Hydrocortisone to Improve Survival without Bronchopulmonary Dysplasia

BACKGROUND

Bronchopulmonary dysplasia is a prevalent complication after extremely preterm birth. Inflammation with mechanical ventilation may contribute to its development. Whether hydrocortisone treatment after the second postnatal week can improve survival without bronchopulmonary dysplasia and without adverse neurodevelopmental effects is unknown.

METHODS

We conducted a trial involving infants who had a gestational age of less than 30 weeks and who had been intubated for at least 7 days at 14 to 28 days. Infants were randomly assigned to receive either hydrocortisone (4 mg per kilogram of body weight per day tapered over a period of 10 days) or placebo. Mandatory extubation thresholds were specified. The primary efficacy outcome was survival without moderate or severe bronchopulmonary dysplasia at 36 weeks of postmenstrual age, and the primary safety outcome was survival without moderate or severe neurodevelopmental impairment at 22 to 26 months of corrected age.

RESULTS

We enrolled 800 infants (mean [±SD] birth weight, 715±167 g; mean gestational age, 24.9±1.5 weeks). Survival without moderate or severe bronchopulmonary dysplasia at 36 weeks occurred in 66 of 398 infants (16.6%) in the hydrocortisone group and in 53 of 402 (13.2%) in the placebo group (adjusted rate ratio, 1.27; 95% confidence interval [CI], 0.93 to 1.74). Two-year outcomes were known for 91.0% of the infants. Survival without moderate or severe neurodevelopmental impairment occurred in 132 of 358 infants (36.9%) in the hydrocortisone group and in 134 of 359 (37.3%) in the placebo group (adjusted rate ratio, 0.98; 95% CI, 0.81 to 1.18). Hypertension that was treated with medication occurred more frequently with hydrocortisone than with placebo (4.3% vs. 1.0%). Other adverse events were similar in the two groups.

CONCLUSIONS

In this trial involving preterm infants, hydrocortisone treatment starting on postnatal day 14 to 28 did not result in substantially higher survival without moderate or severe bronchopulmonary dysplasia than placebo. Survival without moderate or severe neurodevelopmental impairment did not differ substantially between the two groups. (Funded by the National Institutes of Health; ClinicalTrials.gov number, NCT01353313.).

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial

OBJECTIVE

The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP).

SUMMARY BACKGROUND DATA

The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown.

METHODS

We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches.

RESULTS

Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%.

CONCLUSIONS

There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Two-Year Neurodevelopment and Growth Outcomes for Preterm Neonates Who Received Low-Dose Intravenous Soybean Oil

BACKGROUND

In some studies, the dose of intravenous soybean oil (SO) has been associated with a decreased incidence of intestinal failure-associated liver disease. The effect of lipid sparing on neurodevelopment (ND) and growth remains unknown. This study investigated the impact of SO dose on ND and growth over the first 2 years of age in preterm neonates.

MATERIALS AND METHODS

This is a single-site prospective follow-up study. Neonates with a gestational age ≤29 weeks were randomized to low-dose (LOW) or standard-dose (CON) SO. Bayley Scales of Infant Development III and anthropometric measurements were collected at approximately 6, 12, and 24 months corrected gestational age.

RESULTS

Subjects were premature, with a mean (±SD) gestational age of 28 ± 1 and 27 ± 1 weeks (P = .3) for LOW and CON, respectively. Thirty subjects completed follow-up (LOW = 15, CON = 15). There were no differences for ND and growth outcomes when LOW was compared with CON, with the exception of a higher 12-month follow-up cognitive scaled score in the LOW group (P = .02).

CONCLUSION

A reduced SO dose did not adversely affect ND or growth in this cohort of preterm neonates. However, larger studies are needed to determine the long-term safety of SO dose reduction before this strategy can be adopted.

NICU discharge planning and beyond: recommendations for parent psychosocial support

Parents will interact with a multitude of teams from various disciplines during their child's admission to the neonatal intensive care unit. Recognition of the emotional stressors experienced by these parents is a first step in working to provide the crucial support and parenting skills needed for bonding and caring for their infant from admission through discharge and beyond. Family-centered care involves time-sensitive two-way communication between parents and the multidisciplinary team members who coordinate care transition by providing emotional, educational, medical and home visitor support for these families. To do this well, a thoughtful exchange of information between team members and parents is essential to identify psychosocial stress and ameliorate family concerns. Parents will need emotional and educational support and follow-up resources. Establishing individualized, flexible but realistic, pre- and post-discharge plans with parents is needed to start their healthy transition to home and community.

Revisiting early hypothyroidism screening in infants with Down syndrome

OBJECTIVE

To identify if the incidence of hypothyroidism in infants with Down syndrome is higher than previous childhood estimates (15%) when examined prior to the standard retesting at 6 months of age.

STUDY DESIGN

A retrospective observational cohort study of 122 children with Down syndrome admitted to a university-based birthing hospital between May 2000 and March 2012. Demographic data (for example, date of birth, gender, gestational age, inborn) and diagnostic data (Down syndrome, congenital heart disease and gastrointestinal disease) were cross-linked with thyroid hormone laboratory tests (total thyroxine, free thyroxine and thyroid stimulating hormone) to determine incidence of identified hypothyroidism and thyroid testing prior to 4 months of age (n=80).

RESULT

In all, 32.5% were found to have any hypothyroidism. Of these, 14 were primary hypothyroidism (17.5%) needing supplemental T4 therapy, 12 were compensated hypothyroidism (15%) and euthyroid was identified in 54 infants (67.5%).

CONCLUSION

Despite normal newborn screens, the incidence of any hypothyroidism (early compensated hypothyroidism and primary hypothyroidism) was higher than previously reported.

A psychoneuroimmunologic examination of cumulative perinatal steroid exposures and preterm infant behavioral follow-up

PURPOSE

This study's aim was to explore relationships between preterm infant behavioral outcomes and maternal/infant glucocorticoid (dexamethasone [DEX]) treatments using a psychoneuroimmunologic approach. Research questions were (a) do relationships exist between infant cumulative perinatal steroid (PNS) exposure and child behavioral problems? and (b) do maternal/infant characteristics (e.g., immune markers and biophysiologic stressors) influence these relationships?

METHODS

The convenience sample comprised 45 mother-child dyads in which the children (mean age 8 years ± 2.3) had been born at a mean postconceptional age of 28 weeks (± 4.2). We used the Child Behavior Checklist (CBCL) to assess behavior, the Clinical Risk Index for Babies (CRIB) to score stress at birth, and retrospective record review to identify additional perinatal factors (PNS dosage, sepsis, and maternal and infant complete blood counts near delivery).

RESULTS

Children were dichotomized into high (> 0.2 mg/kg; n = 20) versus low-no (≤0.2 mg/kg; n = 25) PNS exposure groups. Significant relationships existed between CBCL Total Problems score and sepsis, PNS exposure, timing of initial PNS, and infant length percentile at discharge. Competence problems were significantly associated with PNS, neonatal intensive care unit (NICU) infant length percentile, CRIB score, sepsis, retinopathy of prematurity, hearing deficit, and immunity markers (i.e., maternal lymphocyte percentage and infant band/seg ratio). Children in the higher PNS group exhibited more behavioral problems (e.g., withdrawn, attention, conduct, social, and rule breaking problems), but there were no significant differences. The findings are reassuring regarding long-term effects of this PNS dose on preterm infant behavioral outcomes.

Biophysiologic and social stress relationships with breast milk feeding pre- and post-discharge from the neonatal intensive care unit

OBJECTIVE

To determine influences on incidence of breast milk feeding (BMF) at time of discharge and 6 months later among infants cared for in the neonatal intensive care unit (NICU).

DESIGN

A 2-year prospective descriptive NICU hospital-based cohort design.

SETTING

Academic Center Level III-IV NICU.

PARTICIPANTS

Five hundred and thirty-five infants cared for in NICU and a subgroup of one hundred twenty-nine participant mothers who answered questionnaires.

METHODS

Predischarge data were collected using maternal and infant medical records. Post-discharge data were collected from maternal questionnaires.

RESULTS

At NICU discharge, biophysiologic stressors predictive of not receiving BMF included birth weight <1500 grams (p < .035), heart surgery (p = .014), and inhaled nitric oxide treatment (p = .002). Teenage mothers were less likely to BMF (p = .022). After discharge, BMF duration correlated with BMF duration of a prior infant (p < .009). Most mothers reported BMF >4 months, 91% continued pumping, and 89% indicated an interest in a hospital support group. Logistic regression analysis (R(2) 0.45) identified factors that significantly increased the likelihood of BMF > 4 months: BMF plan (p < .001), convenience (p = .018), and family as resource (p = .025). Negative associations were: awareness of immune benefits (p = .025), return to work (p = .002), and infants requiring surgical ligation of the patent ductus arterious (p = .019).

CONCLUSIONS

Social and medical stressors contribute to BMF duration pre- and post-NICU discharge. We speculate that active NICU BMF support targeting vulnerable infants and their families and assisting with plans for BMF pre- and post-discharge will help overcome barriers.

B-type natriuretic peptide utilization as an adjunct to management in a case of conjoined twins with pulmonary hypertension

This article reports a case of pulmonary hypertension in 37-week-gestational-age, pygopagus conjoined twins where B-type natriuretic peptide (BNP) was used as a cost-effective and important tool to aid effective management. Pulmonary hypertension in neonates is associated with high morbidity and mortality and multiplies the challenge of caring for conjoined twins. BNP is a peptide hormone secreted by cardiac ventricles that have undergone stress related to ventricular filling, volume overload, and pressure. BNP is commonly used in adults to assess heart failure, but its utility is less established in infants receiving neonatal intensive care. In this case, BNP testing was used as an adjunct to standard assessments for rapid diagnosis which was critical to expediting appropriate treatment management for these high-risk patients.

Vein of Galen arteriovenous malformation with PAPVR and use of serial B-type natriuretic peptide levels in the management: a case report and review of the literature

BACKGROUND

Arteriovenous malformation of the vein of Galen with partial anomalous pulmonary venous return can lead to a critically challenging condition associated with a high morbidity and mortality.

CASE REPORT

We report a case of a full term infant born with a vein of Gallen arteriovenous malformation complicated by partial anomalous pulmonary venous return and congestive heart failure where B-type natriuretic peptide was used as a vital tool in clinical assessment and treatment management.

CONCLUSIONS

Rapid diagnosis and treatment in infants with complex conditions such as this are imperative to expedite appropriate treatments, preventing long term negative outcome.

Cumulative perinatal steroids: child development of preterm infants

The development of premature infants may be altered due to exposure to high cumulative doses of the perinatal corticosteroid dexamethasone during critical growth periods. To compare child behavioral development of prematurely born infants who were exposed to higher perinatal steroids (PNS; >0.2 mg/kg) with that of infants exposed to lower PNS ( Collapse

Key Words

• perinatal steroids
• dexamethasone
• preterm infants
• neurodevelopment

Collapse

MESH Headings

• Adult
• Analysis of Variance
• Anthropometry
• Chi-Square Distribution
• Child
• Developmental Disabilities/chemically induced
• Developmental Disabilities/diagnosis
• Developmental Disabilities/epidemiology
• Dexamethasone/administration & dosage
• Dexamethasone/adverse effects
• Female
• Glucocorticoids/administration & dosage
• Glucocorticoids/adverse effects
• Humans
• Infant, Newborn
• Intensive Care, Neonatal
• Male
• Morbidity
• Obstetric Labor, Premature/drug therapy
• Parents/psychology
• Perinatal Care
• Pregnancy
• Prospective Studies
• Regression Analysis
• Risk Factors
• Severity of Illness Index
• Surveys and Questionnaires
• Treatment Outcome

Collapse

Grants

• T32 NR007077 NINR NIH HHS
• T32 NR007077-05 NINR NIH HHS

Collapse

Affiliation(s)

Isabell B Purdy University of California, Los Angeles, CA 90095-1752, USA.
Dorothy J Wiley
Lynne M Smith
Carollee Howes
Anna Gawlinski
Wendy Robbins
Lina K Badr

Collapse

Embracing bioethics in neonatal intensive care, part II: case histories in neonatal ethics

Ethical treatment dilemmas are not new to the NICU. With technologic advances over the past 20 years, NICU care has developed rapidly, and survival rates have improved for some of the tiniest and most critically ill infants. In guiding clinical practice, however, standards in evidenced- based medicine have often superseded standards in evidence-based ethics. Neonatal nurses attain a more in-depth understanding of the clinical significance of the four principles of bioethics: autonomy, nonmaleficence, beneficence, and justice. Case studies illustrate the principles discussed.

Embracing bioethics in neonatal intensive care, part I: evolving toward neonatal evidence-based ethics

Ethical treatment dilemmas are not new to the NICU. With technologic advances over the past 20 years, NICU care has developed rapidly, and survival rates have improved for some of the tiniest and most critically ill infants. In guiding clinical practice, however, standards in evidenced-based medicine have often superseded standards in evidence-based ethics. Part I of this article presents a historical review of neonatal care and an overview of cases that have set precedents in neonatal ethical debate. It also includes recommendations for enhancing the skills of neonatal nurses as patient advocates in NICU ethical issues, an area that is, at times, controversial and baffling to clinicians.

Vulnerable: a concept analysis

TOPIC

In spite of the significance of vulnerable as a phenomenon that affects the human condition, its essence remains complex and elusive.

PURPOSE

A conceptual analysis to clarify knowledge of this concept to explore the common and scientific usage.

SOURCES OF INFORMATION

A comprehensive and systematic review from bibliographic and abstract databases and online searches.

CONCLUSIONS

Findings contributed to the definition of vulnerable as a highly individualized dynamic process of being open to circumstances that positively or negatively influence outcomes, a definition based on a synthesis of knowledge concerning vulnerable, and offers a reconceptualization that expands its use in nursing scientific theory, research, and clinical practice.

Perinatal corticosteroids: A review of research. Part I: Antenatal administration

The premature infant may receive therapeutic glucocorticoid drugs while in utero or in the postnatal period. This article (part I of a two-part series) discusses the benefits and risks of in utero, or antenatal, corticosteroids (ACS) for the premature infant. Part II addresses the benefits and risks of postnatal corticosteroid (PCS) use. There are numerous clinical studies on the therapeutic use of these steroids for the prevention of respiratory distress syndrome and chronic lung disease in the premature infant, although research results on the efficacy of repeated steroid exposure among premature infants vary. Premature infants who are exposed to repeated courses of ACS and/or high-cumulative-dose PCS may show no neurologic side effects until later in life. Research in newborn animal models focused on the timing, duration, and amounts of ACS and PCS. Current clinical research includes examination of the neurodevelopment of infants who are therapeutically exposed to perinatal corticosteroids, to identify safer minimal dose protocols. Over the past 30 years, corticosteroids have been increasingly prescribed before and after birth. Understanding the potential treatment benefits and risks to human fetuses and neonates is vital to clinical practice. This review presents historic and pharmacokinetic information about prenatal use of corticosteroids. It also offers scientific evidence of the benefits and risks identified in animal models and clinical trials, to stimulate thought that gtiides neonatal clinical practice.

Magnetic resonance imaging and the neonate

Over the past decade, advances in neuroimaging have given birth to a new field of diagnostic pediatric neurologic assessment that includes magnetic resonance imaging (MRI). This invaluable tool helps medical professionals to resolve many clinical and research questions related to neonatal neurodevelopment that other imaging technology cannot explain. Nurses and others who accompany infants to MRI would benefit from a better understanding of early neurodevelopment and of the neuroimaging procedure. Knowing the advantages and disadvantages of MRI techniques can help nurses be better patient advocates, parent liaisons, and caregivers to infants having MRI scans.

Newborn auditory follow-up

Because hearing is a key component in the infant's development of speech, language, and cognition, early detection of infant hearing loss is critically important. The routine evaluation of hearing should include the identification of parental concerns regarding infant hearing as well as the assessment and diagnosis of infants with potential hearing impairment. Identification of hearing loss should be followed by early interventions to prevent developmental delays. This article promotes universal screening of newborn hearing. The article also provides a review of the embryogenesis of hearing and includes a breakdown of risks for hearing loss, recommendations for auditory testing, and suggestions for follow-up, early intervention, and support for families of infants with hearing impairment.