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

Objective: To determine whether full body in-utero MRI (iuMRI) rather than targeted imaging adds useful clinical information when a fetal anomaly is suspected in the brain or the body.

Design: Single-centre retrospective cohort study, from October 2011 to May 2022.

Setting: Regional fetal MRI service in Sheffield, UK.

Patients: All pregnant people undergoing iuMRI.

Interventions: iuMRI of the brain and body was reviewed by a fetal radiologist, and the results discussed by a multidisciplinary team.

Main outcome measures: Additional abnormalities detected on iuMRI outside of the initial area of interest on ultrasound.

Results: 1876 participants: 916 participants had a fetus with brain anomalies only on ultrasound, of which 12 (1.3%) had additional body abnormalities on iuMRI. 960 participants had body anomalies only on ultrasound, of whom 8 (0.8%) had an additional brain abnormality. The additional findings from 12 cases (0.6% of whole cohort) added useful clinical information to guide care or counselling.

Conclusion: If brain or body anomalies are found on ultrasound in the fetus, whole-body iuMRI reveals additional abnormalities in a small number of cases. However, these may provide important information that changes counselling or care. Further research is required to determine how significant this impact is for clinicians and families, whether normal findings reassure families, how long whole-body iuMRI adds to the MRI acquisition time and the health economics implications.

Objective: To assess the association between histological chorioamnionitis without maternal clinical symptoms and neurodevelopmental disabilities at age 5 years in children born very preterm.

Design: French national prospective population-based cohort study, EPIPAGE-2 (Etude épidémiologique sur les petits âges gestationnels).

Setting: All births from 22 to 34 weeks of gestational age in France in 2011 were eligible.

Population: Infants born alive between 24⁺⁰ and 31⁺⁶ weeks following preterm labour (PTL) or preterm premature rupture of membranes (PPROMs).

Exposure: Histological chorioamnionitis without maternal clinical symptoms, also called isolated histological chorioamnionitis, was defined as the presence of neutrophils in the chorionic plate, excluding clinical chorioamnionitis.

Main outcome measures: Neurodevelopmental disabilities, a composite outcome including cerebral palsy, developmental coordination disorders, sensory impairment, developmental cognitive deficiencies or behavioural difficulties. These assessments were comprehensive, standardised and conducted by trained neuropsychologists and paediatricians at age 5 years.

Results: Among 1296 children alive at 5 years of age, 486 (36.3%) were born in a context of isolated histological chorioamnionitis. Overall, 47% vs 33.6% of children exposed and not exposed to isolated histological chorioamnionitis had mild neurodevelopmental disabilities, and 13.8% vs 13.3% had moderate-to-severe neurodevelopmental disabilities. After multiple imputation and multivariable analysis, isolated histological chorioamnionitis was found not to be associated with the occurrence of mild or moderate-to-severe neurodevelopmental disabilities (adjusted OR: 1.0, 95% CI: 0.7 to 1.4 and 0.9, 0.6 to 1.2).

Conclusion: We did not find any association between isolated histological chorioamnionitis and neurodevelopmental disabilities at age 5 years in children born very preterm after PTL or PPROM.

Context: Children born very preterm (<32 weeks' gestation) have increased risk of neurodevelopmental difficulties compared with those born at term. While various neonatal exposures have been linked with later developmental challenges, identifying those at risk of difficulties later in childhood remains a challenge but is essential for targeting early intervention and counselling families.

Objective: To systematically review and synthesise the evidence regarding early medical and environmental factors for neurodevelopmental impairment, cognitive, motor and behavioural outcomes for children born very preterm.

Design: Ovid MEDLINE, Embase and PubMed were searched for articles between 1 January 1990 and 29 April 2024 reporting on a representative, prospective geographical, network-based or multisite cohorts of children born <32 weeks' gestation.

Main outcome measures: Neurodevelopmental impairment, cognitive, motor and emotional-behavioural functioning in children aged 36 months to 18 years. Data were extracted and reported descriptively due to heterogeneity in study measures.

Results: From 18 012 records, 29 studies from 16 cohorts were included. Brain injury, bronchopulmonary dysplasia, male sex and lower socioeconomic status were the most consistent predictors of neurodevelopmental impairment, IQ, working memory, cerebral palsy, fine motor skills and some behavioural measures. Emotional problems were generally not associated with neonatal variables investigated to date.

Conclusion: Numerous factors are independently associated with childhood outcomes after being born very preterm, with specific predictors varying across domains of functioning and limited available evidence for some predictor-outcome combinations. Knowledge of these factors may assist in targeting those at highest risk for closer surveillance and early intervention.PROSPERO registration numberCRD42022368957.

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: Investigate the impact of high stress (HS) using four stressors (physiological, psychological/social, contextual and situational) versus low stress (LS) on stress response and performance during simulated neonatal endotracheal intubation (ETI).

Design: Non-blinded crossover simulated randomised controlled trial. Subjects included paediatric and neonatology residents. Participants were exposed to HS and LS neonatal ETI scenarios. Primary outcomes were stress response measures: (1) physiologic: heart rate (HR) and HR variability (HRV), (2) psychologic: State-Trait Anxiety Questionnaire (STAI) responses and (3) endocrine: salivary cortisol. These were measured at baseline and pre/during/post each scenario. Secondary outcomes were intubation success rate, duration, and performance on a neonatal intubation checklist.

Results: 48 participants completed two scenarios. The HS scenario had a higher HR during (104±15 vs 100±15, mean difference 5 (1-9), p=0.03) and post (97±18 vs 93±15, mean difference 4 (0-9), p=0.04) compared with LS scenario. HRV was not different between groups. STAI trait scores did not differ, but STAI state scores were higher in the HS-post state compared with the LS-post state (38±8 vs 34±7, mean difference 4 (2-6), p=0.001). There was no significant difference in salivary cortisol between scenarios. Success rate, duration and checklist scores did not differ between scenarios.

Conclusions: It is possible to generate a modest physiologic and psychologic stress response in simulated neonatal ETI using a combination of stressors, although without raising salivary cortisol or affecting performance.

Objective: To compare the proportion of infants receiving different respiratory support types between 36 and 40 weeks postmenstrual age (PMA).

Design: Retrospective cohort study using National Neonatal Audit Programme data.

Setting: England and Wales.

Patients: 50 628 infants born <32 weeks of gestation admitted to neonatal units from 2017 to 2023.

Interventions: Not applicable.

Main outcome measures: Respiratory support received and mortality.

Results: The proportion of infants who died increased at 36 weeks (8.1% to 8.6%, p=0.01) and 40 weeks (8.4% to 8.9%, p=0.01) PMA, respectively. This trend was driven by infants born <24 weeks of gestation. In survivors, those receiving any respiratory support or respiratory pressure support at 36 and 40 weeks PMA increased between 2017 and 2023 (p<0.0001). Over the study period, more infants received non-invasive ventilation at 36 weeks PMA (12.6% to 15.1%, p=0.0001) and supplemental oxygen at 40 weeks PMA (12.4% to 13.1%, p=0.002). Between 36 and 40 weeks PMA, there were absolute reductions of 11.8% and 10.6% in the proportion of surviving infants receiving any respiratory support and respiratory pressure support, respectively. This is especially so in infants born between 24 and 27 weeks of gestation, with absolute reductions of 21.3% and 24.2%, respectively.

Conclusions: More surviving preterm infants are receiving respiratory support at 36 and 40 weeks PMA. However, a large proportion of infants born 24-27 weeks of gestation transition to no respiratory support during this period. Strategies to identify infants likely to wean off respiratory support could help safely transition them home at the right time or better plan respiratory support at discharge.

Objective: The objective is to investigate the prevalence of underweight and overweight and obesity (OWOB) and associated risk factors among 5-year-old children born very preterm (VPT).

Design: Multinational area-based cohort study of children born VPT.

Setting: 19 regions in 11 European countries.

Patients: Children born before 32 weeks of gestational age in 2011-2012 and followed up at 5 years of age.

Main outcome measures: Body mass index (BMI) at 5 years of age was classified into underweight and OWOB using International Obesity Task Force references, and associations with sociodemographic, perinatal and neonatal risk factors were assessed using multinomial logistic regression. Data came from medical records during the neonatal hospitalisation and parental questionnaires at 5 years of age. Models accounted for missing data and attrition by using multiple imputation by chained equations and inverse probability weighting.

Results: 27.6% of children were underweight and 10.8% were OWOB. Younger maternal age was associated with lower risks of underweight, while low maternal education, household unemployment and non-European maternal country of birth were associated with having OWOB. Fetal growth restriction, receiving postnatal steroids and bronchopulmonary dysplasia were associated with underweight, and fetal growth restriction, male sex and multiple birth were negatively associated with OWOB.

Conclusions: 38% of children born VPT had suboptimal BMI at 5 years, principally due to being underweight, with differing risk factors for underweight and OWOB. These results raise questions about underlying mechanisms and the growth trajectories and metabolic outcomes of underweight children, in light of high prevalence and association with clinical risk.

Background: In neonatal trials, verbal opt-out consent has been used to reduce burden on families and make recruitment more efficient and representative. It involves information provision through posters and leaflets before randomisation, and parents can verbally 'opt out' of their baby being randomised to the trial. There is limited understanding of how opt-out consent is operationalised in a multicentre neonatal trial, and its acceptability to staff and parents.

Objective: To explore views and experiences of verbal opt-out consent in neoGASTRIC, a neonatal randomised trial comparing routine and no routine measurements of gastric contents in preterm babies.

Methods: A mixed methods (questionnaires, interviews and focus groups) process evaluation within a trial.

Setting: Four UK neonatal units.

Participants: 253 participants: 167 staff (149 questionnaires; 18 across two focus groups), 86 parents (85 questionnaires; 15 interviews; 14 took part in both).

Results: Parents and staff supported opt-out consent in neoGASTRIC as interventions were viewed as low risk and non-invasive. Parents appreciated an appropriately timed research conversation; only 21% noticed study information banners/posters. Operationalisation of opt-out consent varied in terms of when information was provided and randomisation timing. Women approached during labour or within hours of birth reported feeling overwhelmed and lacking capacity to consider research. Some staff operationalised a modified opt-in approach.

Conclusions: An appropriately timed verbal opt-out approach to consent was seen acceptable as proportionate in the neonatal context in a low-risk trial comparing different accepted clinical, non-pharmaceutical, practices. Findings informed neoGASTRIC and will guide approaches to consent in this setting.