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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Anti-seizure medications for neonates with seizures. Cochrane Database Syst Rev 2023; 10:CD014967. [PMID: 37873971 PMCID: PMC10594593 DOI: 10.1002/14651858.cd014967.pub2] [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] [Indexed: 10/25/2023]
Abstract
BACKGROUND Newborn infants are more prone to seizures than older children and adults. The neuronal injury caused by seizures in neonates often results in long-term neurodevelopmental sequelae. There are several options for anti-seizure medications (ASMs) in neonates. However, the ideal choice of first-, second- and third-line ASM is still unclear. Further, many other aspects of seizure management such as whether ASMs should be initiated for only-electrographic seizures and how long to continue the ASM once seizure control is achieved are elusive. OBJECTIVES 1. To assess whether any ASM is more or less effective than an alternative ASM (both ASMs used as first-, second- or third-line treatment) in achieving seizure control and improving neurodevelopmental outcomes in neonates with seizures. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 2. To assess maintenance therapy with ASM versus no maintenance therapy after achieving seizure control. We analysed EEG-confirmed seizures and clinically-diagnosed seizures separately. 3. To assess treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates. SEARCH METHODS We searched MEDLINE, Embase, CENTRAL, Epistemonikos and three databases in May 2022 and June 2023. These searches were not limited other than by study design to trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) that included neonates with EEG-confirmed or clinically diagnosed seizures and compared (1) any ASM versus an alternative ASM, (2) maintenance therapy with ASM versus no maintenance therapy, and (3) treatment of clinical or EEG seizures versus treatment of clinical seizures alone. DATA COLLECTION AND ANALYSIS Two review authors assessed trial eligibility, risk of bias and independently extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence interval (CI). We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 18 trials (1342 infants) in this review. Phenobarbital versus levetiracetam as first-line ASM in EEG-confirmed neonatal seizures (one trial) Phenobarbital is probably more effective than levetiracetam in achieving seizure control after first loading dose (RR 2.32, 95% CI 1.63 to 3.30; 106 participants; moderate-certainty evidence), and after maximal loading dose (RR 2.83, 95% CI 1.78 to 4.50; 106 participants; moderate-certainty evidence). However, we are uncertain about the effect of phenobarbital when compared to levetiracetam on mortality before discharge (RR 0.30, 95% CI 0.04 to 2.52; 106 participants; very low-certainty evidence), requirement of mechanical ventilation (RR 1.21, 95% CI 0.76 to 1.91; 106 participants; very low-certainty evidence), sedation/drowsiness (RR 1.74, 95% CI 0.68 to 4.44; 106 participants; very low-certainty evidence) and epilepsy post-discharge (RR 0.92, 95% CI 0.48 to 1.76; 106 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Phenobarbital versus phenytoin as first-line ASM in EEG-confirmed neonatal seizures (one trial) We are uncertain about the effect of phenobarbital versus phenytoin on achieving seizure control after maximal loading dose of ASM (RR 0.97, 95% CI 0.54 to 1.72; 59 participants; very low-certainty evidence). The trial did not report on mortality or neurodevelopmental disability at 18 to 24 months. Maintenance therapy with ASM versus no maintenance therapy in clinically diagnosed neonatal seizures (two trials) We are uncertain about the effect of short-term maintenance therapy with ASM versus no maintenance therapy during the hospital stay (but discontinued before discharge) on the risk of repeat seizures before hospital discharge (RR 0.76, 95% CI 0.56 to 1.01; 373 participants; very low-certainty evidence). Maintenance therapy with ASM compared to no maintenance therapy may have little or no effect on mortality before discharge (RR 0.69, 95% CI 0.39 to 1.22; 373 participants; low-certainty evidence), mortality at 18 to 24 months (RR 0.94, 95% CI 0.34 to 2.61; 111 participants; low-certainty evidence), neurodevelopmental disability at 18 to 24 months (RR 0.89, 95% CI 0.13 to 6.12; 108 participants; low-certainty evidence) and epilepsy post-discharge (RR 3.18, 95% CI 0.69 to 14.72; 126 participants; low-certainty evidence). Treatment of both clinical and electrographic seizures versus treatment of clinical seizures alone in neonates (two trials) Treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation (MD -1871.16, 95% CI -4525.05 to 782.73; 68 participants; low-certainty evidence), mortality before discharge (RR 0.59, 95% CI 0.28 to 1.27; 68 participants; low-certainty evidence) and epilepsy post-discharge (RR 0.75, 95% CI 0.12 to 4.73; 35 participants; low-certainty evidence). The trials did not report on mortality or neurodevelopmental disability at 18 to 24 months. We report data from the most important comparisons here; readers are directed to Results and Summary of Findings tables for all comparisons. AUTHORS' CONCLUSIONS Phenobarbital as a first-line ASM is probably more effective than levetiracetam in achieving seizure control after the first loading dose and after the maximal loading dose of ASM (moderate-certainty evidence). Phenobarbital + bumetanide may have little or no difference in achieving seizure control when compared to phenobarbital alone (low-certainty evidence). Limited data and very low-certainty evidence preclude us from drawing any reasonable conclusion on the effect of using one ASM versus another on other short- and long-term outcomes. In neonates who achieve seizure control after the first loading dose of phenobarbital, maintenance therapy compared to no maintenance ASM may have little or no effect on all-cause mortality before discharge, mortality by 18 to 24 months, neurodevelopmental disability by 18 to 24 months and epilepsy post-discharge (low-certainty evidence). In neonates with hypoxic-ischaemic encephalopathy, treatment of both clinical and electrographic seizures when compared to treating clinical seizures alone may have little or no effect on seizure burden during hospitalisation, all-cause mortality before discharge and epilepsy post-discharge (low-certainty evidence). All findings of this review apply only to term and late preterm neonates. We need well-designed RCTs for each of the three objectives of this review to improve the precision of the results. These RCTs should use EEG to diagnose seizures and should be adequately powered to assess long-term neurodevelopmental outcomes. We need separate RCTs evaluating the choice of ASM in preterm infants.
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Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, KMCH Institute of Health Sciences and Research (KMCHIHSR), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Ronit Pressler
- Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK
- Clinical Neurophysiology and Neonatology, Cambridge University Hospital, Cambridge, UK
- Clinical Neuroscience, UCL- Great Ormond Street Institute of Child Health, London, UK
| | - Francesco Brigo
- Neurology, Hospital of Merano (SABES-ASDAA), Teaching Hospital of Paracelsus Medical University, Merano-Meran, Italy
- Innovation Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano-Bozen, Italy
| | - Hans Hartmann
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Ramaswamy VV, Dawson JA, de Almeida MF, Trevisanuto D, Nakwa FL, Kamlin COF, Trang J, Wyckoff MH, Weiner GM, Liley HG. Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis. Resuscitation 2023; 191:109934. [PMID: 37597649 DOI: 10.1016/j.resuscitation.2023.109934] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 07/26/2023] [Accepted: 08/05/2023] [Indexed: 08/21/2023]
Abstract
AIM To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation. METHODS Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient. CONCLUSIONS DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.
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Affiliation(s)
- V V Ramaswamy
- Ankura Hospital for Women and Children, Hyderabad, India
| | - J A Dawson
- Newborn Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - M F de Almeida
- Universidade Federal de Sao Paulo, Escola Paulista de Medicina, Sao Paulo, Brazil
| | - D Trevisanuto
- Medical School, University of Padua, Azienda Ospedaliera Padova, Padua, Italy
| | - F L Nakwa
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - C O F Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - J Trang
- Queensland Children's Hospital, Queensland, Australia
| | - M H Wyckoff
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - G M Weiner
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - H G Liley
- Faculty of Medicine and Mater Research, The University of Queensland, Australia.
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Ramaswamy VV, Bandyopadhyay T, Abiramalatha T, Pullattayil S AK, Szczapa T, Wright CJ, Roehr CC. Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis. EClinicalMedicine 2023; 62:102097. [PMID: 37538537 PMCID: PMC10393620 DOI: 10.1016/j.eclinm.2023.102097] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 08/05/2023] Open
Abstract
Background The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS. Methods The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life. Findings 58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) <0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low. Interpretation Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound. Funding None.
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Affiliation(s)
| | | | - Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
| | | | - Tomasz Szczapa
- II Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
- Newborn Services, Southmead Hospital, North Bristol NHS Trust, Bristol, United Kingdom
- Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Rajaiah B, Ramakrishnan S. Re-feeding versus discarding gastric residuals to improve growth in preterm infants. Cochrane Database Syst Rev 2023; 6:CD012940. [PMID: 37387544 PMCID: PMC10312053 DOI: 10.1002/14651858.cd012940.pub3] [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] [Indexed: 07/01/2023]
Abstract
BACKGROUND Routine monitoring of gastric residuals in preterm infants on tube feeds is a common practice in neonatal intensive care units used to guide initiation and advancement of enteral feeding. There is a paucity of consensus on whether to re-feed or discard the aspirated gastric residuals. While re-feeding gastric residuals may aid in digestion and promote gastrointestinal motility and maturation by replacing partially digested milk, gastrointestinal enzymes, hormones, and trophic substances, abnormal residuals may result in vomiting, necrotising enterocolitis, or sepsis. OBJECTIVES To assess the efficacy and safety of re-feeding when compared to discarding gastric residuals in preterm infants. SEARCH METHODS: Searches were conducted in February 2022 in Cochrane CENTRAL via CRS, Ovid MEDLINE and Embase, and CINAHL. We also searched clinical trial databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We selected RCTs that compared re-feeding versus discarding gastric residuals in preterm infants. DATA COLLECTION AND ANALYSIS Review authors assessed trial eligibility and risk of bias and extracted data, in duplicate. We analysed treatment effects in individual trials and reported the risk ratio (RR) for dichotomous data and the mean difference (MD) for continuous data, with respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We found one eligible trial that included 72 preterm infants. The trial was unmasked but was otherwise of good methodological quality. Re-feeding gastric residual may have little or no effect on time to regain birth weight (MD 0.40 days, 95% CI -2.89 to 3.69; 59 infants; low-certainty evidence), risk of necrotising enterocolitis stage ≥ 2 or spontaneous intestinal perforation (RR 0.71, 95% CI 0.25 to 2.04; 72 infants; low-certainty evidence), all-cause mortality before hospital discharge (RR 0.50, 95% CI 0.14 to 1.85; 72 infants; low-certainty evidence), time to establish enteral feeds ≥ 120 mL/kg/d (MD -1.30 days, 95% CI -2.93 to 0.33; 59 infants; low-certainty evidence), number of total parenteral nutrition days (MD -0.30 days, 95% CI -2.07 to 1.47; 59 infants; low-certainty evidence), and risk of extrauterine growth restriction at discharge (RR 1.29, 95% CI 0.38 to 4.34; 59 infants; low-certainty evidence). We are uncertain as to the effect of re-feeding gastric residual on number of episodes of feed interruption lasting for ≥ 12 hours (RR 0.80, 95% CI 0.42 to 1.52; 59 infants; very low-certainty evidence). AUTHORS' CONCLUSIONS We found only limited data from one small unmasked trial on the efficacy and safety of re-feeding gastric residuals in preterm infants. Low-certainty evidence suggests re-feeding gastric residual may have little or no effect on important clinical outcomes such as necrotising enterocolitis, all-cause mortality before hospital discharge, time to establish enteral feeds, number of total parenteral nutrition days, and in-hospital weight gain. A large RCT is needed to assess the efficacy and safety of re-feeding of gastric residuals in preterm infants with adequate certainty of evidence to inform policy and practice.
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Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Balakrishnan Rajaiah
- Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
| | - Srinivas Ramakrishnan
- Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Rajaiah B, Ramakrishnan S. Routine monitoring of gastric residual for prevention of necrotising enterocolitis in preterm infants. Cochrane Database Syst Rev 2023; 6:CD012937. [PMID: 37327390 PMCID: PMC10275261 DOI: 10.1002/14651858.cd012937.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Routine monitoring of gastric residual in preterm infants on gavage feeds is a common practice used to guide initiation and advancement of feeds. It is believed that an increase in or an altered gastric residual may be predictive of necrotising enterocolitis (NEC). Withholding monitoring of gastric residual may take away the early indicator and thus may increase the risk of NEC. However, routine monitoring of gastric residual as a guide, in the absence of uniform standards, may lead to unnecessary delay in initiation and advancement of feeds and hence might result in a delay in establishing full enteral feeds. This in turn may increase the duration of total parenteral nutrition (TPN) and central venous line usage, increasing the risk of associated complications. Furthermore, delays in establishing full enteral feeds increase the risk of extrauterine growth restriction and neurodevelopmental impairment. OBJECTIVES • To assess the efficacy and safety of routine monitoring versus no monitoring of gastric residual in preterm infants • To assess the efficacy and safety of routine monitoring of gastric residual based on two different criteria for interrupting feeds or decreasing feed volume in preterm infants SEARCH METHODS: We conducted searches in Cochrane CENTRAL via CRS, Ovid MEDLINE, Embase and CINAHL in February 2022. We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs), quasi- and cluster-RCTs. SELECTION CRITERIA We selected RCTs that compared routine monitoring versus no monitoring of gastric residual and trials that used two different criteria for gastric residual to interrupt feeds in preterm infants. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial eligibility, risk of bias and extracted data. We analysed treatment effects in individual trials and reported risk ratio (RR) for dichotomous data, and mean difference (MD) for continuous data, with respective 95% confidence intervals (CI). We calculated the number needed to treat for an additional beneficial/harmful outcome (NNTB/NNTH) for dichotomous outcomes with significant results. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included five studies (423 infants) in this updated review. Routine monitoring versus no routine monitoring of gastric residual in preterm infants Four RCTs with 336 preterm infants met the inclusion criteria for this comparison. Three studies were performed in infants with birth weight of < 1500 g, while one study included infants with birth weight between 750 g and 2000 g. The trials were unmasked but were otherwise of good methodological quality. Routine monitoring of gastric residual: - probably has little or no effect on the risk of NEC (RR 1.08, 95% CI 0.46 to 2.57; 334 participants, 4 studies; moderate-certainty evidence); - probably increases the time to establish full enteral feeds (MD 3.14 days, 95% CI 1.93 to 4.36; 334 participants, 4 studies; moderate-certainty evidence); - may increase the time to regain birth weight (MD 1.70 days, 95% CI 0.01 to 3.39; 80 participants, 1 study; low-certainty evidence); - may increase the number of infants with feed interruption episodes (RR 2.21, 95% CI 1.53 to 3.20; NNTH 3, 95% CI 2 to 5; 191 participants, 3 studies; low-certainty evidence); - probably increases the number of TPN days (MD 2.57 days, 95% CI 1.20 to 3.95; 334 participants, 4 studies; moderate-certainty evidence); - probably increases the risk of invasive infection (RR 1.50, 95% CI 1.02 to 2.19; NNTH 10, 95% CI 5 to 100; 334 participants, 4 studies; moderate-certainty evidence); - may result in little or no difference in all-cause mortality before hospital discharge (RR 2.14, 95% CI 0.77 to 5.97; 273 participants, 3 studies; low-certainty evidence). Quality and volume of gastric residual compared to quality of gastric residual alone for feed interruption in preterm infants One trial with 87 preterm infants met the inclusion criteria for this comparison. The trial included infants with 1500 g to 2000 g birth weight. Using two different criteria of gastric residual for feed interruption: - may result in little or no difference in the incidence of NEC (RR 5.35, 95% CI 0.26 to 108.27; 87 participants; low-certainty evidence); - may result in little or no difference in time to establish full enteral feeds (MD -0.10 days, 95% CI -0.91 to 0.71; 87 participants; low-certainty evidence); - may result in little or no difference in time to regain birth weight (MD 1.00 days, 95% CI -0.37 to 2.37; 87 participants; low-certainty evidence); - may result in little or no difference in number of TPN days (MD 0.80 days, 95% CI -0.78 to 2.38; 87 participants; low-certainty evidence); - may result in little or no difference in the risk of invasive infection (RR 5.35, 95% CI 0.26 to 108.27; 87 participants; low-certainty evidence); - may result in little or no difference in all-cause mortality before hospital discharge (RR 3.21, 95% CI 0.13 to 76.67; 87 participants; low-certainty evidence). - we are uncertain about the effect of using two different criteria of gastric residual on the risk of feed interruption episodes (RR 3.21, 95% CI 0.13 to 76.67; 87 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS Moderate-certainty evidence suggests routine monitoring of gastric residual has little or no effect on the incidence of NEC. Moderate-certainty evidence suggests monitoring gastric residual probably increases the time to establish full enteral feeds, the number of TPN days and the risk of invasive infection. Low-certainty evidence suggests monitoring gastric residual may increase the time to regain birth weight and the number of feed interruption episodes, and may have little or no effect on all-cause mortality before hospital discharge. Further RCTs are warranted to assess the effect on long-term growth and neurodevelopmental outcomes.
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Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
- KMCH Research Foundation, Coimbatore, Tamil Nadu, India
| | | | | | - Balakrishnan Rajaiah
- Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
| | - Srinivas Ramakrishnan
- Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India
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Ramaswamy VV, Abiramalatha T, Pullattayil S AK, Trevisanuto D. Multisystem inflammatory disease in neonates (MIS-N) due to maternal COVID-19. Semin Fetal Neonatal Med 2023; 28:101431. [PMID: 37061425 DOI: 10.1016/j.siny.2023.101431] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
Multisystem inflammatory disease in neonates (MIS-N) is a disease of immune dysregulation presenting in the newborn period. Thouvgh its etiopathogenesis is proposed to be similar to multisystem inflammatory disease in Children (MIS-C), the exact pathophysiology is largely unknown as of present. The definition of MIS-N is contentious. The evidence for its incidence, the clinical features, profile of raised inflammatory markers, treatment strategies and outcomes stem from case reports, case series and cohort studies with small sample sizes. Though the incidence of MIS-N in severe acute respiratory syndrome caused by the coronavirus CoVID-2 (SARS-CoV-2) infected asymptomatic neonates is low, its incidence in symptomatic neonates is relatively higher. Further, amongst the neonates who are treated as MIS-N, the mortality rate is high. The review also evaluates the various other unresolved aspects of MIS-N from limited published literature and identifies knowledge gaps which could be areas of future research.
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Affiliation(s)
| | | | | | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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Moschino L, Ramaswamy VV, Reiss IKM, Baraldi E, Roehr CC, Simons SHP. Sedation for less invasive surfactant administration in preterm infants: a systematic review and meta-analysis. Pediatr Res 2023; 93:471-491. [PMID: 35654833 DOI: 10.1038/s41390-022-02121-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 04/23/2022] [Accepted: 05/08/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Sedation to preterm neonates receiving less invasive surfactant administration (LISA) for respiratory distress syndrome is controversial. METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies (OS) to evaluate the effect of sedative drugs for LISA on respiratory outcomes and adverse effects. RESULTS One RCT (78 neonates) and two OS (519 neonates) were analyzed in pairwise meta-analysis and 30 studies (2164 neonates) in proportion-based meta-analysis. Sedative drugs might not affect the duration of the procedure [RCT: mean difference (MD) (95% CI); -11 (-90; 67) s; OS: MD 95% CI: -60 (-178; 58) s; low certainty of evidence (CoE)]. Evidence for success at the first attempt and rescue intubation was uncertain (very low CoE). The risk of nasal intermittent positive pressure ventilation [RCT: 1.97 (1.38-2.81); OS: RR, 95% CI: 2.96 (1.46; 6.00), low CoE], desaturation [RCT: RR, 95% CI: 1.30 (1.03; 1.65), low CoE], and apnea [OS: RR, 95% CI: 3.13 (1.35; 7.24), very low CoE] might be increased with sedation. Bradycardia, hypotension, and mechanical ventilation were comparable between groups (low CoE). CONCLUSIONS Use of sedative drugs for LISA temporarily affects the newborn's breathing. Further trials are warranted to explore the use of sedation for LISA. IMPACT The effect of sedative drugs (analgesics, sedatives, anesthetics) compared to the effect of no-sedation for LISA in preterm infants with RDS is underexplored. This systematic review and meta-analysis assesses the impact of sedative drugs compared to no-sedation for LISA on short-term pulmonary outcomes and potential adverse events. Sedative drugs for LISA temporarily affect the newborn's breathing (desaturation, apnea) and increase the need for nasal intermittent positive pressure ventilation. For most outcomes, certainty of evidence is low/very low.
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Affiliation(s)
- Laura Moschino
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, Padova University Hospital, Padua, Italy
| | | | - Irwin Karl Marcel Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Eugenio Baraldi
- Neonatal Intensive Care Unit, Department of Women's and Children's Health, Padova University Hospital, Padua, Italy
| | - Charles Christoph Roehr
- Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK. .,Faculty of Health Sciences, University of Bristol, Bristol, UK. .,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK.
| | - Sinno Henricus Paulus Simons
- Department of Pediatrics, Division of Neonatology, Erasmus University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
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Ramaswamy VV, Bandyopadhyay T, Abiramalatha T, Shaik NB, Pullattayil S AK, Jasani B, Hegde V, Trevisanuto D, Weiner GM. Placental Transfusion Strategies in Preterm Infants in Low- and Middle-Income Countries: A Systematic Review and Network Meta-Analysis. Neonatology 2023; 120:118-133. [PMID: 36516794 DOI: 10.1159/000527454] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 09/23/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Placental transfusion strategies in preterm newborns have not been evaluated in low- and middle-income countries (LMICs). The objective of this systematic review was to compare placental transfusion strategies in preterm newborns in LMICs, including delayed cord clamping (DCC) for various time intervals, DCC until cord pulsations stop, umbilical cord milking, and immediate cord clamping (ICC). METHODS Medline, Embase, CINAHL, and CENTRAL were searched from inception. Observational studies and randomized controlled trials (RCTs) were included. Two authors independently extracted data for Bayesian random-effects network meta-analysis (NMA) if more than 3 interventions reported an outcome or a pairwise meta-analysis was utilized. RESULTS Among newborns <34 weeks of gestation, NMA of 9 RCTs could not rule out benefit or harm for survival from DCC 30-60 s compared to ICC: relative risk (RR) (95% credible interval) 0.96 (0.78-1.12), moderate certainty, or any included strategy compared to each other (low to very low certainty). Among late preterm newborns, DCC 120 s might be associated with improved survival: RR (95% confidence interval) 1.11 (1.01-1.22), very low certainty. We could not detect differences in the risk of intraventricular hemorrhage grade > II and bronchopulmonary dysplasia for any included intervention (low to very low certainty). DCC 60 s and 120 s might improve the hematocrit level among all preterm newborns (very low certainty), and DCC 45 s may decrease the risk of receipt of inotropes among newborns <34 weeks of gestation (low certainty). CONCLUSIONS In LMICs, DCC for 60 s and 120 s might improve hematocrit level in preterm newborns, and DCC for 45 s may decrease the risk of receipt of inotropes in newborns <34 weeks, with no conclusive effect on survival.
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Affiliation(s)
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr. Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Thangaraj Abiramalatha
- Consultant Neonatologist, Kovai Medical Center and Hospital (KMCH), Associate Professor of Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, India
| | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | | | - Bonny Jasani
- Department of Neonatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vandana Hegde
- Clinical Director, Hegde Hospital, Madhapur, Hyderabad, India
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy
| | - Gary M Weiner
- Department of Pediatrics - Neonatology, University of Michigan, Ann Arbor, Michigan, USA
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Ramaswamy VV, Bandyopadhyay T, Nangia S, Kumar G, Pullattayil AK, Trevisanuto D, Roehr CC, Lakshminrusimha S. Assessment of Change in Practice of Routine Tracheal Suctioning Approach of Non-Vigorous Infants Born through Meconium-Stained Amniotic Fluid: A Pragmatic Systematic Review and Meta-Analysis of Evidence outside Randomized Trials. Neonatology 2023; 120:161-175. [PMID: 36754038 DOI: 10.1159/000528715] [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: 09/17/2022] [Accepted: 12/11/2022] [Indexed: 02/10/2023]
Abstract
AIM The 2015 recommendation of the International Liaison Committee on Resuscitation of no routine tracheal suctioning in non-vigorous neonates born through meconium-stained amniotic fluid (MSAF) was based on very low certainty of evidence (CoE) necessitating ongoing monitoring. The aim of this systematic review was to perform a meta-analysis of observational studies comparing the effect of implementing immediate resuscitation without routine tracheal suctioning versus with routine suctioning in neonates born through MSAF. METHODS MEDLINE, Embase, CENTRAL, and Web of Science were searched. Observational studies with a before-and-after design were included. Two authors extracted data independently. CoE based on GRADE recommendations was performed. RESULTS 13 studies were included. Clinical benefit or harm could not be excluded for the composite primary outcome of mortality or requirement of extracorporeal membranous oxygenation (ECMO) (relative risk, 95% confidence interval: 0.74 [0.47-1.17]), and mortality (0.68 [0.42-1.11]). "Routine tracheal suctioning" epoch had possibly lesser risk of meconium aspiration syndrome (MAS) when compared to "no routine tracheal suctioning" epoch (0.68 [0.47-0.99]). "Routine tracheal suctioning" epoch also possibly had a lower risk of hospital admission for respiratory symptoms, requirement of non-invasive respiratory support, invasive mechanical ventilation, surfactant treatment, air leak, and low-flow oxygen therapy. Clinical benefit or harm could not be excluded for the outcome of mortality or ECMO among those diagnosed with MAS (1.09 [0.86-1.39]), but "routine tracheal suctioning" was possibly associated with lower risk of respiratory morbidities among those diagnosed with MAS. The CoE was very low for most of the outcomes evaluated. CONCLUSIONS Due to the very low CoE for the outcomes evaluated, no definitive conclusions can be drawn warranting the need for additional studies.
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Affiliation(s)
| | - Tapas Bandyopadhyay
- Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Sushma Nangia
- Lady Hardinge Medical College and associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Gunjana Kumar
- Lady Hardinge Medical College and associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Abdul Kareem Pullattayil
- Associate Librarian, Bracken Health Sciences Library, Queen's University, Kingston, Ontario, Canada
| | - Daniele Trevisanuto
- Department of Woman and Child Health, University of Padua, University Hospital of Padua, Padua, Italy
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Division, Nuffield Department of Population Health, Medical Sciences, University of Oxford, Oxford, UK
- Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK
- University of Bristol, Faculty of Health Sciences, Bristol, UK
| | - Satyan Lakshminrusimha
- Department of Pediatrics, University of California at Davis, Sacramento, California, USA
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Kallem VR, Pullattayil AK, Kaushal M. Adjuvant therapy in neonatal sepsis to prevent mortality - A systematic review and network meta-analysis. J Neonatal Perinatal Med 2022; 15:699-719. [PMID: 36189501 DOI: 10.3233/npm-221025] [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: 12/31/2022]
Abstract
BACKGROUND Despite appropriate antibiotic therapy, the risk of mortality in neonatal sepsis still remains high. We conducted a systematic review to comprehensively evaluate different adjuvant therapies in neonatal sepsis in a network meta-analysis. METHODS We included randomized controlled trials (RCTs) and quasi-RCTs that evaluated adjuvant therapies in neonatal sepsis. Neonates of all gestational and postnatal ages, who were diagnosed with sepsis based on blood culture or sepsis screen were included. We searched MEDLINE, CENTRAL, EMBASE and CINAHL until 12th April 2021 and reference lists. Data extraction and risk of bias assessment were performed in duplicate. A network meta-analysis with bayesian random-effects model was used for data synthesis. Certainty of evidence (CoE) was assessed using GRADE. RESULTS We included 45 studies involving 6,566 neonates. Moderate CoE showed IVIG [Relative Risk (RR); 95% Credible Interval (CrI): 1.00; (0.67-1.53)] as an adjunctive therapy probably does not reduce all-cause mortality before discharge, compared to standard care. Melatonin [0.12 (0-0.08)] and granulocyte transfusion [0.39 (0.19-0.76)] may reduce mortality before discharge, but CoE is very low. The evidence is also very uncertain regarding other adjunctive therapies to reduce mortality before discharge. Pentoxifylline may decrease the duration of hospital stay [Mean difference; 95% CrI: -7.48 days (-14.50-0.37)], but CoE is very low. CONCLUSION Given the biological plausibility for possible efficacy of these adjuvant therapies and that the CoE from the available trials is very low to low except for IVIG, we need large adequately powered RCTs to evaluate these therapies in sepsis in neonates.
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Affiliation(s)
- T Abiramalatha
- Associate Professor of Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - V V Ramaswamy
- Consultant Neonatologist, Ankura Hospital for Women and Children, Hyderabad, India
| | - T Bandyopadhyay
- Departmentof Neonatology, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - S H Somanath
- Department of Neonatology, All India Institute of Medical Sciences, Mangalagiri, India
| | - N B Shaik
- Consultant Neonatologist, Ankura Hospital for Women and Children, Hyderabad, India
| | - V R Kallem
- Consultant Neonatologist, Paramitha Children's Hospital, Hyderabad, India
| | - A K Pullattayil
- Health Sciences Librarian, Queen's University, Kingston, Canada
| | - M Kaushal
- Consultant Neonatologist and Head of Department, Emirates Specialty Hospital, DHCC, U.A.E
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Ramaswamy VV, de Almeida MF, Dawson JA, Trevisanuto D, Nakwa FL, Kamlin CO, Hosono S, Wyckoff MH, Liley HG. Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis. Resuscitation 2022; 180:81-98. [PMID: 36174764 DOI: 10.1016/j.resuscitation.2022.09.014] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 11/22/2022]
Abstract
AIM Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation). METHODS Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed. RESULTS 25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes. CONCLUSIONS Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.
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Affiliation(s)
- V V Ramaswamy
- Ankura Hospital for Women and Children, Hyderabad, India
| | - M F de Almeida
- Universidade Federal de Sao Paulo, Escola Paulista de Medicina, Sao Paulo, Brazil
| | - J A Dawson
- Newborn Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - D Trevisanuto
- Medical School, University of Padua, Azienda Ospedaliera Padova, Padua, Italy
| | - F L Nakwa
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg
| | - C O Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - S Hosono
- Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - M H Wyckoff
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - H G Liley
- Faculty of Medicine and Mater Research, The University of Queensland, Australia. hliley%
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Anand P, Kaushal M, Ramaswamy VV, Pullattayil S. AK, Razak A, Trevisanuto D. Nasal Cannula with Long and Narrow Tubing for Non-Invasive Respiratory Support in Preterm Neonates: A Systematic Review and Meta-Analysis. Children 2022; 9:children9101461. [PMID: 36291395 PMCID: PMC9600105 DOI: 10.3390/children9101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/16/2022]
Abstract
Background: Cannulas with long and narrow tubing (CLNT) are increasingly being used as an interface for noninvasive respiratory support (NRS) in preterm neonates; however, their efficacy compared to commonly used nasal interfaces such as short binasal prongs (SBP) and nasal masks (NM) has not been widely studied. Material and Methods: Medline, Embase, CENTRAL, Health Technology Assessment Database, and Web of Science were searched for randomized clinical trials (RCTs) and observational studies investigating the efficacy of CLNT compared to SBP or NM in preterm neonates requiring NRS for primary respiratory and post-extubation support. A random-effects meta-analysis was used for data synthesis. Results: Three RCTs and three observational studies were included. Clinical benefit or harm could not be ruled out for the outcome of need for invasive mechanical ventilation (IMV) for CLNT versus SBP or NM [relative risk (RR) 1.37, 95% confidence interval (CI) 0.61–3.04, certainty of evidence (CoE) low]. The results were also inconclusive for the outcome of treatment failure [RR 1.20, 95% CI 0.48–3.01, CoE very low]. Oropharyngeal pressure transmission was possibly lower with CLNT compared to other interfaces [MD −1.84 cm H20, 95% CI −3.12 to −0.56, CoE very low]. Clinical benefit or harm could not be excluded with CLNT compared to SBP or NM for the outcomes of duration of IMV, nasal trauma, receipt of surfactant, air leak, and NRS duration. Conclusion: Very low to low CoE and statistically nonsignificant results for the clinical outcomes precluded us from making any reasonable conclusions; however, the use of CLNT as an NRS interface, compared to SBP or NM, possibly transmits lower oropharyngeal pressures. We suggest adequately powered multicentric RCTs to evaluate the efficacy of CLNT when compared to other interfaces.
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Affiliation(s)
- Pratima Anand
- Division of Neonatology, Department of Paediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India
| | - Monika Kaushal
- Department of Neonatology, Emirates Speciality Hospital, Dubai P.O. Box 505240, United Arab Emirates
| | | | | | - Abdul Razak
- Division of Neonatology, Department of Paediatrics, Princess Nourah Bint Abdulrahman University, King Abdullah Bin Abdulaziz University Hospital, Riyadh 11564, Saudi Arabia
- Department of Paediatrics, Monash University, Clayton, VIC 3800, Australia
| | - Daniele Trevisanuto
- Department of Woman and Child Health, University of Padua, University Hospital of Padua, 35128 Padua, Italy
- Correspondence: ; Tel.: +39-3406632734l
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13
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Boyle E, Roehr CC. Surfactant therapy in late preterm and term neonates with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:393-397. [PMID: 34686533 DOI: 10.1136/archdischild-2021-322890] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 10/06/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There are no evidence-based recommendations for surfactant use in late preterm (LPT) and term infants with respiratory distress syndrome (RDS). OBJECTIVE To investigate the safety and efficacy of surfactant in LPT and term infants with RDS. METHODS Systematic review, meta-analysis and evidence grading. INTERVENTIONS Surfactant therapy versus standard of care. MAIN OUTCOME MEASURES Mortality and requirement for invasive mechanical ventilation (IMV). RESULTS Of the 7970 titles and abstracts screened, 17 studies (16 observational studies and 1 randomised controlled trial (RCT)) were included. Of the LPT and term neonates with RDS, 46% (95% CI 40% to 51%) were treated with surfactant. We found moderate certainty of evidence (CoE) from observational studies evaluating infants supported with non-invasive respiratory support (NRS) or IMV that surfactant use may be associated with a decreased risk of mortality (OR 0.45, 95% CI 0.32 to 0.64). Very low CoE from observational trials in which surfactant was administered at FiO2 >0.30-0.40 to infants on Continuous Positive Airway Pressure (CPAP) indicated that surfactant did not decrease the risk of IMV (OR 1.20, 95% CI 0.40 to 3.56). Very low to low CoE from the RCT and observational trials showed that surfactant use was associated with a significant decrease in risk of air leak, persistent pulmonary hypertension of the newborn (PPHN), duration of IMV, NRS and hospital stay. CONCLUSIONS Current evidence base on surfactant therapy in LPT and term infants with RDS indicates a potentially decreased risk of mortality, air leak, PPHN and duration of respiratory support. In view of the low to very low CoE and widely varying thresholds for deciding on surfactant replacement in the included studies, further trials are needed.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, Delhi, India
| | - Elaine Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Charles Christoph Roehr
- Nuffield Department of Population Health, Medical Sciences Division, National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK .,Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK.,Faculty of Health Sciences, University of Bristol, Bristol, UK
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Kumar G, Goel S, Nangia S, Ramaswamy VV. Outcomes of Nonvigorous Neonates Born through Meconium-Stained Amniotic Fluid after a Practice Change to No Routine Endotracheal Suctioning from a Developing Country. Am J Perinatol 2022. [PMID: 35288884 DOI: 10.1055/a-1797-7005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The International Liaison Committee on Resuscitation (ILCOR) 2015 gave a weak recommendation based on low certainty of evidence against routine endotracheal (ET) suctioning in non-vigorous (NV) neonates born through meconium-stained amniotic fluid (MSAF) and suggested for immediate resuscitation without direct laryngoscopy. A need for ongoing surveillance post policy change has been stressed upon. This study compared the outcomes of NV MSAF neonates before and after implementation of the ILCOR 2015 recommendation. STUDY DESIGN This was a prospective cohort study of term NV MSAF neonates who underwent immediate resuscitation without ET suctioning (no ET group, July 2018 to June 2019, n = 276) compared with historical control who underwent routine ET suction (ET group, July 2015 to June 2016, n = 271). RESULTS Baseline characteristics revealed statistically significant higher proportion of male gender and small for gestational age neonates in the prospective cohort. There was no significant difference in the incidence of primary outcome of meconium aspiration syndrome (MAS) between the groups (no ET group: 27.2% vs ET group: 25.1%; p = 0.57). NV MSAF neonates with hypoxic ischemic encephalopathy (HIE) was significantly lesser in the prospective cohort (no ET group: 19.2% vs ET group: 27.3%; p = 0.03). Incidence of air leaks and need for any respiratory support significantly increased after policy change. In NV MSAF neonates with MAS, need for mechanical ventilation (MV) (no ET group: 24% vs ET group: 39.7%; p = 0.04) and mortality (no ET group: 18.7% vs ET group: 33.8%; p = 0.04) were significantly lesser. CONCLUSION Current study from a developing country indicates that immediate resuscitation and no routine ET suctioning of NV MSAF may not be associated with increased risk of MAS and may be associated with decreased risk of HIE. Increased requirement of any respiratory support and air leak post policy change needs further deliberation. Decreased risk of MV and mortality among those with MAS was observed. KEY POINTS · Not performing ET suction in NV MSAF infants is not associated with increase in the incidence of MAS.. · Initiating immediate resuscitation without ET suctioning was associated with decreased risk of HIE but increased receipt of any respiratory support and air leak.. · Large multicentric trial is required to generate robust evidence..
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Affiliation(s)
- Gunjana Kumar
- Department of Neonatology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Srishti Goel
- Department of Neonatology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
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Abiramalatha T, Vadakkencherry Ramaswamy V, Thanigainathan S. Platelet transfusions in neonates-Unresolved aspects and future directions. Pediatr Blood Cancer 2022; 69:e29608. [PMID: 35187787 DOI: 10.1002/pbc.29608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH), Coimbatore, Tamil Nadu, India.,Department of Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | | | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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16
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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Abiramalatha T, Thanigainathan S, Ramaswamy VV, Pressler R, Brigo F, Hartmann H. Antiseizure medications for neonates with seizures. Hippokratia 2022. [DOI: 10.1002/14651858.cd014967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Thangaraj Abiramalatha
- Neonatology; Kovai Medical Center and Hospital (KMCH); KMCH Institute of Health Sciences and Research; Coimbatore India
| | | | | | | | - Francesco Brigo
- Department of Neurological and Movement Sciences. Section of Clinical Neurology; University of Verona; Verona Italy
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Abiramalatha T, Ramaswamy VV, Ponnala AK, Kallem VR, Murkunde YV, Punnoose AM, Vivekanandhan A, Pullattayil AK, Amboiram P. Emerging neuroprotective interventions in periventricular leukomalacia: A systematic review of preclinical studies. Expert Opin Investig Drugs 2022; 31:305-330. [PMID: 35143732 DOI: 10.1080/13543784.2022.2040479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Periventricular leukomalacia (PVL) is a result of various antenatal, intrapartum, or postnatal insults to the developing brain and is an important harbinger of cerebral palsy in preterm neonates. There is no proven therapy for PVL. This calls for appraisal of targeted therapies that have been investigated in animal models to evaluate their relevance in clinical research context. AREAS COVERED This systematic review identifies interventions that were evaluated in preclinical studies for neuroprotective efficacy against PVL. We identified 142 studies evaluating various interventions in PVL animal models. (Search method is detailed in section 2). EXPERT OPINION Interventions that have yielded significant results in preclinical research, and that have been evaluated in a limited number of clinical trials include stem cells, erythropoietin, and melatonin. Many other therapeutic modalities evaluated in preclinical studies have been identified, but more data on their neuroprotective potential in PVL must be garnered before they can be considered for clinical trials. Because most of the tested interventions had only a partial efficacy, a combination of interventions that could be synergistic should be investigated in future preclinical studies. Furthermore, since the nature and pattern of perinatal insults to preterm brain predisposing it to PVL are substantially variable, individualised approaches for the choice of appropriate neuroprotective interventions tailored to different sub-groups of preterm neonates should be explored.
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Affiliation(s)
- Thangaraj Abiramalatha
- Consultant Neonatologist, Kovai Medical Center and Hospital (KMCH).,Department of Pediatrics and Neonatology, KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Andelsivj Kumar Ponnala
- Centre for Toxicology and Developmental Research (CEFTE), Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | | | - Yogeshkumar V Murkunde
- Centre for Toxicology and Developmental Research (CEFTE), Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Alan Mathew Punnoose
- Department of Stem Cell Research and Regenerative Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | | | | | - Prakash Amboiram
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Trevisanuto D, Ramaswamy VV, Villani PE. Neonatal Resuscitation in Children 2021: Focus on Training, Technology, and New Clinical Approaches. Children 2022; 9:children9020175. [PMID: 35204896 PMCID: PMC8870172 DOI: 10.3390/children9020175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/10/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Daniele Trevisanuto
- Department of Woman’s and Child’s Health, University Hospital of Padua, 35128 Padua, Italy
- Correspondence: ; Tel.: +39-3406632734
| | | | - Paolo Ernesto Villani
- Department of Pediatrics, Fondazione Poliambulanza Istituto Ospedaliero, 25124 Brescia, Italy;
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Ramaswamy VV, Abiramalatha T, Roehr CC. Addressing the Lack of Clarity About Administering Surfactant in Preterm Infants With Respiratory Distress Syndrome Treated With Noninvasive Respiratory Support. JAMA Pediatr 2022; 176:121-122. [PMID: 34694350 DOI: 10.1001/jamapediatrics.2021.4098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,University of Bristol, Women's and Children Division, Bristol, United Kingdom
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Abiramalatha T, Bandyopadhyay T, Ramaswamy VV, Shaik NB, Thanigainathan S, Pullattayil AK, Amboiram P. Risk Factors for Periventricular Leukomalacia in Preterm Infants: A Systematic Review, Meta-analysis, and GRADE-Based Assessment of Certainty of Evidence. Pediatr Neurol 2021; 124:51-71. [PMID: 34537463 DOI: 10.1016/j.pediatrneurol.2021.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/20/2021] [Accepted: 08/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We analyzed the certainty of evidence (CoE) for risk factors of periventricular leukomalacia (PVL) in preterm neonates, a common morbidity of prematurity. METHODS Medline, CENTRAL, Embase, and CINAHL were searched. Cohort and case-control studies and randomised randomized controlled trials were included. Data extraction was performed in duplicate. A random random-effects meta-analysis was utilizedused. CoE was evaluated as per Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. RESULTS One hundred eighty-six studies evaluating 95 risk factors for PVL were included. Of the 2,509,507 neonates assessed, 16,569 were diagnosed with PVL. Intraventricular hemorrhage [adjusted odds ratio: 3.22 (2.52-4.12)] had moderate CoE for its association with PVL. Other factors such as hypocarbia, chorioamnionitis, PPROM >48 hour, multifetal pregnancy reduction, antenatal indomethacin, lack of antenatal steroids, perinatal asphyxia, ventilation, shock/hypotension, patent ductus arteriosus requiring surgical ligation, late-onset circulatory collapse, sepsis, necrotizing enterocolitis, and neonatal surgery showed significant association with PVL after adjustment for confounders (CoE: very low to low). Amongst the risk factors associated with mother placental fetal (MPF) triad, there was paucity of literature related to genetic predisposition and defective placentation. Sensitivity analysis revealed that the strength of association between invasive ventilation and PVL decreased over time (P < 0.01), suggesting progress in ventilation strategies. Limited studies had evaluated diffuse PVL. CONCLUSION Despite decades of research, our findings indicate that the CoE is low to very low for most of the commonly attributed risk factors of PVL. Future studies should evaluate genetic predisposition and defective placentation in the MPF triad contributing to PVL. Studies evaluating exclusively diffuse PVL are warranted.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, India
| | | | - Prakash Amboiram
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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Hooper RG, Ramaswamy VV, Wahid RM, Satodia P, Bhulani A. Levetiracetam as the first-line treatment for neonatal seizures: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:1283-1293. [PMID: 34124790 DOI: 10.1111/dmcn.14943] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 12/19/2022]
Abstract
AIM To assess the effectiveness and safety of levetiracetam when used as first-line treatment of neonatal seizures. METHOD Four electronic databases, Medline, Embase, Web of Science, and ClinicalTrials.gov were systematically searched from inception until 20th November 2020. Randomized controlled trials (RCTs) and observational studies that included neonates born preterm and term were eligible for inclusion. The primary outcome measure was levetiracetam effectiveness, defined as seizure cessation within 24 hours of starting treatment. Secondary outcomes included short-term adverse events, mortality before discharge, and long-term neurodevelopmental outcomes. RESULTS Fourteen studies assessing 1188 neonates were included: four RCTs, three observational trials with phenobarbital as the control arm, and seven observational studies of levetiracetam with no control arm. Pooled efficacy of levetiracetam from observational studies was 45% (95% confidence interval [CI] 34-57%) (GRADE - very low). Meta-analysis of RCTs evaluating levetiracetam versus phenobarbital showed that both were equally effective (risk ratio [95% CI] 0.6 [0.30-1.20]) (GRADE - very low). Levetiracetam resulted in a lower risk of short-term adverse events compared to phenobarbital (risk ratio [95% CI] 0.24 [0.06-0.92]) (GRADE - moderate). INTERPRETATION Very low certainty of evidence suggests levetiracetam might not be more effective than phenobarbital. Moderate certainty of evidence indicates levetiracetam is associated with a lower risk of adverse events. Future trials on neonatal antiseizure medication therapy should include continuous electroencephalogram (EEG) monitoring as standard of care and enrol a homogenous population with similar seizure aetiology. What this paper adds Levetiracetam is effective in 45% of neonatal seizures. Levetiracetam might not be more effective than phenobarbital. Levetiracetam is likely to be safer than phenobarbital. Evidence available is limited and of very low certainty.
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Affiliation(s)
- Robert G Hooper
- University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Rachael M Wahid
- University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Prakash Satodia
- University of Warwick, Coventry, UK.,University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Adarsh Bhulani
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Shaik NB, Pullattayil S AK, Cavallin F, Roehr CC, Trevisanuto D. Delivery room CPAP in improving outcomes of preterm neonates in low-and middle-income countries: A systematic review and network meta-analysis. Resuscitation 2021; 170:250-263. [PMID: 34757058 DOI: 10.1016/j.resuscitation.2021.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 06/12/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
AIM To study the impact of delivery room continuous positive airway pressure (DRCPAP) on outcomes of preterm neonates in low- and middle- income countries (LMICs) by comparing with interventions: oxygen supplementation, late DRCPAP, DRCPAP with sustained inflation, DRCPAP with surfactant and invasive mechanical ventilation (IMV). METHODS Medline, Embase, CENTRAL, WOS and CINAHL searched. Observational studies and randomized controlled trials (RCTs) were included. Pair-wise meta-analysis and Bayesian network meta-analysis (NMA) were utilized. Primary outcome was receipt of IMV. RESULTS Data from 11 of the 18 included studies (4 observational studies, 7 RCTs) enrolling 4210 preterm infants was synthesized. Moderate certainty of evidence (CoE) from NMA of RCTs comparing DRCPAP with surfactant administration versus DRCPAP alone suggested no decrease in subsequent receipt of IMV [Risk ratio (RR); 95% Credible Interval (CrI): 0.73; (0.34, 1.40)]. Very low CoE from observational studies comparing use of DRCPAP versus oxygen supplementation indicated a trend towards decreased IMV [RR; 95% Confidence Interval (CI): 0.75; (0.56-1.00)]. Although moderate CoE from NMA evaluating DRCPAP versus oxygen supplementation showed a trend towards decreased receipt of surfactant, it did not reach statistical significance [RR; 95% CrI: 0.69; (0.44, 1.06)]. Moderate CoE from NMA indicated that none of the interventions, when compared with use of supplemental oxygen alone or with each other decreased mortality or bronchopulmonary dysplasia. LIMITATIONS CoE was very low for primary outcome. CONCLUSIONS Present evidence is not sufficient for use of DRCPAP, but also did not show harm. Since it seems unlikely that there are marked variations in patient physiology to explain the difference in efficacy between high income countries and LMICs, we suggest future research evaluating other barriers in improving the effectiveness of DRCPAP in LMICs.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | | | | | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences, Division, University of Oxford, Oxford, United Kingdom; Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, United Kingdom; University of Bristol, Women's and Children Division, Bristol, United Kingdom
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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Ramaswamy VV, Roehr CC. Is a New Era Coming for Bronchopulmonary Dysplasia Prevention With Corticosteroids?-Reply. JAMA Pediatr 2021; 175:1079-1080. [PMID: 34228118 DOI: 10.1001/jamapediatrics.2021.1861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Medical Sciences Division, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Vadakkencherry Ramaswamy V, Abiramalatha T, Weiner GM, Trevisanuto D. A comparative evaluation and appraisal of 2020 American Heart Association and 2021 European Resuscitation Council neonatal resuscitation guidelines. Resuscitation 2021; 167:151-159. [PMID: 34464679 DOI: 10.1016/j.resuscitation.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 01/08/2023]
Abstract
AIM The International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support forms the basis for guidelines developed by regional councils such as the American Heart Association (AHA) and the European Resuscitation Council (ERC). We aimed to determine if the updated guidelines are congruent, identify the source of variation, and score their quality. METHODS We compared the approach to developing recommendations, final recommendations, and cited evidence in the AHA 2020 and ERC 2021 neonatal resuscitation guidelines. Two investigators scored guideline quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. RESULTS Differences in the recommendations were found between AHA 2020 and ERC 2021 neonatal resuscitation guidelines. The councils gave differing recommendations for practices that had sparse evidence and made recommendations based on expert consensus or observational studies. AGREE II assessment revealed that AHA scored better for the domain 'rigour of development', but ERC had a higher score for 'stakeholder involvement'. Both AHA and ERC scored relatively less for 'applicability'. CONCLUSION AHA and ERC guidelines are predominantly based on the ILCOR CoSTR. Differences in recommendations between the two were largely related to the evidence gathering process for questions not reviewed by ILCOR, paucity of evidence for some recommendations based on existing regional practices and supported by expert opinion, and different interpretation or application of same evidence. Overall, both guidelines scored well on the AGREE II assessment, but each had domains that could be improved in future editions.
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Gary M Weiner
- Department of Pediatrics - Neonatology, University of Michigan, Ann Arbor, MI, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Pullattayil S AK, Trevisanuto D. Digital tracheal intubation and finger palpation to confirm endotracheal tube tip position in neonates: A systematic review and meta-analysis. Pediatr Pulmonol 2021; 56:2893-2902. [PMID: 34265176 PMCID: PMC8457083 DOI: 10.1002/ppul.25551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/21/2021] [Accepted: 06/21/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND To evaluate digital tracheal intubation (DTI) when compared to laryngoscope-assisted TI; finger palpation of endotracheal tube (ETT) tip position when compared to any standard method. DESIGN A systematic review of Medline, Embase, CENTRAL, and CINAHL with synthesis of data using meta-analysis was performed. MAIN OUTCOME MEASURE The proportion of successful TI and correct ETT tip positioning were the main outcome measures. RESULTS Five studies (one observational study and four RCTs) enrolling 310 neonates were included. 94% (81%-98%) of the DTI were successful on the first attempt (certainty of evidence [CoE]: low). The proportion of successful intubation on the first attempt was higher with DTI when compared to laryngoscope-assisted TI (RR 95% CI: 1.81 [1.18; 2.76]) (CoE: very low). Time to successful TI with DTI was 7.4 (95% CI: 6.3, 8.5) s (CoE: low). Time to successful TI was significantly shorter with DTI when compared to laryngoscope assisted TI (MD [95% CI]: -4.9 [-7.3, -2.4] s) (CoE: very low). There was a trend towards a higher proportion of correct ETT tip positions with finger palpation when compared to weight-based formulae alone (RR 95% CI: 1.12 [0.96; 1.31]) (CoE: very low). CONCLUSIONS DTI and finger palpation to ascertain ETT tip position in neonates are promising strategies. Future studies with emphasis on their learning trajectory and generalizability are needed.
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Affiliation(s)
| | | | - Tapas Bandyopadhyay
- Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | - Daniele Trevisanuto
- Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Pullattayil AK, Thanigainathan S, Trevisanuto D, Roehr CC. Delivery Room Interventions for Hypothermia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr 2021; 175:e210775. [PMID: 34028513 PMCID: PMC8145154 DOI: 10.1001/jamapediatrics.2021.0775] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/26/2021] [Indexed: 12/31/2022]
Abstract
Importance Prevention of hypothermia in the delivery room is a cost-effective, high-impact intervention to reduce neonatal mortality, especially in preterm neonates. Several interventions for preventing hypothermia in the delivery room exist, of which the most beneficial is currently unknown. Objective To identify the delivery room thermal care intervention that can best reduce neonatal hypothermia and improve clinical outcomes for preterm neonates born at 36 weeks' gestation or less. Data Sources MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and CINAHL databases were searched from inception to November 5, 2020. Study Selection Randomized and quasi-randomized clinical trials of thermal care interventions in the delivery room for preterm neonates were included. Peer-reviewed abstracts and studies published in non-English language were also included. Data Extraction and Synthesis Data from the included trials were extracted in duplicate using a structured proforma. A network meta-analysis with bayesian random-effects model was used for data synthesis. Main Outcomes and Measures Primary outcomes were core body temperature and incidence of moderate to severe hypothermia on admission or within the first 2 hours of life. Secondary outcomes were incidence of hyperthermia, major brain injury, and mortality before discharge. The 9 thermal interventions evaluated were (1) plastic bag or plastic wrap covering the torso and limbs with the head uncovered or covered with a cloth cap; (2) plastic cap covering the head; (3) skin-to-skin contact; (4) thermal mattress; (5) plastic bag or plastic wrap with a plastic cap; (6) plastic bag or plastic wrap along with use of a thermal mattress; (7) plastic bag or plastic wrap along with heated humidified gas for resuscitation or for initiating respiratory support in the delivery room; (8) plastic bag or plastic wrap along with an incubator for transporting from the delivery room; and (9) routine care, including drying and covering the body with warm blankets, with or without a cloth cap. Results Of the 6154 titles and abstracts screened, 34 studies that enrolled 3688 neonates were analyzed. Compared with routine care alone, plastic bag or wrap with a thermal mattress (mean difference [MD], 0.98 °C; 95% credible interval [CrI], 0.60-1.36 °C), plastic cap (MD, 0.83 °C; 95% CrI, 0.28-1.38 °C), plastic bag or wrap with heated humidified respiratory gas (MD, 0.76 °C; 95% CrI, 0.38-1.15 °C), plastic bag or wrap with a plastic cap (MD, 0.62 °C; 95% CrI, 0.37-0.88 °C), thermal mattress (MD, 0.62 °C; 95% CrI, 0.33-0.93 °C), and plastic bag or wrap (MD, 0.56 °C; 95% CrI, 0.44-0.69 °C) were associated with greater core body temperature. Certainty of evidence was moderate for 5 interventions and low for plastic bag or wrap with a thermal mattress. When compared with routine care alone, a plastic bag or wrap with heated humidified respiratory gas was associated with less risk of major brain injury (risk ratio, 0.23; 95% CrI, 0.03-0.67; moderate certainty of evidence) and a plastic bag or wrap with a plastic cap was associated with decreased risk of mortality (risk ratio, 0.19; 95% CrI, 0.02-0.66; low certainty of evidence). Conclusions and Relevance Results of this study indicate that most thermal care interventions in the delivery room for preterm neonates were associated with improved core body temperature (with moderate certainty of evidence). Specifically, use of a plastic bag or wrap with a plastic cap or with heated humidified gas was associated with lower risk of major brain injury and mortality (with low to moderate certainty of evidence).
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, India
| | - Daniele Trevisanuto
- Department of Pediatrics, Medical School, University of Padua, Azienda Ospedaliera Padova, Padua, Italy
| | - Charles C. Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Shaik NB, Bandiya P, Nanda D, Pullattayil S. AK, Murki S, Roehr CC. ELBW and ELGAN outcomes in developing nations-Systematic review and meta-analysis. PLoS One 2021; 16:e0255352. [PMID: 34352883 PMCID: PMC8342042 DOI: 10.1371/journal.pone.0255352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/15/2021] [Indexed: 11/20/2022] Open
Abstract
Context Morbidity and mortality amongst extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGANs) in developing nations has not been well studied. Objectives Evaluate survival until discharge, short- and long-term morbidities of ELBW and ELGANs in LMICs. Data sources CENTRAL, EMBASE, MEDLINE and Web of Science. Study selection Prospective and retrospective observational studies were included. Data extraction and synthesis Four authors extracted data independently. Random-effects meta-analysis of proportions was used to synthesize data, modified QUIPS scale to evaluate quality of studies and GRADE approach to ascertain the certainty of evidence (CoE). Results 192 studies enrolling 22,278 ELBW and 18,338 ELGANs were included. Survival was 34% (95% CI: 31% - 37%) (CoE–low) for ELBW and 39% (34% - 44%) (CoE—moderate) for ELGANs. For ELBW neonates, the survival for low-income (LI), lower middle-income (LMI) and upper middle income (UMI) countries was 18% (11% - 28%), 28% (21% - 35%) and 39% (36% - 42%), respectively. For ELGANs, it was 13% (8% - 20%) for LI, 28% (21% - 36%) for LMI and 48% (42% - 53%) for UMI countries. There was no difference in survival between two epochs: 2000–2009 and 2010–2020. Except for necrotising enterocolitis [ELBW and ELGANs—8% (7% - 10%)] and periventricular leukomalacia [ELBW—7% (4% - 11%); ELGANs—6% (5%-7%)], rates of all other morbidities were higher compared to developed nations. Rates of neurodevelopmental impairment was 17% (7% - 34%) in ELBW neonates and 29% (23% - 37%) in ELGANs. Limitations CoE was very low to low for all secondary outcomes. Conclusions Mortality and morbidity amongst ELBW and ELGANs is still a significant burden in LMICs. CoE was very low to low for all the secondary outcomes, emphasizing the need for high quality prospective cohort studies. Trial registration PROSPERO (CRD42020222873).
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Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
- * E-mail:
| | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Orissa, India
| | | | - Srinivas Murki
- Department of Neonatology, Paramitha Women and Children’s Hospital, Hyderabad, India
| | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences, Division, University of Oxford, Oxford, United Kingdom
- Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, United Kingdom
- University of Bristol, Women’s and Children Division, Bristol, United Kingdom
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Ramaswamy VV, Bandyopadhyay T, Ahmed J, Bandiya P, Zivanovic S, Roehr CC. Enteral Feeding Strategies in Preterm Neonates ≤32 weeks Gestational Age: A Systematic Review and Network Meta-Analysis. Ann Nutr Metab 2021; 77:204-220. [PMID: 34247152 DOI: 10.1159/000516640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/18/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Critical aspects of time of feed initiation, advancement, and volume of feed increment in preterm neonates remain largely unanswered. METHODS Medline , Embase, CENTRAL and CINAHL were searched from inception until 25th September 2020. Network meta-analysis with the Bayesian approach was used. Randomized controlled trials (RCTs) evaluating preterm neonates ≤32 weeks were included. Feeding regimens were divided based on the following categories: initiation day: early (<72 h), moderately early (72 h-7 days), and late (>7 days); advancement day: early (<72 h), moderately early (72 h-7 days), and late (>7 days); increment volume: small volume (SV) (<20 mL/kg/day), moderate volume (MoV) (20-< 30 mL/kg/day), and large volume (≥30 mL/kg/day); and full enteral feeding from the first day. Sixteen regimens were evaluated. Combined outcome of necrotizing enterocolitis (NEC) stage ≥ II or mortality before discharge was the primary outcome. RESULTS A total of 39 studies enrolled around 6,982 neonates. Early initiation (EI) with moderately early or late advancement using MoV increment enteral feeding regimens appeared to be most efficacious in decreasing the risk of NEC or mortality when compared to EI and early advancement with SV increment (risk ratio [95% credible interval]: 0.39 [0.12, 0.95]; 0.34 [0.10, 0.86]) (GRADE-very low). CONCLUSIONS Early initiated, moderately early, or late advanced with MoV increment feeding regimens might be most appropriate in decreasing the risk of NEC stage ≥II or mortality. In view of the certainty of evidence being very low, adequately powered RCTs evaluating these 2 strategies are warranted.
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Affiliation(s)
- Viraraghavan Vadakkencherry Ramaswamy
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr. Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Javed Ahmed
- Women's Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Sanja Zivanovic
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Medical Sciences Division, Nuffield Department of Population Health, National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom.,University of Bristol, Women and Children's Health Research Unit, The Children's Southmead Hospital, Bristol, United Kingdom
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Ramaswamy VV, Oommen VI, Gupta A, Weerapperuma N, Zivanovic S, Roehr CC. Care practices and outcomes of extremely preterm neonates born at 22-24 weeks -A single centre experience. J Neonatal Perinatal Med 2021; 14:575-582. [PMID: 34120919 DOI: 10.3233/npm-200670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Wide variation in the care practices and survival rates of neonates born at peri-viable gestational ages of 22 +0 -24 +6 weeks exists. This study elucidates the postnatal risk factors for morbidity/mortality, contrasts the care practices and short-term outcomes of this vulnerable group of preterm neonates from a single center with others. METHODS Retrospective study of neonates born at 22 +0 -24 +6 weeks in a level 3 neonatal intensive care unit in UK, over a period of 4 years (2016-2019). RESULTS 94 neonates given active care studied. Survival until discharge was 51.1%(22-23 wks -44%, 24 wks -59.1%) and survival with no major brain injury (MBI) [grade III/IV IVH, cystic periventricular leukomalacia] was 38.3%(22-23 wks -32%, 24 wks -45.4%). Of those who survived until discharge, 75%had no MBI (22-23 wks -72.7%, 24 wks -76.9%). Neonates requiring significant respiratory support within first 72 hours as well as needing rescue high frequency ventilation had significantly high risk of mortality or MBI [aOR -7.17 (2.24-25.79), p = 0.00; 4.76 (1.43-20.00), p = 0.01]. CONCLUSIONS Survival rate differed from other centres. MBI was low amongst survivors. Severe respiratory disease in the initial days was associated with a higher risk of death or MBI.
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Affiliation(s)
- V V Ramaswamy
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - V I Oommen
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - A Gupta
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - N Weerapperuma
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - S Zivanovic
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - C C Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Medical Sciences, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
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Abiramalatha T, Ramaswamy VV, Thanigainathan S, Pullattayil AK, Kirubakaran R. Frequency of ventilator circuit changes to prevent ventilator-associated pneumonia in neonates and children-A systematic review and meta-analysis. Pediatr Pulmonol 2021; 56:1357-1365. [PMID: 33713572 DOI: 10.1002/ppul.25345] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/08/2021] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the effect of different frequencies of ventilator circuit changes in neonates and children through a systematic review and meta-analysis. INTERVENTIONS (1) "No routine change of ventilator circuit (unless visibly soiled)" versus "routine change at any fixed interval"; (2) routine change of circuit at "less frequent" versus "more frequent" intervals. OUTCOMES Primary outcomes were VAP rate (number of VAP episodes per 1000 ventilator-days) and all-cause mortality before discharge. METHODS MEDLINE, CENTRAL, EMBASE, and CINAHL were systematically searched from inception till November 3, 2020. Two authors assessed trial eligibility and risk of bias, and independently extracted data. Data were synthesized using fixed effects model. GRADE was used to assess certainty of evidence (CoE). RESULTS We identified six studies enrolling 768 participants evaluating circuit changes at two fixed intervals. Meta-analysis of studies on circuit changes "once in less than 7 days" versus "once weekly" showed no difference in VAP rate (risk ratio: 0.83 [0.38-1.81]; one randomized controlled trial (RCT) and 0.94 [0.49-1.81]; two before-after studies) or mortality before discharge (0.67 [0.34-1.3]; one RCT and 1.01 [0.63-1.64]; two before-after studies). CoE was very low. Less frequent circuit changes reduced health-care costs. No study evaluating "circuit changes only when visibly soiled" versus "circuit changes at a fixed interval" was identified. CONCLUSION There is no evidence to suggest that ventilator circuits can be safely left unchanged until visibly soiled in neonates and children. Extending circuit changes interval to "once weekly" may not increase VAP rate (CoE-very low) and reduces healthcare costs.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | | | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | | | - Richard Kirubakaran
- Department of Biostatistics, Prof. BV Moses Centre for Evidence-Informed Healthcare and Health Policy, Christian Medical College, Vellore, Tamil Nadu, India
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Ramaswamy VV, Bandyopadhyay T, Nanda D, Bandiya P, Ahmed J, Garg A, Roehr CC, Nangia S. Assessment of Postnatal Corticosteroids for the Prevention of Bronchopulmonary Dysplasia in Preterm Neonates: A Systematic Review and Network Meta-analysis. JAMA Pediatr 2021; 175:e206826. [PMID: 33720274 PMCID: PMC7961472 DOI: 10.1001/jamapediatrics.2020.6826] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IMPORTANCE The safety of postnatal corticosteroids used for prevention of bronchopulmonary dysplasia (BPD) in preterm neonates is a controversial matter, and a risk-benefit balance needs to be struck. OBJECTIVE To evaluate 14 corticosteroid regimens used to prevent BPD: moderately early-initiated, low cumulative dose of systemic dexamethasone (MoLdDX); moderately early-initiated, medium cumulative dose of systemic dexamethasone (MoMdDX); moderately early-initiated, high cumulative dose of systemic dexamethasone (MoHdDX); late-initiated, low cumulative dose of systemic dexamethasone (LaLdDX); late-initiated, medium cumulative dose of systemic dexamethasone (LaMdDX); late-initiated, high cumulative dose of systemic dexamethasone (LaHdDX); early-initiated systemic hydrocortisone (EHC); late-initiated systemic hydrocortisone (LHC); early-initiated inhaled budesonide (EIBUD); early-initiated inhaled beclomethasone (EIBEC); early-initiated inhaled fluticasone (EIFLUT); late-initiated inhaled budesonide (LIBUD); late-initiated inhaled beclomethasone (LIBEC); and intratracheal budesonide (ITBUD). DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, World Health Organization's International Clinical Trials Registry Platform (ICTRP), and CINAHL were searched from inception through August 25, 2020. STUDY SELECTION In this systematic review and network meta-analysis, the randomized clinical trials selected included preterm neonates with a gestational age of 32 weeks or younger and for whom a corticosteroid regimen was initiated within 4 weeks of postnatal age. Peer-reviewed articles and abstracts in all languages were included. DATA EXTRACTION AND SYNTHESIS Two independent authors extracted data in duplicate. Network meta-analysis used a bayesian model. MAIN OUTCOMES AND MEASURES Primary combined outcome was BPD, defined as oxygen requirement at 36 weeks' postmenstrual age (PMA), or mortality at 36 weeks' PMA. The secondary outcomes included 15 safety outcomes. RESULTS A total of 62 studies involving 5559 neonates (mean [SD] gestational age, 26 [1] weeks) were included. Several regimens were associated with a decreased risk of BPD or mortality, including EHC (risk ratio [RR], 0.82; 95% credible interval [CrI], 0.68-0.97); EIFLUT (RR, 0.75; 95% CrI, 0.55-0.98); LaHdDX (RR, 0.70; 95% CrI, 0.54-0.87); MoHdDX (RR, 0.64; 95% CrI, 0.48-0.82); ITBUD (RR, 0.73; 95% CrI, 0.57-0.91); and MoMdDX (RR, 0.61; 95% CrI, 0.45-0.79). Surface under the cumulative ranking curve (SUCRA) value ranking showed that MoMdDX (SUCRA, 0.91), MoHdDX (SUCRA, 0.86), and LaHdDX (SUCRA, 0.76) were the 3 most beneficial interventions. ITBUD (RR, 4.36; 95% CrI, 1.04-12.90); LaHdDX (RR, 11.91; 95% CrI, 1.64-44.49); LaLdDX (RR, 6.33; 95% CrI, 1.62-18.56); MoHdDX (RR, 4.96; 95% CrI, 1.14-14.75); and MoMdDX (RR, 3.16; 95% CrI, 1.35-6.82) were associated with more successful extubation from invasive mechanical ventilation. EHC was associated with a higher risk of gastrointestinal perforation (RR, 2.77; 95% CrI, 1.09-9.32). MoMdDX showed a higher risk of hypertension (RR, 3.96; 95% CrI, 1.10-30.91). MoHdDX had a higher risk of hypertrophic cardiomyopathy (RR, 5.94; 95% CrI, 1.95-18.11). CONCLUSIONS AND RELEVANCE This study suggested that MoMdDX may be the most appropriate postnatal corticosteroid regimen for preventing BPD or mortality at a PMA of 36 weeks, albeit with a risk of hypertension. The quality of evidence was low.
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Affiliation(s)
- Viraraghavan Vadakkencherry Ramaswamy
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom,Ankura Hospital for Women and Children, Hyderabad, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital and Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Orissa, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Javed Ahmed
- Women’s Wellness and Research Centre, Hamad Medical Corporation, Doha, Qatar
| | - Anip Garg
- Department of Neonatology, James Cook University Hospital, Middlesbrough, United Kingdom
| | - Charles C. Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
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Oommen VI, Ramaswamy VV, Szyld E, Roehr CC. Resuscitation of non-vigorous neonates born through meconium-stained amniotic fluid: post policy change impact analysis. Arch Dis Child Fetal Neonatal Ed 2021; 106:324-326. [PMID: 32963086 DOI: 10.1136/archdischild-2020-319771] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 05/25/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND We investigated the impact of policy change in delivery room resuscitation from routine endotracheal (ET) suctioning of non-vigorous neonates born through meconium-stained amniotic fluid (MSAF) to immediate non-invasive respiratory support. DESIGN Single-centre cohort study. Prospective group (October 2016-September 2017)-non-vigorous neonates born through MSAF managed according to the current (2015) guidance of commencing respiratory support without prior suctioning. Retrospective group (August 2015-July 2016)-non-vigorous neonates born through MSAF who underwent routine ET suctioning. RESULTS 1138 neonates born through MSAF were analysed. No differences in the incidence of meconium aspiration syndrome (MAS), requirement of mechanical ventilation, inhaled nitric oxide or surfactant therapy were found between groups. Less neonatal intensive care unit (NICU) admissions were necessary in the prospective cohort compared with the retrospective group (19.1% vs 55.6%, respectively; p<0.05). CONCLUSION The policy change towards not routinely suctioning non-vigorous neonates born through MSAF at birth was not associated with an increase in the local incidence of MAS and was associated with fewer NICU admissions.
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Affiliation(s)
- Vinod Idicula Oommen
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | | | - Edgardo Szyld
- Division of Newborn Medicine, Department of Paediatrics, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK .,National Perinatal Epidemiology Unit, University of Oxford Nuffield Department of Population Health, Oxford, Oxfordshire, UK
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Ramaswamy VV, Bandyopadhyay T, Nanda D, Bandiya P, More K, Oommen VI, Gupta A. Efficacy of noninvasive respiratory support modes as postextubation respiratory support in preterm neonates: A systematic review and network meta-analysis. Pediatr Pulmonol 2020; 55:2924-2939. [PMID: 32757365 DOI: 10.1002/ppul.25007] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/31/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multiple noninvasive respiratory support (NRS) modalities are used for postextubation support in preterm neonates. Seven NRS modalities were compared-constant flow continuous positive airway pressure (CPAP) (CF-CPAP) (bubble CPAP; ventilator CPAP), variable flow CPAP (VF-CPAP), high flow nasal cannula (HFNC), synchronized noninvasive positive pressure ventilation (S-NIPPV), nonsynchronized NIPPV (NS-NIPPV), bilevel CPAP (BiPAP), noninvasive high-frequency oscillation ventilation (nHFOV). DESIGN Systematic review and network meta-analysis (NMA) using the Bayesian random-effects approach. MEDLINE, EMBASE, CENTRAL, WHO-ICTRP were searched. MAIN OUTCOME MEASURE Requirement of invasive mechanical ventilation within 7 days of extubation. RESULTS A total of 33 studies with 4080 preterm neonates were included. S-NIPPV, NS-NIPPV, nHFOV, and VF-CPAP were more efficacious in preventing reintubation than CF-CPAP (risk ratio [RR] [95% credible intervals {CrI}]: 0.22 [0.12, 0.35]; 0.44 [0.27, 0.67]; 0.42 [0.18, 0.81]; 0.73 [0.52, 0.99]). Surface under the cumulative ranking curve (SUCRA) value ranked S-NIPPV to be the best postextubation intervention (SUCRA: 0.98). S-NIPPV was more effective than NS-NIPPV, BiPAP, VF-CPAP, and HFNC (RR [95% CrI]: 0.52 [0.24, 0.97]; 0.32 [0.14, 0.64]; 0.30 [0.16, 0.50]; 0.24 [0.12, 0.41]). NS-NIPPV resulted in lesser reintubation compared to VF-CPAP and HFNC (RR [95% CrI]: 0.61 [0.36, 0.97]; 0.49 [0.27, 0.80]). BiPAP, VF-CPAP, and HFNC had comparable efficacies. The overall quality of evidence was very low to moderate. CONCLUSION Results of this NMA indicate that S-NIPPV might be the most effective and CF-CPAP the least effective NRS modality for preventing extubation failure.
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Affiliation(s)
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Orissa, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Kiran More
- Division of Neonatology, Sidra Medical and Research Center, Doha, Qatar
| | - Vinod Idicula Oommen
- Department Of Neonatology, Newborn Services, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Amit Gupta
- Department Of Neonatology, Newborn Services, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
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Ramaswamy VV, More K, Roehr CC, Bandiya P, Nangia S. Efficacy of noninvasive respiratory support modes for primary respiratory support in preterm neonates with respiratory distress syndrome: Systematic review and network meta-analysis. Pediatr Pulmonol 2020; 55:2940-2963. [PMID: 32762014 DOI: 10.1002/ppul.25011] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [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: 06/06/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare the efficacy of different noninvasive respiratory support (NRS) modes for primary respiratory support of preterm infants with respiratory distress syndrome (RDS). DESIGN Systematic review and network meta-analysis using the Bayesian random-effects approach. MEDLINE, EMBASE, and CENTRAL were searched. INTERVENTIONS High flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), bilevel CPAP (BiPAP), noninvasive positive pressure ventilation (NIPPV). MAIN OUTCOME MEASURES Requirement of invasive mechanical ventilation (MV), any treatment failure. RESULTS A total of 35 studies including 4078 neonates were included. NIPPV was more effective in decreasing the requirement of MV than CPAP (risk ratios [95% credible interval]: 0.60 [0.44, 0.77]) and HFNC [0.66 (0.43, 0.97)]. Surface under the cumulative ranking curve (SUCRA) for NIPPV, BiPAP, HFNC, and CPAP were 0.95, 0.59, 0.32, and 0.13. For the outcome of treatment failure, both NIPPV and BiPAP were more efficacious compared to CPAP and HFNC (0.56 [0.44, 0.71] {NIPPV vs CPAP}, 0.69 [0.51, 0.93] {BiPAP vs CPAP}, 0.42 [0.30, 0.63] {NIPPV vs HFNC}, 0.53 [0.35, 0.81] {BiPAP vs HFNC}). The SUCRA for NIPPV, BiPAP, CPAP, and HFNC were 0.96, 0.70, 0.32, and 0.01. NIPPV was associated with a reduced risk of air leak compared to BiPAP and CPAP (0.36 [0.16, 0.73]; 0.54 [0.30, 0.87], respectively). NIPPV resulted in lesser incidence of bronchopulmonary dysplasia or mortality when compared to CPAP (0.74 [0.52, 0.98]). Nasal injury was lesser with HFNC compared to CPAP (0.15 [0.01, 0.60]). CONCLUSIONS Most effective primary mode of NRS in preterm neonates with RDS was NIPPV.
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Affiliation(s)
| | - Kiran More
- Division of Neonatology, Sidra Medical and Research Center, Doha, Qatar
| | - Charles Christoph Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,National Perinatal Epidemiology Unit, Medical Sciences Division, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
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Sanghamitra GS, Ramaswamy VV, Malakar S, Kadwa RA. Case 2: Multiple Cranial Nerve Palsies in a Neonate with a History of Perinatal Asphyxia. Neoreviews 2020; 21:e574-e576. [PMID: 32737175 DOI: 10.1542/neo.21-8-e574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- G S Sanghamitra
- Department of Neonatology, Nori Multi-Speciality Hospital, Vijayawada, Andhra Pradesh, India
| | | | - Sudeshna Malakar
- Department of Radiology, Lady Hardinge Medical College, New Delhi, India
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Abstract
Background: Donor human milk plays a vital part in the care of sick neonates. There is paucity of literature on the profile of human milk donors of low- and middle-income countries (LMICs). Materials and Methods: This retrospective observational study evaluated the demographic profile of 1,553 donors of a human milk bank of a tertiary care center from a LMIC over a period of 21 months. Results: The mean age of the donors was 21.6 ± 2.7 years. Around 63% of the donors were from the postnatal care wards and 53.3% had given birth to a premature infant. The total volume of human milk donated was 413 L and the mean volume of milk per donor was 268 ± 386 mL. The mean amount of milk donated by the neonatal intensive care unit (NICU) mothers was significantly higher when compared to that donated by the postnatal care ward mothers (p = 0.0001). Two-thirds (65.5%) of the donated milk was from mothers who gave birth to a preterm infant and 20.8% was from mothers of preterm neonates of <32 weeks of gestation. There was no statistical difference between the mean amount of milk donated by a mother who had delivered extremely preterm neonates when compared to those who had delivered very preterm neonates (p = 0.18). Conclusions: The predominant donors of a human milk bank from a LMIC are of a younger age group, are more likely to have delivered a premature or a low birth weight baby, and are mostly the ones whose neonates require NICU admission or from postnatal care wards.
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Affiliation(s)
- Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
| | | | - Maheshwar Bhasin
- Vatsalya Maatri Amrit Kosh, Comprehensive Lactation Management Centre, Lady Hardinge Medical College, New Delhi, India
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Ramaswamy VV, Rao GV, Suryanarayana N, Kumar Darisi P, Gummadapu S. Case 3: Hydrops Fetalis, Pancytopenia, and Hemolytic Jaundice in a Preterm Neonate: A Diagnosis Made After 3 Months. Neoreviews 2019; 20:e597-e599. [PMID: 31575783 DOI: 10.1542/neo.20-10-e597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
| | - Gajanan Venkat Rao
- Department of Neonatology, Nori Multi-Speciality Hospital, Vijayawada, Andhra Pradesh, India
| | - Nori Suryanarayana
- Department of Neonatology, Nori Multi-Speciality Hospital, Vijayawada, Andhra Pradesh, India
| | - Pavan Kumar Darisi
- Department of Neonatology, Nori Multi-Speciality Hospital, Vijayawada, Andhra Pradesh, India
| | - Sanghamitra Gummadapu
- Department of Neonatology, Nori Multi-Speciality Hospital, Vijayawada, Andhra Pradesh, India
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Ramaswamy VV, Singh A. Can Small for Gestational Age Status Affect the Weight-based Formula for Calculation of Insertional Length of Endotracheal Tube in Neonates? Indian Pediatr 2019; 56:694-695. [PMID: 31477659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
| | - Anchala Singh
- Department of Pediatrics, AIIMS, Gorakhpur, Uttar Pradesh; India
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Ramaswamy VV, Gummadapu S. Balancing the Covariates in Studies on Enteral Feeding in Preterm Neonates. Indian Pediatr 2019; 56:693. [PMID: 31477657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
| | - Sanghamitra Gummadapu
- Department of Neonatology, Nori Multispeciality Hospital, Vijayawada, Andhra Pradesh, India
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Ramaswamy VV, Gummadapu S, Suryanarayana N. Nosocomial pneumonia and sepsis caused by a rare organism Cedecea lapagei in an infant and a review of literature. BMJ Case Rep 2019; 12:12/7/e229854. [PMID: 31300600 DOI: 10.1136/bcr-2019-229854] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 11/04/2022] Open
Abstract
A late preterm male infant of 36 weeks gestation and a birth weight of 2100 g was admitted on day 35 of life with complaints of respiratory distress and lethargy. He was diagnosed as a case of sepsis screen positive culture negative sepsis and was managed with respiratory support and intravenous antibiotics for 10 days. The infant improved clinically and was on spoon feeds by day 14 of admission. On day 14 of admission, he developed new-onset respiratory distress and was diagnosed as a case of nosocomial pneumonia based on chest radiography findings. The blood culture grew a rare organism Cedecea lapagei and a diagnosis of sepsis was also made. The antibiotics were tailored as per the blood culture sensitivity pattern and the infant had clinical improvement in the next 72 hours.
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Affiliation(s)
| | | | - Nori Suryanarayana
- Neonatology, Nori Multispeciality Hospital, Vijayawada, Andhra Pradesh, India
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Abstract
A preterm 32-week neonate presented on the 14th day of life with respiratory distress and cyanosis. The respiratory distress worsened progressively, which was managed with continuous positive airway pressure support. The neonate had blood-tinged oral secretions on the 39th day of life, for which bronchoscopy was performed, whose findings were suggestive of pulmonary hemosiderosis. Lung biopsy confirmed the diagnosis of pulmonary interstitial glycogenosis with pulmonary arterial hypertension. The neonate was treated successfully with systemic corticosteroids and discharged home at 3 months of age.
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Affiliation(s)
| | - Sushma Nangia
- Department of Neonatology, Lady Hardinge Medical College, New Delhi, India
| | - Anu Thukral
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Varinder Singh
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
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Ramaswamy VV, Rao GV, Suryanarayana N, Gummadapu S. Unusual finding in the karyotype of a neonate with glandular hypospadias with chordee. BMJ Case Rep 2019; 12:12/3/e228429. [PMID: 30898940 DOI: 10.1136/bcr-2018-228429] [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: 11/03/2022] Open
Abstract
A 37-week, 2700 g vaginally delivered baby was admitted for respiratory distress which was attributed to transient tachypnoea of newborn. A clinical finding of glandular hypospadias with ventral chordee was detected. The penis was normal in size, and gonads were palpable bilaterally in the scrotal sac. The parents were informed of the good prognosis associated with this milder variety of hypospadias. In view of parental concerns, a fluorescent in situ hybridisation (FISH) for X and Y chromosome was performed. Surprisingly, FISH revealed the presence of 46, XY in 90% of cells and 46, XX in 10% of the remainder cells suggesting a diagnosis of chimerism.
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Affiliation(s)
| | - Gajanan Venkat Rao
- Department of Neonatology, Nori Multispeciality Hospital, Vijayawada, Andhra Pradesh, India
| | - Nori Suryanarayana
- Department of Neonatology, Nori Multispeciality Hospital, Vijayawada, Andhra Pradesh, India
| | - Sanghamitra Gummadapu
- Department of Neonatology, Nori Multispeciality Hospital, Vijayawada, Andhra Pradesh, India
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Ramaswamy VV. A randomized controlled trial comparing the effect of fortification of human milk with an infant formula powder versus unfortified human milk on the growth of preterm very low birth weight infants. J Matern Fetal Neonatal Med 2019; 33:3719. [PMID: 30786792 DOI: 10.1080/14767058.2019.1580260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ramaswamy VV, Rao GV, Suryanarayana N. A Rare Cause of Ophthalmia Neonatorum-Achromobacter denitrificans. J Clin Diagn Res 2018. [DOI: 10.7860/jcdr/2018/37366.12112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Choudhary S, Ramaswamy VV, Nangia S, Saili A. Myoclonic Seizures and Lactic Acidemia in a Term Newborn Born with no History of Asphyxia. J Clin Diagn Res 2018. [DOI: 10.7860/jcdr/2018/31090.11223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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