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

Objectives: To compare the effect of liberal versus restrictive transfusion strategies on the proportion of time (%time) spent with intermittent hypoxaemia (IH, ie, arterial haemoglobin oxygen saturation measured by pulse oximetry (SpO₂) <80% lasting ≥60 s) in the 'Effects of Transfusion Thresholds on Neurocognitive Outcome' (ETTNO) population, and to investigate whether infants with above-median exposure to IH might benefit more from liberal transfusion strategies than those with lower exposure.

Design, setting, patients: Secondary analysis in all 554/1013 infants of <1000 g birth weight recruited into the ETTNO trial (mean gestational age 26.2 weeks) with >80% completeness of SpO₂ recordings during postnatal days 8-49.

Intervention: Randomly assigned liberal (n=268) or restrictive (n=286) transfusion strategies, defining transfusion triggers based on postnatal age and health status.

Main outcome measures: %time with IH, rate and mean duration of IH episodes during postnatal days 8-49. Interaction between exposure to IH and transfusion strategies with respect to ETTNO's composite primary outcome, death or disability at 24 months corrected age.

Results: The median (quartile 1-quartile 3) %time with IH was similar between treatment groups (0.91% (0.13%-2.83%) with liberal vs 0.79% (0.16%-2.44%) with restrictive transfusions). There was no interaction between exposure to IH and transfusion strategies on outcome at 24 months.

Conclusions: In infants <1000 g birth weight, a liberal transfusion strategy did not reduce IH. Blood transfusions should not be administered 'liberally' to reduce IH or to improve neurocognitive outcome in infants with above-average exposure to IH.

Trial registration number: NCT01393496.

Objective: Neonates requiring Non-InVasive respiratory Support (NIVS) are at high risk of device-related pressure injury (DRPI), with incidence rates of 20%-60% in extremely premature infants. Over a 4-year period, our team undertook a Quality Improvement Project to review aspects of the clinical management of NIVS: types of interfaces, introduction of hydrocolloid dressing and the development and implementation of nasal injury care plan (NICP) to reduce DRPI in high-risk neonates.

Design: A prospective descriptive study was completed in three stages: trial of nCPAP interfaces, preintroduction NICP (2016-2018), post-NICP (2018-2020) and (2021-2022) to measure sustainability of implementation. Data included: gestational age (GA), birth weight, NIVS days, incidence, grade and day of DRPI. Statistical analysis of incidence rate ratio was completed between pre and postgroups.

Setting: Australian neonatal intensive care unit.

Patients: All neonates ≤32 weeks requiring nCPAP.

Interventions: Evaluation of types of interfaces, introduction of hydrocolloid dressing and the development and implementation of NICPMain outcome measures: incidence and severity of DRPI.

Results: Total DRPI recorded in all CPAP babies pre/post NICP were (59/659 (9.0%), 26/574 (4.5%), p=0.0032, respectively). Analysis showed DRPI incidence rates per 1000 NIVS days ((10.6, 5.5), p=0.0001, respectively). 75 (88%) of DRPI occurred in the ≤32 week group of neonates requiring NIVS. Review of babies ≤32 weeks across the three intervals showed significant improvement with time (55 (19%); 27 (13%); 19 (9%), p=0.0001).

Conclusions: Preferred nCPAP interface, nasal dressing and NICP have reduced the incidence and severity of DRPI in the NICU.

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.

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.