To reduce the risk of bronchopulmonary dysplasia in extremely-low-birth-weight infants, clinicians attempt to minimize the use of endotracheal intubation by the early introduction of less invasive ...forms of positive airway pressure.
We randomly assigned 1009 infants with a birth weight of less than 1000 g and a gestational age of less than 30 weeks to one of two forms of noninvasive respiratory support--nasal intermittent positive-pressure ventilation (IPPV) or nasal continuous positive airway pressure (CPAP)--at the time of the first use of noninvasive respiratory support during the first 28 days of life. The primary outcome was death before 36 weeks of postmenstrual age or survival with bronchopulmonary dysplasia.
Of the 497 infants assigned to nasal IPPV for whom adequate data were available, 191 died or survived with bronchopulmonary dysplasia (38.4%), as compared with 180 of 490 infants assigned to nasal CPAP (36.7%) (adjusted odds ratio, 1.09; 95% confidence interval, 0.83 to 1.43; P=0.56). The frequencies of air leaks and necrotizing enterocolitis, the duration of respiratory support, and the time to full feedings did not differ significantly between treatment groups.
Among extremely-low-birth-weight infants, the rate of survival to 36 weeks of postmenstrual age without bronchopulmonary dysplasia did not differ significantly after noninvasive respiratory support with nasal IPPV as compared with nasal CPAP. (Funded by the Canadian Institutes of Health Research; NIPPV ClinicalTrials.gov number, NCT00433212; Controlled-Trials.com number, ISRCTN15233270.).
Routine brain imaging to detect injuries affecting preterm infants is used to predict long-term outcomes and identify complications that might necessitate an intervention. Although magnetic resonance ...imaging may be indicated in some specific cases, head ultrasound is the most widely used technique and, because of portability and ease of access, is the best modality for routine imaging. Routine head ultrasound examination is recommended for all infants born at or before 31+6 weeks gestation. For preterm neonates born between 32+0 to 36+6 weeks gestation, routine head ultrasound is recommended only in presence of risk factors for intracranial hemorrhage or ischemia. Brain imaging in the first 4 to 7 days postbirth is advised to detect most germinal matrix and intraventricular hemorrhages. Repeat imaging at 4 to 6 weeks of age is recommended to detect white matter injury. In preterm neonates born before 26 weeks gestation, a repeat HUS at term-equivalent age is recommended.
Background Lack of appropriate temperature management has been associated with significant adverse outcomes in preterm and low birthweight neonates. There is a lack of similar investigations in the ...late preterm (34.sup.0-36.sup.6) and term (greater than or equal to37.sup.0) neonate population. Our aim was to identify key risk factors as well as clinical outcomes associated with hypothermia in this population. Methods A retrospective chart review was conducted at the Ottawa Hospital including all eligible infants greater than or equal to34.sup.0 weeks' gestation over a one-month period in November 2020. Infant, maternal, and delivery room variables were collected, including prematurity, maternal temperature, delivery mode, birthweight, and premature rupture of membranes, as well as clinical outcomes such as NICU/SCN admission and length of stay. Regression models were generated, adjusted for covariates, and stepwise regression was performed. Results Four hundred forty infants were included in the analysis; 26.8% (118/440) were hypothermic within 6 hours of delivery. In the multivariable analysis, prematurity, low 5 minute Apgar score (< 7) or need for resuscitation, maternal hypertension, and absence of premature rupture of membranes > 18 hours or suspected maternal infection were significantly associated with hypothermia within 6 hours of delivery (p < 0.05). Multivariable analysis of clinical outcomes demonstrated a significant association between hypothermia within 6 hours of delivery and NICU/SCN admission (OR = 2.87; 95% CI 1.36, 6.04), need for respiratory support or diagnosis of respiratory distress syndrome (OR = 3.94; 95% CI 1.55, 10.50), and length of stay (exp(beta) = 1.20; 95% bootstrap CI 1.04, 1.37). Conclusions Our results suggest there are similar factors associated with hypothermia in our study population of infants born at greater than or equal to34.sup.0 weeks' gestation compared to prior studies in preterm and low-birthweight infants. Furthermore, hypothermia is associated with higher risk of adverse outcomes, which highlights the need to prevent hypothermia in all newborns. Keywords: Neonatal, Newborn, Hypothermia, Risk factors, Morbidity, Multivariable analysis
Background Data regarding the effects of antenatal corticosteroids in twin pregnancies are limited because of the insufficient number of women with twins enrolled in randomized controlled trials on ...antenatal corticosteroids. Furthermore, the interpretation of available data is limited by the fact that the interval from the administration of antenatal corticosteroids to delivery is greater than 7 days in a large proportion of twins, a factor that has been shown to affect the efficacy of antenatal corticosteroids and has not been controlled for in previous studies. Objective The objective of the study was to compare neonatal mortality and morbidity in preterm twins receiving a complete course of antenatal corticosteroids 1–7 days before birth to those who did not receive antenatal corticosteroids and to compare these outcome effects with those observed in singletons. Study Design We performed a retrospective cohort study using data collected on singleton and twin neonates born between 240/7 and 336/7 weeks’ gestational age and were admitted to tertiary neonatal units in Canada between 2010 and 2014. A comparison of neonatal outcomes between twin neonates who received a complete course of antenatal corticosteroids 1–7 days before birth (n = 1758) and those who did not receive antenatal corticosteroids (n = 758) and between singleton neonates who received a complete course of antenatal corticosteroids 1–7 days before birth (n = 4638) and those did not receive antenatal corticosteroids (n = 2312) was conducted after adjusting for gestational age, sex, hypertension, outborn status, small for gestational age, parity, and cesarean birth. Adjusted odds ratios and 95% confidence intervals for various neonatal outcomes were calculated. Results Administration of a complete course of antenatal corticosteroids within 1–7 days before birth in both twins and singletons was associated with similar reduced odds of neonatal death (for twins adjusted odds ratio 0.42 95% confidence interval, 0.24–0.76 and for singletons adjusted odds ratios, 0.38 95% confidence interval, 0.28–0.50; P = .7 for comparison of twins vs singletons), mechanical ventilation (for twins adjusted odds ratio, 0.47 95% confidence interval, 0.35–0.63 and for singletons adjusted odds ratio, 0.47 95% confidence interval, 0.41–0.55; P = .9), respiratory distress syndrome (for twins adjusted odds ratio, 0.53 95% confidence interval, 0.40–0.69, and for singletons adjusted odds ratio, 0.54 95% confidence interval, 0.47–0.62; P = .9) and severe neurological injury (for twins adjusted odds ratio, 0.50 95% confidence interval, 0.30–0.83 and for singletons adjusted odds ratio, 0.45 95% confidence interval, 0.34–0.59; P = .7). Administration of a complete course of antenatal corticosteroids was not associated with a reduced odds of bronchopulmonary dysplasia, severe retinopathy of prematurity, or necrotizing enterocolitis in both twins and singletons. Conclusion Administration of a complete course of antenatal corticosteroids 1–7 days before birth in twin pregnancies is associated with a clinically significant decrease in neonatal mortality, short-term respiratory morbidity, and severe neurological injury that is similar in magnitude to that observed among singletons.
Pre-eclampsia: Fetal assessment and neonatal outcomes Gruslin, Andrée, MD FRCS; Lemyre, Brigitte, MD FRCPC
Best practice & research. Clinical obstetrics & gynaecology,
08/2011, Letnik:
25, Številka:
4
Journal Article
Recenzirano
Pre-eclampsia is associated with a number of short- and long-term perinatal and neonatal complications, including death. These are mostly related to birth weight and gestational age at delivery, and ...therefore are most relevant to severe or early onset pre-eclamptic toxaemia. Currently, little information is available on the optimal antenatal testing modality to be used for pre-eclampsia. Significant limitations are associated with fetal movement counts and the biophysical profile. Evidence is accumulating, however, to support the incorporation of umbilical artery and venous Doppler velocimetry in the evaluation of such fetuses, especially in cases of associated placental insufficiency. Pre-eclampsia might confer some survival advantage to small gestational age infants and prematurely born infants compared with infants born after spontaneous preterm labour. The degree of intrauterine growth restriction also has a negative effect on early morbidity. Longer term outcomes for prematurely born infants are dependent on gestational age, and it is unclear whether the survival advantage conferred by pre-eclampsia translates into better long-term neurodevelopmental outcomes. Abnormal umbilical artery flows might predict poorer cognitive outcomes, although evidence for this is not strong.
To compare short term respiratory outcomes in preterm infants treated with bovine lipid extract surfactant or poractant alfa.
Prospective comparative effectiveness cohort study of infants <32 weeks' ...gestational age requiring surfactant in thirteen centers. Each center provided bovine lipid extract surfactant for a set period of time in the year 2019 and then changed to poractant alfa for the remainder of the year. The primary outcome was total duration of respiratory support.
968 infants were included. 494 received bovine lipid extract surfactant and 474 received poractant alfa. No difference was observed in the total duration of respiratory support (mechanical ventilation or non-invasive) (median 38 vs 40.5 days), need to re-dose surfactant, bronchopulmonary dysplasia, survival to discharge, or length of admission.
In this pragmatic study, we did not identify any difference in short term outcomes between the groups based on the type of surfactant received.
To identify characteristics and outcomes of infants who received multiple doses of surfactant vs those who received one dose or none.
In this retrospective study, we included neonates of 22-28 weeks' ...gestation admitted to NICUs in the Canadian Neonatal Network. Patients were divided into three groups: no surfactant, single dose, and multiple doses. The primary outcome was a composite of mortality or any of the major morbidities, including severe neurological injury, bronchopulmonary dysplasia, or ≥stage 3 retinopathy of prematurity.
Of 8024 eligible neonates, 2461 (31%) did not receive surfactant, 3545 (44%) received one dose, and 2018 (25%) received >1 dose. Receiving one or more doses of surfactant was associated with significantly higher adjusted odds of mortality or major morbidities in a dose-dependent manner.
Receiving one or more doses of surfactant was associated with adverse neonatal outcomes. Receipt of more than one dose may reflect underlying severe lung immaturity.
To assess the association of antenatal corticosteroids and neonatal outcomes of preterm small-for-gestational-age (SGA) neonates and estimate whether the association is similar to that observed in ...appropriate-for-gestational-age (AGA) neonates.
We conducted a retrospective cohort study using data collected on singleton neonates born between 24 0/7 and 33 6/7 weeks of gestation and admitted to tertiary neonatal units in Canada between 2010 and 2014. Outcomes of SGA neonates (birth weight less than the 10th percentile) who received antenatal corticosteroids 1-7 days before birth (n=698) were compared with those of SGA neonates who did not receive antenatal corticosteroids (n=220). A similar comparison was performed between AGA neonates (birth weight between 10th and 90th percentile) who received antenatal corticosteroids 1-7 days before birth (n=3,781) and AGA neonates that did not receive antenatal corticosteroids (n=1,868). The association of antenatal corticosteroid exposure with outcomes was assessed using multivariable logistic regression and adjusted odds ratios (ORs) were compared between SGA and AGA groups.
Of the 6,567 neonates eligible for the study, 918 (14.0%) were SGA. Women in the SGA group who were exposed to antenatal corticosteroids had a lower rate of neonatal death (7% compared with 12%, P=.01) compared with those not exposed to antenatal corticosteroids, whereas the rate of composite outcome was similar between the two groups (28% compared with 30%, P=.56). After adjustment for potential confounders, exposure to antenatal corticosteroids 1-7 days before birth was associated with beneficial effects among both the SGA and AGA groups with similar reduced odds of neonatal death (SGA: adjusted OR 0.29 95% confidence interval (CI) 0.15-0.57 compared with AGA: adjusted OR 0.40 95% CI 0.29-0.54, P=.40), composite outcome (SGA: adjusted OR 0.53 95% CI 0.33-0.87 compared with AGA: adjusted OR 0.51 95% CI 0.42-0.62, P=.85), need for mechanical ventilation (SGA: adjusted OR 0.60 95% CI 0.39-0.91 compared with AGA: adjusted OR 0.54 95% CI 0.46-0.64, P=.70), and severe brain injury (SGA: adjusted OR 0.42 95% CI 0.22-0.84 compared with AGA: adjusted OR 0.39 95% CI 0.30-0.51, P=.80). Similar reduction in the odds of neonatal death was observed in the subgroup of neonates with birth weight less than the fifth percentile for gestational age and sex: adjusted OR 0.38 (95% CI 0.16-0.92).
For SGA preterm neonates, exposure to antenatal corticosteroids 1-7 days before birth was associated with decreased odds of neonatal mortality and morbidity similar in magnitude to that observed among AGA neonates.
To compare the efficacy and safety of poractant alfa and bovine lipid extract surfactant in preterm infants.
Randomized, partially-blinded, multicenter trial. Infants <32 weeks needing surfactant ...before 48 hours were randomly assigned to receive poractant alfa or bovine lipid extract surfactant. The primary outcome was being alive and extubated at 48 hours post-randomization. Secondary outcomes included need for re-dosing, duration of respiratory support and oxygen, bronchopulmonary dysplasia, mortality and complications during administration.
Three centers recruited 87 infants (mean 26.7 weeks and 906 grams) at a mean age of 5.9 hours, between March 2013 and December 2015. 21/42 (50%) were alive and extubated at 48 hours in the poractant alfa group vs 26/45 (57.8%) in the bovine lipid extract surfactant group; adjusted OR 0.76 (95% CI 0.30-1.93) (p = 0.56). No differences were observed in the need to re-dose. Duration of oxygen support (41.5 vs 62 days; adjusted OR 1.69 95% CI 1.02-2.80; p = 0.04) was reduced in infants who received poractant alfa. We observed a trend in bronchopulmonary dysplasia among survivors (51.5% vs 72.1%; adjusted OR 0.35 95%CI 0.12-1.04; p = 0.06) favoring poractant alfa. Twelve infants died before discharge, 9 in the poractant alfa group and 3 in the bovine lung extract group. Severe airway obstruction following administration was observed in 0 (poractant alfa) and 5 (bovine lipid extract surfactant) infants (adjusted OR 0.09 95%CI <0.01-1.27; p = 0.07).
No statistically significant difference was observed in the proportion of infants alive and extubated within 48h between the two study groups. Poractant alfa may be more beneficial and associated with fewer complications than bovine lipid extract surfactant. However, we observed a trend towards higher mortality in the poractant alfa group. Larger studies are needed to determine whether observed possible benefits translate in shorter hospital admissions, or other long term benefits and determine whether there is a difference in mortality.
Abstract
Counselling couples facing the birth of an extremely preterm infant is a complex and delicate task, entailing both challenges and opportunities. This revised position statement proposes ...using a prognosis-based approach that takes the best estimate of gestational age into account, along with additional factors, including estimated fetal weight, receipt of antenatal corticosteroids, singleton versus multiple pregnancy, fetal status and anomalies on ultrasound and place of birth. This statement updates data on survival in Canada, long-term neurodevelopmental disability at school age and quality of life, with focus on strategies to communicate effectively with parents. It also proposes a framework for determining the prognosis-based management option(s) to present to parents when initiating the decision-making process. This statement replaces the 2012 position statement.
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