Epidemiology of post-hemorrhagic ventricular dilatation in very preterm infants

OBJECTIVE

To describe the incidence, trends, management's variability and short-term outcomes of preterm infants with severe post-hemorrhagic ventricular dilatation (sPHVD).

METHODS

We reviewed infants <33 weeks' gestation who had PHVD and were admitted to the Canadian Neonatal Network between 2010 and 2018. We compared perinatal characteristics and short-term outcomes between those with sPHVD and those with mild/moderate PHVD and those with and without ventriculo-peritoneal (VP) shunt.

RESULTS

Of 29,417 infants, 2439 (8%) had PHVD; rate increased from 7.3% in 2010 to 9.6% in 2018 (P = 0.005). Among infants with PHVD, sPHVD (19%) and VP shunt (29%) rates varied significantly across Canadian centers and between geographic regions (P < 0.01 and P = 0.0002). On multivariable analysis, sPHVD was associated with greater mortality, seizures and meningitis compared to mild/moderate PHVD.

CONCLUSIONS

Significant variability in sPHVD and VP shunt rates exists between centers and regions in Canada. sPHVD was associated with increased mortality and morbidities.

Next generation sequencing in neonatology: what does it mean for the next generation?

Rapid whole genome sequencing (WGS) and whole exome sequencing (WES), sometimes referred to as "next generation sequencing" (NGS) are now recommended by some experts as a first-line diagnostic test to diagnose infants with suspected monogenic conditions. Estimates of how often NGS leads to diagnoses or changes in management vary widely depending on the population being studied and the indications for testing. Finding a genetic variant that is classified as pathogenic may not necessarily equate with being able to predict the resultant phenotype or to give a reliable prognosis. Molecular diagnoses do not usually lead to changes in clinical management but they often end a family's diagnostic Odyssey and allow informed decisions about future reproductive choices. The likelihood that NGS will be beneficial for patients and families in the NICU remains uncertain. The goal of this paper is to highlight the implications of these ambiguities in interpreting the results of NGS. To do that, we will first review the types of cases that are admitted to NICUs and show why, at least in theory, NGS is unlikely to be useful for most NICU patients and families and may even be harmful for some, although it can help families in some cases. We then present a number of real cases in which NGS results were obtained and show that they often lead to unforeseen and unpredictable consequences. Finally, we will suggest ways to communicate with families about NGS testing and results in order to help them understand the meaning of NGS results and the uncertainty that surrounds them.

Impact of Deferred Cord Clamping on Mortality and Severe Neurologic Injury in Twins Born at <30 Weeks of Gestation

OBJECTIVE

To determine whether deferred cord clamping (DCC) compared with early cord clamping (ECC) was associated with reduction in death and/or severe neurologic injury among twins born at <30 weeks of gestation.

STUDY DESIGN

We performed a retrospective cohort study including all liveborn twins of <30 weeks admitted to a tertiary-level neonatal intensive care unit (NICU) in Canada between 2015 and 2018 using the Canadian Neonatal/Preterm Birth Network database. We compared DCC ≥30 seconds vs ECC <30 seconds. Our primary outcome was a composite of death and/or severe neurologic injury (severe intraventricular hemorrhage grade III/IV and/or periventricular leukomalacia). Secondary outcomes included neonatal morbidity and health care utilization outcomes. We calculated aORs and β coefficients for categorical and continuous variables, along with 95% CI. Models were fitted with generalized estimated equations accounting for twin correlation.

RESULTS

We included 1597 twins (DCC, 624 [39.1%]; ECC, 973 [60.9%]). Death/severe neurologic injury occurred in 17.8% (n = 111) of twins who received DCC and in 21.7% (n = 211) of those who received ECC. The rate of death/severe neurologic injury did not differ significantly between the DCC and ECC groups (aOR 1.07; 95% CI, 0.78-1.47). DCC was associated with reduced blood transfusions (adjusted β coefficient, -0.49; 95% CI, -0.86 to -0.12) and NICU length of stay (adjusted β coefficient, -4.17; 95% CI, -8.15 to -0.19).

CONCLUSIONS

The primary composite outcome of death and/or severe neurologic injury did not differ between twins born at <30 weeks of gestation who received DCC and those who received ECC, but DCC was associated with some benefits.

Neurodevelopmental outcomes of preterm infants conceived by assisted reproductive technology

BACKGROUND

There have been concerns about the development of children conceived through assisted reproductive technology. Despite multiple studies investigating the outcomes of assisted conception, data focusing specifically on the neurodevelopmental outcomes of infants conceived through assisted reproductive technology and born preterm are limited.

OBJECTIVE

This study aimed to evaluate and compare the neurodevelopmental outcomes of preterm infants born at <29 weeks' gestation at 18 to 24 months' corrected age who were conceived through assisted reproductive technology and those who were conceived naturally.

STUDY DESIGN

This retrospective cohort study included inborn, nonanomalous infants, born at <29 weeks' gestation between January 1, 2010, and December 31, 2016, who had a neurodevelopmental assessment at 18 to 24 months' corrected age at any of the 10 Canadian Neonatal Follow-Up Network clinics. The primary outcome was neurodevelopmental impairment at 18 to 24 months, defined as the presence of any of the following: cerebral palsy; Bayley-III cognitive, motor, or language composite score of <85; sensorineural or mixed hearing loss; and unilateral or bilateral visual impairment. Secondary outcomes included mortality, composite of mortality or neurodevelopmental impairment, significant neurodevelopmental impairment, and each component of the primary outcome. We compared outcomes between infants conceived through assisted reproductive technology and those conceived naturally, using bivariate and multivariable analyses after adjustment.

RESULTS

Of the 4863 eligible neonates, 651 (13.4%) were conceived using assisted reproductive technology. Maternal age; education level; and rates of diabetes mellitus, receipt of antenatal corticosteroids, and cesarean delivery were higher in the assisted reproduction group than the natural conception group. Neonatal morbidity and death rates were similar except for intraventricular hemorrhage, which was lower in the assisted reproduction group (33% [181 of 546] vs 39% [1284 of 3318]; P=.01). Of the 4176 surviving infants, 3386 (81%) had a follow-up outcome at 18 to 24 months' corrected age. Multivariable logistic regression adjusting for gestational age, antenatal steroids, sex, small for gestational age, multiple gestations, mode of delivery, maternal age, maternal education, pregnancy-induced hypertension, maternal diabetes mellitus, and smoking showed that infants conceived through assisted reproduction was associated with lower odds of neurodevelopmental impairment (adjusted odds ratio, 0.67; 95% confidence interval, 0.52-0.86) and the composite of death or neurodevelopmental impairment (adjusted odds ratio, 0.67; 95% confidence interval, 0.54-0.84). Conception through assisted reproductive technology was associated with decreased odds of a Bayley-III composite cognitive score of <85 (adjusted odds ratio, 0.68; 95% confidence interval, 0.48-0.99) and composite language score of <85 (adjusted odds ratio, 0.67; 95% confidence interval, 0.50-0.88).

CONCLUSION

Compared with natural conception, assisted conception was associated with lower odds of adverse neurodevelopmental outcomes, especially cognitive and language outcomes, at 18 to 24 months' corrected age among preterm infants born at <29 weeks' gestation. Long-term follow-up studies are required to assess the risks of learning disabilities and development of complex visual-spatial and processing skills in these children as they reach school age.

Intervention and Outcome for Neonatal Hypotension

Many observational studies have shown that infants with blood pressures (BPs) that are in the lower range for their gestational age tend to have increased complications such as an increased rate of significant intraventricular hemorrhage and adverse long-term outcome. This relationship does not prove causation nor should it create an indication for treatment. However, many continue to intervene with medication for low BP on the assumption that an increase in BP will result in improved outcome. Only adequately powered prospective randomized controlled trials can answer the question of whether individual treatments of low BP are beneficial.

Lactoferrin infant feeding trial_Canada (LIFT_Canada): protocol for a randomized trial of adding lactoferrin to feeds of very-low-birth-weight preterm infants

BACKGROUND

In Canada alone, almost 3000 VLBW infants are born and treated annually with almost 1200 going onto death or survival with severe brain injury, chronic lung disorders, aggressive retinopathy of prematurity, late-onset sepsis, or significant necrotizing enterocolitis. Lactoferrin is an antimicrobial, antioxidant, anti-inflammatory iron-carrying, bifidogenic glycoprotein found in all vertebrates and in mammalian milk, leukocytes and exocrine secretions. Lactoferrin aids in creating an environment for growth of beneficial bacteria in the gut, thus reducing colonization with pathogenic bacteria. It is hypothesized that oral bovine lactoferrin (bLF), through its antimicrobial, antioxidant and anti-inflammatory properties, will reduce the rate of mortality or major morbidity in very low birth weight preterm infants.

METHOD

Lactoferrin Infant Feeding Trial_Canada (LIFT_Canada) is a multi-centre, double-masked, randomized controlled trial with the aim to enroll 500 infants whose data will be combined with the data of the 1542 infants enrolled from Lactoferrin Infant Feeding Trial_Australia/New Zealand (LIFT_ANZ) in a pooled intention-to-treat analysis. Eligible infants will be randomized and allocated to one of two treatment groups: 1) a daily dose of 200 mg/kg bLF in breast/donor human milk or formula milk until 34 weeks corrected gestation or for a minimum of 2 weeks, whichever is longer, or until discharge home or transfer, if earlier; 2) no bLF with daily feeds. The primary outcome will be determined at 36 weeks corrected gestation for the presence of neonatal morbidity and at discharge for survival and treated retinopathy of prematurity. The duration of the trial is expected to be 36 months.

DISCUSSION

Currently, there continues to be no clear answer related to the benefit of bLF in reducing mortality or any or all of the significant neonatal morbidities in very low birth weight infants. LIFT_Canada is designed with the hope that the pooled results from Australia, New Zealand, and Canada may help to clarify the situation.

TRIAL REGISTRATION

Clinical Trials.Gov, Identifier: NCT03367013, Registered December 8, 2017.

Duration of Initial Empirical Antibiotic Therapy and Outcomes in Very Low Birth Weight Infants

: media-1vid110.1542/5984244681001PEDS-VA_2018-2286Video Abstract BACKGROUND: Overuse of antibiotics can facilitate antibiotic resistance and is associated with adverse neonatal outcomes. We studied the association between duration of antibiotic therapy and short-term outcomes of very low birth weight (VLBW) (<1500 g) infants without culture-proven sepsis.

METHODS

We included VLBW infants admitted to NICUs in the Canadian Neonatal Network between 2010-2016 who were exposed to antibiotics but did not have culture-proven sepsis in the first week. Antibiotic exposure was calculated as the number of days an infant received antibiotics in the first week of life. Composite primary outcome was defined as mortality or any major morbidity (severe neurologic injury, retinopathy of prematurity, necrotizing enterocolitis, chronic lung disease, or hospital-acquired infection).

RESULTS

Of the 14 207 included infants, 21% (n = 2950), 38% (n = 5401), and 41% (n = 5856) received 0, 1 to 3, and 4 to 7 days of antibiotics, respectively. Antibiotic exposure for 4 to 7 days was associated with higher odds of the composite outcome (adjusted odds ratio 1.24; 95% confidence interval [CI] 1.09-1.41). Each additional day of antibiotic use was associated with 4.7% (95% CI 2.6%-6.8%) increased odds of composite outcome and 7.3% (95% CI 3.3%-11.4%) increased odds in VLBW infants at low risk of early-onset sepsis (born via cesarean delivery, without labor and without chorioamnionitis).

CONCLUSIONS

Prolonged empirical antibiotic exposure within the first week after birth in VLBW infants is associated with increased odds of the composite outcome. This practice is a potential target for antimicrobial stewardship.

Severe Neurodevelopmental Impairment in Neonates Born Preterm: Impact of Varying Definitions in a Canadian Cohort

OBJECTIVE

To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort.

STUDY DESIGN

Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23-28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months' corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI.

RESULTS

The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37-5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, employment status, antenatal corticosteroid treatment, and gestational age were not associated consistently with severe NDI. Although maternal substance use, sex, score of neonatal acute physiology >20, late-onset sepsis, bronchopulmonary dysplasia, and brain injury were consistently associated with severe NDI irrespective of definition, the strength of the associations varied.

CONCLUSIONS

The definition of severe NDI significantly influences the incidence and the associations between risk factors and severe NDI. A standardized definition would facilitate site comparisons and scientific communication.

CEREBRAL OXYGENATION AND PERIPHERAL OXIMETRY IN EXTREMELY PRETERM INFANTS WITH PULMONARY AND/OR CEREBRAL INTRAVENTRICULAR HEMORRHAGE IN THE FIRST 72 HOURS OF LIFE

BACKGROUND

Extremely premature infants born <28 weeks of gestation are at higher risk of pulmonary (PH) and cerebral intraventricular (IVH) hemorrhage due to immature cardiovascular and transitioning physiology. Non-invasive monitoring has the potential to detect early abnormal circulation.

OBJECTIVES

To explore time-frequency relationships between cerebral oxygenation and peripheral oximetry.

DESIGN/METHODS

Near infrared spectroscopy cerebral regional haemoglobin oxygen saturation (CrSO2), preductal peripheral perfusion index (PI), heart rate (HR), capillary oxygen saturation (SpO2), and blood pressure (BP) were monitored in the first 72h of life. Patients were grouped in infants with PH and/or IVH (n=8) and controls (n=10). Signals were decomposed in wavelets allowing the analysis of localized variations of power. This approach allowed to quantify the common power and determine the duration of significant cross-correlation, phase and coherence between each pair of signals. Groups were compared with Wilcoxon tests.

RESULTS

Figure 1 shows an example of CrSO2 and PI, and their cross-correlation, phase (semblance) and coherence in a control (left column) and a PH-IVH patient (right column). Durations of significant cross-correlation between CrSO2 and HR (p<0.01), and CrSO2 and SpO2 (p=0.02) were significantly lower in PH-IVH infants compared to controls. The duration of significant anti-phase between CrSO2 and SpO2 (p=0.01) and the duration of significant coherence between PI and BP (p=0.03) were also significantly lower in PH-IVH infants compared to controls. These differences may indicate a disruption in auto-regulation, which is currently incompletely understood in this population.

CONCLUSION

This study is the first to apply time-frequency analysis to simultaneous NIRS and preductal peripheral oximetry in extremely preterm infants early in life. Significantly lower durations of cross-correlation (CrSO2 with HR and SpO2), anti-phase (CrSO2, SpO2) and coherence (PI, BP) in PH-IVH patients may reflect early abnormal circulation. Our results show the potential of non-invasive monitoring to identify premature infants at-risk of early PH-IVH.

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth

OBJECTIVE

To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs).

STUDY DESIGN

Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity.

RESULTS

Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3).

CONCLUSIONS

The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Corticosteroid Therapy in Neonatal Septic Shock-Do We Prevent Death?

OBJECTIVE

The aim was to compare survival of patients with septic shock receiving or not hydrocortisone (HC) and to analyze the hemodynamic response to HC.

STUDY DESIGN

It is a retrospective study of 62 premature neonates with septic shock (confirmed bacteremia) and/or necrotizing enterocolitis (NEC) stage 2 and above receiving inotropes with or without HC. We analyzed survival and hemodynamic response to HC.

RESULTS

Thirty-nine (63%) premature neonates received HC and were compared with 23 (37%) who only received inotropes. Vasoactive index score (VAI) decreased and blood pressure, urine output, and oxygen requirements improved significantly following HC. Despite receiving more inotropes (VAI of 33 [20-53] vs 10 [8-20], p < 0.001), being more premature (26 ± 2 vs 27 ± 2 weeks, p = 0.02) and more frequently having NEC (64 vs 26%, p = 0.004), patients who received HC had similar survival from septic episode (death: 22% vs 41%, p = 0.12). However, patients receiving HC during their sepsis were less likely to survive at their 1-year postmenstrual age follow-up when accounted for gestational age (GA) at birth and duration of inotropes (hazard ratio 6.08 p = 0.01).

CONCLUSION

HC was used in infants with increased inotropic support. HC during septic shock was associated with similar survival from episode, but with decreased survival at 1-year postmenstrual age.

Association of Resident Duty Hour Reform and Neonatal Outcomes of Very Preterm Infants

Objective To assess the association of the 2011 Quebec provincial resident duty hour reform, which reduced the maximum consecutive hours worked by all residents from 24 to 16 hours, with neonatal outcomes.

Study Design Retrospective observational study of 4,271 infants born between 23 and 32 weeks, admitted at five Quebec neonatal intensive care units (NICUs) participating in the Canadian Neonatal Network (CNN) between 2008 and 2015 was conducted. Adjusted odds ratios (AORs) were calculated to compare mortality and the composite outcome of mortality or major morbidity before and after the implementation of the duty hour reform.

Results The mortality rate was 8.4% (218/2,598) before the resident duty hour reform and 8.6% (182/2,123) after the reform (odds ratio [OR] = 1.02, 95% confidence interval [CI] = 0.83–1.26). The composite outcome rate was 32% (830/2,598) before the duty hour reform and 29% (615/2,123) after the reform (OR = 0.87, 95% CI = 0.77–0.98). In the adjusted analyses, the resident call-hour reform was not associated with a significant change in mortality (AOR = 1.17, 95% CI = 0.91–1.50) or composite outcome (AOR = 0.87, 95% CI = 0.74–1.03).

Conclusion Reducing residents' duty hours from 24 to 16 hours in Quebec was not associated with a difference in mortality or the composite outcome of very preterm infants.

Admission Systolic Blood Pressure and Outcomes in Preterm Infants of ≤ 26 Weeks' Gestation

Objective To examine the relationship between admission systolic blood pressure (SBP) and adverse neonatal outcomes. Specifically, we aimed to identify the optimal SBP that is associated with the lowest rates of adverse outcomes in extremely preterm infants of ≤ 26 weeks' gestation.

Methods In this retrospective study, inborn neonates born at ≤ 26 weeks' gestational age and admitted to tertiary neonatal units participating in the Canadian Neonatal Network between 2003 and 2009 were included. The primary outcome was early mortality (≤ 7 days). Secondary outcomes included severe brain injury, late mortality, and a composite outcome defined as early mortality or severe brain injury. Nonlinear multivariable logistic regression models examined the relationship between admission SBP and outcomes.

Results Admission SBP demonstrated a U-shaped relationship with early mortality, severe brain injury, and composite outcome after adjustment for confounders (p < 0.01). The lowest risks of early mortality, severe brain injury, and composite outcome occurred at admission SBPs of 51, 55, and 54 mm Hg, respectively.

Conclusion In extremely preterm infants of ≤ 26 weeks' gestational age, the relationship between admission SBP, and early mortality and severe brain injury was “U-shaped.” The optimal admission SBP associated with lowest rates of adverse outcome was between 51 and 55 mm Hg.

Changes in perinatal hospital deaths occurring outside the neonatal intensive care unit over a decade

AIM

Perinatal deaths occurring outside the neonatal intensive care unit (NICU) are rarely recorded in outcome studies, despite having a direct impact on perinatal statistics. Our aim was to investigate the timing and modes of perinatal deaths that occurred outside the NICU and changes over time.

METHOD

We reviewed all perinatal deaths from 22 weeks of gestation onwards, without NICU admissions, during two periods in a Canadian tertiary mother and baby hospital and categorised deaths according to nine specific categories.

RESULTS

There were 444 perinatal deaths that satisfied the inclusion criteria. The total number of perinatal deaths increased from 2000 to 2002 (n = 197) and 2007 to 2010 (n = 247). The proportion of foetuses alive at the time of their mother's hospital admission, but then stillborn, decreased. There was a significant increase in terminations for congenital anomalies in the second cohort and a decrease in deaths following induction of labour and comfort care for foetal anomalies.

CONCLUSION

Approaches to end-of-life care changed between the two study periods. Paediatricians should be aware of the epidemiology of perinatal mortality in their own practice, as it has a direct impact on the denominator in NICU outcome studies.

The role of antenatal corticosteroids in twin pregnancies complicated by preterm birth

BACKGROUND

Data regarding the effects of antenatal corticosteroids in twin pregnancies are limited because of the insufficient number of women with twins enrolled in randomized controlled trials on antenatal corticosteroids. Furthermore, the interpretation of available data is limited by the fact that the interval from the administration of antenatal corticosteroids to delivery is greater than 7 days in a large proportion of twins, a factor that has been shown to affect the efficacy of antenatal corticosteroids and has not been controlled for in previous studies.

OBJECTIVE

The objective of the study was to compare neonatal mortality and morbidity in preterm twins receiving a complete course of antenatal corticosteroids 1-7 days before birth to those who did not receive antenatal corticosteroids and to compare these outcome effects with those observed in singletons.

STUDY DESIGN

We performed a retrospective cohort study using data collected on singleton and twin neonates born between 24(0/7) and 33(6/7) weeks' gestational age and were admitted to tertiary neonatal units in Canada between 2010 and 2014. A comparison of neonatal outcomes between twin neonates who received a complete course of antenatal corticosteroids 1-7 days before birth (n = 1758) and those who did not receive antenatal corticosteroids (n = 758) and between singleton neonates who received a complete course of antenatal corticosteroids 1-7 days before birth (n = 4638) and those did not receive antenatal corticosteroids (n = 2312) was conducted after adjusting for gestational age, sex, hypertension, outborn status, small for gestational age, parity, and cesarean birth. Adjusted odds ratios and 95% confidence intervals for various neonatal outcomes were calculated.

RESULTS

Administration of a complete course of antenatal corticosteroids within 1-7 days before birth in both twins and singletons was associated with similar reduced odds of neonatal death (for twins adjusted odds ratio 0.42 [95% confidence interval, 0.24-0.76] and for singletons adjusted odds ratios, 0.38 [95% confidence interval, 0.28-0.50]; P = .7 for comparison of twins vs singletons), mechanical ventilation (for twins adjusted odds ratio, 0.47 [95% confidence interval, 0.35-0.63] and for singletons adjusted odds ratio, 0.47 [95% confidence interval, 0.41-0.55]; P = .9), respiratory distress syndrome (for twins adjusted odds ratio, 0.53 [95% confidence interval, 0.40-0.69], and for singletons adjusted odds ratio, 0.54 [95% confidence interval, 0.47-0.62]; P = .9) and severe neurological injury (for twins adjusted odds ratio, 0.50 [95% confidence interval, 0.30-0.83] and for singletons adjusted odds ratio, 0.45 [95% confidence interval, 0.34-0.59]; P = .7). Administration of a complete course of antenatal corticosteroids was not associated with a reduced odds of bronchopulmonary dysplasia, severe retinopathy of prematurity, or necrotizing enterocolitis in both twins and singletons.

CONCLUSION

Administration of a complete course of antenatal corticosteroids 1-7 days before birth in twin pregnancies is associated with a clinically significant decrease in neonatal mortality, short-term respiratory morbidity, and severe neurological injury that is similar in magnitude to that observed among singletons.

Stronger and More Vulnerable: A Balanced View of the Impacts of the NICU Experience on Parents

For parents, the experience of having an infant in the NICU is often psychologically traumatic. No parent can be fully prepared for the extreme stress and range of emotions of caring for a critically ill newborn. As health care providers familiar with the NICU, we thought that we understood the impact of the NICU on parents. But we were not prepared to see the children in our own families as NICU patients. Here are some of the lessons our NICU experience has taught us. We offer these lessons in the hope of helping health professionals consider a balanced view of the NICU's impact on families.

Can We Predict Post-Hemorrhagic Ventricular Dilatation in Preterm Infants with Severe Intraventricular Hemorrhage?

BACKGROUND: The incidence of post-hemorrhagic ventricular dilatation (PHVD) remains high in preterm infants. Little is known about the risk factors for PHVD in infants with severe intraventricular hemorrhage (IVH).

OBJECTIVES: To determine the predictors of PHVD among preterm infants with severe IVH.

DESIGN/METHODS: We conducted a retrospective review of all pre-term infants (22+0 - 32+6 weeks) who were admitted to NICUs participating in the Canadian Neonatal Network between 2010 and 2014. Infants with severe IVH (IVH with ventricular dilatation or parenchymal bleeding) who survived ≥ 72 hours were included. Perinatal and neonatal risk factors were compared between infants with and without PHVD (lateral ventricles &gt;10 mm).

RESULTS: Of 16600 eligible infants, 1964 (11.8%) developed severe IVH. Of 1815 infants with severe IVH who survived ≥72 hours, 616 (34%) developed PHVD. Factors associated with occurrence of PHVD include: lower gestational age, small for gestational age, low 5 minute Apgar score, SNAPII score&gt;20, surfactant therapy, high frequency oscillatory ventilation (HFOV), inotropes and occurrence of pneumothorax. [table 1]. There were no differences between both groups in relation to antenatal steroids, multiple pregnancy, mode of delivery, birth weight, gender or the proportion received prophylactic indomethacin. Multivariate analysis showed low five-minute Apgar score and HFOV to be independent predictors of PHVD while maternal magnesium sulfate and small for gestation (SGA) to be protective against PHVD.[table 2].

CONCLUSION: Our study identified factors involved in the prediction of PHVD in a national cohort of preterm infants. The mechanisms by which these factors may impact PHVD need further investigation.

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Cardiac surgery for children with trisomies 13 and 18: Where are we now?

The objective is to examine whether cardiac surgery should be considered for children with trisomy 13 or 18 (T13 or 18).T13 or 18 were previously referred to as "lethal" conditions due to high mortality rates and severe disability among survivors. In the last decade, investigations have revealed these conditions are heterogeneous, with increasing numbers of studies describing interventions for these children. A number of factors makes the interpretation of reported outcomes after cardiac surgery challenging: (1) dissimilarities in practice lead to a wide variation in reported outcomes after cardiac surgery; (2) cardiac surgery is generally offered to older, healthier children; (3) cardiac surgeries of widely varying risks are often lumped together in individual studies, and (4) cases where cardiac surgery has been withheld are generally not included in publications. It is unclear whether withholding cardiac surgery for some children with a ventricular septal defect will lead to death, or the development of pulmonary hypertension, or if death will occur from other causes. In this article, we describe two children with different clinical situations and examine whether cardiac surgery would benefit them and how to communicate with their families. Cardiac surgery may be beneficial to some children with trisomy 13 or 18, but may harm others. Every child should be approached in an individual fashion and the goals of each family should be addressed. Children who are more likely to benefit from surgery may be older, healthier children without respiratory support. Rigorous and transparent research is needed to identify factors that affect survival in trisomy 13 or 18.

Epidemiology of Posthemorrhagic Ventricular Dilatation in Canadian Neonatal Intensive Care Units

BACKGROUND: Severe intraventricular hemorrhage (IVH) is a common cause of neonatal morbidity and mortality .The incidence and management of post-hemorrhagic ventricular dilatation (PHVD) vary among different centres.

OBJECTIVES: To assess the incidence, temporal trend, management and associated outcomes of PHVD in Canadian NICUs.

DESIGN/METHODS: We conducted a retrospective review of all pre-term infants (22+0 -32+6 weeks) who were admitted to NICUs participating in the Canadian Neonatal Network between 2010 and 2014. Infants with severe IVH (IVH with ventricular dilatation or parenchymal bleeding) who survived ≥ 72 hours were included. We compared the rates of severe IVH, PHVD and VP shunting between the 5 Canadian regions. Short-term outcomes of infants who developed PHVD (ventricles size ≥10 mm) were compared with those who did not.

RESULTS: Of 16600 eligible infants, 1964 (11.8%) developed severe IVH. Of 1815 infants with severe IVH who survived ≥72 hours, 616 (34%) developed PHVD and 91 (5%) treated with VP shunt. No significant difference in the incidence of severe IVH, PHVD or VP shunting over the last five years was noted. There was a statistically significant difference in the rates of severe IVH (p&lt;0.0001) and PHVD (p=0.02) among the 5 Canadian regions. VP shunts rates were variable with some Canadian regions with higher rates of PHVD had low rates of VP shunts. [figure 1]. Infants with PHVD had significantly higher mortality and short term morbidities. [table 1]. On regression analysis, PHVD is an independent predictor of death in infants with severe IVH [adjusted OR 1.55, 95% CI (1.18, 2.04)]. Infants with VP shunt had significantly higher rates of severe ROP (p&lt;0.0001), meningitis (p&lt;0.0001), and hospitalization (89 vs 41 days, p&lt;0.0001).

CONCLUSION: PHVD is an independent predictor of death and is associated with adverse short- term outcomes. Variability exists between different regions in managing PHVD. Further studies are needed to investigate the impact of this variability on long-term outcomes.

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Trainee Perspectives on Manikin Death During Mock Codes

BACKGROUND

The acceptability of simulated death has been debated by experts, but there is scarce information regarding trainees' perspective.

METHODS

Trainees in a large pediatric program were invited to perform mock codes, including pre and post questionnaires. Participants were exposed to 2 mock codes of neonates born pulseless. In the RESUSC scenario, the manikin responded to adequate resuscitation; in the DEATH scenario, the manikin remained pulseless. Mock codes were videotaped and evaluated by using the Neonatal Resuscitation Program score sheet. Debriefing was analyzed by using qualitative methodology.

RESULTS

Fifty-nine of 62 trainees answered the questionnaire, and 42 performed a total of 84 mock codes. All trainees found mock codes beneficial and would appreciate being exposed to more. Most found them realistic and 78% agreed with the following statement: "During mock codes the manikin improves when adequate resuscitation steps are provided." The scenario or order of scenario did not affect performance (RESUSC versus DEATH). Only 1 trainee stopped resuscitation after 10 minutes of asystole; 31% had not ceased resuscitation efforts by 20 minutes. During debriefing and post questionnaire, trainees found the DEATH scenario more stressful than RESUSC. Trainees all answered the following question during debriefing: "How did this go for you?" Two themes were identified in their answers: (1) the manikin does not die; and (2) death equals inadequate resuscitation.

CONCLUSIONS

The death of the manikin was stressful, but trainees thought this was acceptable and prepared them for their future. Trainees did not state that "death disclosures" were necessary before a simulated death.

Association of early caffeine administration and neonatal outcomes in very preterm neonates

IMPORTANCE

Advantages of caffeine for apnea of prematurity have prompted clinicians to use it prophylactically even before apnea.

OBJECTIVE

To determine the effect of early initiation of caffeine therapy on neonatal outcomes in very preterm infants born in Canada.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted. Patients included preterm neonates born at less than 31 weeks' gestation admitted to 29 participating Canadian Neonatal Network neonatal intensive care units between January 1, 2010, and December 31, 2012.

EXPOSURES

Neonates who received caffeine were divided into 2 groups based on the following timing of caffeine initiation: within the first 2 days after birth (early) and on or after the third day following birth (late).

MAIN OUTCOME AND MEASURE

A composite of death or bronchopulmonary dysplasia.

RESULTS

Of 5517 eligible neonates, 5101 (92.5%) received caffeine (early: 3806 [74.6%]; late: 1295 [25.4%]). There was no difference in weight or gestational age at birth between the groups. Neonates in the early group had decreased odds of a composite outcome of death or bronchopulmonary dysplasia (adjusted odds ratio [AOR], 0.81; 95% CI, 0.67-0.98) and patent ductus arteriosus (AOR, 0.74; 95% CI, 0.62-0.89). There was no difference between the groups in mortality (AOR, 0.98; 95% CI, 0.70-1.37), necrotizing enterocolitis (AOR, 0.88; 95% CI, 0.65-1.20), severe neurological injury (AOR, 0.80; 95% CI, 0.63-1.01), or severe retinopathy of prematurity (AOR, 0.78; 95% CI, 0.56-1.10).

CONCLUSIONS AND RELEVANCE

In very preterm neonates, early (prophylactic) caffeine use was associated with a reduction in the rates of death or bronchopulmonary dysplasia and patent ductus arteriosus. No adverse impact on any other outcomes was observed.

Communication with parents concerning withholding or withdrawing of life-sustaining interventions in neonatology

The nature and content of the conversations between the healthcare team and the parents concerning withholding or withdrawing of life-sustaining interventions for neonates vary greatly. These depend upon the status of the infant; for some neonates, death may be imminent, while other infants may be relatively stable, yet with a potential risk for surviving with severe disability. Healthcare providers also need to communicate with prospective parents before the birth of premature infants or neonates with uncertain outcomes. Many authors recommend that parents of fragile neonates receive detailed information about the potential outcomes of their children and the choices they have provided in an unbiased and empathetic manner. However, the exact manner this is to be achieved in clinical practice remains unclear. Parents and healthcare providers may have different values regarding the provision of life-sustaining interventions. However, parents base their decisions on many factors, not just probabilities. The role of emotions, regret, hope, quality of life, resilience, and relationships is rarely discussed. End-of-life discussions with parents should be individualized and personalized. This article suggests ways to personalize these conversations. The mnemonic "SOBPIE" may help providers have fruitful discussions: (1) What is the Situation? Is the baby imminently dying? Should withholding or withdrawing life-sustaining interventions be considered? (2) Opinions and options: personal biases of healthcare professionals and alternatives for patients. (3) Basic human interactions. (4) Parents: their story, their concerns, their needs, and their goals. (5) Information: meeting parental informational needs and providing balanced information. (6) Emotions: relational aspects of decision making which include the following: emotions, social supports, coping with uncertainty, adaptation, and resilience. In this paper, we consider some aspects of this complex process.

Health care professionals' attitudes about pregnancy termination for different fetal anomalies

BACKGROUND

Health care professionals (HCPs) may be involved in counselling women after an antenatal diagnosis of various fetal anomalies. Many pregnant women consider termination of pregnancy (TOP) after antenatal diagnosis of various fetal anomalies. Little is known, however, about the attitudes of HCPs regarding TOP for specific antenatal diagnoses.

OBJECTIVE

To determine the attitudes and opinions of HCPs in maternal and child health regarding TOP for fetal anomalies of varying severity.

METHODS

AN ANONYMOUS QUESTIONNAIRE WAS DISTRIBUTED TO FOUR GROUPS OF HCPS: obstetric residents; paediatric residents; delivery room nurses; and neonatal intensive care nurses. Respondents were asked about TOP if they or their spouse were to receive an antenatal diagnosis for five prenatally diagnosed conditions: trisomy 21; trisomy 18; cleft lip and palate; Turner syndrome; and hypoplastic left heart syndrome.

RESULTS

Two hundred eighty HCPs answered the questionnaire (90% response rate). Ten per cent of respondents would not consider TOP under any of the circumstances described. Among those who would consider TOP, they were most likely to do so for trisomy 18 and least likely for cleft lip and palate, and fairly evenly divided among the remaining three conditions (hypoplastic left heart syndrome [65%], trisomy 21 [56%] and Turner syndrome [37%]). Paediatric residents were less likely to choose TOP than other groups and obstetrics residents were most likely.

CONCLUSIONS

Attitudes of HCPs toward TOP vary according to prenatally identified condition and professional group. More rigorous analysis should be performed regarding the process of counselling and the impact of HCPs beliefs on parental decisions.

Inhaled nitric oxide in preterm infants: an individual-patient data meta-analysis of randomized trials

BACKGROUND

Inhaled nitric oxide (iNO) is an effective therapy for pulmonary hypertension and hypoxic respiratory failure in term infants. Fourteen randomized controlled trials (n = 3430 infants) have been conducted on preterm infants at risk for chronic lung disease (CLD). The study results seem contradictory.

DESIGN/METHODS

Individual-patient data meta-analysis included randomized controlled trials of preterm infants (<37 weeks' gestation). Outcomes were adjusted for trial differences and correlation between siblings.

RESULTS

Data from 3298 infants in 12 trials (96%) were analyzed. There was no statistically significant effect of iNO on death or CLD (59% vs 61%: relative risk [RR]: 0.96 [95% confidence interval (CI): 0.92-1.01]; P = .11) or severe neurologic events on imaging (25% vs 23%: RR: 1.12 [95% CI: 0.98-1.28]; P = .09). There were no statistically significant differences in iNO effect according to any of the patient-level characteristics tested. In trials that used a starting iNO dose of >5 vs ≤ 5 ppm there was evidence of improved outcome (interaction P = .02); however, these differences were not observed at other levels of exposure to iNO. This result was driven primarily by 1 trial, which also differed according to overall dose, duration, timing, and indication for treatment; a significant reduction in death or CLD (RR: 0.85 [95% CI: 0.74-0.98]) was found.

CONCLUSIONS

Routine use of iNO for treatment of respiratory failure in preterm infants cannot be recommended. The use of a higher starting dose might be associated with improved outcome, but because there were differences in the designs of these trials, it requires further examination.

Long-distance air transport of an infant weighing less than 500 g: Is it in the patient's best interest?

When a preterm infant is delivered in a region where resources are limited, long-distance air transport may be required. However, such transport is a significant stressor on an extremely fragile patient, and the neonate's best interest must be evaluated. The current article presents the case of the smallest infant ever reported to have been transported by air, over more than 2300 km, and reflects on clinical and ethical challenges. Is a fragile 450 g baby born in a developing country better off spending the first week of his/her life where he/she was born, or risking a difficult transport to where he/she could have optimal care? What if this baby had already suffered a significant intraventricular hemorrhage? What if we were transporting the baby to provide palliative care 'at home'? These questions are discussed to illustrate the complexity of the decision-making process, and to facilitate a debate on transport of such fragile patients.

Life-threatening event during skin-to-skin contact in the delivery room

After an uncomplicated term delivery, a newborn infant experienced a life-threatening even a few minutes after being born. Few such events have been described before, they may be due to suffocation; minor changes in surveillance can probably prevent these potentially devastating events.

Anesthetic technique and postoperative outcome in preterm infants undergoing PDA closure

OBJECTIVE

To describe the various anesthetic techniques used for surgical closure of PDA in premature infants at the Montreal Children's Hospital and assess their impact on postoperative outcome.

STUDY DESIGN

The charts of all preterms who underwent PDA ligation during a 21-month period were reviewed for preoperative status, intraoperative anesthetic management and postoperative outcome. We determined the associations between independent variables and two postoperative outcome variables: unstable postoperative respiratory course (UPRC) and hypotension.

RESULT

The mean weight at surgery of the 33 infants was 1.031±0.29 kg. All infants, but one, received intraoperative opioids. Eight patients presented UPRC. Mean fentanyl doses were 5.3±2.6 mcg kg(-1) for patients with UPRC vs 22.6±16.6 mcg kg(-1) for patients without UPRC (P=0.004). Applying the receiver-operator characteristic curve (ROC), 10.5 mcg kg(-1) of fentanyl was established as the dose that discriminated and identified patients who experienced UPRC. The postnatal and postmenstrual age of the patient, birthweight, current weight, ventilator settings preoperatively, previous courses of indomethacin, sex and preoperative creatinine, were not correlated with the dose of fentanyl equivalent used. Logistic regression did not show a relationship between any of the previously mentioned factors and receiving a fentanyl equivalent of >10.5 mcg kg(-1). The only factor associated with the total fentanyl equivalent dose (as a continuous variable) or receiving <10.5 mcg kg(-1) (as a dichotomous variable) was the identity of the anesthetist involved, P<0.001.

CONCLUSION

We conclude that the use of at least 10.5 mcg kg(-1) of fentanyl equivalent as a component of the anesthetic regimen for surgical closure of a PDA in premature infants, avoids an unstable postoperative respiratory course.

Inhaled nitric oxide in preterm infants: a systematic review and individual patient data meta-analysis

Background

Preterm infants requiring assisted ventilation are at significant risk of both pulmonary and cerebral injury. Inhaled Nitric Oxide, an effective therapy for pulmonary hypertension and hypoxic respiratory failure in the full term infant, has also been studied in preterm infants. The most recent Cochrane review of preterm infants includes 11 studies and 3,370 participants. The results show a statistically significant reduction in the combined outcome of death or chronic lung disease (CLD) in two studies with routine use of iNO in intubated preterm infants. However, uncertainty remains as a larger study (Kinsella 2006) showed no significant benefit for iNO for this combined outcome. Also, trials that included very ill infants do not demonstrate significant benefit. One trial of iNO treatment at a later postnatal age reported a decrease in the incidence of CLD. The aim of this individual patient meta-analysis is to confirm or refute these potentially conflicting results and to determine the extent to which patient or treatment characteristics may explain the results and/or may predict benefit from inhaled Nitric Oxide in preterm infants.

Methods/Design

The Meta-Analysis of Preterm Patients on inhaled Nitric Oxide (MAPPiNO) Collaboration will perform an individual patient data meta-analysis to answer these important clinical questions. Studies will be included if preterm infants receiving assisted ventilation are randomized to receive inhaled Nitric Oxide or to a control group. The individual patient data provided by the Collaborators will be analyzed on an intention-to-treat basis where possible. Binary outcomes will be analyzed using log-binomial regression models and continuous outcomes will be analyzed using linear fixed effects models. Adjustments for trial differences will be made by including the trial variable in the model specification.

Discussion

Thirteen (13) trials, with a total of 3567 infants are eligible for inclusion in the MAPPiNO systematic review. To date 11 trials (n = 3298, 92% of available patients) have agreed to participate. Funding was successfully granted from Ikaria Inc as an unrestricted grant. A collaborative group was formed in 2006 with data collection commencing in 2007. It is anticipated that data analysis will commence in late 2009 with results being publicly available in 2010.

The Premature Infants in Need of Transfusion (PINT) study: a randomized, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants

OBJECTIVE

To determine whether extremely low birth weight infants (ELBW) transfused at lower hemoglobin thresholds versus higher thresholds have different rates of survival or morbidity at discharge.

STUDY DESIGN

Infants weighing <1000 g birth weight were randomly assigned within 48 hours of birth to a transfusion algorithm of either low or high hemoglobin transfusion thresholds. The composite primary outcome was death before home discharge or survival with any of either severe retinopathy, bronchopulmonary dysplasia, or brain injury on cranial ultrasound. Morbidity outcomes were assessed, blinded to allocation.

RESULTS

Four hundred fifty-one infants were randomly assigned to low (n = 223) or high (n = 228) hemoglobin thresholds. Groups were similar, with mean birth weight of 770 g and gestational age of 26 weeks. Fewer infants received one or more transfusions in the low threshold group (89% low versus 95% high, P = .037). Rates of the primary outcome were 74.0% in the low threshold group and 69.7% in the high (P = .25; risk difference, 2.7%; 95% CI -3.7% to 9.2%). There were no statistically significant differences between groups in any secondary outcome.

CONCLUSIONS

In extremely low birth weight infants, maintaining a higher hemoglobin level results in more infants receiving transfusions but confers little evidence of benefit.

Short and long term outcomes following partial exchange transfusion in the polycythaemic newborn: a systematic review

BACKGROUND

Severe polycythaemia in the neonate may produce symptoms due to hyperviscosity and may be associated with serious complications. Partial exchange transfusion will reduce the packed cell volume.

OBJECTIVE

To determine whether partial exchange transfusion in term infants with polycythaemia (symptomatic and asymptomatic) is associated with improved short and long term outcomes.

SEARCH STRATEGY

Medline, EMBASE, and the Cochrane Controlled Trials Register of the Cochrane Library were searched. The following keywords were used: polycythaemia, partial exchange transfusion, hyperviscosity, and limited to the newborn. This covered years 1966-2004. Abstracts of the Pediatric Academic Societies and personal files were also searched.

SELECTION CRITERIA

Randomised or quasi-randomised trials in term infants with polycythaemia and/or documented hyperviscosity were considered. Clinically relevant outcomes included were short term (resolution of symptoms, neurobehavioural scores, major complications) and long term neurodevelopmental outcome.

DATA COLLECTION AND ANALYSIS

All data for each study were extracted, assessed, and coded separately. Any disagreements were resolved by discussion.

MAIN RESULTS

Six studies were identified; five had data that could be evaluated for analysis. There is no evidence of an improvement in long term neurological outcome (mental developmental index, incidence of mental delay, and incidence of neurological diagnoses) after partial exchange transfusion in symptomatic or asymptomatic infants. There is no evidence of improvement in early neurobehavioural assessment scores (Brazelton neonatal behavioural assessment scale). Partial exchange transfusion may be associated with an earlier improvement in symptoms, but there are insufficient data to calculate the size of the effect. Necrotising enterocolitis is probably increased by partial exchange transfusion (relative risk 8.68, 95% confidence interval 1.06 to 71.1).

CONCLUSION

There is no evidence of long term benefit from partial exchange in polycythaemic infants, and the incidence of gastrointestinal injury is increased. The long term outcome is more likely to be related to the underlying cause of polycythaemia.

Crystalloid or colloid for partial exchange transfusion in neonatal polycythemia: a systematic review and meta-analysis

AIMS

To determine whether crystalloid solutions are as effective as colloid solutions when a partial exchange transfusion is performed in newborns with polycythemia.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Controlled Trials Register of the Cochrane Library (1966-2004). Keywords used were: polycythemia, partial exchange transfusion, hyperviscosity, and limited to newborn. Randomized studies in newborns with polycythemia were selected for evaluation. Outcomes examined were: long-term neurodevelopment; short-term physiological effects; improvement in clinical symptoms; reduction in haematocrit at 4-6 h; haematocrit at 24 h; and frequency of serious complications.

RESULTS

Four randomized controlled clinical trials, including 200 patients in total, with evaluable data, which satisfied our criteria, were found. There were no data on long-term outcomes. There is no reported important difference in short-term physiologic effects. Use of crystalloid was as effective as colloid in both correction of haematological values and reduction of clinical symptoms following partial exchange transfusion.

CONCLUSION

Crystalloid solutions are as effective as colloid solutions for partial exchange transfusion. When crystalloid solutions are used for this purpose, there is no risk of transmission of blood-borne diseases, there is no risk of anaphylaxis, they are rapidly and easily available, and are less expensive. The use of crystalloid should become the standard for partial exchange transfusion.