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Peebles PJ, Jensen EA, Herrick HM, Wildenhain PJ, Rumpel J, Moussa A, Singh N, Abou Mehrem A, Quek BH, Wagner M, Pouppirt NR, Glass KM, Tingay DG, Hodgson KA, O’Shea JE, Sawyer T, Brei BK, Jung P, Unrau J, Kim JH, Barry J, DeMeo S, Johnston LC, Nishisaki A, Foglia EE. Endotracheal Tube Size Adjustments Within Seven Days of Neonatal Intubation. Pediatrics 2024; 153:e2023062925. [PMID: 38469643 PMCID: PMC10979295 DOI: 10.1542/peds.2023-062925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Accepted: 12/08/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Neonatal endotracheal tube (ETT) size recommendations are based on limited evidence. We sought to determine data-driven weight-based ETT sizes for infants undergoing tracheal intubation and to compare these with Neonatal Resuscitation Program (NRP) recommendations. METHODS Retrospective multicenter cohort study from an international airway registry. We evaluated ETT size changes (downsizing to a smaller ETT during the procedure or upsizing to a larger ETT within 7 days) and risk of procedural adverse outcomes associated with first-attempt ETT size selection when stratifying the cohort into 200 g subgroups. RESULTS Of 7293 intubations assessed, the initial ETT was downsized in 5.0% of encounters and upsized within 7 days in 1.5%. ETT downsizing was most common when NRP-recommended sizes were attempted in the following weight subgroups: 1000 to 1199 g with a 3.0 mm (12.6%) and 2000 to 2199 g with a 3.5 mm (17.1%). For infants in these 2 weight subgroups, selection of ETTs 0.5 mm smaller than NRP recommendations was independently associated with lower odds of adverse outcomes compared with NRP-recommended sizes. Among infants weighing 1000 to 1199 g: any tracheal intubation associated event, 20.8% with 2.5 mm versus 21.9% with 3.0 mm (adjusted OR [aOR] 0.62, 95% confidence interval [CI] 0.41-0.94); severe oxygen desaturation, 35.2% with 2.5 mm vs 52.9% with 3.0 mm (aOR 0.53, 95% CI 0.38-0.75). Among infants weighing 2000 to 2199 g: severe oxygen desaturation, 41% with 3.0 mm versus 56% with 3.5mm (aOR 0.55, 95% CI 0.34-0.89). CONCLUSIONS For infants weighing 1000 to 1199 g and 2000 to 2199 g, the recommended ETT size was frequently downsized during the procedure, whereas 0.5 mm smaller ETT sizes were associated with fewer adverse events and were rarely upsized.
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Affiliation(s)
- Patrick J. Peebles
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Erik A. Jensen
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Jennifer Rumpel
- Univeristy of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ahmed Moussa
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Canada
| | - Neetu Singh
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | | | | | | | | | - David G. Tingay
- Neonatal Research, Murdoch Children’s Research Institute, Melbourne, Australia; Royal Children’s, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Australia
| | | | | | | | | | - Philipp Jung
- University Hospital Schleswig Holstein, Campus Lübeck, Lübeck, Germany
| | - Jennifer Unrau
- Alberta Children’s Hospital, University of Calgary, Alberta, Canada
| | - Jae H. Kim
- Perinatal Institute, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - James Barry
- University of Colorado School of Medicine, Aurora, Colorado
| | | | | | - Akira Nishisaki
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Jensen EA, Watterberg KL. Postnatal Corticosteroids To Prevent Bronchopulmonary Dysplasia. Neoreviews 2023; 24:e691-e703. [PMID: 37907402 DOI: 10.1542/neo.24-11-e691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is a common, severe chronic respiratory disease that affects very preterm infants. In utero and postnatal exposure to proinflammatory stimuli contribute to the pathophysiology of BPD. Corticosteroids, because of their potent anti-inflammatory properties, may decrease respiratory morbidity and reduce the risk of BPD in very preterm infants. However, these medications can have adverse effects on the developing brain and other organ systems. This review examines current evidence on the risks and benefits of postnatal corticosteroids used to prevent BPD in preterm infants.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
| | - Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM
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Vitale JL, DeMauro SB, Gibbs K, Kielt MJ, Nelin LD, Jensen EA. Clinician opinions on nasal versus oral intubation in infants with BPD: A multicenter survey. Pediatr Pulmonol 2023; 58:3354-3358. [PMID: 37701999 PMCID: PMC11056036 DOI: 10.1002/ppul.26653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 08/13/2023] [Accepted: 08/19/2023] [Indexed: 09/14/2023]
Affiliation(s)
- Jessica L. Vitale
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Division of Neonatology, Philadelphia, Pennsylvania, United States
| | - Sara B. DeMauro
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Division of Neonatology, Philadelphia, Pennsylvania, United States
| | - Kathleen Gibbs
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Division of Neonatology, Philadelphia, Pennsylvania, United States
| | - Matthew J. Kielt
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio, United States
| | - Leif D. Nelin
- Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children’s Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio, United States
| | - Erik A. Jensen
- Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Division of Neonatology, Philadelphia, Pennsylvania, United States
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Katz TA, Bancalari E, Gordijn SJ, Higgins RD, Isayama T, Jensen EA, Offringa M, Pillow JJ, Shah PS, Soll RF, Stoecklin B, Mugie SM, van Kaam AH, Onland W. Towards a harmonized bronchopulmonary dysplasia definition: a study protocol for an international Delphi procedure. BMJ Paediatr Open 2023; 7:e002112. [PMID: 37899128 PMCID: PMC10619096 DOI: 10.1136/bmjpo-2023-002112] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/09/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION Bronchopulmonary dysplasia (BPD) remains the most common complication of preterm birth with lifelong consequences. Multiple BPD definitions are currently used in daily practice. Uniformity in defining BPD is important for clinical care, research and benchmarking. The aim of this Delphi procedure is to determine what clinicians and researchers consider the key features for defining BPD. With the results of this study, we hope to advance the process of reaching consensus on the diagnosis of BPD. METHODS AND ANALYSIS A Delphi procedure will be used to establish why, when and how clinicians propose BPD should be diagnosed. This semi-anonymous iterative technique ensures an objective approach towards gaining these insights. An international multidisciplinary panel of clinicians and researchers working with preterm infants and/or patients diagnosed with BPD will participate. Steering committee members will recruit potential participants in their own region or network following eligibility guidelines to complete a first round survey online. This round will collect demographic information and opinions on key features of BPD definitions. Subsequent rounds will provide participants with the results from the previous round, for final acceptance or rejection of key features. Statements will be rated using a 5-point Likert scale. After completing the Delphi procedure, an (online) consensus meeting will be organised to discuss the results. ETHICS AND DISSEMINATION For this study, ethical approval a waiver has been provided. However, all participants will be asked to provide consent for the use of personal data. After the Delphi procedure is completed, it will be published in a peer-reviewed journal and disseminated at international conferences.
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Affiliation(s)
- Trixie A Katz
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
| | - Eduardo Bancalari
- Division of Neonatology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Sanne J Gordijn
- Department of Obstetrics and Gynecology, UMCG, Groningen, The Netherlands
| | - Rosemary D Higgins
- Research and Sponsored Programs, Florida Gulf Coast University, Fort Myers, Florida, USA
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Erik A Jensen
- Division of Neonatology, The Children's Hospital, Philadelphia, Pennsylvania, USA
| | - Martin Offringa
- Division of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - J Jane Pillow
- Division of Pediatrics, Medical School, The University of Western Australia and Telethon Kids Institute, Perth, Washington, Australia
| | - Prakesh S Shah
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Roger F Soll
- Division of Neonatology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Benjamin Stoecklin
- Department of Neonatology, University Children's Hospital Basel, Basel, Switzerland
| | - Suzanne M Mugie
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
| | - Wes Onland
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
- Department of Neonatology, Emma Childrens' Hospital UMC, Amsterdam, The Netherlands
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Wright CJ, McCulley DJ, Mitra S, Jensen EA. Acetaminophen for the patent ductus arteriosus: has safety been adequately demonstrated? J Perinatol 2023; 43:1230-1237. [PMID: 37169914 PMCID: PMC10626600 DOI: 10.1038/s41372-023-01697-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/25/2023] [Accepted: 04/28/2023] [Indexed: 05/13/2023]
Abstract
Patent ductus arteriosus (PDA) is the most common cardiovascular condition diagnosed in premature infants. Acetaminophen was first proposed as a potential treatment for PDA in 2011. Since that time acetaminophen use among extremely preterm neonates has increased substantially. The limited available data demonstrate that acetaminophen reduces PDA without evident hepatotoxicity. These findings have led some to suggest that acetaminophen is a safe and effective therapy for PDA closure. However, the lack of apparent hepatoxicity is predictable. Acetaminophen induced cellular injury is due to CYP2E1 derived metabolites; and hepatocyte CYP2E1 expression is low in the fetal and neonatal period. Here, we review preclinical and clinical data that support the hypothesis that the lung, which expresses high levels of CYP2E1 during fetal and early postnatal development, may be particularly susceptible to acetaminophen induced toxicity. Despite these emerging data, the true potential pulmonary risks and benefits of acetaminophen for PDA closure are largely unknown. The available clinical studies in are marked by significant weakness including low sample sizes and minimal evaluation of extremely preterm infants who are typically at highest risk of pulmonary morbidity. We propose that studies interrogating mechanisms linking developmentally regulated, cell-specific CYP2E1 expression and acetaminophen-induced toxicity as well as robust assessment of pulmonary outcomes in large trials that evaluate the safety and efficacy of acetaminophen in extremely preterm infants are needed.
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Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO, USA.
| | - David J McCulley
- Division of Neonatology, Department of Pediatrics, University of California, San Diego, CA, USA
| | - Souvik Mitra
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health Centre, Halifax, NS, Canada
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Nelin TD, Yang N, Radack J, Lorch SA, DeMauro SB, Bamat NA, Jensen EA, Gibbs K, Just AC, Burris HH. Associations of neighborhood social vulnerability with emergency department visits and readmissions among infants with bronchopulmonary dysplasia. J Perinatol 2023; 43:1308-1313. [PMID: 37491473 PMCID: PMC10864938 DOI: 10.1038/s41372-023-01735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 04/14/2023] [Revised: 07/05/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
OBJECTIVES To characterize associations of the CDC Social Vulnerability Index (SVI) with medically attended acute respiratory illness among infants with bronchopulmonary dysplasia (BPD). STUDY DESIGN Retrospective cohort of 378 preterm infants with BPD from a single center. Multivariable logistic regression quantified associations of SVI with medically attended acute respiratory illness, defined as emergency department (ED) visits or hospital readmissions within a year after first hospital discharge. Mediation analysis quantified the extent to which differences in SVI may explain known Black-White disparities in medically attended acute respiratory illness. RESULTS SVI was associated with medically attended respiratory illness (per SVI standard deviation increment, aOR 1.44, 95% CI: 1.17-1.78). Adjustment for race and ethnicity attenuated the association (aOR 1.27, 95% CI: 0.97-1.64). SVI significantly mediated 31% of the Black-White disparity in ED visits (p = 0.04). CONCLUSIONS SVI was associated with, and may partially explain racial disparities in, medically attended acute respiratory illness among infants with BPD.
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Affiliation(s)
- Timothy D Nelin
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Center of Excellence in Environmental Toxicology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Nancy Yang
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joshua Radack
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott A Lorch
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Sara B DeMauro
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Neonatal Follow-Up Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicolas A Bamat
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Newborn/Infant Chronic Lung Disease Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Newborn/Infant Chronic Lung Disease Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen Gibbs
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Newborn/Infant Chronic Lung Disease Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Allan C Just
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Heather H Burris
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Center of Excellence in Environmental Toxicology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
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Gentle SJ, Rysavy MA, Li L, Laughon MM, Patel RM, Jensen EA, Hintz S, Ambalavanan N, Carlo WA, Watterberg K. Heterogeneity of Treatment Effects of Hydrocortisone by Risk of Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants in the National Institute of Child Health and Human Development Neonatal Research Network Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2315315. [PMID: 37256621 PMCID: PMC10233424 DOI: 10.1001/jamanetworkopen.2023.15315] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Received: 12/26/2022] [Accepted: 04/11/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Extremely preterm infants who develop bronchopulmonary dysplasia (BPD) are at a higher risk for adverse pulmonary and neurodevelopmental outcomes. In the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN) Hydrocortisone Trial, hydrocortisone neither reduced rates of BPD or death nor increased rates of neurodevelopmental impairment (NDI) or death. Objective To determine whether estimated risk for grades 2 to 3 BPD or death is associated with the effect of hydrocortisone on the composite outcomes of (1) grades 2 to 3 BPD or death and (2) moderate or severe NDI or death. Design, Setting, and Participants This secondary post hoc analysis used data from the NICHD NRN Hydrocortisone Trial, which was a double-masked, placebo-controlled, randomized clinical trial conducted in 19 US academic centers. The NICHD HRN Hydrocortisone Trial enrolled infants born at a gestational age of less than 30 weeks who received mechanical ventilation for at least 7 days, including at the time of enrollment, and who were aged 14 to 28 postnatal days. Infants were enrolled between August 22, 2011, and February 4, 2018, with follow-up between 22 and 26 months of corrected age completed on March 29, 2020. Data were analyzed from September 13, 2021, to March 25, 2023. Intervention Infants were randomized to 10 days of hydrocortisone or placebo treatment. Main Outcomes and Measures Infants' baseline risk of grades 2 to 3 BPD or death was estimated using the NICHD Neonatal BPD Outcome Estimator. Differences in absolute and relative treatment effects by baseline risk were evaluated using interaction terms in models fitted to the efficacy outcome of grades 2 to 3 BPD or death and the safety outcome of moderate or severe NDI or death by follow-up. Results Among the 799 infants included in the analysis (421 boys [52.7%]), the mean (SD) gestational age was 24.9 (1.5) weeks, and the mean (SD) birth weight was 715 (167) g. The mean estimated baseline risk for grades 2 to 3 BPD or death was 54% (range, 18%-84%) in the study population. The interaction between treatment group and baseline risk was not statistically significant on a relative or absolute scale for grades 2 to 3 BPD or death; the size of the effect ranged from a relative risk of 1.13 (95% CI, 0.82-1.55) in quartile 1 to 0.94 (95% CI, 0.81-1.09) in quartile 4. Similarly, the interaction between treatment group and baseline risk was not significant on a relative or absolute scale for moderate or severe NDI or death; the size of the effect ranged from a relative risk of 1.04 (95% CI, 0.80-1.36) in quartile 1 to 0.99 (95% CI, 0.80-1.22) in quartile 4. Conclusions and Relevance In this secondary analysis of a randomized clinical trial, the effect of hydrocortisone vs placebo was not appreciably modified by baseline risk for grades 2 to 3 BPD or death. Trial Registration ClinicalTrials.gov Identifier: NCT01353313.
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Affiliation(s)
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas Health Science Center at Houston
| | - Lei Li
- Statistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | | | - Ravi M. Patel
- Department of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Erik A. Jensen
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Hintz
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, California
| | | | | | - Kristi Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque
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Jensen EA, Wiener LE, Rysavy MA, Dysart KC, Gantz MG, Eichenwald EC, Greenberg RG, Harmon HM, Laughon MM, Watterberg KL, Walsh MC, Yoder BA, Lorch SA, DeMauro SB. Assessment of Corticosteroid Therapy and Death or Disability According to Pretreatment Risk of Death or Bronchopulmonary Dysplasia in Extremely Preterm Infants. JAMA Netw Open 2023; 6:e2312277. [PMID: 37155165 PMCID: PMC10167571 DOI: 10.1001/jamanetworkopen.2023.12277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 01/06/2023] [Accepted: 03/24/2023] [Indexed: 05/10/2023] Open
Abstract
Importance Meta-analyses suggest that corticosteroids may be associated with increased survival without cerebral palsy in infants at high risk of bronchopulmonary dysplasia (BPD) but are associated with adverse neurologic outcomes in low-risk infants. Whether this association exists in contemporary practice is uncertain because most randomized clinical trials administered corticosteroids earlier and at higher doses than currently recommended. Objective To evaluate whether the pretreatment risk of death or grade 2 or 3 BPD at 36 weeks' postmenstrual age modified the association between postnatal corticosteroid therapy and death or disability at 2 years' corrected age in extremely preterm infants. Design, Setting, and Participants This cohort study analyzed data on 482 matched pairs of infants from 45 participating US hospitals in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database (GDB). Infants were included in the cohort if they were born at less than 27 weeks' gestation between April 1, 2011, and March 31, 2017; survived the first 7 postnatal days; and had 2-year death or developmental follow-up data collected between January 2013 and December 2019. Corticosteroid-treated infants were propensity score matched with untreated controls. Data were analyzed from September 1, 2019, to November 30, 2022. Exposure Systemic corticosteroid therapy to prevent BPD that was initiated between day 8 and day 42 after birth. Main Outcomes and Measures The primary outcome was death or moderate to severe neurodevelopmental impairment at 2 years' corrected age. The secondary outcome was death or moderate to severe cerebral palsy at 2 years' corrected age. Results A total of 482 matched pairs of infants (mean [SD] gestational age, 24.1 [1.1] weeks]; 270 males [56.0%]) were included from 656 corticosteroid-treated infants and 2796 potential controls. Most treated infants (363 [75.3%]) received dexamethasone. The risk of death or disability associated with corticosteroid therapy was inversely associated with the estimated pretreatment probability of death or grade 2 or 3 BPD. The risk difference for death or neurodevelopmental impairment associated with corticosteroids decreased by 2.7% (95% CI, 1.9%-3.5%) for each 10% increase in the pretreatment risk of death or grade 2 or 3 BPD. This risk transitioned from estimated net harm to benefit when the pretreatment risk of death or grade 2 or 3 BPD exceeded 53% (95% CI, 44%-61%). For death or cerebral palsy, the risk difference decreased by 3.6% (95% CI, 2.9%-4.4%) for each 10% increase in the risk of death or grade 2 or 3 BPD and transitioned from estimated net harm to benefit at a pretreatment risk of 40% (95% CI, 33%-46%). Conclusions and Relevance Results of this study suggested that corticosteroids were associated with a reduced risk of death or disability in infants at moderate to high pretreatment risk of death or grade 2 or 3 BPD but with possible harm in infants at lower risk.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Laura Elizabeth Wiener
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Matthew A. Rysavy
- Department of Pediatrics, University of Texas McGovern Medical School, Houston
| | - Kevin C. Dysart
- Neonatal/Perinatal Medicine, Nemours Children’s Hospital, Wilmington, Delaware
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Eric C. Eichenwald
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Rachel G. Greenberg
- Department of Pediatrics and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Heidi M. Harmon
- Stead Family Department of Pediatrics, University of Iowa, Iowa City
| | - Matthew M. Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Michele C. Walsh
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Scott A. Lorch
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
| | - Sara B. DeMauro
- Division of Neonatology and Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia
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Raffay TM, Jensen EA. Can Intermittent Hypoxemia Help Detect Pulmonary Hypertension in High-Risk Preemies? Am J Respir Crit Care Med 2023; 207:809-811. [PMID: 36630576 PMCID: PMC10111985 DOI: 10.1164/rccm.202212-2290ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Thomas M Raffay
- UH Rainbow Babies & Children's, 159284, Pediatrics, Cleveland, Ohio, United States;
| | - Erik A Jensen
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Division of Neonatology, Philadelphia, Pennsylvania, United States
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10
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Vyas-Read S, Jensen EA, Bamat N, Lagatta JM, Murthy K, Patel RM. Correction to: Chronic lung disease-related mortality in the US from 1999-2017: trends and racial disparities. J Perinatol 2022; 42:1558. [PMID: 36127396 DOI: 10.1038/s41372-022-01508-0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shilpa Vyas-Read
- Emory University/Children's Healthcare of Atlanta, 2015 Uppergate Drive NE, Atlanta, GA, 30322, USA.
| | - Erik A Jensen
- University of Pennsylvania/The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicolas Bamat
- University of Pennsylvania/The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joanne M Lagatta
- Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI, USA
| | - Karna Murthy
- Northwestern University/Ann & Robert H Lurie Children's Hospital, Chicago, IL, USA
| | - Ravi M Patel
- Emory University/Children's Healthcare of Atlanta, 2015 Uppergate Drive NE, Atlanta, GA, 30322, USA
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11
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Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, Watterberg KL. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022; 46:151638. [PMID: 36085059 DOI: 10.1016/j.semperi.2022.151638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite improvements in the care and outcomes of infants born extremely preterm, bronchopulmonary dysplasia (BPD) remains a common and frustrating complication of prematurity. This review summarizes the BPD-focused research conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). To improve disease classification and outcome prediction, the NRN developed new data-driven diagnostic criteria for BPD and web-based tools that allow clinicians and investigators to reliably estimate BPD risk in preterm infants. Randomized trials of intramuscular vitamin A and prophylactic nasal continuous positive airway pressure conducted by the NRN have contributed to our current use of these therapies as evidence-based approaches to reduce BPD risk. A recent large, randomized trial of hydrocortisone administered beginning between the 2nd and 4th postnatal weeks provided strong evidence that this therapy promotes successful extubation but does not lower BPD rates. Ongoing studies within the NRN will address important, unanswered questions on the risks and benefits of intratracheal surfactant/corticosteroid combinations and treatment versus expectant management of the patent ductus arteriosus to prevent BPD.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara B DeMauro
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Barbara Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristi L Watterberg
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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12
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Tsukahara K, Johnson B, Klimowich K, Chiotos K, Jensen EA, Planet P, Phinizy P, Piccione J. Comparison of tracheal aspirate and bronchoalveolar lavage samples in the microbiological diagnosis of lower respiratory tract infection in pediatric patients. Pediatr Pulmonol 2022; 57:2405-2410. [PMID: 35781810 PMCID: PMC9489655 DOI: 10.1002/ppul.26049] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/01/2022] [Accepted: 06/25/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bacterial cultures from tracheal aspirates (TA) and bronchoalveolar lavage (BAL) specimens can be used to assess patients with artificial airways for lower respiratory tract infections (LRTI). TA collection may be advantageous in situations of limited resources or critical illness. Literature comparing these diagnostic modalities in pediatric populations is scarce. METHODS Single-center, retrospective analysis of 52 pediatric patients with an artificial airway undergoing evaluation for LRTI. All patients had a TA specimen collected for semiquantitative Gram stain and culture followed by BAL within 48 h. Microbiologic diagnosis of LRTI was defined as a BAL sample with >25% neutrophils and growth of >104 colony-forming units/ml of one or more bacterial species. The test characteristics of TA were compared with these BAL results as the reference standard. Concordance in microorganism identification was also assessed. RESULTS Overall, 24 patients (47%) met criteria for LRTI using BAL as the diagnostic standard. TA samples positive for an isolated organism had poor sensitivity for acute LRTI when compared with BAL, regardless of semiquantitative white blood cell (WBC) count by Gram stain. Using a TA diagnostic threshold of organism growth and at least "moderate" WBC yielded a specificity of 93%. Positive predictive value was highest when an organism was identified by TA. Negative predictive value was >70% for TA samples with no WBC by semiquantitative analysis, with or without growth of an organism. Complete concordance of cultured species was 58% for all patients, with a higher rate seen among those with endotracheal tubes. CONCLUSIONS The role of cultures obtained by TA remains limited for the diagnosis of acute LRTI as demonstrated by the poor correlation to BAL results within our cohort. Optimal strategies for diagnosing LRTI across patient populations and airway types remain elusive.
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Affiliation(s)
- Katharine Tsukahara
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brandy Johnson
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katelyn Klimowich
- Department of Urologic Surgery, Jefferson Health NJ,
Stratford, New Jersey
| | - Kathleen Chiotos
- Division of Critical Care Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
- Division of Infectious Diseases, Children’s Hospital
of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik A. Jensen
- Division of Neonatology, Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul Planet
- Division of Infectious Diseases, Children’s Hospital
of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pelton Phinizy
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph Piccione
- Division of Pulmonary and Sleep Medicine, Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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13
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Vyas-Read S, Jensen EA, Bamat N, Lagatta JM, Murthy K, Patel RM. Chronic lung disease-related mortality in the US from 1999-2017: trends and racial disparities. J Perinatol 2022; 42:1244-1245. [PMID: 35906284 DOI: 10.1038/s41372-022-01468-5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/19/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Shilpa Vyas-Read
- Emory University/Children's Healthcare of Atlanta, 2015 Uppergate Drive NE, Atlanta, GA, 30322, USA.
| | - Erik A Jensen
- University of Pennsylvania/The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicolas Bamat
- University of Pennsylvania/The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joanne M Lagatta
- Medical College of Wisconsin/Children's Wisconsin, Milwaukee, WI, USA
| | - Karna Murthy
- Northwestern University/Ann & Robert H Lurie Children's Hospital, Chicago, IL, USA
| | - Ravi M Patel
- Emory University/Children's Healthcare of Atlanta, 2015 Uppergate Drive NE, Atlanta, GA, 30322, USA
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14
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McCulley DJ, Jensen EA, Sucre JMS, McKenna S, Sherlock LG, Dobrinskikh E, Wright CJ. Racing against time: leveraging preclinical models to understand pulmonary susceptibility to perinatal acetaminophen exposures. Am J Physiol Lung Cell Mol Physiol 2022; 323:L1-L13. [PMID: 35503238 PMCID: PMC9208439 DOI: 10.1152/ajplung.00080.2022] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/20/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
Over the past decade, clinicians have increasingly prescribed acetaminophen (APAP) for patients in the neonatal intensive care unit (NICU). Acetaminophen has been shown to reduce postoperative opiate burden, and may provide similar efficacy for closure of the patent ductus arteriosus (PDA) as nonsteroidal anti-inflammatory drugs (NSAIDs). Despite these potential benefits, APAP exposures have spread to increasingly less mature infants, a highly vulnerable population for whom robust pharmacokinetic and pharmacodynamic data for APAP are lacking. Concerningly, preclinical studies suggest that perinatal APAP exposures may result in unanticipated adverse effects that are unique to the developing lung. In this review, we discuss the clinical observations linking APAP exposures to adverse respiratory outcomes and the preclinical data demonstrating a developmental susceptibility to APAP-induced lung injury. We show how clinical observations linking perinatal APAP exposures to pulmonary injury have been taken to the bench to produce important insights into the potential mechanisms underlying these findings. We argue that the available data support a more cautious approach to APAP use in the NICU until large randomized controlled trials provide appropriate safety and efficacy data.
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Affiliation(s)
- David J McCulley
- Division of Neonatology, Department of Pediatrics, University of California, San Diego, California
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | - Sarah McKenna
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Laura G Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Evgenia Dobrinskikh
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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15
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Bamat NA, Jensen EA, Mitra S. EBNEO Commentary: A network meta-analysis of postnatal corticosteroids for bronchopulmonary dysplasia: Has the most appropriate treatment been revealed? Acta Paediatr 2022; 111:903-904. [PMID: 34989022 DOI: 10.1111/apa.16228] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/03/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Nicolas A. Bamat
- Children’s Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Erik A. Jensen
- Children’s Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania Philadelphia Pennsylvania USA
| | - Souvik Mitra
- Dalhousie University and IWK Health Halifax Nova Scotia Canada
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16
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Jensen EA, Greenspan JS, Aghai ZH, Carola DL, Eichenwald EC, DeMauro SB, Dysart K. Is it time to study routine car seat tolerance screening in a randomized controlled trial? An international survey of current practice and clinician equipoise. J Perinatol 2022; 42:507-509. [PMID: 34453111 PMCID: PMC8882206 DOI: 10.1038/s41372-021-01167-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 05/28/2021] [Accepted: 07/13/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Erik A Jensen
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Jay S Greenspan
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Zubair H Aghai
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - David L Carola
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric C Eichenwald
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara B DeMauro
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kevin Dysart
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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17
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Wright CJ, Jensen EA. EBNEO Commentary: Paracetamol/acetaminophen to avoid PDA ligation: How to interpret impact on 18- to 24-month outcomes. Acta Paediatr 2022; 111:901-902. [PMID: 35099086 DOI: 10.1111/apa.16238] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/01/2021] [Accepted: 12/27/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Clyde J. Wright
- Section of Neonatology Department of Pediatrics Children's Hospital Colorado University of Colorado School of Medicine Aurora Colorado USA
| | - Erik A. Jensen
- Division of Neonatology Department of Pediatrics The Children's Hospital of Philadelphia The University of Pennsylvania School of Medicine Philadelphia Pennsylvania USA
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18
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Gentle SJ, Carper B, Laughon MM, Jensen EA, Williams A, Travers CP, Ambalavanan N, Lal CV, Carlo WA. Duration of noninvasive respiratory support and risk for bronchopulmonary dysplasia or death. J Perinatol 2022; 42:454-460. [PMID: 35034096 PMCID: PMC9007818 DOI: 10.1038/s41372-021-01269-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 10/20/2021] [Accepted: 11/02/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether the duration of noninvasive respiratory support exposure is associated with bronchopulmonary dysplasia (BPD) or death in preterm infants. METHODS Multicenter, retrospective study of infants born at <29 weeks' gestation. The association between days on noninvasive respiratory support and BPD or death was determined using instrumental variable techniques and generalized propensity score matching to account for potential confounding by illness severity. RESULTS Among 6268 infants 36% developed BPD or died. The median duration of noninvasive respiratory support was 18 days. There was inconsistency in the association between noninvasive support and BPD or death when analyzed by instrumental variable techniques (Average Marginal Effect -0.37; 95% CI -1.23 to 0.50) and generalized propensity score matching (Average Marginal Effect 0.46; 95% CI 0.33 to 0.60). CONCLUSION Findings on the association between duration of exposure to noninvasive respiratory support and the development of BPD or death were inconclusive. CLINICALTRIALS GOV ID Generic Database:NCT00063063.
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Affiliation(s)
- Samuel J Gentle
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Benjamin Carper
- Statistics and Epidemiology Unit, RTI International, Research Triangle, NC, USA
| | - Matthew M Laughon
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Erik A Jensen
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Austin Williams
- Statistics and Epidemiology Unit, RTI International, Research Triangle, NC, USA
| | - Colm P Travers
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Charitharth V Lal
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar A Carlo
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
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19
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Flibotte J, Laptook AR, Shankaran S, McDonald SA, Baserga MC, Bell EF, Cotten CM, Das A, DeMauro SB, DuPont TL, Eichenwald EC, Heyne R, Jensen EA, Van Meurs KP, Dysart K. Blanket temperature during therapeutic hypothermia and outcomes in hypoxic ischemic encephalopathy. J Perinatol 2022; 42:348-353. [PMID: 34999716 PMCID: PMC9121861 DOI: 10.1038/s41372-021-01302-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 07/13/2021] [Revised: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Determine whether blanket temperatures during therapeutic hypothermia (TH) are associated with 18-22 month outcomes for infants with hypoxic ischemic encephalopathy (HIE). STUDY DESIGN Retrospective cohort study of 181 infants with HIE who received TH in two randomized trials within the Neonatal Research Network. We defined summative blanket temperature constructs and evaluated for association with a primary composite outcome of death or moderate/ severe disability at 18-22 months. RESULTS Each 0.5 °C above 33.5 °C in the mean of the highest quartile blanket temperature was associated with a 52% increase in the adjusted odds of death/ disability (aOR 1.52, 95% CI 1.09-2.11). Having >8 consecutive blanket temperatures above 33.5 °C rendered an aOR of death/disability of 5.04 in the first 24 h (95% CI 1.54-16.6) and 6.92 in the first 48 h (95% CI 2.20-21.8) of TH. CONCLUSIONS Higher blanket temperature during TH may be an early, clinically useful biomarker of HIE outcome.
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Affiliation(s)
- John Flibotte
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Abbot R Laptook
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, RI, USA
| | - Seetha Shankaran
- Department of Pediatrics, Wayne State University, Detroit, MI, USA
| | - Scott A McDonald
- Biostatistics and Epidemiology, RTI International, Research Triangle Park, NC, USA
| | - Mariana C Baserga
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | | | - Abhik Das
- Biostatistics and Epidemiology, RTI International, Rockville, MD, USA
| | - Sara B DeMauro
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tara L DuPont
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric C Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Roy Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Erik A Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Krisa P Van Meurs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin Dysart
- Division of Neonatal and Perinatal Medicine, Alfred I. duPont Hospital for Children, Wilmington, DE, USA.
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20
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Jensen EA, Whyte RK, Schmidt B, Bassler D, Vain NE, Roberts RS. Association between Intermittent Hypoxemia and Severe Bronchopulmonary Dysplasia in Preterm Infants. Am J Respir Crit Care Med 2021; 204:1192-1199. [PMID: 34428130 PMCID: PMC8759313 DOI: 10.1164/rccm.202105-1150oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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] [Received: 05/10/2021] [Accepted: 08/23/2021] [Indexed: 11/16/2022] Open
Abstract
Rationale: Bronchopulmonary dysplasia increases the risk of disability in extremely preterm infants. Although the pathophysiology remains uncertain, prior exposure to intermittent hypoxemia may play a role in this relationship. Objectives: To determine the association between prolonged episodes of intermittent hypoxemia and severe bronchopulmonary dysplasia. Methods: A post hoc analysis of extremely preterm infants in the Canadian Oxygen Trial who survived to 36 weeks' postmenstrual age was performed. Oxygen saturations <80% for ⩾1 minute and the proportion of time per day with hypoxemia were quantified using continuous pulse oximetry data that had been sampled every 10 seconds from within 24 hours of birth until 36 weeks' postmenstrual age. The study outcome was severe bronchopulmonary dysplasia as defined in the 2001 NIH Workshop Summary. Measurements and Main Results: Of 1,018 infants, 332 (32.6%) developed severe bronchopulmonary dysplasia. The median number of hypoxemic episodes ranged from 0.8/day (interquartile range, 0.2-1.1) to 60.2/day (interquartile range, 51.4-70.3) among the least and most affected 10% of infants. Compared with the lowest decile of exposure to hypoxemic episodes, the adjusted relative risk of severe bronchopulmonary dysplasia increased progressively from 1.72 (95% confidence interval, 1.55-1.90) at the 2nd decile to 20.40 (95% confidence interval, 12.88-32.32) at the 10th decile. Similar risk gradients were observed for time in hypoxemia. Significant differences in the rates of hypoxemia between infants with and without severe bronchopulmonary dysplasia emerged within the first week after birth. Conclusions: Prolonged intermittent hypoxemia beginning in the first week after birth was associated with an increased risk of developing severe bronchopulmonary dysplasia among extremely preterm infants. Clinical trial registered with www.isrctn.com (ISRCTN62491227) and www.clinicaltrials.gov (NCT00637169).
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robin K. Whyte
- Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Barbara Schmidt
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Dirk Bassler
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nestor E. Vain
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina; and
- Division of Newborn Medicine, Department of Pediatrics, Hospital Sanatorio Trinidad, Buenos Aires, Argentina
| | - Robin S. Roberts
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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21
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DeMauro SB, Burkhardt M, Wood A, Nilan K, Jensen EA, Bamat NA, Zhang H, Gibbs K. Early motor development in infants with moderate or severe bronchopulmonary dysplasia. J Neonatal Perinatal Med 2021; 15:55-62. [PMID: 34657851 DOI: 10.3233/npm-210750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Timely development of early motor skills is essential for later skill development in multiple domains. Infants with severe bronchopulmonary dysplasia (BPD) have significant risk for developmental delays. Early motor skill development in this population has not been described. The aim of the present study was to characterize motor skill acquisition at 3 and 6 months corrected age (CA) and assess trajectories of skill development over this time period in infants with severe BPD. METHODS We performed a single-center, retrospective descriptive study. Motor skills were categorized as present and normal, present but atypical, or absent at 3 and 6 months CA. Logistic regression was used to identify clinical characteristics associated with negative trajectories of skill acquisition. RESULTS Data were available for 232 infants and 187 infants at 3 and 6 months CA, respectively. Ten motor skills were present and normal in 5-44%(range) of subjects at 3 months. Nineteen motor skills were present and normal in 1-63%(range) of subjects at 6 months. Significant postural asymmetry was noted throughout the study period. Loss of skills and worsening asymmetries over time were common. Exposure to sedating medications was significantly associated with poor development. CONCLUSION We report delays in motor skill acquisition and postural asymmetries in infants with severe BPD at both 3 and 6 months CA. The association between sedating medications and poor development suggests that efforts to limit these exposures may lead to improved development. Targeted interventions to facilitate early motor development may improve outcomes of this high-risk population.
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Affiliation(s)
- S B DeMauro
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - M Burkhardt
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - A Wood
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - K Nilan
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - E A Jensen
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - N A Bamat
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - H Zhang
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - K Gibbs
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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22
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Affiliation(s)
- Sara B DeMauro
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erik A Jensen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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23
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Napolitano N, Roberts T, Nickel AJ, McDonough J, Sun H, Feng R, Jensen EA, Dysart K, Lin R. Performance Evaluation of Nasal Prong Interface for CPAP Delivery on a Critical Care Ventilator: A Bench Experiment. Respir Care 2021; 66:1514-1520. [PMID: 34230212 PMCID: PMC9993573 DOI: 10.4187/respcare.09018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The RAM cannula (Neotech, Valencia, CA) has become a commonly used interface for CPAP in neonatal intensive care. Performance characteristics of this interface used with a critical care ventilator are not well described. METHODS This was a bench study utilizing a lung simulator configured as an actively breathing infant (weights of 800 g, 1.5 kg, and 3 kg) with moderate lung disease and a critical care ventilator in CPAP mode with leak compensation on. Three sizes of the RAM cannulae (preemie, newborn, and infant) were compared to 3 BabyFlow nasal prongs (Dräger Medical, Lübeck, Germany) (medium, large, and extra-large). Fabricated nasal models produced a 70% occlusive fit for the RAM cannula and an occlusive fit with the Dräger prongs. Delivered flow and pressure levels were recorded at 9 CPAP levels between 5 and 20 cm H2O. RESULTS The Dräger prongs produced a mean airway pressure ([Formula: see text]) within 0.20 cm H2O (range -0.10 to 0.35) of the set CPAP across all evaluated prong sizes and CPAP levels. In contrast, the RAM cannula produced [Formula: see text] values that averaged 8.5 cm H2O (range -15 to -3.5) below the set CPAP levels. The deficit in delivered versus target CPAP level for the RAM cannula increased with greater set CPAP. Set CPAP of 5 cm H2O delivered [Formula: see text] values that ranged from 0.6 to 1.5 cm H2O (difference of 3.5-4.4 cm H2O). Set CPAP of 20 cm H2O delivered [Formula: see text] values that ranged from 5.0 to 8.4 cm H2O (difference of 11.7-15 cm H2O). Inspiratory flow required to achieve set CPAP levels did not differ between interfaces, suggesting high resistance in the RAM cannula device masks the delivered CPAP levels. CONCLUSIONS Use of the RAM cannula with a 30% leak on a critical care ventilator delivered [Formula: see text] values lower than set CPAP. This may be clinically meaningful and should be considered when choosing a nasal interface.
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Affiliation(s)
- Natalie Napolitano
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Tracey Roberts
- Department of Respiratory Therapy, Lucile Packard Children's Hospital, Stanford, California
| | - Amanda J Nickel
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph McDonough
- Department of Respiratory Therapy, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Haorui Sun
- Pennsylvania State College of Medicine, Hershey, Pennsylvania
| | - Rui Feng
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erik A Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin Dysart
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Lin
- Division of Anesthesia and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Jensen EA, Edwards EM, Greenberg LT, Soll RF, Ehret DE, Horbar JD. Severity of Bronchopulmonary Dysplasia Among Very Preterm Infants in the United States. Pediatrics 2021; 148:peds.2020-030007. [PMID: 34078747 PMCID: PMC8290972 DOI: 10.1542/peds.2020-030007] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [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] [Accepted: 03/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network recently proposed new, severity-based diagnostic criteria for bronchopulmonary dysplasia (BPD). This study provides the first benchmark epidemiological data applying this definition. METHODS Retrospective cohort study of infants born from 22 to 29 weeks' gestation in 2018 at 715 US hospitals in the Vermont Oxford Network. Rates of BPD, major neonatal morbidities, and common respiratory therapies, stratified by BPD severity, were determined. RESULTS Among 24 896 infants, 2574 (10.3%) died before 36 weeks' postmenstrual age (PMA), 12 198 (49.0%) did not develop BPD, 9192 (36.9%) developed grade 1 or 2 BPD, and 932 (3.7%) developed grade 3 BPD. Rates of mortality before 36 weeks' PMA and grade 3 BPD decreased from 52.7% and 9.9%, respectively, among infants born at 22 weeks' gestation to 17.3% and 0.8% among infants born at 29 weeks' gestation. Grade 1 or 2 BPD peaked in incidence (51.8%) among infants born at 25 weeks' gestation. The frequency of severe intraventricular hemorrhage or cystic periventricular leukomalacia increased from 4.8% among survivors without BPD to 23.4% among survivors with grade 3 BPD. Similar ranges were observed for late onset sepsis (4.8%-31.4%), surgically treated necrotizing enterocolitis (1.4%-17.1%), severe retinopathy of prematurity (1.2%-23.0%), and home oxygen therapy (2.0%-67.5%). CONCLUSIONS More than one-half of very preterm infants born in the United States died before 36 weeks' PMA or developed BPD. Greater BPD severity was associated with more frequent development of major neonatal morbidities, in-hospital mortality, and use of supplemental respiratory support at discharge.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erika M. Edwards
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine,Department of Mathematics and Statistics, College of Engineering and Mathematical Sciences, The University of Vermont, Burlington, Vermont,Vermont Oxford Network, Burlington, Vermont
| | | | - Roger F. Soll
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine,Vermont Oxford Network, Burlington, Vermont
| | - Danielle E.Y. Ehret
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine,Vermont Oxford Network, Burlington, Vermont
| | - Jeffrey D. Horbar
- Department of Pediatrics, The Robert Larner, M.D. College of Medicine,Vermont Oxford Network, Burlington, Vermont
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25
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Flannery DD, Jensen EA, Tomlinson LA, Yu Y, Ying GS, Binenbaum G. Poor postnatal weight growth is a late finding after sepsis in very preterm infants. Arch Dis Child Fetal Neonatal Ed 2021; 106:298-304. [PMID: 33148685 PMCID: PMC8291375 DOI: 10.1136/archdischild-2020-320221] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 07/10/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To characterise the association between sepsis and postnatal weight growth when accounting for the degree of growth restriction present at birth. DESIGN Retrospective matched cohort study using data from the Postnatal Growth and Retinopathy of Prematurity study. Participants were born with birth weights of <1500 g or gestational ages of <32 weeks between 2006 and 2011 at 29 neonatal centres in the USA and Canada. Sepsis was defined as a culture-confirmed bacterial or fungal infection of the blood or cerebrospinal fluid before 36 weeks' postmenstrual age (PMA). Growth was assessed as the change in weight z-score between birth and 36 weeks' PMA. RESULTS Of 4785 eligible infants, 813 (17%) developed sepsis and 693 (85%) were matched 1:1 to controls. Sepsis was associated with a greater decline in weight z-score (mean difference -0.09, 95% CI -0.14 to -0.03). Postnatal weight growth failure (decline in weight z- score>1) was present in 237 (34%) infants with sepsis and 179 (26%) controls (adjusted OR 1.49, 95% CI 1.12 to 1.97). Longitudinal growth trajectories showed similar initial changes in weight z-scores between infants with and without sepsis. By 3 weeks after sepsis onset, there was a greater decline in weight z-scores relative to birth values in those with sepsis than without sepsis (delta z-score -0.89 vs -0.77; mean difference -0.12, 95% CI -0.18 to -0.05). This significant difference persisted until 36 weeks or discharge. CONCLUSION Infants with sepsis had similar early weight growth trajectories as infants without sepsis but developed significant deficits in weight that were not apparent until several weeks after the onset of sepsis.
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Affiliation(s)
- Dustin D. Flannery
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania Perelman School of Medicine,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia
| | - Erik A. Jensen
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania Perelman School of Medicine,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia
| | - Lauren A. Tomlinson
- Division of Ophthalmology, Children’s Hospital of Philadelphia/University of Pennsylvania Perelman School of Medicine
| | - Yinxi Yu
- Division of Ophthalmology, Children’s Hospital of Philadelphia/University of Pennsylvania Perelman School of Medicine,Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine
| | - Gui-shuang Ying
- Division of Ophthalmology, Children’s Hospital of Philadelphia/University of Pennsylvania Perelman School of Medicine,Center for Preventive Ophthalmology and Biostatistics, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine,Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine
| | - Gil Binenbaum
- Division of Ophthalmology, Children’s Hospital of Philadelphia/University of Pennsylvania Perelman School of Medicine
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26
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Nelin TD, Lorch S, Jensen EA, Alexiou S, Gibbs K, Napolitano N, Monk HM, Furth S, Shults J, Bamat NA. The association between diuretic class exposures and enteral electrolyte use in infants developing grade 2 or 3 bronchopulmonary dysplasia in United States children's hospitals. J Perinatol 2021; 41:779-785. [PMID: 33510422 DOI: 10.1038/s41372-021-00924-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 05/29/2020] [Revised: 11/04/2020] [Accepted: 01/14/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To evaluate the association between chronic diuretic exposures and enteral electrolyte use in infants developing severe bronchopulmonary dysplasia (sBPD). STUDY DESIGN Retrospective longitudinal cohort study in infants admitted to United States children's hospitals. We identified diuretic exposures and measured enteral NaCl and KCl use during pre-defined exposure risk-interval days. We used mixed-effects logistic regression to model the association between diuretic exposures and electrolyte use. RESULTS We identified 442,341 subject-days in 3252 infants. All common diuretic classes and class combinations were associated with increased NaCl and KCl use. Thiazide monotherapy was associated with greater electrolyte use than loop monotherapy. The addition of potassium-sparing diuretics was associated with a limited reduction in KCl use compared to thiazide monotherapy. CONCLUSIONS Chronic diuretic exposures are associated with increased NaCl and KCl use. Presumptions about the relative impact of different diuretic classes on electrolyte derangements may be inaccurate and require further study.
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Affiliation(s)
- Timothy D Nelin
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Scott Lorch
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erik A Jensen
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Chronic Lung Disease Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stamatia Alexiou
- Chronic Lung Disease Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathleen Gibbs
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Chronic Lung Disease Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie Napolitano
- Chronic Lung Disease Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Respiratory Therapy Department, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Heather M Monk
- Pharmacy Services, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan Furth
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Justine Shults
- Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicolas A Bamat
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Chronic Lung Disease Program, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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27
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Bamat NA, Nelin TD, Eichenwald EC, Kirpalani H, Laughon MM, Jackson WM, Jensen EA, Gibbs KA, Lorch SA. Loop Diuretics in Severe Bronchopulmonary Dysplasia: Cumulative Use and Associations with Mortality and Age at Discharge. J Pediatr 2021; 231:43-49.e3. [PMID: 33152371 PMCID: PMC8005411 DOI: 10.1016/j.jpeds.2020.10.073] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 07/12/2020] [Revised: 10/01/2020] [Accepted: 10/28/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To measure between-center variation in loop diuretic use in infants developing severe bronchopulmonary dysplasia (BPD) in US children's hospitals, and to compare mortality and age at discharge between infants from low-use centers and infants from high-use centers. STUDY DESIGN We performed a retrospective cohort study of preterm infants at <32 weeks of gestational age with severe BPD. The primary outcome was cumulative loop diuretic use, defined as the proportion of days with exposure between admission and discharge. Infant characteristics associated with loop diuretic use at P < .10 were included in multivariable models to adjust for center differences in case mix. Hospitals were ranked from lowest to highest in adjusted use and dichotomized into low-use centers and high-use centers. We then compared mortality and postmenstrual age at discharge between the groups through multivariable analyses. RESULTS We identified 3252 subjects from 43 centers. Significant variation between centers remained despite adjustment for infant characteristics, with use present in an adjusted mean range of 7.3% to 49.4% of days (P < .0001). Mortality did not differ significantly between the 2 groups (aOR, 0.98; 95% CI, 0.62-1.53; P = .92), nor did postmenstrual age at discharge (marginal mean, 47.3 weeks [95% CI, 46.8-47.9 weeks] in the low-use group vs 47.4 weeks [95% CI, 46.9-47.9 weeks] in the high-use group; P = .96). CONCLUSIONS A marked variation in loop diuretic use for infants developing severe BPD exists among US children's hospitals, without an observed difference in mortality or age at discharge. More research is needed to provide evidence-based guidance for this common exposure.
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Affiliation(s)
- Nicolas A. Bamat
- Division of Neonatology and Center for Pediatric Clinical Effectiveness; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Timothy D. Nelin
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eric C. Eichenwald
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Haresh Kirpalani
- Division of Neonatology; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew M. Laughon
- Division of Neonatology, Department of Pediatrics, The University of North Carolina at Chapel Hill
| | - Wesley M. Jackson
- Division of Neonatology, Department of Pediatrics, The University of North Carolina at Chapel Hill
| | - Erik A. Jensen
- Division of Neonatology; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathleen A. Gibbs
- Division of Neonatology; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott A. Lorch
- Division of Neonatology; Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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28
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Abstract
Bronchopulmonary dysplasia (BPD) is an acquired, developmental chronic lung disease that is a consequence of premature birth. In the most severe form of the disease, infants may require prolonged periods of positive pressure ventilation. BPD is a heterogeneous disease with lung mechanics that differ from those in respiratory distress syndrome; strategies to manage the respiratory support in infants with severe BPD should take this into consideration. When caring for these infants, practitioners need to shift from the acute care ventilation strategies that use frequent blood gases and support adjustments designed to minimize exposure to positive pressure. Infants with severe BPD benefit from a chronic care model that uses less frequent ventilator adjustments and provides the level of positive support that will achieve the longer-term goal of ongoing lung growth and repair.
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Affiliation(s)
| | | | - Stamatia Alexiou
- Pulmonology, Department of Pediatrics, Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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29
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Abstract
Bronchopulmonary dysplasia (BPD) is among the most severe complications of very premature birth. Clinical and laboratory studies indicate that lung immaturity, inflammatory lung injury, and disordered lung repair are the primary mechanisms responsible for the development of BPD. Caffeine, initiated within the first 10 days after birth, is one of few drug therapies shown to significantly decrease the risk of BPD in very low birth weight infants. This benefit is likely derived, at least in part, from reduced exposure to positive airway pressure and supplemental oxygen with caffeine therapy. Additional cardiorespiratory benefits of caffeine that may contribute to the lower risk of BPD include less frequent treatment for a PDA, improved pulmonary mechanics, and direct effects on pulmonary inflammation, alveolarization, and angiogenesis. Routine administration of caffeine is indicated in the vast majority of very low birth weight infants. However, current preventative strategies including widespread use of caffeine do not avert BPD in all cases. As such, there is continued need for novel methods to further reduce the risk of BPD in very low birth weight infants.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
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30
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Wu KY, Jensen EA, White AM, Wang Y, Biko DM, Nilan K, Fraga MV, Mercer-Rosa L, Zhang H, Kirpalani H. Characterization of Disease Phenotype in Very Preterm Infants with Severe Bronchopulmonary Dysplasia. Am J Respir Crit Care Med 2020; 201:1398-1406. [PMID: 31995403 DOI: 10.1164/rccm.201907-1342oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Bronchopulmonary dysplasia (BPD) is a heterogenous condition with poorly characterized disease subgroups.Objectives: To define the frequency of three disease components: moderate-severe parenchymal disease, pulmonary hypertension (PH), or large airway disease, in a referral cohort of preterm infants with severe BPD. The association between each component and a primary composite outcome of death before hospital discharge, tracheostomy, or home pulmonary vasodilator therapy was assessed.Methods: This was a retrospective, single-center cohort study of infants born at <32 weeks' gestation with severe BPD who underwent both chest computed tomography with angiography (CTA) and echocardiography between 40 and 50 weeks postmenstrual age between 2011 and 2015. Moderate-severe parenchymal lung disease was defined as an Ochiai score ≥8 on CTA. PH was diagnosed by echocardiogram using standard criteria. Large airway disease was defined as tracheomalacia or bronchomalacia on bronchoscopy and/or tracheoscopy or CTA.Measurements and Main Results: Of 76 evaluated infants, 73 (96%) were classifiable into phenotypic subgroups: 57 with moderate-severe parenchymal disease, 48 with PH, and 44 with large airway disease. The presence of all three disease components was most common (n = 23). Individually, PH and large airway disease, but not moderate-severe parenchymal disease, were associated with increased risk for the primary study outcome. Having more disease components was associated with an incremental increase in the risk for the primary outcome (2 vs. 1: odds ratio, 4.9; 95% confidence interval, 1.4-17.2 and 3 vs. 1: odds ratio, 12.8; 95% confidence interval, 2.4-70.0).Conclusions: Infants with severe BPD are variable in their predominant pathophysiology. Disease phenotyping may enable better risk stratification and targeted therapeutic intervention.
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Affiliation(s)
| | | | - Ammie M White
- Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Yan Wang
- Division of Pediatric Cardiology, Department of Pediatrics, and
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | | | | | - Huayan Zhang
- Division of Neonatology.,Division of Neonatology and Center for Newborn Care, Guangzhou Women and Children's Medical Center, Guangzhou, China
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31
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Jensen EA, Roberts RS, Schmidt B. Drugs to Prevent Bronchopulmonary Dysplasia: Effect of Baseline Risk on the Number Needed to Treat. J Pediatr 2020; 222:244-247. [PMID: 32143932 DOI: 10.1016/j.jpeds.2020.01.070] [Citation(s) in RCA: 8] [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: 11/08/2019] [Revised: 01/08/2020] [Accepted: 01/31/2020] [Indexed: 10/24/2022]
Abstract
Infants born very preterm have a variable baseline risk of bronchopulmonary dysplasia (BPD). Using the example of evidence-based drug therapies to prevent BPD, we designed a visual aid that displays the "number needed to treat" with CIs for caffeine, vitamin A, and hydrocortisone over a range of baseline risks.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Robin S Roberts
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Schmidt
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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32
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Jensen EA, Zhang H, Feng R, Dysart K, Nilan K, Munson DA, Kirpalani H. Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding. Arch Dis Child Fetal Neonatal Ed 2020; 105:399-404. [PMID: 31685527 PMCID: PMC7453998 DOI: 10.1136/archdischild-2019-317148] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 09/26/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Compare rates of hypoxaemia during transpyloric and gastric feedings in very preterm infants with severe bronchopulmonary dysplasia. DESIGN N-of-1 multiple crossover trials with individual patient and pooled data analyses. SETTING Level IV intensive care nursery. PATIENTS Infants receiving positive airway pressure between 36 and 55 weeks postmenstrual age were enrolled between December 2014-July 2016. INTERVENTION N-of-1 trial consisting of two blocks, each with a 4-day gastric and 4-day transpyloric feeding period assigned in random order. MAIN OUTCOME MEASURES The primary outcome was the frequency of daily intermittent hypoxaemic events (SpO2 ≤80% lasting 10-180 s). Secondary outcomes included the daily proportion of time with an SpO2 ≤80% and mean daily fraction of inspired oxygen. RESULTS Of 15 infants, 13 completed the trial and 2 stopped early for transient worsening in respiratory status during gastric feedings. In the intention-to-treat analyses, transpyloric feedings resulted in increased rates of intermittent hypoxaemia in five infants, greater time per day in hypoxaemia in three infants and more supplemental oxygen use in three infants. One infant received more supplemental oxygen during gastric feedings. The remaining study outcomes were similar between the feeding routes in all other infants. Pooling all data, transpyloric feedings resulted in a higher frequency of intermittent hypoxaemic events (median 7.5/day (IQR 1-23.5) vs 3/day (1-11); adjusted incidence rate ratio 1.8, 95% CI 1.3 to 2.5) and a greater proportion of daily hypoxaemia time (median 0.8% (IQR 0.1-2.3) vs 0.4% (0.07-1.8); adjusted mean difference 1.6, 95% CI 1.1 to 2.5). CONCLUSIONS Transpyloric compared with gastric feedings modestly increased rates of hypoxaemia among study participants. TRIAL REGISTRATION NUMBER NCT02142621.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Huayan Zhang
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rui Feng
- Department of Biostatistics and Epidemiology, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, United States
| | - Kevin Dysart
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Kathleen Nilan
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David A Munson
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, the Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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33
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Liu Y, Perego M, Xiao Q, He Y, Fu S, He J, Liu W, Li X, Tang Y, Li X, Yuan W, Zhou W, Wu F, Jia C, Cui Q, Worthen GS, Jensen EA, Gabrilovich DI, Zhou J. Lactoferrin-induced myeloid-derived suppressor cell therapy attenuates pathologic inflammatory conditions in newborn mice. J Clin Invest 2020; 129:4261-4275. [PMID: 31483289 DOI: 10.1172/jci128164] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022] Open
Abstract
Inflammation plays a critical role in the development of severe neonatal morbidities. Myeloid-derived suppressor cells (MDSCs) were recently implicated in the regulation of immune responses in newborns. Here, we report that the presence of MDSCs and their functional activity in infants are closely associated with the maturity of newborns and the presence of lactoferrin (LF) in serum. Low amounts of MDSCs at birth predicted the development of severe pathology in preterm infants - necrotizing enterocolitis (NEC). In vitro treatment of newborn neutrophils and monocytes with LF converted these cells to MDSCs via the LRP2 receptor and activation of the NF-κB transcription factor. Decrease in the expression of LRP2 was responsible for the loss of sensitivity of adult myeloid cells to LF. LF-induced MDSCs (LF-MDSCs) were effective in the treatment of newborn mice with NEC, acting by blocking inflammation, resulting in increased survival. LF-MDSCs were more effective than treatment with LF protein alone. In addition to affecting NEC, LF-MDSCs demonstrated potent ability to control ovalbumin-induced (OVA-induced) lung inflammation, dextran sulfate sodium-induced (DSS-induced) colitis, and concanavalin A-induced (ConA-induced) hepatitis. These results suggest that cell therapy with LF-MDSCs may provide potent therapeutic benefits in infants with various pathological conditions associated with dysregulated inflammation.
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Affiliation(s)
- Yufeng Liu
- Key Laboratory of Immune Microenvironment and Disease of the Ministry of Education, Department of Immunology, School of Basic Sciences, Tianjin Medical University, Tianjin, China
| | | | - Qiang Xiao
- Institute of Human Virology, Zhongshan School of Medicine
| | - Yumei He
- Institute of Human Virology, Zhongshan School of Medicine
| | - Shuyu Fu
- Wistar Institute, Philadelphia, Pennsylvania, USA
| | - Juan He
- Institute of Human Virology, Zhongshan School of Medicine
| | | | - Xing Li
- Third Affiliated Hospital, Sun Yat-sen University (SYSU), Guangzhou, China
| | | | | | - Weiming Yuan
- Guangzhou Women and Children's Medical Centre, Guangzhou, China
| | - Wei Zhou
- Guangzhou Women and Children's Medical Centre, Guangzhou, China
| | - Fan Wu
- Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Chunhong Jia
- Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Qiliang Cui
- Third Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - George S Worthen
- Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Children's Hospital of Philadelphia (CHOP), Philadelphia, Pennsylvania, USA
| | | | - Jie Zhou
- Key Laboratory of Immune Microenvironment and Disease of the Ministry of Education, Department of Immunology, School of Basic Sciences, Tianjin Medical University, Tianjin, China
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Flannery DD, Mukhopadhyay S, Jensen EA, Gerber JS, Passarella MR, Dysart K, Aghai ZH, Greenspan J, Puopolo KM. Influence of Patient Characteristics on Antibiotic Use Rates Among Preterm Infants. J Pediatric Infect Dis Soc 2020; 10:97-103. [PMID: 32170951 PMCID: PMC7996645 DOI: 10.1093/jpids/piaa022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/13/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The antibiotic use rate (AUR) has emerged as a potential metric for neonatal antibiotic use, but reported center-level AURs are limited by differences in case mix. The objective of this study was to identify patient characteristics associated with AUR among a large cohort of preterm infants. METHODS Retrospective observational study using the Optum Neonatal Database, including infants born from January 1, 2010 through November 30, 2016 with gestational age 23-34 weeks admitted to neonatal units across the United States. Exposures were patient-level characteristics including length of stay, gestational age, sex, race/ethnicity, bacterial sepsis, necrotizing enterocolitis, and survival status. The primary outcome was AUR, defined as days with ≥ 1 systemic antibiotic administered divided by length of stay. Descriptive statistics, univariable comparative analyses, and generalized linear models were utilized. RESULTS Of 17 910 eligible infants, 17 836 infants (99.6%) from 1090 centers were included. Median gestation was 32.9 (interquartile range [IQR], 30.3-34) weeks. Median length of stay was 25 (IQR, 15-46) days and varied by gestation. Overall median AUR was 0.13 (IQR, 0-0.26) and decreased over time. Gestational age, sex, and race/ethnicity were independently associated with AUR (P < .01). AUR and gestational age had an unexpected inverse parabolic relationship, which persisted when only surviving infants without bacterial sepsis or necrotizing enterocolitis were analyzed. CONCLUSIONS Neonatal AURs are influenced by patient-level characteristics besides infection and survival status, including gestational age, sex, and race/ethnicity. Neonatal antibiotic use metrics that account for patient-level characteristics as well as morbidity case mix may allow for more accurate comparisons and better inform neonatal antibiotic stewardship efforts.
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Affiliation(s)
- Dustin D Flannery
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA,Corresponding Author: Dustin D. Flannery, DO, Children’s Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, 800 Spruce St, Philadelphia, PA 19107. E-mail:
| | - Sagori Mukhopadhyay
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Molly R Passarella
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Dysart
- Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zubair H Aghai
- Division of Neonatology, Nemours/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jay Greenspan
- Division of Neonatology, Nemours/Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Karen M Puopolo
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,Division of Neonatology, Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ekhaguere OA, Padula MA, Jensen EA. Use of Point-of-Care Gastric pH Testing to Assess the Efficacy of Acid Suppression Therapy in the Neonatal Intensive Care Unit. Am J Perinatol 2020; 37:415-420. [PMID: 30780184 DOI: 10.1055/s-0039-1679917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 10/27/2022]
Abstract
OBJECTIVE The use of acid suppression therapies in newborns lacks efficacy and is associated with adverse effects. Point-of-care (POC) assessment of gastric aspirate pH may provide an objective, noninvasive measure of gastric acidity in tube fed infants. We conducted the present study to characterize the POC gastric pH levels in gastric tube fed infants before and after initiation of enteral omeprazole or ranitidine. STUDY DESIGN Retrospective cohort study of infants with gastric aspirate pH levels determined by POC pH strips. Gastric pH levels recorded during 7 days before and 14 days after medication initiation were compared using Wilcoxon's sign-rank tests. RESULTS Among 307 evaluated infants, 284 (92%) had a median gastric pH level ≥4 in 7 days prior to ranitidine or omeprazole. In 14 days after medication initiation, the median gastric pH of infants with pretreatment median gastric pH < 4 increased to 4.5 and 5 (p < 0.01) in the ranitidine and omeprazole groups, respectively. There was no change in infants with pretreatment median gastric pH ≥4. CONCLUSION Among infants receiving gastric tube feedings and enteral omeprazole or ranitidine, only those with a pretreatment gastric pH level <4 demonstrated a significant increase in gastric pH. Validation of our findings against esophageal pH multichannel intraluminal impedance testing is needed.
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Affiliation(s)
- Osayame A Ekhaguere
- Division of Neonatology, Department of Pediatrics, Riley Children's Hospital, Indiana University, Indianapolis, Indiana
| | - Michael A Padula
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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Thom CS, Devine M, Kleinman S, Jensen EA, Lambert MP, Padula MA. Neonatal platelet count trends during inhaled nitric oxide therapy. Br J Haematol 2020; 188:e28-e30. [PMID: 31840227 PMCID: PMC6982552 DOI: 10.1111/bjh.16301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
MESH Headings
- Administration, Inhalation
- Female
- Hernias, Diaphragmatic, Congenital/blood
- Hernias, Diaphragmatic, Congenital/drug therapy
- Humans
- Hypertension, Pulmonary/blood
- Hypertension, Pulmonary/congenital
- Hypertension, Pulmonary/drug therapy
- Infant, Newborn
- Infant, Newborn, Diseases/blood
- Infant, Newborn, Diseases/drug therapy
- Male
- Nitric Oxide/administration & dosage
- Platelet Count
- Retrospective Studies
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Affiliation(s)
- Christopher S Thom
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Matthew Devine
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stacey Kleinman
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erik A Jensen
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michele P Lambert
- Division of Hematology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael A Padula
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Foglia EE, Jensen EA, Wyckoff MH, Sawyer T, Topjian A, Ratcliffe SJ. Survival after delivery room cardiopulmonary resuscitation: A national registry study. Resuscitation 2020; 152:177-183. [PMID: 31982507 DOI: 10.1016/j.resuscitation.2020.01.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Received: 10/10/2019] [Revised: 12/12/2019] [Accepted: 01/16/2020] [Indexed: 01/05/2023]
Abstract
AIMS Survival after delivery room cardiopulmonary resuscitation (DR-CPR) is not well characterized in full-term infants, and survival outcomes after DR-CPR have not been defined across the spectrum of gestation. The study objectives were to define gestational age (GA) specific survival following DR-CPR and to assess the association between GA and DR-CPR characteristics and survival outcomes. METHODS Retrospective cohort study of prospectively collected data in the American Heart Association Get With the Guidelines-Resuscitation registry. Newborn infants without congenital abnormalities who received greater than 1 min of chest compressions for DR-CPR were included. GA was stratified by categorical subgroups: ≥36 weeks; 33-356/7 weeks; 29-326/7 weeks; 25-286/7 weeks; 22-246/7 weeks. The primary outcome was survival to hospital discharge; the secondary outcome was return of circulation (ROC). RESULTS Among 1022 infants who received DR-CPR, 83% experienced ROC and 64% survived to hospital discharge. GA-stratified hospital survival rates were 83% (≥36 weeks), 66% (33-35 weeks), 60% (29-32 weeks), 52% (25-28 weeks), and 25% (22-24 weeks). Compared with GA ≥ 36 weeks, lower GA was independently associated with decreasing odds of survival (33-35 weeks: adjusted Odds Ratio [aOR] 0.46, 95% Confidence Interval [CI] 0.26-0.81; 29-32 weeks: aOR 0.40, 95% CI 0.23-0.69; 25-28 weeks: aOR 0.21, 95% CI 0.11-0.41; 22-24 weeks: aOR 0.06, 95% CI 0.03-0.10). CONCLUSIONS In this national registry of infants who received delivery room cardiopulmonary resuscitation (DR-CPR), 83% survived the event and two-thirds survived to hospital discharge. These results contribute to defining survival outcomes following DR-CPR across the continuum of gestation.
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Affiliation(s)
- Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Erik A Jensen
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Myra H Wyckoff
- Division of Neonatology, Department of Pediatrics, UT Southwestern, Dallas, TX, United States
| | - Taylor Sawyer
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, United States
| | - Alexis Topjian
- Divsion of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
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38
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Affiliation(s)
- Erik A Jensen
- University of Pennsylvania Perelman School of MedicinePhiladelphia, Pennsylvania
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39
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Warren MG, Do B, Das A, Smith PB, Adams-Chapman I, Jadcherla S, Jensen EA, Goldstein RF, Goldberg RN, Cotten CM, Bell EF, Malcolm WF. Gastrostomy Tube Feeding in Extremely Low Birthweight Infants: Frequency, Associated Comorbidities, and Long-term Outcomes. J Pediatr 2019; 214:41-46.e5. [PMID: 31427096 PMCID: PMC6815700 DOI: 10.1016/j.jpeds.2019.06.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/07/2019] [Accepted: 06/25/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To assess the frequency of gastrostomy tube (GT) placement in extremely low birth weight (ELBW) infants, associated comorbidities, and long-term outcomes. STUDY DESIGN Analysis of ELBW infants from 25 centers enrolled in the National Institute of Child Health and Human Development Neonatal Research Network's Generic Database and Follow-up Registry from 2006 to 2012. Frequency of GT placement before 18-22 months, demographic and medical factors associated with GT placement, and associated long-term outcomes at 18-22 months of corrected age were described. Associations between GT placement and neonatal morbidities and long-term outcomes were assessed with logistic regression after adjustment for center and common co-variables. RESULTS Of the 4549 ELBW infants included in these analyses, 333 (7.3%) underwent GT placement; 76% had the GT placed postdischarge. Of infants with GTs, 11% had birth weights small for gestational age, 77% had bronchopulmonary dysplasia, and 29% severe intraventricular hemorrhage or periventricular leukomalacia. At follow-up, 56% of infants with a GT had weight <10th percentile, 61% had neurodevelopmental impairment (NDI), and 55% had chronic breathing problems. After adjustment, small for gestational age, bronchopulmonary dysplasia, intraventricular hemorrhage/periventricular leukomalacia, poor growth, and NDI were associated with GT placement. Thirty-two percent of infants with GTs placed were taking full oral feeds at follow-up. CONCLUSIONS GT placement is common in ELBW infants, particularly among those with severe neonatal morbidities. GT placement in this population was associated with poor growth, NDI, and chronic respiratory and feeding problems at follow-up. The frequency of GT placement postneonatal discharge indicates the need for close nutritional follow-up of ELBW infants. TRIAL REGISTRATION ClinicalTrials.gov: NCT00063063.
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Affiliation(s)
| | - Barbara Do
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - P Brian Smith
- Department of Pediatrics, Duke University, Durham, NC
| | - Ira Adams-Chapman
- Emory University School of Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA
| | | | - Erik A Jensen
- Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Edward F Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
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40
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Jensen EA, Dysart K, Gantz MG, McDonald S, Bamat NA, Keszler M, Kirpalani H, Laughon MM, Poindexter BB, Duncan AF, Yoder BA, Eichenwald EC. The Diagnosis of Bronchopulmonary Dysplasia in Very Preterm Infants. An Evidence-based Approach. Am J Respir Crit Care Med 2019; 200:751-759. [PMID: 30995069 PMCID: PMC6775872 DOI: 10.1164/rccm.201812-2348oc] [Citation(s) in RCA: 475] [Impact Index Per Article: 95.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/16/2019] [Indexed: 01/06/2023] Open
Abstract
Rationale: Current diagnostic criteria for bronchopulmonary dysplasia rely heavily on the level and duration of oxygen therapy, do not reflect contemporary neonatal care, and do not adequately predict childhood morbidity.Objectives: To determine which of 18 prespecified, revised definitions of bronchopulmonary dysplasia that variably define disease severity according to the level of respiratory support and supplemental oxygen administered at 36 weeks' postmenstrual age best predicts death or serious respiratory morbidity through 18-26 months' corrected age.Methods: We assessed infants born at less than 32 weeks of gestation between 2011 and 2015 at 18 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network.Measurements and Main Results: Of 2,677 infants, 683 (26%) died or developed serious respiratory morbidity. The diagnostic criteria that best predicted this outcome defined bronchopulmonary dysplasia according to treatment with the following support at 36 weeks' postmenstrual age, regardless of prior or current oxygen therapy: no bronchopulmonary dysplasia, no support (n = 773); grade 1, nasal cannula ≤2 L/min (n = 1,038); grade 2, nasal cannula >2 L/min or noninvasive positive airway pressure (n = 617); and grade 3, invasive mechanical ventilation (n = 249). These criteria correctly predicted death or serious respiratory morbidity in 81% of study infants. Rates of this outcome increased stepwise from 10% among infants without bronchopulmonary dysplasia to 77% among those with grade 3 disease. A similar gradient (33-79%) was observed for death or neurodevelopmental impairment.Conclusions: The definition of bronchopulmonary dysplasia that best predicted early childhood morbidity categorized disease severity according to the mode of respiratory support administered at 36 weeks' postmenstrual age, regardless of supplemental oxygen use.
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Affiliation(s)
- Erik A. Jensen
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin Dysart
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marie G. Gantz
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Scott McDonald
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
| | - Nicolas A. Bamat
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Martin Keszler
- Department of Pediatrics, Women and Infant’s Hospital of Rhode Island, Brown University, Providence, Rhode Island
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew M. Laughon
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brenda B. Poindexter
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Andrea F. Duncan
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas; and
| | - Bradley A. Yoder
- Division of Neonatology, University of Utah, Salt Lake City, Utah
| | - Eric C. Eichenwald
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network*
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, North Carolina
- Department of Pediatrics, Women and Infant’s Hospital of Rhode Island, Brown University, Providence, Rhode Island
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Perinatal Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, Texas; and
- Division of Neonatology, University of Utah, Salt Lake City, Utah
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Sloane AJ, Flannery DD, Lafferty M, Jensen EA, Dysart K, Cook A, Greenspan J, Aghai ZH. Hypertensive disorders during pregnancy are associated with reduced severe intraventricular hemorrhage in very-low-birth-weight infants. J Perinatol 2019; 39:1125-1130. [PMID: 31263202 DOI: 10.1038/s41372-019-0413-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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] [Received: 02/08/2019] [Revised: 04/12/2019] [Accepted: 05/10/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine differences in severe intraventricular hemorrhage (IVH) between very-low-birth-weight (≤1500 g, VLBW) infants born to mothers with and without hypertensive disorders (HD). DESIGN/METHODS Retrospective analysis from the Optum Neonatal Database. The primary outcome of interest was severe IVH (grade 3 or 4). Secondary outcomes included other neonatal morbidities, mortality, and length of hospitalization. Outcomes were compared between VLBW infants born to mothers with and without HD. RESULTS A total of 5456 infants met inclusion criteria. After multivariable regression analysis, risks of severe IVH and bronchopulmonary dysplasia (BPD) were lower ([OR 0.42, 95% CI 0.33-0.89, p = 0.01] and [OR 0.75, 95% CI 0.58-0.97, p = 0.03], respectively) and median length of hospitalization was decreased in the HD group (49 versus 61 days, p < 0.001). CONCLUSIONS VLBW infants born to mothers with HD have a decreased risk of severe IVH, BPD, and a shorter duration of hospitalization.
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Affiliation(s)
- Amy J Sloane
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Dustin D Flannery
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Margaret Lafferty
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Erik A Jensen
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Dysart
- Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jay Greenspan
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA
| | - Zubair H Aghai
- Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, USA.
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Gaulton JS, Mercer-Rosa LM, Glatz AC, Jensen EA, Capone V, Scott C, Appel SM, Stoller JZ, Fraga MV. Relationship between pulmonary artery acceleration time and pulmonary artery pressures in infants. Echocardiography 2019; 36:1524-1531. [PMID: 31260138 DOI: 10.1111/echo.14430] [Citation(s) in RCA: 10] [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] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 05/28/2019] [Accepted: 06/11/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pulmonary artery acceleration time measured by echocardiography inversely correlates with pulmonary artery pressures in adults and children older than 1 year of age. There is a paucity of data investigating this relationship in young children, particularly among preterm infants. OBJECTIVE To characterize the relationship between pulmonary artery acceleration time (PAAT) and pulmonary artery pressures in infants. DESIGN/METHODS Patients ≤ 1 year of age at Children's Hospital of Philadelphia between 2011 and 2017 were reviewed. Infants with congenital heart disease were excluded, except those with a patent ductus arteriosus (PDA), atrial septal defect (ASD), or ventricular septal defect (VSD). Linear regression analysis was used to assess the correlation between PAAT measured by echocardiography and systolic pulmonary artery pressure, mean pulmonary artery pressure, and indexed pulmonary vascular resistance from cardiac catheterization. RESULTS Fifty-seven infants were included, of which 61% were preterm and 49% had a diagnosis of bronchopulmonary dysplasia. The median postmenstrual age and weight at catheterization were 51.1 weeks (IQR 35.8-67.9 weeks) and 4400 g (IQR 3100-6500 g), respectively. Forty-four infants (77%) had a patent ductus arteriosus (PDA). There was a weak inverse correlation between PAAT with mPAP (r = -0.35, P = 0.01), sPAP (r = -0.29, P = 0.03), and PVRi (r = -0.29, P = 0.03). CONCLUSION There is a weak inverse relationship between PAAT and pulmonary artery pressures. This relationship is less robust in our population of infants with a high incidence of PDAs compared to previous studies in older children. Thus, PAAT may be less clinically meaningful for diagnosing pulmonary arterial hypertension in infants, particularly those with PDAs.
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Affiliation(s)
- Jessica S Gaulton
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura M Mercer-Rosa
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Valerie Capone
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Courtney Scott
- Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott M Appel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Z Stoller
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - María V Fraga
- Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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DeMauro SB, Jensen EA, Bann CM, Bell EF, Hibbs AM, Hintz SR, Lorch SA. Home Oxygen and 2-Year Outcomes of Preterm Infants With Bronchopulmonary Dysplasia. Pediatrics 2019; 143:peds.2018-2956. [PMID: 30975699 PMCID: PMC6564066 DOI: 10.1542/peds.2018-2956] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [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] [Accepted: 01/29/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To compare medical and developmental outcomes over the first 2 years of life in extremely preterm infants with bronchopulmonary dysplasia (BPD) who were discharged on supplemental oxygen via nasal cannula with outcomes of infants with a similar severity of respiratory illness who were discharged breathing in room air. METHODS We performed a propensity score-matched cohort study. Eligible infants were born at <27 weeks' gestation, were receiving supplemental oxygen or respiratory support at 36 weeks' postmenstrual age, and were assessed at 18 to 26 months' corrected age. Study outcomes included growth, resource use, and neurodevelopment between discharge and follow-up. Outcomes were compared by using multivariable models adjusted for center and age at follow-up. RESULTS A total of 1039 infants discharged on supplemental oxygen were propensity score matched 1:1 to infants discharged breathing in room air. Infants on oxygen had a marginal improvement in weight z score (adjusted mean difference 0.11; 95% confidence interval [CI] 0.00 to 0.22), with a significantly improved weight-for-length z score (adjusted mean difference 0.13; 95% CI 0.06 to 0.20) at 22 to 26 months' corrected age. Infants on oxygen were more likely to be rehospitalized for respiratory illness (adjusted relative risk 1.33; 95% CI 1.16 to 1.53) and more likely to use respiratory medications and equipment. Rates of neurodevelopmental impairment were similar between the groups. CONCLUSIONS In this matched cohort of infants with BPD, postdischarge oxygen was associated with marginally improved growth and increased resource use but no difference in neurodevelopmental outcomes. Ongoing and future trials are critical to assess the efficacy and safety of postdischarge supplemental oxygen for infants with BPD.
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Affiliation(s)
- Sara B. DeMauro
- Department of Pediatrics, Perelman School of
Medicine, University of Pennsylvania and Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Erik A. Jensen
- Department of Pediatrics, Perelman School of
Medicine, University of Pennsylvania and Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
| | - Carla M. Bann
- Division of Statistical and Data Sciences, RTI
International, Research Triangle Park, North Carolina
| | - Edward F. Bell
- Department of Pediatrics, The University of Iowa,
Iowa City, Iowa
| | - Anna Maria Hibbs
- Department of Pediatrics, Case Western Reserve
University and Rainbow Babies and Children’s Hospital, Cleveland, Ohio;
and
| | - Susan R. Hintz
- Department of Pediatrics, Stanford University, Palo
Alto, California
| | - Scott A. Lorch
- Department of Pediatrics, Perelman School of
Medicine, University of Pennsylvania and Children’s Hospital of
Philadelphia, Philadelphia, Pennsylvania
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic complication associated with extremely preterm birth. Although BPD is now an uncommon condition in infants born with birthweights higher than 1,500 g, among infants born at or near the current limits of viability, BPD rates have not improved over the past 2 to 3 decades and may be increasing. No single therapeutic intervention is effective at preventing BPD. As such, clinicians must use multiple evidence-based strategies to help reduce BPD rates. This review examines current evidence-based approaches to BPD prevention, primarily focusing on data obtained from randomized controlled trials.
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Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics; Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
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Jensen EA, Foglia EE, Dysart KC, Simmons RA, Aghai ZH, DO AC, Greenspan JS, DeMauro SB. Adverse effects of small for gestational age differ by gestational week among very preterm infants. Arch Dis Child Fetal Neonatal Ed 2019; 104:F192-F198. [PMID: 29730594 PMCID: PMC6335180 DOI: 10.1136/archdischild-2017-314171] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [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] [Received: 09/25/2017] [Revised: 04/09/2018] [Accepted: 04/16/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To characterise the excess risk for death, grade 3-4 intraventricular haemorrhage (IVH), bronchopulmonary dysplasia (BPD) and stage 3-5 retinopathy of prematurity independently associated with birth small for gestational age (SGA) among very preterm infants, stratified by completed weeks of gestation. METHODS Retrospective cohort study using the Optum Neonatal Database. Study infants were born <32 weeks gestation without severe congenital anomalies. SGA was defined as a birth weight <10th percentile. The excess outcome risk independently associated with SGA birth among SGA babies was assessed using adjusted risk differences (aRDs). RESULTS Of 6708 infants sampled from 717 US hospitals, 743 (11.1%) were SGA. SGA compared with non-SGA infants experienced higher unadjusted rates of each study outcome except grade 3-4 IVH among survivors. The excess risk independently associated with SGA birth varied by outcome and gestational age. The highest aRD for death (0.27; 95% CI 0.13 to 0.40) occurred among infants born at 24 weeks gestation and declined as gestational age increased. In contrast, the peak aRDs for BPD among survivors (0.32; 95% CI 0.20 to 0.44) and the composites of death or BPD (0.35; 95% CI 0.24 to 0.46) and death or major morbidity (0.35; 95% CI 0.24 to 0.45) occurred at 27 weeks gestation. The risk-adjusted probability of dying or developing one or more of the evaluated morbidities among SGA infants was similar to that of non-SGA infants born approximately 2-3 weeks less mature. CONCLUSION The excess risk for neonatal morbidity and mortality associated with being born SGA varies by adverse outcome and gestational age.
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Affiliation(s)
- Erik A Jensen
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kevin C Dysart
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rebecca A Simmons
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Zubair H Aghai
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Jay S Greenspan
- Division of Neonatology, Nemours/Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Sara B DeMauro
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Avitabile CM, Ansems S, Wang Y, Fraga MV, Kirpalani HM, Zhang H, Mercer-Rosa L, Jensen EA. Accuracy of Brain Natriuretic Peptide for Diagnosing Pulmonary Hypertension in Severe Bronchopulmonary Dysplasia. Neonatology 2019; 116:147-153. [PMID: 31096210 DOI: 10.1159/000499082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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] [Received: 12/03/2018] [Accepted: 02/19/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Premature infants with severe bronchopulmonary dysplasia (sBPD) are at risk of pulmonary hypertension (PH). Serum brain natriuretic peptide (BNP) is used to predict disease severity in adult PH. Its diagnostic utility in sBPD-associated PH is unknown. OBJECTIVE The aim of this paper was to determine the accuracy of BNP, against echocardiogram (echo), to diagnose PH in infants born <32 weeks' gestation with sBPD. METHODS We conducted a retrospective cohort study of all infants with sBPD with an echo and BNP within a 24-h period, at ≥36 weeks postmenstrual age. PH was defined as: right ventricular pressure >½ systemic blood pressure estimated from tricuspid regurgitant jet or patent ductus arteriosus (PDA) velocity, bidirectional or right-to left-PDA, and/or flat/bowing ventricular septum at end-systole. Receiver-operating characteristic (ROC) curves were constructed to test the diagnostic accuracy of BNP. RESULTS Of 128 infants, 68 (53%) had echo evidence of PH. BNP was higher among the infants with PH (median [interquartile range]: 127 pg/mL [39-290] vs. 35 [20-76], p < 0.001). The area under the ROC curve for diagnosing PH using BNP was 0.74 (95% CI 0.66-0.83). At an optimal cutpoint of 130 pg/mL, BNP correctly classified the presence or absence of PH in 70% of the infants (specificity: 92, sensitivity: 50%). CONCLUSIONS BNP, relative to concurrent echo, demonstrated moderate accuracy for diagnosing PH in this cohort of preterm infants with sBPD. BNP may help rule in PH in this population but has low utility to rule out the disease.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA, .,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA,
| | - Sophie Ansems
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Yan Wang
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maria V Fraga
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Haresh M Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Huayan Zhang
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ansems SM, Kirpalani H, Mercer-Rosa L, Wang Y, Hopper RK, Fraga MV, Jensen EA. Patent Ductus Arteriosus and the Effects of Its Late Closure in Preterm Infants with Severe Bronchopulmonary Dysplasia. Neonatology 2019; 116:236-243. [PMID: 31269508 PMCID: PMC6878755 DOI: 10.1159/000500269] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 10/16/2018] [Accepted: 04/09/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The natural history and optimal management of a patent ductus arteriosus (PDA) among infants with established severe bronchopulmonary dysplasia (sBPD) remains uncertain. OBJECTIVES To describe the characteristics of PDA present at ≥36 weeks' postmenstrual age (PMA) and the effects of late surgical PDA closure in a referral cohort of very preterm infants with sBPD. STUDY DESIGN This retrospective cohort study was performed in a tertiary neonatal intensive care unit. Study infants were born at <32 weeks' gestation between 2010 and 2016, diagnosed with sBPD, and had an echocardiographic PDA at ≥36 weeks' PMA. We reviewed echocardiograms performed closest to 3 time points (≥36 weeks' PMA, hospital discharge, and 1 year of age) and assessed clinical outcomes among infants with versus without late PDA treatment. RESULTS Among 329 infants with sBPD, 59 had a PDA at ≥36 weeks' PMA. Most PDAs were small (n = 33) and shunted left to right (n = 53). The PDA closed spontaneously prior to discharge in 5 of 21 infants who did not undergo surgical closure and decreased in size in 3. The PDA spontaneously closed by 1 year of age in 6 out of 12 infants with an open duct at discharge. PDA surgery (n = 23) at ≥36 weeks' PMA was not associated with increased risk for the composite outcome of tracheostomy, systemic vasodilator at discharge, or death after adjusting for potential confounders (OR 3.2, 95% CI 0.81-13.0). CONCLUSIONS The majority of conservatively treated late PDAs closed spontaneously or decreased in size.PDA surgery was not associated with severe adverse clinical outcomes.
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Affiliation(s)
- Sophia M Ansems
- University of Groningen, Groningen, The Netherlands, .,Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA,
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yan Wang
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Rachel K Hopper
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - María V Fraga
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Erik A Jensen
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Flannery DD, Dysart K, Cook A, Greenspan J, Aghai ZH, Jensen EA. Association between early antibiotic exposure and bronchopulmonary dysplasia or death. J Perinatol 2018; 38:1227-1234. [PMID: 29895965 PMCID: PMC6195849 DOI: 10.1038/s41372-018-0146-3] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/12/2018] [Accepted: 05/17/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To characterize the independent association between antibiotic exposure in the first week of life and the risk of bronchopulmonary dysplasia (BPD) or death among very preterm infants without culture-confirmed sepsis. METHODS Retrospective cohort study using the Optum Neonatal Database. Infants without culture-confirmed sepsis born less than 1500 g and less than 32 weeks gestation between 1/2010 and 11/2016 were included. The independent association between antibiotic therapy during the first week of life and BPD or death prior to 36 weeks postmenstrual age (PMA) was assessed by multivariable logistic regression. RESULTS Of 4950 infants, 3946 (79.7%) received antibiotics during the first week of life. Rates of BPD or death (41.5% vs. 31.1%, p < 0.001) and the two individual outcomes were significantly higher among antibiotic treated infants. After adjusting for potential confounding variables, antibiotic use in the first week of life was not associated with increased risk of BPD or death (OR 0.96, 95% CI [0.76,1.21]) or BPD among survivors (OR 0.86, 95% CI [0.67,1.09]). Antibiotic use was associated with increased risk of death prior to 36 weeks PMA (OR 3.01, 95% CI [1.59,5.71]), however, secondary analyses suggested this association may be confounded by unmeasured illness severity. CONCLUSIONS Antibiotic exposure in the first week of life among preterm infants without culture-confirmed sepsis was not independently associated with increased risk of BPD or death.
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Affiliation(s)
- Dustin D Flannery
- Division of Neonatology, Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Kevin Dysart
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | | | - Jay Greenspan
- Department of Pediatrics, Division of Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, United States
| | - Zubair H Aghai
- Department of Pediatrics, Division of Neonatology, Thomas Jefferson University Hospital/Nemours, Philadelphia, PA, United States
| | - Erik A Jensen
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Luo J, Shepard S, Nilan K, Wood A, Monk HM, Jensen EA, Harrington AT, Maschhoff K, Kirpalani H, Feng Z, Zhang H. Improved growth and developmental activity post tracheostomy in preterm infants with severe BPD. Pediatr Pulmonol 2018; 53:1237-1244. [PMID: 29972635 PMCID: PMC6335026 DOI: 10.1002/ppul.24087] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [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: 02/03/2018] [Accepted: 06/10/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To examine growth, sedation needs, and participation in developmental activities before and after tracheostomy among infants with severe bronchopulmonary dysplasia. METHODS Retrospective analysis of infants born at <32 weeks' gestation or birth weights <1500 g with severe BPD who underwent tracheostomy placement between January 1, 2010 and December 31, 2016 in a quaternary referral newborn and infant intensive care unit. Changes in growth parameters and frequency/type of participation in physical therapy sessions performed during the 4-weeks before tracheostomy and 4-weeks after the first tracheostomy tube change were compared. RESULTS A total of 72 patient were included in the study. Average weekly gain in weight, length, and head circumference were significantly higher during the 4-week period after compared to before tracheostomy. The most significant change occurred for linear growth (0.71 ± 0.40 cm/wk pre vs 0.97 ± 0.48 cm/wk pre, P < 0.001). Median Z score improved for weight (pre -1.42 [-3,10, -0.33] vs post -0.91 [-2.7, 0.27], P < 0.001), length (pre -3.07 [-4.39, -1.31] vs post -1.95 [-3.83, -0.93], P < 0.001) and weight-to-length ratio (pre 1.66 [0.58, 2.55] vs post 1.32 [0.17, 2.2], P = 0.02). Participation in developmental therapies significantly improved post tracheostomy (pre vs post: 5.2 ± 2.9 vs 8.7 ± 4.3 sessions performed over 4 weeks, P < 0.0001). Physical therapy sessions more often promoted developmental skill acquisition after tracheostomy compared to facilitating physiologic stability before tracheostomy. Daily sedation requirements decreased post tracheostomy. CONCLUSIONS Tracheostomy was associated with improved proportional growth and increased participation in activities promoting developmental skill acquisition and reduced daily sedation requirements in preterm infants with severe BPD.
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Affiliation(s)
- Jun Luo
- Department of Neonatology, Bao'an Maternity and Child Health Hospital of Shenzhen Affiliated to Jinan University, Guangdong, China.,Department of Neonatology, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing, China
| | - Suzanne Shepard
- Department of Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathleen Nilan
- Division of Neonatology and Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Audrey Wood
- Department of Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather M Monk
- Department of Pharmacy Services, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erik A Jensen
- Division of Neonatology and Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ann T Harrington
- Department of Physical Therapy, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathryn Maschhoff
- Division of Neonatology and Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Haresh Kirpalani
- Division of Neonatology and Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Zhichun Feng
- Department of Neonatology, BaYi Children's Hospital Affiliated to Clinical Medical College in Beijing Military General Hospital of Southern Medical University, Beijing, China
| | - Huayan Zhang
- Division of Neonatology and Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Affiliation(s)
- Erik A Jensen
- Department of Pediatrics Division of Neonatology The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine Philadelphia, Pennsylvania.
| | - Clyde J Wright
- Section of Neonatology Department of Pediatrics University of Colorado School of Medicine and Children's Hospital Colorado Aurora, Colorado
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