Extremely low birthweight infants become anaemic during their care in the neonatal intensive care unit because of the physiological anaemia experienced by all newborn infants compounded by early ...umbilical cord clamping, blood loss by phlebotomy for laboratory monitoring and delayed erythropoiesis. The majority of these infants receive transfusions of packed red blood cells, usually based on haemoglobin values below a certain threshold. The haemoglobin or haematocrit thresholds used to guide transfusion practices vary with infant status and among institutions and practitioners. Previous smaller studies have not given clear guidance with respect to the haemoglobin thresholds that should trigger transfusions or even if this is the best way to decide when to transfuse an infant. Two large clinical trials of similar design comparing higher and lower haemoglobin thresholds for transfusing extremely low birthweight infants were recently published, the ETTNO and TOP trials. These trials found reassuringly conclusive and concordant results. Within the range of haemoglobin transfusion thresholds studied, there was no difference in the primary outcome (which was the same in both studies), neurodevelopmental impairment at 2 years' corrected age or death before assessment, in either study. In addition, there was no difference in either study in either of the components of the primary outcome. In conclusion, haemoglobin transfusion thresholds within the ranges used in these trials, 11-13 g/dL for young critically ill or ventilated infants and 7-10 g/dL for stable infants not requiring significant respiratory support, can be safely used without expecting adverse consequences on survival or neurodevelopment.
Background
Most premature infants are physiologically not sufficiently mature to orally ingest all of their required water and nutrients. Therefore, premature infants rely on their caregivers to ...regulate their volume of water intake. Thus, the caregiver must determine the amount of water to be given each day to such infants.
Objectives
To determine the effect of water intake on postnatal weight loss and the risks of dehydration, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia, intracranial hemorrhage, and death in premature infants.
Search methods
Randomized clinical trials (RCTs) identified in previous versions of this review were re‐examined and, in each case, retained. Additional trials were sought that compared the outcomes of interest in groups of premature infants who were given different levels of water intake according to an experimental protocol. Such trials were sought in a list of trials provided by the Cochrane Neonatal Review Group, with a PubMed search and in the authors' personal files.
This search was updated in 2014.
Selection criteria
Only RCTs of varying water intake in premature infants were included. The review was limited to trials that included infants whose water intake was provided mainly or entirely by intravascular infusion.
Data collection and analysis
The standard methods of The Cochrane Collaboration were used. Study selection and data ion were performed independently by each review author. The adverse event rates were calculated for the restricted and liberal water intake groups for each dichotomous outcome, and the relative risk and risk difference were computed. In addition, the maximal weight loss results were recorded and the weighted mean difference was computed.
Main results
The analysis of the five studies taken together indicated that restricted water intake significantly increased postnatal weight loss and significantly reduced the risks of patent ductus arteriosus and necrotizing enterocolitis. With restricted water intake, there were trends toward increased risk of dehydration and reduced risks of bronchopulmonary dysplasia, intracranial hemorrhage, and death but these trends were not statistically significant.
Authors' conclusions
Based on this analysis, the most prudent prescription for water intake to premature infants would seem to be careful restriction of water intake so that physiological needs are met without allowing significant dehydration. This practice could be expected to decrease the risks of patent ductus arteriosus and necrotizing enterocolitis without significantly increasing the risk of adverse consequences.
To assess the outcomes in actively managed extremely preterm infants after admission to a neonatal intensive care unit.
Retrospective cohort of 255 infants born at 22-25 weeks of gestation between ...2006 and 2015 at a single study institution. Infants were excluded for congenital anomaly, death in delivery room, or parental request for palliation (n = 7). Neurodevelopmental outcomes were analyzed for 169 of 214 survivors (78.9%) at 18-22 months of corrected age. Outcomes were evaluated using the Mann-Whitney U, χ2, or Fisher exact test, where appropriate. In addition, cognitive scores of the Bayley Scales of Infant-Toddler Development (3rd edition) were assessed using generalized estimating equations.
Seventy infants born at 22-23 weeks of gestation (22 weeks, n = 20; 23 weeks, n = 50) and 178 infants born at 24-25 weeks of gestation (24 weeks, n = 79; 25 weeks, n = 99 infants) were included. Survival to hospital discharge of those surviving to NICU admission was 78% (55/70; 95% CI, 69%-88%) at 22-23 weeks and 89% (159/178; 95% CI, 84%-93% at 24-25 weeks; P = .02). No or mild neurodevelopmental impairment in surviving infants was 64% (29/45; 95% CI, 50%-77%) at 22-23 weeks and 76% (94/124; 95% CI, 68%-83%; P = .16) at 24-25 weeks.
Although survival was lower in infants born at 22-23 weeks than at 24-25 weeks of gestation, the majority of survivors in both groups had positive outcomes with no or mild neurodevelopmental impairments. Further evaluation of school performance is warranted.
The past six decades have seen remarkable improvements in health outcomes for people with cystic fibrosis, which was once a fatal disease of infants and young children. However, although life ...expectancy for people with cystic fibrosis has increased substantially, the disease continues to limit survival and quality of life, and results in a large burden of care for people with cystic fibrosis and their families. Furthermore, epidemiological studies in the past two decades have shown that cystic fibrosis occurs and is more frequent than was previously thought in populations of non-European descent, and the disease is now recognised in many regions of the world. The Lancet Respiratory Medicine Commission on the future of cystic fibrosis care was established at a time of great change in the clinical care of people with the disease, with a growing population of adult patients, widespread genetic testing supporting the diagnosis of cystic fibrosis, and the development of therapies targeting defects in the cystic fibrosis transmembrane conductance regulator (CFTR), which are likely to affect the natural trajectory of the disease. The aim of the Commission was to bring to the attention of patients, health-care professionals, researchers, funders, service providers, and policy makers the various challenges associated with the changing landscape of cystic fibrosis care and the opportunities available for progress, providing a blueprint for the future of cystic fibrosis care. The discovery of the CFTR gene in the late 1980s triggered a surge of basic research that enhanced understanding of the pathophysiology and the genotype-phenotype relationships of this clinically variable disease. Until recently, available treatments could only control symptoms and restrict the complications of cystic fibrosis, but advances in CFTR modulator therapies to address the basic defect of cystic fibrosis have been remarkable and the field is evolving rapidly. However, CFTR modulators approved for use to date are highly expensive, which has prompted questions about the affordability of new treatments and served to emphasise the considerable gap in health outcomes for patients with cystic fibrosis between high-income countries, and low-income and middle-income countries (LMICs). Advances in clinical care have been multifaceted and include earlier diagnosis through the implementation of newborn screening programmes, formalised airway clearance therapy, and reduced malnutrition through the use of effective pancreatic enzyme replacement and a high-energy, high-protein diet. Centre-based care has become the norm in high-income countries, allowing patients to benefit from the skills of expert members of multidisciplinary teams. Pharmacological interventions to address respiratory manifestations now include drugs that target airway mucus and airway surface liquid hydration, and antimicrobial therapies such as antibiotic eradication treatment in early-stage infections and protocols for maintenance therapy of chronic infections. Despite the recent breakthrough with CFTR modulators for cystic fibrosis, the development of novel mucolytic, anti-inflammatory, and anti-infective therapies is likely to remain important, especially for patients with more advanced stages of lung disease. As the median age of patients with cystic fibrosis increases, with a rapid increase in the population of adults living with the disease, complications of cystic fibrosis are becoming increasingly common. Steps need to be taken to ensure that enough highly qualified professionals are present in cystic fibrosis centres to meet the needs of ageing patients, and new technologies need to be adopted to support communication between patients and health-care providers. In considering the future of cystic fibrosis care, the Commission focused on five key areas, which are discussed in this report: the changing epidemiology of cystic fibrosis (section 1); future challenges of clinical care and its delivery (section 2); the building of cystic fibrosis care globally (section 3); novel therapeutics (section 4); and patient engagement (section 5). In panel 1, we summarise key messages of the Commission. The challenges faced by all stakeholders in building and developing cystic fibrosis care globally are substantial, but many opportunities exist for improved care and health outcomes for patients in countries with established cystic fibrosis care programmes, and in LMICs where integrated multidisciplinary care is not available and resources are lacking at present. A concerted effort is needed to ensure that all patients with cystic fibrosis have access to high-quality health care in the future.
The Tiniest Babies Registry was launched in the year 2000 as a web-based registry for patients who survived to discharge after being born with birth weights below 400 grams. The registry began with ...15 patients and by January 2022 had grown to 291, ranging in birth weight from 212 to 399 grams and in gestational age from 21 to 34 weeks. Three patients were born in the 1930s, and no others were born until 1985. The greatest number in a single year was 21 in 2010. The infants were born in 16 countries, but 166 of 291 (57%) were born in the U.S. All except 10 of the infants were small for gestational age at birth. No systematic data on the long-term outcomes of these patients is available, but the information submitted by selected registry participants indicates they are at increased risk for continued delays in growth and development.
Among hospitals in the NICHD Neonatal Research Network, rates of active treatment of infants born at 22 to 24 weeks of gestation varied substantially and accounted for a substantial proportion of ...between-hospital variation in overall survival and survival without impairment.
The decision to initiate or forgo potentially lifesaving treatment in infants who are born near the limit of viability is extremely difficult.
1
,
2
Clinicians recognize that in some cases, the infant is too immature for treatment to be effective, whereas in other cases, treatment is clearly indicated. Yet, in many cases, it is unclear whether treatment is in the infant’s best interest.
3
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4
Although factors such as the infant’s birth weight and sex, plurality of birth (singleton vs. multiple), and exposure to antenatal glucocorticoids affect the prognosis of extremely preterm infants,
5
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6
many groups still make recommendations about active treatment . . .
Early CPAP versus Surfactant in Extremely Preterm Infants Finer, Neil N; Carlo, Waldemar A; Walsh, Michele C ...
New England journal of medicine/The New England journal of medicine,
05/2010, Letnik:
362, Številka:
21
Journal Article
Recenzirano
Odprti dostop
In this part of a randomized, 2-by-2 factorial trial involving extremely preterm infants, use of intubation and surfactant treatment (within 1 hour after birth) was compared with initiation of ...continuous positive airway pressure (CPAP) in the delivery room and subsequent use of a protocol-driven limited ventilation strategy. The rate of death or bronchopulmonary dysplasia (the primary outcome) did not differ significantly between the groups; the CPAP group required intubation less frequently and for fewer days than did the surfactant group. These results support consideration of CPAP as an alternative to intubation and surfactant in preterm infants.
Use of intubation and surfactant treatment was compared with initiation of CPAP in the delivery room. The rate of death or bronchopulmonary dysplasia did not differ significantly between the groups. The CPAP group required intubation less frequently and for fewer days than did the surfactant group.
It has been shown that surfactant treatment at less than 2 hours of life significantly decreases the rates of death, air leak, and death or bronchopulmonary dysplasia in preterm infants.
1
,
2
Overall, prophylactic treatment with surfactant has not been shown to significantly reduce the risk of bronchopulmonary dysplasia alone, whereas studies comparing early with later rescue use of surfactant have shown that there is a decreased risk of chronic lung disease with early use.
2
Several studies have shown that the use of surfactant does not have a significant effect on the risk of subsequent neurodevelopmental impairment,
3
although a recent follow-up . . .
Objectives To describe and compare the incidence of late-onset sepsis (LOS) and demographic and clinical characteristics associated with LOS in very low birth weight (VLBW) infants from singleton and ...multiple births, and to examine the heritability of susceptibility to LOS among VLBW twins by comparing same-sex and unlike-sex twin pairs. Study design The study group comprised infants with birth weight 401-1500 g seen at clinical centers of the Eunice Kennedy Shriver National Institute of Child and Human Development Neonatal Research Network between 2002 and 2008. Only the first episode of LOS was included in our analysis. Stepwise logistic regression models were fitted separately for singleton and multiple pregnancies to examine the maternal and neonatal factors associated with LOS. LOS due solely to gram-negative bacteria in singleton and multiple pregnancies was also examined in separate models. The heritability of LOS was estimated by examining the concordance of LOS in twins from same-sex and unlike-sex pairs. Results LOS occurred in 25.0% (3797 of 15 178) of singleton and 22.6% (1196 of 5294) of multiple-birth VLBW infants. Coagulase-negative staphylococci were the most common infecting organisms, accounting for 53.2% of all LOS episodes in singletons and 49.2% in multiples. Escherichia coli and Klebsiella species were the most commonly isolated gram-negative organisms, and Candida albicans was the most commonly isolated fungus. Concordance of LOS did not differ significantly between same-sex and unlike-sex twin pairs. Conclusion LOS remains a common problem in VLBW infants. The incidence of LOS is similar for singleton and multiple-birth infants. The similar concordance of LOS in same-sex and unlike-sex twin pairs provides no evidence that susceptibility to LOS among VLBW infants is genetically determined.
IMPORTANCE: The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN) extremely preterm birth outcome model is widely used for ...prognostication by practitioners caring for families expecting extremely preterm birth. The model provides information on mean outcomes from 1998 to 2003 and does not account for substantial variation in outcomes among US hospitals. OBJECTIVE: To update and validate the NRN extremely preterm birth outcome model for most extremely preterm infants in the United States. DESIGN, SETTING, AND PARTICIPANTS: This prognostic study included 3 observational cohorts from January 1, 2006, to December 31, 2016, at 19 US centers in the NRN (derivation cohort) and 637 US centers in Vermont Oxford Network (VON) (validation cohorts). Actively treated infants born at 22 weeks’ 0 days’ to 25 weeks’ 6 days’ gestation and weighing 401 to 1000 g, including 4176 in the NRN for 2006 to 2012, 45 179 in VON for 2006 to 2012, and 25 969 in VON for 2013 to 2016, were studied. VON cohorts comprised more than 85% of eligible US births. Data analysis was performed from May 1, 2017, to March 31, 2019. EXPOSURES: Predictive variables used in the original model, including infant sex, birth weight, plurality, gestational age at birth, and exposure to antenatal corticosteroids. MAIN OUTCOMES AND MEASURES: The main outcome was death before discharge. Secondary outcomes included neurodevelopmental impairment at 18 to 26 months’ corrected age and measures of hospital resource use (days of hospitalization and ventilator use). RESULTS: Among 4176 actively treated infants in the NRN cohort (48% female; mean SD gestational age, 24.2 0.8 weeks), survival was 63% vs 62% among 3702 infants in the era of the original model (47% female; mean SD gestational age, 24.2 0.8 weeks). In the concurrent (2006-2012) VON cohort, survival was 66% among 45 179 actively treated infants (47% female; mean SD gestational age, 24.1 0.8 weeks) and 70% among 25 969 infants from 2013 to 2016 (48% female; mean SD gestational age, 24.1 0.8 weeks). Model C statistics were 0.74 in the 2006-2012 validation cohort and 0.73 in the 2013-2016 validation cohort. With the use of decision curve analysis to compare the model with a gestational age–only approach to prognostication, the updated model showed a predictive advantage. The birth hospital contributed equally as much to prediction of survival as gestational age (20%) but less than the other factors combined (60%). CONCLUSIONS AND RELEVANCE: An updated model using well-known factors to predict survival for extremely preterm infants performed moderately well when applied to large US cohorts. Because survival rates change over time, the model requires periodic updating. The hospital of birth contributed substantially to outcome prediction.
Intravitreal bevacizumab is increasingly used to treat severe retinopathy of prematurity (ROP), but it enters the bloodstream, and there is concern that it may alter development of other organs. ...Previously we reported short-term outcomes of 61 infants enrolled in a dose de-escalation study, and we report the late recurrences and additional treatments.
Masked, multicenter, dose de-escalation study.
A total of 61 premature infants with type 1 ROP.
If type 1 ROP was bilateral at enrollment, then the study eye was randomly selected. In the study eye, bevacizumab intravitreal injections were given at de-escalating doses of 0.25 mg, 0.125 mg, 0.063 mg, or 0.031 mg; if needed, fellow eyes received 1 dose level higher: 0.625 mg, 0.25 mg, 0.125 mg, or 0.063 mg, respectively. After 4 weeks, additional treatment was at the discretion of the investigator.
Early and late ROP recurrences, additional treatments, and structural outcomes after 6 months.
Of 61 study eyes, 25 (41%; 95% confidence interval CI, 29%-54%) received additional treatment: 3 (5%; 95% CI, 1%-14%) for early failure (within 4 weeks), 11 (18%; 95% CI, 9%-30%) for late recurrence of ROP (after 4 weeks), and 11 (18%; 95% CI, 9%-30%) for persistent avascular retina. Re-treatment for early failure or late recurrence occurred in 2 of 11 eyes (18%; 95% CI, 2%-52%) treated with 0.25 mg, 4 of 16 eyes (25%; 95% CI, 7%-52%) treated with 0.125 mg, 8 of 24 eyes (33%; 95% CI, 16%-55%) treated with 0.063 mg, and 0 (0%; 95% CI, 0%-31%) of 10 eyes treated with 0.031 mg. By 6 months corrected age, 56 of 61 study eyes had regression of ROP with normal posterior poles, 1 study eye had developed a Stage 5 retinal detachment, and 4 infants had died of preexisting medical conditions.
Retinal structural outcomes are very good after low-dose bevacizumab treatment for ROP, although many eyes received additional treatment.
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