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Predanič Drobne I, Kornhauser Cerar L, Erčulj V, Grosek Š. A Higher Amount of Nutritional Intake as a Possible Cause of Hyperglycemia in Extremely Premature Infants in Parenteral and Enteral Nutrition at the Tertiary Neonatal Intensive Care Unit. Children (Basel) 2023; 10:1651. [PMID: 37892314 PMCID: PMC10605466 DOI: 10.3390/children10101651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/18/2023] [Accepted: 10/02/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND This study aimed to find an association between infants who had hyperglycemia and those who did not, those treated with insulin or not and several prenatal and postnatal variables or the suboptimal prescription of parenteral nutrition. METHODS We conducted a retrospective study, which included extremely premature infants (<28 weeks of gestation) admitted to the tertiary NICU, University Medical Centre Ljubljana, between 1 January 2021 and 31 December 2021. Blood glucose measurements, insulin treatment, general characteristics, nutritional data and complications of prematurity were obtained retrospectively from hospital data. RESULTS There were 21 infants included in the study who did not receive insulin and 17 who were treated with insulin. Infants receiving insulin were younger and lighter compared to the non-insulin treatment group (mean gestational age 178 vs. 188 days; median birth weight 680 g vs. 990 g). The younger insulin group of infants received the same daily number of total macronutrients per kg per day compared to the older non-insulin group, i.e., glucose, lipids and amino acids, as recommended for the gestational age and birth weight. After adjusting for gestational age, no significant association with complications of prematurity was found. CONCLUSIONS The postulated explanation (with the prescription of a higher amount of macronutrients during the first seven days) for hyperglycemia and treatment with insulin in the less mature and lighter infants cannot be supported by the data given.
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Affiliation(s)
- Iza Predanič Drobne
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
| | - Lilijana Kornhauser Cerar
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
| | - Vanja Erčulj
- Rho Sigma Research & Statistics, 1000 Ljubljana, Slovenia;
- Faculty of Criminal Justice and Security, University of Maribor, 1000 Ljubljana, Slovenia
| | - Štefan Grosek
- Neonatology Section, Department of Perinatology, Division of Gynecology and Obstetrics, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (I.P.D.); (L.K.C.)
- Department of Pediatrics, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
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2
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Oh SH, Jin HS, Park CH. Risk factors and neonatal outcomes of pulmonary air leak syndrome in extremely preterm infants: A nationwide descriptive cohort study. Medicine (Baltimore) 2023; 102:e34759. [PMID: 37653823 PMCID: PMC10470716 DOI: 10.1097/md.0000000000034759] [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: 02/21/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
Most extremely preterm infants (EPIs), who were born before 28 weeks of gestation, with pulmonary air leak syndrome (ALS) are symptomatic, often severe, and require drainage. EPIs with severe air leak syndrome (sALS) that require tube drainage or needle aspiration are at high risk of morbidities and mortality. This study aimed to investigate perinatal characteristics, morbidities, and mortality in EPIs with sALS, and to estimate the risk of mortality according to gestational age (GA). A prospective cohort study conducted from 2013 to 2020 compiled the Korean Neonatal Network database to evaluate the incidence, perinatal characteristics, and outcomes of sALS in EPIs born before 28 weeks of gestation. Among 5666 EPIs, the incidence of sALS was 9.4% and inversely related to GA. From this cohort, we compared 532 EPIs with sALS to 1064 EPIs without sALS as controls, matching the subjects by GA and birth weight. Preterm premature rupture of membranes, oligohydramnios, resuscitation after birth, low Apgar scores, repeated surfactant administration, persistent pulmonary hypertension of the newborn, and pulmonary hemorrhage were associated with the development of pneumothorax. The sALS group required a higher fraction of inspired oxygen and more invasive respiratory support at both 28 days of life and 36 weeks of postmenstrual age. The sALS group had a higher incidence of bronchopulmonary dysplasia and major brain injury. The mortality rate was higher in the sALS group than in the control group (55.3% vs 32.5%, P < .001), and the ALS group had a 1.7 times risk of mortality than the control group. More attention should be paid to sALS in EPIs because the frequency of sALS increased as GA decreased, and the risk of mortality was more significant at lower GA.
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Affiliation(s)
- Seong Hee Oh
- Department of Pediatrics, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
- Department of Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Hyun-Seung Jin
- Department of Pediatrics, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Chan-Hoo Park
- Department of Pediatrics, Gyeongsang National University College of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Korea
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3
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Cao JK, Liu CG, Wang D, Li QP. Impact of premature rupture of membranes on clinical outcomes of extremely premature infants: A propensity score matching study. Front Pediatr 2023; 11:1144373. [PMID: 37063674 PMCID: PMC10098209 DOI: 10.3389/fped.2023.1144373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 03/13/2023] [Indexed: 04/18/2023] Open
Abstract
Background Premature rupture of membranes (PROM) is a common cause of extremely premature infants (EPIs) and also leads to adverse preterm complications. However, the effect of PROM on EPIs remains contradictory. This study used propensity score matching (PSM) to adjust the baseline characteristics to explore the impact of PROM on clinical outcomes of extremely premature infants (EPIs). Methods Medical data of 470 EPIs at gestational age < 28weeks who received prenatal examination in our hospital between January 1, 2015 and December 31, 2020 were analyzed retrospectively. According to the presence or absence of PROM, they were divided into a PROM group and a non-PROM group. Ten covariates including birth weight, male sex, artificial conception, cesarean delivery, 5-min Apgar score ≤ 7, oligohydramnios, gestational hypertension, preeclampsia, antenatal steroid use, and complete steroid treatment were matched 1:1 by PSM. The major complication occurrence and mortality during hospitalization were compared between the two groups by t-test, nonparametric test or x 2 test. Results Among the 470 infants enrolled, 157 (33.4%) were in the PROM group and 313 in the no-PROM group. After matching the ten confounding factors,276 cases were successfully enrolled. The incidence of early pulmonary hypertension (EPH) and severe retinopathy of prematurity (ROP) in the PROM group were higher than those in the no-PROM group [44.2% (61/138) vs. 29.0% (40/138); 34.8% (48/138) vs. 21.7% (30/138), x 2 = 6.886 and 5.790, both P < 0.05]. However, there was no significant difference in the in-hospital mortality and the incidence of other major complications between the two groups (all P > 0.05). Conclusions PROM increased the incidence of EPH and severe ROP in EPI, but had no significant impact on in-hospital mortality, length of hospital stay, and the incidence of other complications.
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Affiliation(s)
- Jing-Ke Cao
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Chang-Geng Liu
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Dan Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Qiu-Ping Li
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
- Department of Neonatology, Senior Department of Pediatrics, The Seventh Medical Center of PLA General Hospital, Beijing, China
- Correspondence: Qiu-Ping Li
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Moser JJ, Archer DP, Walker AM, Rice TK, Dewey D, Lodha AK, McAllister DL. Association of sedation and anesthesia on cognitive outcomes in very premature infants: a retrospective observational study. Can J Anaesth 2023; 70:56-68. [PMID: 36536155 DOI: 10.1007/s12630-022-02353-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/24/2022] [Accepted: 05/30/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Cognitive outcomes in preterm infants may be adversely affected by use of sedation and anesthetic agents. We investigated the associations between anesthetics/sedatives and full-scale intelligence quotient (FSIQ) measured at 36 months corrected age (CA) in very preterm infants (born < 29 weeks gestational age). METHODS This retrospective cohort study included preterm infants born at < 29 weeks of gestation between 1 January 2006 and 31 December 2012, whose cognitive outcomes were assessed at 36 months CA. Imputed and complete case univariable and adjusted multivariable linear regressions were used to investigate the associations between FSIQ [standardized to mean (standard deviation) 100 (15)] and exposure to volatile anesthetics, propofol, benzodiazepines, barbiturates, and ketamine. These agents were the subject of a 2016 warning from regulatory authorities in the USA recommending caution for administration to children and pregnant women. RESULTS A total of 731 infants met the inclusion criteria. Unadjusted associations were -7 (95% confidence interval [CI], -10 to -4; P < 0.001) and -6 (95% CI, -10 to -3; P < 0.001) FSIQ points with exposure to warned medications using imputed and complete case analyses, respectively. Imputed and complete case adjusted associations between FSIQ and warned medications were -3 (95% CI, -7 to 0; P = 0.045) and -4 (95% CI, -8 to 0; P = 0.071) FSIQ points, respectively. Adjusted associations between volatile anesthetic exposure only and FSIQ were -3 (95% CI, -6 to 0; P = 0.072) and -5 (95% CI, -9 to -2; P = 0.004) FSIQ points using imputed and complete case data sets, respectively. FSIQ was not associated with opioid exposure. CONCLUSION Exposure of very preterm infants to anesthetics/sedatives on the United States Food and Drug Administration warning list was associated with a decrease in FSIQ points at 36 months CA. There was no association between opioid exposure and FSIQ.
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Affiliation(s)
- Joanna J Moser
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street S.E, Calgary, AB, T3M 1M4, Canada.
| | - David P Archer
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street S.E, Calgary, AB, T3M 1M4, Canada.,Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andrew M Walker
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street S.E, Calgary, AB, T3M 1M4, Canada
| | - Tiffany K Rice
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street S.E, Calgary, AB, T3M 1M4, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Deborah Dewey
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Owerko Center at the Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Abhay K Lodha
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Debbie L McAllister
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street S.E, Calgary, AB, T3M 1M4, Canada.,Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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5
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Su Z, Lin L, Fan X, Jia C, Shi B, Huang X, Wei J, Cui Q, Wu F. Increased Risk for Respiratory Complications in Male Extremely Preterm Infants: A Propensity Score Matching Study. Front Endocrinol (Lausanne) 2022; 13:823707. [PMID: 35634508 PMCID: PMC9134850 DOI: 10.3389/fendo.2022.823707] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/11/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Many factors can affect the clinical outcome of extremely premature infants (EPIs), but the effect of sex is paradoxical. This study used propensity score matching to adjust baseline information to reassess the clinical outcome of EPIs based on sex. METHODS A retrospective analysis was performed on EPIs admitted in the Department of Neonatology of the Third Affiliated Hospital of Guangzhou Medical University from 2011 to 2020. A propensity score matching (PSM) analysis was used to adjust the confounding factors including gestational age, birth weight, 1-minute Apgar score ≤ 3, withholding or withdrawing life-sustaining treatment(WWLST), mechanical ventilation, duration of mechanical ventilation, the mother with advanced age (≥35 years old), complete-course antenatal steroid therapy and hypertensive disorders of pregnancy. The survival rate at discharge and the incidence of major complications were evaluated between the male and female groups. RESULTS A total of 439 EPIs were included, and 240 (54.7%) infants were males. After matching the nine confounding factors, 148 pairs of infants were finally enrolled. There was no significant difference in the survival rate at discharge, as well as the mortality of activating treatment or WWLST between the two groups (all P>0.05). However, the incidence of respiratory distress syndrome, bronchopulmonary dysplasia (BPD), and moderate to severe BPD in the male group was significantly increased (all P<0.01), especially at birth weight between 750 and 999 grams. CONCLUSIONS The male EPIs have a higher risk of respiratory complications than females, particularly at 750 to 999 grams of birth weight.
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Affiliation(s)
- Zhiwen Su
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lili Lin
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xi Fan
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chunhong Jia
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bijun Shi
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoxia Huang
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianwei Wei
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiliang Cui
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- *Correspondence: Qiliang Cui, ; Fan Wu,
| | - Fan Wu
- Department of Pediatrics, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Major Obstetric Diseases, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- *Correspondence: Qiliang Cui, ; Fan Wu,
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6
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Cavolo A, Dierckx de Casterlé B, Naulaers G, Gastmans C. Neonatologists' Resuscitation Decisions at Birth for Extremely Premature Infants. A Belgian Qualitative Study. Front Pediatr 2022; 10:852073. [PMID: 35402353 PMCID: PMC8989134 DOI: 10.3389/fped.2022.852073] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions. METHODS We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven. RESULTS We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician. CONCLUSION Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA.
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Affiliation(s)
- Alice Cavolo
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | | | - Gunnar Naulaers
- Pregnancy, Fetus and Newborn, Department of Development and Regeneration, UZ Leuven, Leuven, Belgium
| | - Chris Gastmans
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
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7
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Bhargava S, Lumba R, Mally P, Bailey S, Verma S. Horizontal Transmission of COVID-19 in a 24-Week Premature Infant and Post-discharge Follow-Up. Cureus 2021; 13:e18455. [PMID: 34650838 PMCID: PMC8489781 DOI: 10.7759/cureus.18455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 11/17/2022] Open
Abstract
The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has rapidly spread across the globe. The clinical spectrum of infection with SARS-CoV-2 among the most vulnerable extremely premature patient population in the neonatal intensive care units (NICUs), particularly those with chronic lung disease (CLD), remains unclear. Additionally, post-COVID conditions have been described in children with limited published data among infants. Symptoms in children appear similar to those described in the adults. We report a case of SARS-CoV-2 infection in a 24-week preterm infant with CLD acquired via horizontal transmission while still in the NICU. We also provide follow-up data on patient until one year post-discharge. Our patient developed fever prompting testing for SARS-CoV-2. Although extremely premature infants with CLD are known to be at high risk for morbidities if they acquire respiratory viral infections, infection with SARS-CoV-2 in this case report presented with relatively mild clinical symptoms. He remained clinically stable on respiratory support (nasal cannula) with eventual weaning to room air. Our patient was followed until one year post-discharge (chronological age: 20 months) and had follow-up by various subspecialties for chronic lung disease, hypothyroidism, chronic kidney disease, and poor growth. We did not observe any specific post-COVID symptoms. This case illustrates that horizontal transmission of SARS-CoV-2 infection among extremely premature infants with CLD is possible in the NICU but likely presents with mild clinical symptoms during acute infection and less chances of post-COVID conditions. Additionally, this case highlights the need for adherence to infection prevention guidelines to prevent nosocomial transmission amid the ongoing pandemic.
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Affiliation(s)
- Sweta Bhargava
- Department of Pediatrics, Division of Neonatology, New York University Grossman School of Medicine, New York, USA.,Department of Pediatrics, Division of Neonatology, Bellevue Hospital Center, New York, USA
| | - Rishi Lumba
- Department of Pediatrics, Division of Neonatology, New York University Grossman School of Medicine, New York, USA
| | - Pradeep Mally
- Department of Pediatrics, Division of Neonatology, New York University Grossman School of Medicine, New York, USA.,Department of Pediatrics, Division of Neonatology, Bellevue Hospital Center, New York, USA
| | - Sean Bailey
- Department of Pediatrics, Division of Neonatology, New York University Grossman School of Medicine, New York, USA.,Department of Pediatrics, Division of Neonatology, Bellevue Hospital Center, New York, USA
| | - Sourabh Verma
- Department of Pediatrics, Division of Neonatology, New York University Grossman School of Medicine, New York, USA.,Department of Pediatrics, Division of Neonatology, Bellevue Hospital Center, New York, USA
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Seki D, Mayer M, Hausmann B, Pjevac P, Giordano V, Goeral K, Unterasinger L, Klebermaß-Schrehof K, De Paepe K, Van de Wiele T, Spittler A, Kasprian G, Warth B, Berger A, Berry D, Wisgrill L. Aberrant gut-microbiota-immune-brain axis development in premature neonates with brain damage. Cell Host Microbe 2021; 29:1558-1572.e6. [PMID: 34480872 PMCID: PMC8525911 DOI: 10.1016/j.chom.2021.08.004] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/30/2021] [Accepted: 08/09/2021] [Indexed: 02/08/2023]
Abstract
Premature infants are at substantial risk for suffering from perinatal white matter injury. Though the gut microbiota has been implicated in early-life development, a detailed understanding of the gut-microbiota-immune-brain axis in premature neonates is lacking. Here, we profiled the gut microbiota, immunological, and neurophysiological development of 60 extremely premature infants, which received standard hospital care including antibiotics and probiotics. We found that maturation of electrocortical activity is suppressed in infants with severe brain damage. This is accompanied by elevated γδ T cell levels and increased T cell secretion of vascular endothelial growth factor and reduced secretion of neuroprotectants. Notably, Klebsiella overgrowth in the gut is highly predictive for brain damage and is associated with a pro-inflammatory immunological tone. These results suggest that aberrant development of the gut-microbiota-immune-brain axis may drive or exacerbate brain injury in extremely premature neonates and represents a promising target for novel intervention strategies.
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Affiliation(s)
- David Seki
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, 1090 Vienna, Austria; Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Margareta Mayer
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, 1090 Vienna, Austria
| | - Bela Hausmann
- Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, 1090 Vienna, Austria; Department of Laboratory Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Petra Pjevac
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, 1090 Vienna, Austria; Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, 1090 Vienna, Austria
| | - Vito Giordano
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Katharina Goeral
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Lukas Unterasinger
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Katrin Klebermaß-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Kim De Paepe
- Department of Biotechnology, Faculty of Bioscience Engineering, Center for Microbial Ecology and Technology, Ghent University, 9000 Ghent, Belgium
| | - Tom Van de Wiele
- Department of Biotechnology, Faculty of Bioscience Engineering, Center for Microbial Ecology and Technology, Ghent University, 9000 Ghent, Belgium
| | - Andreas Spittler
- Core Facility Flow Cytometry & Department of Surgery, Research Lab, Medical University of Vienna, 1090 Vienna, Austria
| | - Gregor Kasprian
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Benedikt Warth
- Department of Food Chemistry and Toxicology, University of Vienna, 1090 Vienna, Austria
| | - Angelika Berger
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - David Berry
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, 1090 Vienna, Austria; Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, 1090 Vienna, Austria.
| | - Lukas Wisgrill
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria.
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9
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Fauchère J, Klein SD, Hendriks MJ, Baumann‐Hölzle R, Berger TM, Bucher HU. Swiss neonatal caregivers express diverging views on parental involvement in shared decision-making for extremely premature infants. Acta Paediatr 2021; 110:2074-2081. [PMID: 33657661 DOI: 10.1111/apa.15828] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/20/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 11/30/2022]
Abstract
AIM Due to scarce available national data, this study assessed current attitudes of neonatal caregivers regarding decisions on life-sustaining interventions, and their views on parents' aptitude to express their infant's best interest in shared decision-making. METHODS Self-administered web-based quantitative empirical survey. All 552 experienced neonatal physicians and nurses from all Swiss NICUs were eligible. RESULTS There was a high degree of agreement between physicians and nurses (response rates 79% and 70%, respectively) that the ability for social interactions was a minimal criterion for an acceptable quality of life. A majority stated that the parents' interests are as important as the child's best interest in shared decision-making. Only a minority considered the parents as the best judges of what is their child's best interest. Significant differences in attitudes and values emerged between neonatal physicians and nurses. The language area was very strongly associated with the attitudes of neonatal caregivers. CONCLUSION Despite clear legal requirements and societal expectations for shared decision-making, survey respondents demonstrated a gap between their expressed commitment to shared decision-making and their view on parental aptitude to formulate their infant's best interest. National guidelines need to address these barriers to shared decision-making to promote a more uniform nationwide practice.
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Affiliation(s)
- Jean‐Claude Fauchère
- Department of Neonatology University Hospital Zurich University of Zurich Zurich Switzerland
| | - Sabine D. Klein
- Department of Neonatology University Hospital Zurich University of Zurich Zurich Switzerland
| | - Manya J. Hendriks
- Department of Neonatology University Hospital Zurich University of Zurich Zurich Switzerland
| | - Ruth Baumann‐Hölzle
- Dialogue Ethics Foundation Interdisciplinary Institute for Ethics in Healthcare Zurich Switzerland
| | - Thomas M.B. Berger
- Department of Neonatology University Children’s Hospital Basel Basel Switzerland
| | - Hans Ulrich Bucher
- Department of Neonatology University Hospital Zurich University of Zurich Zurich Switzerland
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Nakashima T, Inoue H, Sakemi Y, Ochiai M, Yamashita H, Ohga S. Trends in Bronchopulmonary Dysplasia Among Extremely Preterm Infants in Japan, 2003-2016. J Pediatr 2021; 230:119-125.e7. [PMID: 33246013 DOI: 10.1016/j.jpeds.2020.11.041] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate recent trends in bronchopulmonary dysplasia (BPD) and its risk factors among extremely preterm infants. STUDY DESIGN Demographic and clinical data were reviewed for 19 370 infants born at 22-27 weeks of gestation registered in the affiliated hospitals of the Neonatal Research Network of Japan between 2003 and 2016. We investigated the overall survival and prevalence of bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age and risk factors for developing BPD among the survivors. RESULTS Among 19 370 infants, 2244 (11.6%) died by 36 weeks' postmenstrual age. The mortality rate decreased from 19.0% (99% CI, 15.7%-22.8%) in 2003 to 8.0% (99% CI, 6.2%-10.3%) in 2016. Among 17 126 survivors, BPD developed in 7792 (45.5%) infants, and its proportion significantly increased from 41.4% (99% CI, 36.5%-46.4%) in 2003 to 52.0% (99% CI, 48.2%-55.9%) in 2016. A multivariable analysis of the survivors showed a positive association of BPD with ≥4 weeks' supplemental oxygen or invasive ventilation, birth weight <750 g, small for gestational age, ≥4 weeks' noninvasive positive pressure ventilation, chorioamnionitis, <26 weeks' gestational age, <20 cases per year of center patient volume, or treated patent ductus arteriosus. Although the median duration of invasive ventilation was shortened, the proportions of factors associated adversely with BPD generally showed increasing trends over time. CONCLUSIONS The mortality rate of extremely preterm infants has decreased, but the rate of BPD has increased in survivors between 2003 and 2016. Despite the decreasing duration of invasive ventilation over time, increasing rates of BPD suggest that differences in the patient population or other management strategies influence the development of BPD.
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Affiliation(s)
- Toshinori Nakashima
- Department of Pediatrics, National Hospital Organization Kokura Medical Center, Fukuoka, Japan.
| | - Hirosuke Inoue
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshihiro Sakemi
- Department of Pediatrics, National Hospital Organization Kokura Medical Center, Fukuoka, Japan
| | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hironori Yamashita
- Department of Pediatrics, National Hospital Organization Kokura Medical Center, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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11
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Grass B, Ye XY, Kelly E, Synnes A, Lee S. Association between Transport Risk Index of Physiologic Stability in Extremely Premature Infants and Mortality or Neurodevelopmental Impairment at 18 to 24 Months. J Pediatr 2020; 224:51-56.e5. [PMID: 32442448 DOI: 10.1016/j.jpeds.2020.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 01/26/2020] [Revised: 05/07/2020] [Accepted: 05/13/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To examine the association between mortality or neurodevelopmental impairment at 18-24 months of corrected age and the Transport Risk Index of Physiologic Stability (TRIPS) score on admission to the neonatal intensive care unit (NICU) in extremely premature infants. STUDY DESIGN Retrospective cohort study of extremely premature infants (inborn and outborn) born at 22-28 weeks of gestational age and admitted to NICUs in the Canadian Neonatal Network between April 2009 and September 2011. TRIPS scores and clinical data were collected from the Canadian Neonatal Network database. Follow-up data at 18-24 months of corrected age were retrieved from the Canadian Neonatal Follow-Up Network database. Neurodevelopment was assessed using the Bayley Scales of Infant and Toddler Development, Edition III. The primary outcome was death or significant neurodevelopmental impairment at 18-24 months of corrected age. The secondary outcomes were individual components of the Bayley Scales of Infant and Toddler Development, Edition III assessment. RESULTS A total of 1686 eligible infants were included. A TRIPS score of ≥20 on admission to the NICU was significantly associated with mortality (aOR 2.71 [95% CI, 2.02-3.62]) and mortality or significant neurodevelopmental impairment (aOR 1.91 [95% CI, 1.52-2.41]) at 18-24 months of corrected age across all gestational age groups of extremely premature infants. CONCLUSION The TRIPS score on admission to the NICU can be used as an adjunctive, objective tool for counselling the parents of extremely premature infants early after their admission to the NICU.
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Affiliation(s)
- Beate Grass
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada.
| | - Xiang Y Ye
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Edmond Kelly
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Anne Synnes
- Division of Neonatology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Shoo Lee
- Division of Neonatology, Mount Sinai Hospital, Toronto, Ontario, Canada
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Sharma A, Xin Y, Chen X, Sood BG. Early prediction of moderate to severe bronchopulmonary dysplasia in extremely premature infants. Pediatr Neonatol 2020; 61:290-299. [PMID: 32217025 DOI: 10.1016/j.pedneo.2019.12.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 05/03/2019] [Revised: 11/15/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Bronchopulmonary Dysplasia (BPD) is the commonest morbidity in extremely preterm infants (PTIs). Risk factors for BPD have been described in the era before the widespread availability of non-invasive ventilation (NIV) in the delivery room (DR). The objective of this study is to identify risk factors for Moderate/Severe BPD in an era of widespread availability of NIV in the DR. METHODS Detailed antenatal and postnatal data were abstracted for PTIs, 230/7-276/7 weeks GA. Multivariate logistic regression and classification and regression tree analyses (CART) identified predictors for the primary outcome of Moderate/Severe BPD. RESULTS Of 263 eligible infants, 59% had Moderate/Severe BPD. Moderate/Severe BPD was significantly associated with birthweight, gender, DR intubation and surfactant compared to No/Mild BPD. Of infants not intubated in the DR, 40% with No/Mild BPD and 80% with Moderate/Severe BPD received intubation by 48 hours (p < 0.05). Infants with Moderate/Severe BPD received longer duration of oxygen and mechanical (MV). On logistic regression, birthweight, gender, oxygen concentration, cumulative duration of oxygen and MV, surfactant, and blood transfusions predicted Moderate/Severe BPD. Both CART analysis and logistic regression showed duration of oxygen and MV to be the most important predictors for Moderate/Severe BPD. CONCLUSIONS In an era of increasing availability of NIV in the DR, lower birthweight, male gender, surfactant treatment, blood transfusions and respiratory support in the first 2-3 weeks after birth predict Moderate/Severe BPD with high sensitivity and specificity. The majority of these infants received intubation within 48 hours of birth (97%). These data suggest that early failures of NIV represent opportunities for improvement of NIV techniques and of non-invasive surfactant to avoid intubation in the first 48 hours. Furthermore, these risk factors may allow earlier identification of infants most likely to benefit from interventions to prevent or decrease severity of BPD.
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Affiliation(s)
- Amit Sharma
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA; Hutzel Women's Hospital, Detroit, MI 48201, USA; Children's Hospital of Michigan, Detroit, MI 48201, USA
| | - Yuemin Xin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA
| | - Xinguang Chen
- University of Florida College of Medicine, College of Public Health, USA
| | - Beena G Sood
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Wayne State University, Detroit, MI 48201, USA; Hutzel Women's Hospital, Detroit, MI 48201, USA; Children's Hospital of Michigan, Detroit, MI 48201, USA.
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13
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Wang LJ, Hu Y, Wang W, Zhang CY, Bai YZ, Zhang SC. Gastroesophageal Reflux Poses a Potential Risk for Late Complications of Bronchopulmonary Dysplasia: A Prospective Cohort Study. Chest 2020; 158:1596-1605. [PMID: 32450238 DOI: 10.1016/j.chest.2020.05.523] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/01/2020] [Revised: 04/17/2020] [Accepted: 05/09/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is the most common respiratory disorder in extremely low birth weight infants. Although most symptoms of BPD improve, some late complications exist, even with regular treatment. Gastroesophageal reflux (GER), also common in extremely premature infants, may be related to many cardiorespiratory symptoms. However, the potential of GER as a risk factor for late complications associated with BPD is still unclear. RESEARCH QUESTION The goal of this study was to determine if GER increases the risk of late complications of BPD in infants. STUDY DESIGN AND METHODS A multicenter prospective cohort of 131 infants (79 male subjects, 52 female subjects) with BPD was enrolled. The development of late complications was assessed over an 18-month follow-up period. Twenty-four-hour pH-multichannel intraluminal impedance and gastric sodium concentrations were analyzed in all infants at 36 weeks' postmenstrual age and at the last interview. Prevalence and risk factors of late complications of BPD were analyzed by using forward logistic regression. RESULTS The prevalence of late complications in BPD infants was 63.79% and included respiratory symptoms (49.14%), vomiting (38.79%), retinopathy of prematurity (25.86%), hypoxic-ischemic injury (3.45%), rehospitalization (26.72%), and sudden death (0.86%). Respiratory diseases constituted the most frequent complication. The prevalence of GER in BPD was 42.24% and included acid GER (18.10%) and duodenogastroesophageal reflux (DGER; 24.14%). Risk factors for respiratory symptoms were gestational age ≤ 30 weeks (OR, 3.213; 95% CI, 1.221-8.460), birth weight < 1,500 g (OR, 2.803; 95% CI, 1.014-7.749), invasive ventilation > 7 days (OR, 4.952; 95% CI, 1.508-16.267), acid GER (OR, 4.630; 95% CI, 1.305-16.420), and DGER (OR, 5.588; 95% CI, 1.770-17.648). Infants with BPD and DGER were more prone to late complications than those with acid GER or no reflux. INTERPRETATION The prevalence of late complications is high in infants with BPD. GER (and in particular, DGER) poses a tentative risk for these late complications. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03014453; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Luo-Jia Wang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China; Department of Pediatrics, Shanghai General Hospital of Shanghai Jiao Tong University, Shanghai, China
| | - Yu Hu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Wang
- Department of Nursing, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chun-Yan Zhang
- Department of Pediatrics, the First Hospital of Jilin University, Changchun, China
| | - Yu-Zuo Bai
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Cheng Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China.
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Ganguly A, Makkar A, Sekar K. Volume Targeted Ventilation and High Frequency Ventilation as the Primary Modes of Respiratory Support for ELBW Babies: What Does the Evidence Say? Front Pediatr 2020; 8:27. [PMID: 32117833 PMCID: PMC7025474 DOI: 10.3389/fped.2020.00027] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/20/2020] [Indexed: 12/01/2022] Open
Abstract
Respiratory management of the extremely low birth weight (ELBW) newborn has evolved over time. Although non-invasive ventilation is being increasingly used for respiratory support in these ELBW infants, invasive ventilation still remains the primary mode in this population. Current ventilators are microprocessor driven and have revolutionized the respiratory support for these neonates synchronizing the baby's breath to ventilator breaths. High frequency ventilators with the delivery of tidal volumes less than the dead space have been introduced to minimize barotrauma and chronic lung disease. Despite these advances, the incidence of chronic lung disease has not decreased. There is still controversy regarding which mode is ideal as the primary mode of ventilation in ELBW infants. The most common modes seem to be pressure targeted conventional ventilation, volume targeted conventional ventilation and high frequency ventilation which includes high frequency oscillatory ventilation, high frequency jet ventilation and high frequency flow interrupter. In recent years, several randomized controlled trials and meta-analyses have compared volume vs. pressure targeted ventilation and high frequency ventilation. While volume targeted ventilation and high frequency ventilation does show promise, substantial practice variability among different centers persists. In this review, we weighed the evidence for each mode and evaluated which modes show promise as the primary support of ventilation in ELBW babies.
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Affiliation(s)
- Abhrajit Ganguly
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Abhishek Makkar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Abstract
BACKGROUND Neonatologists, legal experts and ethicists extensively discuss the ethical challenges of decision-making when a child is born at the limit of viability. The voices of parents are less heard in this discussion. In Norway, parents are actively shielded from the burden of decision-making responsibility. In an era of increasing patient autonomy, is this position still defendable? RESEARCH QUESTION In this article, we discuss the role of parents in neonatal decision-making, based on the following research question: Should parents decide whether to provide lifesaving treatment when their child is born at the limit of viability? RESEARCH DESIGN We conducted eight interviews with 12 parents, 4 individuals and 4 couples, all having experienced prenatal counselling at the limit of viability. The interviews took place at different university locations in Norway in the years 2014-2018. ETHICAL CONSIDERATIONS All study participants gave their written informed consent. The Regional Committee for Medical Research Ethics approved the study. FINDINGS We identified six main themes in parents' responses to the research question. Parents (1) experienced an emotional turmoil confronted with birth at the border of viability, (2) emphasized the importance of being involved in decision-making, (3) described and reflected on the need to balance the parental instinct of saving, (4) were concerned about the dilemmas involved in protecting the family, (5) were worried about the burden of overwhelming responsibility and (6) called for guideline relief. CONCLUSION The perceived parental instinct of saving the life of their child makes it hard for parents to step away from a call for 'everything to be done'. Involvement of an interprofessional periviability team drawing on the experiences and viewpoints of nurses and neonatologists in decision-making is needed to protect both infants and parents against undue parental push for treatment and enable parents to make good decisions regarding their child.
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Affiliation(s)
- Lars Ursin
- Norwegian University of Science and Technology, Norway
| | - Janicke Syltern
- St. Olav's University Hospital, Norway; Norwegian University of Science and Technology, Norway
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16
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Yasuoka K, Inoue H, Egami N, Ochiai M, Tanaka K, Sawano T, Kurata H, Ichiyama M, Fujiyoshi J, Matsushita Y, Sakai Y, Ohga S; Neonatal Research Network of Japan. Late-Onset Circulatory Collapse and Risk of Cerebral Palsy in Extremely Preterm Infants. J Pediatr 2019; 212:117-123.e4. [PMID: 31229321 DOI: 10.1016/j.jpeds.2019.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/25/2019] [Accepted: 05/13/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate whether the development of postnatal, late-onset refractory hypotension, referred to as late-onset circulatory collapse, was associated with an increased risk of developing cerebral palsy (CP) at 3 years of age in extremely preterm infants. METHODS In this historical cohort study, infants who were born at 22-27 weeks of gestation from 2008 to 2012 in the Neonatal Research Network of Japan were eligible. The study sample consisted of 3474 infants (45.6% of 7613 potentially eligible infants) who were evaluated at 36-42 months of age. Late-onset circulatory collapse was defined as a clinical diagnosis of late-onset circulatory collapse requiring treatment with corticosteroids. We compared the neurodevelopmental outcomes between infants with and without late-onset circulatory collapse. RESULTS Late-onset circulatory collapse was diagnosed in 666 of the infants studied. Infants with late-onset circulatory collapse had a higher incidence of CP than those without late-onset circulatory collapse (18.0% vs 9.8%; P < .01). In multivariable logistic analysis, late-onset circulatory collapse was independently associated with CP (aOR, 1.52; 95% CI, 1.13-2.04) and developmental quotient score of <50 (OR, 1.83; 95% CI, 1.23-2.72). CONCLUSIONS Late-onset circulatory collapse may be a relatively common event occurring in extremely preterm infants and an independent risk factor for CP at 3 years of age.
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17
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Smith LK, Blondel B, Van Reempts P, Draper ES, Manktelow BN, Barros H, Cuttini M, Zeitlin J. Variability in the management and outcomes of extremely preterm births across five European countries: a population-based cohort study. Arch Dis Child Fetal Neonatal Ed 2017; 102:F400-F408. [PMID: 28232518 DOI: 10.1136/archdischild-2016-312100] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 01/16/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To explore international variations in the management and survival of extremely low gestational age and birthweight births. DESIGN Area-based prospective cohort of births SETTING: 12 regions across Belgium, France, Italy, Portugal and the UK PARTICIPANTS: 1449 live births and fetal deaths between 22+0 and 25+6 weeks gestation born in 2011-2012. MAIN OUTCOME MEASURES Percentage of births; recorded live born; provided antenatal steroids or respiratory support; surviving to discharge (with/without severe morbidities). RESULTS The percentage of births recorded as live born was consistently low at 22 weeks and consistently high at 25 weeks but varied internationally at 23 weeks for those weighing 500 g and over (range 33%-70%) and at 24 weeks for those under 500 g (range 5%-71%). Antenatal steroids and provision of respiratory support at 22-24 weeks gestation varied between countries, but were consistently high for babies born at 25 weeks. Survival to discharge was universally poor at 22 weeks gestation (0%) and at any gestation with birth weight <500 g, irrespective of treatment provision. In contrast, births at 23 and 24 weeks weighing 500 g and over showed significant international variation in survival (23 weeks: range: 0%-25%; 24 weeks range: 21%-50%), reflecting levels of treatment provision. CONCLUSIONS Wide international variation exists in the management and survival of extremely preterm births at 22-24 weeks gestation. Universally poor outcomes for babies at 22 weeks and for those weighing under 500 g suggest little impact of intervention and support the inclusion of birth weight along with gestational age in ethical decision-making guidelines.
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Affiliation(s)
- Lucy K Smith
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Beatrice Blondel
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm UMR 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
| | - Patrick Van Reempts
- Department of Neonatology, Antwerp University Hospital, University of Antwerp, Antwerp and Study Centre for Perinatal Epidemiology Flanders, Brussels, Belgium
| | | | | | - Henrique Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Jennifer Zeitlin
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm UMR 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
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18
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Greenberg RG, Kandefer S, Do BT, Smith PB, Stoll BJ, Bell EF, Carlo WA, Laptook AR, Sánchez PJ, Shankaran S, Van Meurs KP, Ball MB, Hale EC, Newman NS, Das A, Higgins RD, Cotten CM. Late-onset Sepsis in Extremely Premature Infants: 2000-2011. Pediatr Infect Dis J 2017; 36:774-779. [PMID: 28709162 PMCID: PMC5627954 DOI: 10.1097/inf.0000000000001570] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [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: 11/25/2022]
Abstract
BACKGROUND Late-onset sepsis (LOS) is an important cause of death and neurodevelopmental impairment in premature infants. The purpose of this study was to assess overall incidence of LOS, distribution of LOS-causative organisms and center variation in incidence of LOS for extremely premature infants over time. METHODS In a retrospective analysis of infants 401-1000 g birth weight and 22-28 6/7 weeks of gestational age born at 12 National Institute of Child Health and Human Development Neonatal Research Network centers in the years 2000-2005 (era 1) or 2006-2011 (era 2) who survived >72 hours, we compared the incidence of LOS and pathogen distribution in the 2 eras using the χ test. We also examined the effect of birth year on the incidence of LOS using multivariable regression to adjust for nonmodifiable risk factors and for center. To assess whether the incidence of LOS was different among centers in era 2, we used a multivariable regression model to adjust for nonmodifiable risk factors. RESULTS Ten-thousand one-hundred thirty-one infants were studied. LOS occurred in 2083 of 5031 (41%) infants in era 1 and 1728 of 5100 (34%) infants in era 2 (P < 0.001). Birth year was a significant predictor of LOS on adjusted analysis, with birth years 2000-2009 having a significantly higher odds of LOS than the reference year 2011. Pathogens did not differ, with the exception of decreased fungal infection (P < 0.001). In era 2, 9 centers had significantly higher odds of LOS compared with the center with the lowest incidence. CONCLUSIONS The incidence of LOS decreased over time. Further investigation is warranted to determine which interventions have the greatest impact on infection rates.
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Affiliation(s)
- Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Sarah Kandefer
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - Barbara T. Do
- Social, Statistical and Environmental Sciences Unit, RTI International, Research Triangle Park, NC
| | - P. Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Barbara J. Stoll
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Waldemar A. Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL
| | - Abbot R. Laptook
- Department of Pediatrics, Women & Infants Hospital, Brown University, Providence, RI
| | - Pablo J. Sánchez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Krisa P. Van Meurs
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - M. Bethany Ball
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University School of Medicine and Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Ellen C. Hale
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, GA
| | - Nancy S. Newman
- Department of Pediatrics, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH
| | - Abhik Das
- Social, Statistical and Environmental Sciences Unit, RTI International, Rockville, MD
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
| | - C. Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC
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19
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Abstract
Despite substantial progress in neonatal care over the past two decades leading to improved survival of extremely premature infants, extreme prematurity continues to be associated with long term neurodevelopmental impairments. Cerebral white matter injury is the predominant form of insult in preterm brain leading to adverse neurological consequences. Such brain injury pattern and unfavorable neurologic sequelae is commonly encountered in premature infants exposed to systemic inflammatory states such as clinical or culture proven sepsis with or without evidence of meningitis, prolonged mechanical ventilation, bronchopulmonary dysplasia, necrotizing enterocolitis and chorioamnionitis. Underlying mechanisms may include cytokine mediated processes without direct entry of pathogens into the brain, developmental differences in immune response and complex neurovascular barrier system that play a critical role in regulating the cerebral response to various systemic inflammatory insults in premature infants. Understanding of these pathologic mechanisms and clinical correlates of such injury based on serum biomarkers or brain imaging findings on magnetic resonance imaging will pave way for future research and translational therapeutic opportunities for the developing brain.
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Affiliation(s)
- Aparna Patra
- OMNI Academic Service Line and Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Hong Huang
- OMNI Academic Service Line and Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - John A Bauer
- OMNI Academic Service Line and Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Peter J Giannone
- OMNI Academic Service Line and Division of Neonatology, Department of Pediatrics, Kentucky Children's Hospital, College of Medicine, University of Kentucky, Lexington, KY, USA
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Kavanaugh K, Nantais-Smith LM, Savage T, Schim SM, Natarajan G. Extended family support for parents faced with life-support decisions for extremely premature infants. Neonatal Netw 2016; 33:255-62. [PMID: 25161133 DOI: 10.1891/0730-0832.33.5.255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To outline parents' descriptions of extended family involvement and support surrounding decision making for their extremely preterm infant. DESIGN Collective case study design in a prospective, descriptive, longitudinal research. Seventy-five digitally recorded interviews were done with parents before and after the birth. SAMPLE Fifty-four parents (40 mothers, 14 fathers). MAIN OUTCOME VARIABLE Categories of family involvement and support in the parents' decision making. RESULTS Most parents did not seek advice from family members for life-support decisions made prenatally. Instead, parents made the decision as a couple with their physician without seeking family input. Family members provided certain types of support: emotional support, advice and information, prayer, and instrumental help such as child care. Most parents described at least one way their family supported them. For postnatal and end-of-life decisions, parents were more likely to seek advice from extended family in addition to the other forms of support.
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21
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Abstract
OBJECTIVE To increase our understanding of moral distress experienced by neonatal registered nurses when directly or indirectly involved in the decision-making process of resuscitating infants who are born extremely premature. DESIGN A secondary qualitative analysis was conducted on a portion of the data collected from an earlier study which explored the ethical decision-making process among health professionals and parents concerning resuscitation of extremely premature infants. SETTING A regional, tertiary academic referral hospital in Ontario offering a perinatal program. PARTICIPANTS A total of 15 registered nurses were directly or indirectly involved in the resuscitation of extremely premature infants. METHODS Interview transcripts of nurses from the original study were purposefully selected from the original 42 transcripts of health professionals. Inductive content analysis was conducted to identify themes describing factors and situations contributing to moral distress experienced by nurses regarding resuscitation of extremely premature infants. ETHICAL CONSIDERATIONS Ethical approval was obtained from the research ethics review board for both the initial study and this secondary data analysis. RESULTS Five themes, uncertainty, questioning of informed consent, differing perspectives, perceptions of harm and suffering, and being with the family, contribute to the moral distress felt by nurses when exposed to neonatal resuscitation of extremely premature infants. An interesting finding was the nurses' perceived lack of power and influence in the neonatal resuscitation decision-making process. CONCLUSION Moral distress continues to be a significant issue for nursing practice, particularly among neonatal nurses. Strategies are needed to help mediate the moral distress experienced by nurses, such as debriefing sessions, effective communication, role clarification, and interprofessional education and collaboration.
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Affiliation(s)
| | - Marilyn Evans
- School of Nursing, Faculty of Health Sciences, University of Western Ontario, London, ON, Canada
| | - Kevin Coughlin
- Division of Neonatal-Perinatal Medicine, Department of Paediatrics, University of Western Ontario, London, ON, Canada
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Lamberska T, Vaňkova J, Plavka R. Efficacy of FiO2 increase during the initial resuscitation of premature infants < 29 weeks: an observational study. Pediatr Neonatol 2013; 54:373-9. [PMID: 24126011 DOI: 10.1016/j.pedneo.2013.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 04/01/2013] [Revised: 06/06/2013] [Accepted: 06/29/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE To evaluate the heart rate (HR) and oxygen saturation (SpO2) at 15-second intervals within 60 seconds after incremental increases of fractional inspired oxygen (FiO2) during resuscitation of infants younger than 29 weeks requiring two different forms of ventilatory support. STUDY DESIGN Retrospective observational study. METHODS Forty-three infants were stabilized, 14 by continuous positive airway pressure exclusively (CPAP group), and 29 by positive pressure ventilation (PPV group). Both groups received ventilatory support in a special bed with two cameras enabling the evaluation of all interventions including HR, SpO2, FiO2, positive inflation pressure, and positive end-expiratory pressure values. FiO2 was commenced at 0.30 and titrated in 0.1-0.2 increments every 30-60 seconds. The relationships between the incremental increases of FiO2 and related SpO2 and HR changes were evaluated. RESULTS Although there was an inverse correlation between initial FiO2 and SpO2 in both groups, a significant positive correlation between the incremental increase of FiO2 and SpO2 changes after 30 seconds was found only in the CPAP group. Only higher initial levels of FiO2 had a positive effect on the improvement in SpO2 in the PPV group. CONCLUSION The efficacy of FiO2 titration in 0.1-0.2 increments may be attenuated and delayed in extremely preterm infants required PPV during the first 6 minutes of life.
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Affiliation(s)
- Tereza Lamberska
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants' risk of necrotizing enterocolitis or death. J Perinatol 2009; 29:57-62. [PMID: 18716628 DOI: 10.1038/jp.2008.117] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the association between human milk (HM) intake and risk of necrotizing enterocolitis (NEC) or death among infants 401 to 1000 g birth weight. STUDY DESIGN Analysis of 1272 infants in the National Institute of Child Health and Human Development Neonatal Network Glutamine Trial was performed to determine if increasing HM intake was associated with decreased risk of NEC or death. HM intake was defined as the proportion of HM to total intake, to enteral intake and total volume over the first 14 days. Known NEC risk factors were included as covariates in Cox proportional hazard analyses for duration of survival time free of NEC. RESULT Among study infants, 13.6% died or developed NEC after 14 days. The likelihood of NEC or death after 14 days was decreased by a factor of 0.83 (95% confidence interval, CI 0.72, 0.96) for each 10% increase in the proportion of total intake as HM. Each 100 ml kg(-1) increase in HM intake during the first 14 days was associated with decreased risk of NEC or death (hazard ratio, HR 0.87 (95% CI 0.77, 0.97)). There appeared to be a trend towards a decreased risk of NEC or death among infants who received 100% HM as a proportion to total enteral intake (HM plus formula), although this finding was not statistically significant (HR 0.85 (95% CI 0.60, 1.19)). CONCLUSION These data suggest a dose-related association of HM feeding with a reduction of risk of NEC or death after the first 2 weeks of life among extremely low birth weight infants.
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Sekar K. The role of continuous positive airway pressure therapy in the management of respiratory distress in extremely premature infants. J Pediatr Pharmacol Ther 2006; 11:145-52. [PMID: 23118651 DOI: 10.5863/1551-6776-11.3.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The use of mechanical ventilation for the treatment of respiratory distress syndrome (RDS) in low birth weight infants may cause barotrauma, volutrauma, and chronic lung disease. Different continuous positive airway pressure (CPAP) delivery systems exist, each with its own practical and clinical advantages and disadvantages. CPAP can be used as either a primary or an adjunctive respiratory support for RDS. Research demonstrates that CPAP decreases the incidence of respiratory failure after extubation. Clinical trials indicate that the optimal management of neonatal RDS consists of early surfactant treatment followed quickly by extubation and stabilization on CPAP. Early surfactant treatment combined with CPAP reduces the need for mechanical ventilation, compared to later surfactant treatment. Evidence suggests a synergistic effect between early surfactant administration and rapid extubation to nasal CPAP.
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Affiliation(s)
- Kris Sekar
- Neonatal Intensive Care Unit, Infant Breathing Disorders Center, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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