that vitamin A supplementation reduced bronchopulmonary dysplasia (O2 at 36 weeks' postmenstrual age) or death in extremely low birth weight (ELBW) neonates (relative risk [RR]: 0.89). As with postnatal steroids or other interventions, it is important to ensure that there are no longer-term adverse effects that outweigh neonatal benefits. PRIMARY OBJECTIVE To determine if vitamin A supplementation in ELBW infants during the first month after birth affects survival without neurodevelopmental impairment at a corrected age of 18 to 22 months. DESIGN/METHODS Infants enrolled in the National Institute of Child Health and Human Development vitamin A trial were evaluated at 18 to 22 months by carefully standardized assessments: Bayley Mental Index (MDI) and Psychomotor Index (PDI), visual and hearing screens, and physical examination for cerebral palsy (CP). The medical history was also obtained. Neurodevelopmental impairment (NDI) was predefined as > or =1 of MDI <70, PDI <70, CP, blind in both eyes, or hearing aids in both ears. RESULTS Of 807 enrolled infants, 133 died before and 16 died after discharge. Five hundred seventy-nine (88%) of the 658 remaining infants were followed up. The primary outcome of NDI or death could be determined for 687 of 807 randomized infants (85%). Baseline characteristics and predischarge and postdischarge mortality were comparable in both study groups. NDI or death by 18 to 22 months occurred in 190 of 345 (55%) infants in the vitamin A group and in 204 of 342 (60%) of the control group (RR: 0.94; 95% confidence interval: 0.80-1.07). RRs for low MDI, low PDI, and CP were also <1.0. We found no evidence that neonatal vitamin A supplementation reduces hospitalizations or pulmonary problems after discharge. CONCLUSION Vitamin A supplementation for ELBW infants reduces bronchopulmonary dysplasia without increasing mortality or neurodevelopmental impairment at 18 to 22 months. However, this study was not powered to evaluate small magnitudes of change in long-term outcomes.
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48
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Abstract
Bronchopulmonary dysplasia (BPD) has classically been described as including inflammation, architectural disruption, fibrosis, and disordered/delayed development of the infant lung. As infants born at progressively earlier gestations have begun to survive the neonatal period, a 'new' BPD, consisting primarily of disordered/delayed development, has emerged. BPD causes not only significant complications in the newborn period, but is associated with continuing mortality, cardiopulmonary dysfunction, re-hospitalization, growth failure, and poor neurodevelopmental outcome after hospital discharge. Four major risk factors for BPD include premature birth, respiratory failure, oxygen supplementation, and mechanical ventilation, although it is unclear whether any of these factors is absolutely necessary for development of the condition. Genetic susceptibility, infection, and patent ductus arteriosus have also been implicated in the pathogenesis of the disease. The strategies with the strongest evidence for effectiveness in preventing or lessening the severity of BPD include prevention of prematurity and closure of a clinically significant patent ductus arteriosus. Some evidence of effectiveness also exists for single-course therapy with antenatal glucocorticoids in women at risk for delivering premature infants, surfactant replacement therapy in intubated infants with respiratory distress syndrome, retinol (vitamin A) therapy, and modes of respiratory support designed to minimize 'volutrauma' and oxygen toxicity. The most effective treatments for ameliorating symptoms or preventing exacerbation in established BPD include oxygen therapy, inhaled glucocorticoid therapy, and vaccination against respiratory pathogens.Many other strategies for the prevention or treatment of BPD have been proposed, but have weaker or conflicting evidence of effectiveness. In addition, many therapies have significant side effects, including the possibility of worsening the disease despite symptom improvement. For instance, supraphysiologic systemic doses of glucocorticoids lessen the incidence of BPD in infants at risk for the disease, and promote weaning of oxygen and mechanical ventilation in infants with established BPD. However, the side effects of systemic glucocorticoid therapy, most notably the recently recognized adverse effects on neurodevelopment, preclude their routine use for the prevention or treatment of BPD. Future research in BPD will most probably focus on continued incremental improvements in outcome, which are likely to be achieved through the combined effects of many therapeutic modalities.
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Affiliation(s)
- Carl T D'Angio
- Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
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49
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Abstract
OBJECTIVE Vitamin E is required by very low birth weight (VLBW) infants to prevent vitamin E deficiency. However, prolonged intravenous intakes of vitamin E >4 international units (IU)/kg/day often yield potentially toxic serum tocopherol levels. This study was designed to assess the frequency of potentially inadequate or excessive doses of intravenous vitamin E in parenteral nutrition for VLBW infants in the US. STUDY DESIGN A questionnaire was sent to the 100 neonatal-perinatal training program centers listed in the 2003 directory (American Academy of Pediatrics (AAP)). Using the information provided for each neonatal unit, we calculated the doses of vitamin E (IU/kg/day) that would have been given to infants with body weights of 0.5, 1.0 and 1.5 kg in that unit. The doses were then recoded as inadequate if less than recommended (2.8 IU/kg/day, maximum 7 IU/day) by the American Society for Clinical Nutrition and the AAP, and excessive if >4 IU/kg/day, and frequencies were compared using chi2 analysis. RESULTS The 65 centers that responded were predominantly among those that offered the highest level of subspecialty neonatal intensive care (level IIID). The predicted dose of vitamin E had a median value of 2.8 IU/kg/day for all three weights, and was no significantly different among the three weights. VLBW infants with weights of 0.5, 1.0 and 1.5 kg were predicted to receive doses <2.8 IU/kg/day in 12, 12 and 19% of the neonatal intensive care units (NICUs), respectively, and doses >4 IU/kg/day in 40, 31 and 10% of the NICUs, respectively. Excessive doses were significantly associated with body weight, with more frequent excessive doses at lower weight (p=0.0008). CONCLUSION This survey showed a lack of uniformity of dosing of intravenous vitamin E in VLBW infants. The smallest infants (<1.0 kg) were receiving excessive, potentially toxic doses of vitamin E in a significant number of NICUs in the US in 2003.
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Affiliation(s)
- Luc P Brion
- Albert Einstein College of Medicine (L.P.B.), Children's Hospital at Montefiore, Bronx, NY 10461-2373, USA
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Ambalavanan N, Kennedy K, Tyson J, Carlo WA. Survey of vitamin A supplementation for extremely-low-birth-weight infants: is clinical practice consistent with the evidence? J Pediatr 2004; 145:304-7. [PMID: 15343179 DOI: 10.1016/j.jpeds.2004.04.046] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To survey the attitudes and practices among level III neonatal intensive care units in the United States regarding vitamin A supplementation for extremely-low-birth-weight (ELBW; birth weight < or =1000 g) infants. Study design A pretested questionnaire regarding vitamin A supplementation was distributed to all (n=102) neonatal-perinatal training program directors (TPD) and 105 randomly selected directors of level III neonatal intensive care units (nontraining program directors, NTPD). RESULTS Ninety-nine percent of TPD and 94% of NTPD responded. In a minority of programs (20% TPD, 13% NTPD), >90% of eligible extremely-low-birth-weight neonates are supplemented with vitamin A, whereas in most programs (69% TPD, 82% NTPD), routine supplementation is not practiced. Most centers (91% TPD, 81% NTPD) supplementing vitamin A use a dose of 5000 IU IM 3 times per week for 4 weeks. The most common reason that TPD give for not supplementing vitamin A is the perceived small benefit, whereas the most common reason for NTPD is that they consider the intervention unproven. CONCLUSIONS These findings indicate inconsistency in practicing evidence-based medicine in neonatal practice, where therapies are often administered on the basis of weaker evidence of safety and benefit than supports vitamin A supplementation. Educational interventions may be required to endorse the benefits and safety of vitamin A supplementation.
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Affiliation(s)
- Namasivayam Ambalavanan
- Department of Pediatrics, University of Alabama at Birmingham, 619 South 20th Street, Birmingham, AL 35249, USA.
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