Archives of Disease in Childhood - Fetal and Neonatal Edition最新文献

Objective: To conduct a systematic review of barriers and facilitators to the practice of neonatal Family Integrated Care (FICare) from the perspective of healthcare professionals (HCPs).

Design: A systematic search strategy was developed to identify qualitative studies exploring neonatal HCPs' views of any of the principles of FICare. Six literature databases (CINAHL, (Cumulated Index in Nursing and Allied Health Literature) Embase, Medline, PsycINFO, Scopus, Web of Science) were searched using the terms Healthcare Professionals, Neonatal, Environment, FICare, Education, Well-being, Culture, Partnership and Empowerment. Studies meeting the inclusion criteria were thematically analysed.

Results: 11032 titles and abstracts and 85 full-text papers were screened. Thirty-seven studies met the inclusion criteria and reported interviews with 1243 HCPs, predominantly nurses. Three themes were synthesised in relation to barriers and facilitators: (1) 'advocacy and acknowledgement', whereby HCPs are expected to advocate for the emotional and mental health of the whole family, not solely the baby's needs; (2) 'belief and behaviour', whereby the degree to which FICare is practised is dependent on HCPs' belief in its benefits in relation to other activities; (3) 'conditions and consistency', whereby a lack of space, resources, policy and consistent practice of FICare created apathy and contradictory approaches to care.

Conclusion: Although HCPs see value in FICare, successful implementation is multifactorial and requires the expectation to deliver FICare to be aligned with resourcing at the hospital, team and individual levels. Shifting the practice paradigm to FICare remains challenging for some HCPs. Greater understanding of HCPs' views on barriers, facilitators and how FICare practice impacts individuals is required.

Objective: To evaluate the efficacy and safety of azithromycin in eradicating Ureaplasma and preventing bronchopulmonary dysplasia (BPD) in preterm infants.

Design: Six literature databases and three clinical trial registration platforms were searched for studies up to 22 July 2024. The meta-analysis was performed using RevMan V.5.3.

Results: A total of 1723 preterm infants from 10 randomised controlled trials and 3 case series were included. In all preterm infants, azithromycin significantly improved Ureaplasma clearance (relative risk (RR)=1.47, 95% CI 1.17 to 1.85) and reduced the duration of mechanical ventilation (mean difference (MD)=-2.16, 95% CI -2.65 to -1.68), duration of supplemental oxygen (MD=-5.46, 95% CI -6.65 to -4.37) and length of stay (MD=-4.98, 95% CI -7.19 to -2.76) compared with placebo; however, there was no significant reduction in BPD, BPD-death or mortality, with low quality of evidence. In Ureaplasma-positive preterm infants, azithromycin significantly reduced BPD-death (RR=0.83, 95% CI 0.70 to 0.99) and mechanical ventilation (MD=-2.20, 95% CI -2.72 to -1.69), compared with placebo, and significantly increased Ureaplasma clearance rate. Additionally, compared with erythromycin, azithromycin reduced BPD, without a statistically significant difference. Compared with placebo, azithromycin showed no statistically significant differences in the incidence of necrotising enterocolitis, retinopathy, intraventricular haemorrhage, etc. CONCLUSIONS: Low-quality evidence indicated prophylactic use of azithromycin could reduce the incidence of BPD-death and the duration of mechanical ventilation in Ureaplasma-positive preterm infants. However, such benefits were not observed in all preterm infants. Meanwhile, azithromycin was found to be safe for administration in preterm infants.

Prospero registration number: CRD42024585836.

Objective: To compare growth, tolerance and safety parameters in very preterm infants receiving human milk (HM) fortified with a multicomponent cow's milk-based HM fortifier (HMF; control) versus a novel HMF-containing lipids (including docosahexaenoic acid and arachidonic acid), higher protein and lower carbohydrate levels (test). Our hypothesis was that weight growth velocity in the test group would be non-inferior to that in the control group.

Design: Double-blind, randomised controlled trial.

Setting: Nine European neonatal intensive care units.

Patients: HM-fed infants born at <32-week gestational age.

Interventions: Fortification of HM with Test or Control HMF for a minimum of 21 days.

Primary outcome: Weight growth velocity between baseline and intervention day 21.

Results: From March 2018 to July 2020, 102 and 103 infants were enrolled in the test and control groups, respectively. Weight growth velocity during the first 21 days in the test group (mean 18.4 g/kg/day) was non-inferior to that of controls (mean 18.5 g/kg/day), with a difference in estimated means of -0.175 g/kg/day (90% CI -1.34 to +0.99 g/kg/day; per-protocol population). No significant differences between groups were observed for gain in length, head circumference or anthropometric Z-scores. Rates of digestive intolerance, stool frequency and consistency were comparable. No significant differences were reported in common neonatal morbidities including necrotising enterocolitis (test: 2.9%, control: 6.9%, mean difference -4.0% (95% CI -11.1% to 2.2%); all subjects treated population).

Conclusions: Use of the novel HMF containing lipids, higher protein and lower carbohydrate levels supports adequate postnatal growth and appears safe and well tolerated in very preterm infants.

Trial registration number: NCT03315221.

Objective: To evaluate the effect of minimising blood sampling losses on red blood cell (RBC) transfusion-related outcomes in preterm infants <37 weeks' gestation.

Study design: We searched PubMed, Embase, Web of Science and Google Scholar from inception to October 2024 for studies that evaluated sampling stewardship practices (SSP) in preterm infants during initial hospitalisation. Two authors independently screened articles that evaluated one or more sampling approaches to minimise blood loss or non-invasive methods to avoid sampling losses. Meta-analysis was conducted using a random effects model.

Results: Eighteen studies (4 randomised controlled trials (RCTs) and 14 non-randomised studies) were included. Five studies used umbilical cord blood sampling, four used protocol-based sampling and two used retransfusion of sampled blood back to the infant as an SSP. Sampling care bundles were used in seven studies. Meta-analysis showed that SSP reduced early RBC transfusion rates (RCTs: Relative risk(RR) =0.50, 95% CI 0.36, 0.68; non-RCTs: RR=0.78, 95% CI 0.69, 0.90), the average number of transfusions per infant (RCTs: mean difference=-0.4 transfusions, 95% CI -0.68, -0.05; non-RCTs: standardised mean difference=-0.40, 95% CI -0.55, -0.25) and the rates of multiple transfusions (non-RCTs: RR=0.51, 95% CI 0.42, 0.62). There were no significant effects on mortality and other morbidities. Certainty of evidence was high for transfusion-related outcomes and moderate for other outcomes.

Conclusion: SSPs are associated with a significant reduction in RBC transfusion rates among very and extremely preterm infants. Large RCTs are required to assess the effects of SSP on other important outcomes.

Prospero registration number: CRD42024539665.

Objective: To determine survival and neurodevelopmental outcomes in the Hypotension in Preterm (HIP) trial.

Design: Prospective follow-up of infants enrolled in randomised controlled trial.

Participants: 58 infants born before 28 weeks of gestation with low mean arterial blood pressure.

Intervention: Random allocation to treatment of low blood pressure values with infusion of dopamine or placebo.

Primary outcome: Survival without neurodevelopmental impairment to 24 months corrected age (CA).

Results: The HIP trial stopped early due to logistic and recruitment difficulties. Outcomes were determined for 55 infants (27 in the dopamine group and 28 in the placebo group) at 24 months CA. Survival without impairment was present in 13 (48%) infants in the dopamine group and 7 (25%) infants in the placebo group (OR 2.79 (95% CI 0.89, 8.72); p=0.078). The components of the primary outcome were similarly distributed between the two arms. Mean Bayley composite scores and the frequency of somatic impairments did not differ significantly between groups but infants were shorter and lighter at 2 years of age after dopamine administration.

Conclusion: In this placebo-controlled trial of the treatment of hypotension in extremely preterm infants, dopamine administration did not increase survival without impairment at 2 years CA. However, the study was not sufficiently powered and a clinically important effect cannot be excluded. The role of inotropic medication in facilitating good outcomes requires further study.

Objective: Babies born between 27⁺⁰ and 31⁺⁶ weeks of gestation contribute substantially towards infant mortality and morbidity. In England, their care is delivered in maternity services colocated with highly specialised neonatal intensive care units (NICU) or less specialised local neonatal units (LNU). We investigated whether birth setting offered survival and/or morbidity advantages to inform National Health Service delivery.

Design: Retrospective national cohort study.

Setting: LNU, NICU, England.

Patients: UK National Neonatal Research Database whole population data for births between 27⁺⁰ and 31⁺⁶ weeks of gestation, discharged from/died within neonatal units between 1 January 2014 and 31 December 2018. We linked baby-level data to mortality information from the Office for National Statistics.

Outcome measures: Death during neonatal care, up to 1 year (infant mortality), surgically treated necrotising enterocolitis, retinopathy of prematurity, severe brain injury (SBI), bronchopulmonary dysplasia.

Intervention: Birth in NICU versus LNU setting. We used an instrumental variable (maternal excess travel time between the nearest NICU and LNU) estimation approach to determine treatment effect.

Results: Of 18 847 babies (NICU: 10 379; LNU: 8468), 574 died in NICU/LNU care, and 121 postdischarge (infant mortality 3.7%). We found no effect of birth setting on neonatal or infant mortality. Significantly more babies born into LNU settings experienced SBI (mean difference -1.1% (99% CI -2.2% to -0.1%)). This was attenuated after excluding births at 27 weeks, and early postnatal transfers.

Conclusions: In England, LNU teams should use clinical judgement, risk assessing benefits of transfer versus risk of SBI for preterm births at 27 weeks of gestation. 28 weeks of gestation is a safe threshold for preterm birth in either NICU/LNU settings.

Trial registration number: NCT02994849/ISRCTN74230187.

Objectives: To compare success and safety of endotracheal tube (ETT) exchanges with primary intubations and identify factors associated with ETT exchange outcomes.

Design: Retrospective observational study of prospectively collected National Emergency Airway Registry for Neonates data. ETT exchanges are the placement of a new ETT when one is already in place, whereas primary intubations do not have a pre-existing ETT. The primary outcome was first-attempt success. Secondary outcomes included number of attempts, adverse tracheal intubation-associated events (TIAEs), severe TIAEs, desaturation and bradycardia. Descriptive statistics compared characteristics for ETT exchanges and primary intubations. Univariable and multivariable analyses compared primary and secondary outcomes and identified factors independently associated with ETT exchange outcomes.

Results: A total of 1572 ETT exchanges and 9999 primary intubations across 21 sites were included from October 2014 to September 2022. ETT exchanges represented 2.3%-31.2% (mean 13.6%) of intubations across sites. Patient, provider and practice characteristics varied significantly between ETT exchanges and primary intubations. In univariable analyses, ETT exchanges were associated with higher first-attempt success (70.5% vs 53.6%; p<0.001) and fewer safety events. In multivariable analyses, ETT exchanges were associated with an increased adjusted OR (aOR) of first-attempt success (1.71; 95% CI 1.57 to 1.86; p<0.001). ETT exchanges were associated with lower aOR of all safety outcomes except severe TIAEs. Factors independently associated with ETT exchange first-attempt success included video laryngoscopy and paralytic premedication.

Conclusion: Compared with primary intubations, ETT exchanges were associated with higher first-attempt success and fewer safety events. Video laryngoscope and paralytic premedication were associated with improved ETT exchange outcomes.

Objective: To ascertain the sociodemographic and geographical determinants of exclusive and no mother's own milk (MOM) feeding for infants <34 weeks' gestational age (GA) in England and Wales.

Study design: Retrospective cohort study using the National Neonatal Research Database (2016-2022). We calculated unadjusted and mutually adjusted ORs for exclusive and no MOM feeding throughout an infant's neonatal stay, by maternal age group, ethnicity and deprivation quintile. Neonatal Operational Delivery Network and unit were included as random effects, and the adjusted models included other potential confounders such as gestational age and mode of delivery.

Results: Among the 90 730 infants, 11 962 (13.2%) were exclusively MOM fed, while 9018 (9.9%) never received MOM. The odds of exclusive MOM feeding increased with decreasing maternal social deprivation (OR for least deprived vs most deprived quintile 2.16, 95% CI 2.01 to 2.33), while the odds of no MOM decreased (OR 0.33, 95% CI 0.30 to 0.36). The odds of exclusive MOM feeding were lower for Asian/Asian-British mothers compared with white mothers (OR 0.88, 95% CI 0.82 to 0.95). The odds of never receiving MOM were lower for Black, Asian and mixed ethnicities compared with white mothers. Infants of mothers aged 26-35 years had the highest odds of exclusive MOM feeding. There was a geographical variation in feeding practices with a north-south divide in the prevalence of never receiving MOM. There was a significant variation in feeding practices between neonatal units.

Conclusion: Provision of MOM to preterm infants in England and Wales is associated with maternal sociodemographic characteristics.

Objective: The James Lind Alliance (JLA) Most Premature Babies Priority Setting Partnership aimed to identify the most important areas for research for infants born <25 weeks' gestation.

Design: Employing standardised JLA methodology, questions for research were sought from stakeholders via an online survey. Summary questions were formed and checked against existing evidence, with unanswered questions compiled into a second shortlisting survey for prioritisation by stakeholders. A stakeholder consensus workshop was held to determine the top 10 research priorities.

Participants: People with lived experience of neonatal intensive care, including parents/carers of preterm infants and adults born preterm, and healthcare professionals caring for preterm infants across Australia, New Zealand and the UK.

Main outcome measure: The top 10 research priorities for infants born <25 weeks' gestation.

Results: From 844 questions received from the initial survey, 81 summary questions were formed, of which 80 were unanswered and included in the second shortlisting survey. The 19 top-ranked questions were taken to the final prioritisation workshop, where the top 10 research priorities were determined by people with lived experience and healthcare professionals. The most important research question identified was 'What can be done in the neonatal intensive care unit to improve long-term health and developmental outcomes?'. Other important areas for research included antenatal interventions and neonatal care at birth, preventing intraventricular haemorrhages, managing pain, postnatal corticosteroid treatment and supporting families.

Conclusions: This study identified the most important areas of research for infants born <25 weeks' gestation, as determined jointly by stakeholders. These findings should be used to guide future research and funding aimed at improving meaningful outcomes for these infants and their families.