The impact of neurally adjusted ventilatory assist mode on respiratory severity score and energy expenditure in infants: a randomized crossover trial

OBJECTIVE

Examine respiratory severity scores (RSS) (mean airway pressure × fraction of inspired oxygen) and resting energy expenditure (REE) on neurally adjusted ventilatory assist (NAVA) compared with synchronized intermittent mandatory ventilation with pressure controlled and supported breath (SIMV (PC)PS).

STUDY DESIGN

A randomized, crossover trial in a level IV neonatal intensive care unit. Twenty-four patients were ventilated with NAVA or SIMV (PC) PS for 12 h and then crossed over to the alternative mode for 12 h. The primary outcome (RSS) and additional secondary respiratory outcomes were analyzed.

RESULTS

RSS and measured REE were not different between modes. On NAVA, peak inspiratory pressures were lower (17.8 vs 19.9 cmH₂O (P<0.05)) without higher oxygen requirements. Respiratory rates were higher on NAVA (52 vs 39 (P<0.05)), estimated work of breathing (WOB) (0.01 vs 0.04 J l^-1 (P<0.05)) was improved.

CONCLUSION

NAVA mode can be safe without increase in RSS or REE. Although respiratory rates were higher, this was offset by lower peak inspiratory pressures and WOB during NAVA.

Short-term outcomes after perinatal hypoxic ischemic encephalopathy: a report from the Children's Hospitals Neonatal Consortium HIE focus group

OBJECTIVE

To characterize infants affected with perinatal hypoxic ischemic encephalopathy (HIE) who were referred to regional neonatal intensive care units (NICUs) and their related short-term outcomes.

STUDY DESIGN

This is a descriptive study evaluating the data collected prospectively in the Children's Hospital Neonatal Database, comprised of 27 regional NICUs within their associated children's hospitals. A consecutive sample of 945 referred infants born ⩾36 weeks' gestation with perinatal HIE in the first 3 days of life over approximately 3 years (2010-July 2013) were included. Maternal and infant characteristics are described. Short-term outcomes were evaluated including medical comorbidities, mortality and status of survivors at discharge.

RESULT

High relative frequencies of maternal predisposing conditions, cesarean and operative vaginal deliveries were observed. Low Apgar scores, profound metabolic acidosis, extensive resuscitation in the delivery room, clinical and electroencephalographic (EEG) seizures, abnormal EEG background and brain imaging directly correlated with the severity of HIE. Therapeutic hypothermia was provided to 85% of infants, 15% of whom were classified as having mild HIE. Electrographic seizures were observed in 26% of the infants. Rates of complications and morbidities were similar to those reported in prior clinical trials and overall mortality was 15%.

CONCLUSION

Within this large contemporary cohort of newborns with perinatal HIE, the application of therapeutic hypothermia and associated neurodiagnostic studies appear to have expanded relative to reported clinical trials. Although seizure incidence and mortality were lower compared with those reported in the trials, it is unclear whether this represented improved outcomes or therapeutic drift with the treatment of milder disease.

The Children's Hospitals Neonatal Database: an overview of patient complexity, outcomes and variation in care

The Children's Hospitals Neonatal Consortium is a multicenter collaboration of leaders from 27 regional neonatal intensive care units (NICUs) who partnered with the Children's Hospital Association to develop the Children's Hospitals Neonatal Database (CHND), launched in 2010. The purpose of this report is to provide a first summary of the population of infants cared for in these NICUs, including representative diagnoses and short-term outcomes, as well as to characterize the participating NICUs and institutions. During the first 2 1/2 years of data collection, 40910 infants were eligible. Few were born inside these hospitals (2.8%) and the median gestational age at birth was 36 weeks. Surgical intervention (32%) was common; however, mortality (5.6%) was infrequent. Initial queries into diagnosis-specific inter-center variation in care practices and short-term outcomes, including length of stay, showed striking differences. The CHND provides a contemporary, national benchmark of short-term outcomes for infants with uncommon neonatal illnesses. These data will be valuable in counseling families and for conducting observational studies, clinical trials and collaborative quality improvement initiatives.

Predicting death or tracheostomy placement in infants with severe bronchopulmonary dysplasia

OBJECTIVE

To estimate the risk of death or tracheostomy placement (D/T) in infants with severe bronchopulmonary dysplasia (sBPD) born < 32 weeks' gestation referred to regional neonatal intensive care units.

STUDY DESIGN

We conducted a retrospective cohort study in infants born < 32 weeks' gestation with sBPD in 2010-2011, using the Children's Hospital Neonatal Database. sBPD was defined as the need for FiO2 ⩾ 0.3, nasal cannula support >2 l min(-1) or positive pressure at 36 weeks' post menstrual age. The primary outcome was D/T before discharge. Predictors associated with D/T in bivariable analyses (P < 0.2) were used to develop a multivariable logistic regression equation using 80% of the cohort. This equation was validated in the remaining 20% of infants.

RESULT

Of 793 eligible patients, the mean gestational age was 26 weeks' and the median age at referral was 6.4 weeks. D/T occurred in 20% of infants. Multivariable analysis showed that later gestational age at birth, later age at referral along with pulmonary management as the primary reason for referral, mechanical ventilation at the time of referral, clinically diagnosed pulmonary hypertension, systemic corticosteroids after referral and occurrence of a bloodstream infection after referral were each associated with D/T. The model performed well with validation (area under curve 0.86, goodness-of-fit χ(2), P = 0.66).

CONCLUSION

Seven clinical variables predicted D/T in this large, contemporary cohort with sBPD. These results can be used to inform clinicians who counsel families of affected infants and to assist in the design of future prospective trials.

Therapeutic interventions and short-term outcomes for infants with severe bronchopulmonary dysplasia born at <32 weeks' gestation

OBJECTIVE

To characterize the treatments and short-term outcomes in infants with severe bronchopulmonary dysplasia (sBPD) referred to regional neonatal intensive care units.

STUDY DESIGN

Infants born <32 weeks' gestation with sBPD were identified using the Children's Hospital Neonatal Database. Descriptive outcomes are reported.

RESULT

A total of 867 patients were eligible. On average, infants were born at 26 weeks' gestation and referred 43 days after birth. Infants frequently experienced lung injury (pneumonia: 24.1%; air leak: 9%) and received systemic corticosteroids (61%) and mechanical ventilation (median duration 37 days). Although 91% survived to discharge, the mean post-menstrual age was 47 weeks. Ongoing care such as supplemental oxygen (66%) and tracheostomy (5%) were frequently needed.

CONCLUSION

Referred infants with sBPD sustain multiple insults to lung function and development. Because affected infants have no proven, safe or efficacious therapy and endure an exceptional burden of care even after referral, urgent work is required to observe and improve their outcomes.

Enigma of maternal race and infant birth weight: a population-based study of US-born Black and Caribbean-born Black women

The authors used 1985-1990 Illinois' vital records to determine the low birth weight components of infants delivered to US-born Black women, Caribbean-born Black women, and US-born White women. The moderately low birth weight rate (1,500-2,499 g) was 10% for infants with US-born Black mothers (n = 67,357) and 6% for infants with Caribbean-born mothers (n = 2,265) compared with 4% for infants with US-born White mothers (n = 34,124); the relative risk equaled 2.7 (95% confidence interval (CI): 2.5, 2.8) and 1.7 (95% CI: 1.4, 2.0), respectively. The very low birth weight rate (<1,500 g) was 2.6% for infants delivered to US-born Black women and 2.4% for infants to Caribbean-born women compared with 0.7% for infants to US-born White women; the relative risk equaled 3.6 (95% CI: 3.1, 4.1) and 3.3 (95% CI: 2.5, 4.4), respectively. Among the lowest risk mothers, the relative risk of moderately low birth weight for infants with US-born Black mothers and Caribbean-born mothers (compared with US-born White mothers) was 2.7 (95% CI: 2.1, 3.4) and 1.2 (95% CI: 0.4, 3.1), respectively; the relative risk of very low birth weight for infants with US-born Black mothers and Caribbean-born mothers was 6.7 (95% CI: 3.8, 12) and 4.2 (95% CI: 1.0, 18), respectively. The authors conclude that Caribbean-born women and US-born Black women have disparate moderate rates but equivalent very low birth weight rates.