Seminars in Fetal & Neonatal Medicine最新文献

Survival rates for extremely low birth weight (ELBW) infants have improved over the recent years, yet morbidity remains high. This review explores respiratory management strategies for this unique cohort and how it may impact their long-term outcomes. Although there is a preference towards non-invasive respiratory support in less immature infants, ELBW infants often require invasive ventilation. This comes with an increased risk of bronchopulmonary dysplasia, adverse neurodevelopmental outcomes and lifelong respiratory impairment. There are a range of options available to reduce volutrauma and minimise lung injury, including volume targeted ventilation and high-frequency ventilation. In the absence of high-quality evidence focussing on ELBW infants, much of current practice is inferred from studies involving infants with a broader range of gestational ages and experiences at high-volume centres. This highlights the need for further research targeted to this specific population with a focus on long-term respiratory health.

Delirium is a common and serious complication of critical illness that has been increasingly recognized in pediatric patients. There have been several published cases of delirium in newborns and infants over the last decade, though research on neonatal delirium is severely lacking. The true prevalence of delirium and its associated consequences in this population remain unknown, although the risk of delirium in this population appears to be elevated compared to older youth. The current approach to management of delirium in neonates is extrapolated from older children. In the present review, the pathophysiology and clinical presentation of delirium are outlined. Strategies for prevention, evaluation, and management of delirium in neonates are explored.

Surfactant therapy in preterm and term born infants has been a huge success story. In the meantime, we have very detailed answers to the five essential questions of each medical therapy: which infant should be treated, when, with which drug, in/at what dose, and via which route of administration. The answers to these questions depend on the gestational age of the infant. We have focused on preterm infants <28 weeks of gestation as they are the most vulnerable and may have the maximum benefit of appropriate treatment. Therefore, we performed a sub-group analysis for data available from the published trials in infants less than 28 weeks who received less/minimal invasive surfactant administration/therapy [LISA/MIST] versus intubation-surfactant-extubation (INSURE). The need for mechanical ventilation (MV) was significantly reduced by 28 % (RR:0.72, 95%CI:0.64-0.80, n = 548 infants) after LISA/MIST. The incidence of bronchopulmonary dysplasia (BPD) was significantly decreased by 30 % (RR:0.70, 95%CI:0.66-0.75, n = 6528 infants) after LISA/MIST. No difference in mortality was noted between the two groups. In the current review, we discuss the applicability of guidelines to individual patient groups like the infants <28 weeks and emphasize the individual assessment of published data by the treating physician.

Over the past last 50 years, patent ductus arteriosus (PDA) continues to be the leading hot topic debated worldwide in search of best treatment approach and the uncertainty around whether to treat or not treat a PDA. With the availability of bedside echocardiography and the increasing number of neonatologists acquiring this skill, on one hand there is better understanding of PDA physiology during transitional circulation and objectivity in management, but on the other hand clinicians are uncertain about benefits in health outcomes. Evidence from recent trials utilizing early selective treatment guided by bedside echocardiography should help in dispelling some myths if not providing the answer about how to manage the PDA.

Neonatal encephalopathy (NE) is a significant cause of neonatal mortality in low- and middle-income (LAMI) countries, with far-reaching impacts on families and national human capital. Quantifying the disease burden in monetary terms is crucial for resource allocation and public health prioritization, yet data on the economic impact of NE-related neonatal mortality and prevention is limited. This study estimates the country-specific disease burden and economic impacts of NE for the ten countries with the highest death tolls in 2019. Using data from the Global Burden of Disease (GBD) Collaborative Network, we analyzed NE-specific mortality trends and calculated years of life lost (YLLs) based on life expectancy, with and without age weighting and discounting. Economic losses were evaluated using the value per statistical life (VSL) and value per statistical life year (VSLY) methodologies, with sensitivity analyses incorporating variable discount rates. In 2019, the ten countries with the highest NE burden was estimated at 138,763 neonatal deaths. YLLs ranged from 4.5 million with discounting to 9.8 million without. While nine of these countries reduced overall neonatal mortality from 2010 to 2019, six saw rising NE-specific mortality. Economic losses were estimated at $80 billion using the VSL method and between $72 billion and $163 billion using VSLY. Despite overall progress in reducing neonatal mortality, targeted funded strategies are needed to address NE in LAMI countries. Burden of NE could be reduced with improved strategic access to quality antenatal care and effective peripartum practices through efficient and enhanced resource allocation.

The major focus of neonatal research for many years has been the smallest and most vulnerable infants born before 32 weeks of gestation. More recently it has become clear that a gradient of risk for adverse outcomes spans the whole spectrum of gestational age, from those born at the margins of viability, to those born close to their estimated date of delivery. Whilst effect sizes may be smaller for the more mature babies born late preterm and early term, the size of the problem is related to very large numbers with less severe difficulties, yet whose problems affect many domains of health, development and education, and may have impact across the whole life course. Our knowledge of the mechanisms and influencing factors contributing to outcomes of individuals born late preterm and early term is inadequate. The unique challenges associated with managing pregnancies, babies, children, adults and families affected by late preterm or early term birth in the face of limited evidence mandate further research to guide practice and optimise short- and long-term outcomes.

Extreme preterm births between 20 and 25 weeks' gestation present significant challenges in neonatal care and ethics. This manuscript advocates for neonatology presence from 20 weeks onwards to optimize outcomes. Neonatology attendance ensures accurate gestational age assessment, immediate intervention, and informed decision-making. Survival rates for extremely preterm infants have improved significantly, ranging from 0 to 37 % at 22 weeks to 31-78 % at 24 weeks. However, outcomes vary widely based on factors such as healthcare access and socioeconomic conditions. We propose using "preterm birth between 20 and 25 weeks" instead of "periviability" for clarity in clinical protocols and parental counseling. Ethical considerations, including potential overtreatment and parental autonomy, are addressed through clear guidelines. While challenges exist in implementing this approach, particularly in smaller or rural hospitals, solutions such as strengthening regional networks and telemedicine can address these issues. Despite concerns about resource allocation, we argue that the benefits of neonatologist attendance outweigh the challenges, providing the best opportunity for survival and optimal outcomes in these ethically complex situations.

There is a substantial body of literature that supports neonatal monitoring and signal analysis of the collected data to provide valuable insights for improving patient clinical care and to inform new research studies. This comprehensive monitoring approach extends beyond the collection of conventional vital signs to include the acquisition of continuous waveform data from patient monitors and other bedside medical devices. This paper discusses the necessary infrastructure for waveform retrieval from bedside monitors, and explores options provided by leading healthcare companies, third-party vendors or academic research teams to implement scalable monitoring systems across entire critical care units. Additionally, we discuss the application of advanced signal processing that transcend traditional statistics, including heart rate variability in both the time- and frequency-domains, spectral analysis of EEG, and cerebral pressure autoregulation. The infrastructures and signal processing techniques outlined here are indispensable tools for intensivists, empowering them to enhance care for critically ill infants. In addition, we briefly address the emergence of advanced tools for fetal monitoring.