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

Objective: Decision-making in the neonatal intensive care unit (NICU) is complex. In grey zones (where there are multiple morally acceptable pathways), families and clinicians may disagree about the best plan. While negative moral phenomena (NMP) such as moral distress are well recognised within clinicians, little is known about parental experiences. We sought to understand parental experiences of decision-making, particularly if parents experienced NMP.

Design: This was a mixed-methodology phenomenological study, using surveys. Statistical analysis was used for categorical data and thematic analysis for textual data.

Setting: Four tertiary or quaternary NICUs in Australia and Canada.

Participants: Parents of infants admitted to NICUs between July 2018 and August 2022 who engaged in decision-making in grey zones.

Results: 71 parents (80% mothers) completed the survey. 80% were bereaved.Thematic analysis revealed five themes: (1) decision burdens, (2) internal tensions, (3) actualising beliefs and values through decision-making, (4) inauthentic shared decision-making (SDM) and (5) external factors that shaped decision-making.Parents reported variable experiences of SDM. Despite decisions being described as burdensome, 89% wanted to be very involved in SDM, while 63% felt included. Actualisation of beliefs and values was important. Time pressures, competing interests and environmental factors influenced internal tensions experienced. Despite framing as SDM, some parents reported feeling coerced and experiences consistent with NMP.

Conclusion: Some parents do experience significant NMP during SDM in the grey zones of the NICU. Clinician awareness of NMP and their antecedents may enhance communication and the SDM process in this challenging setting.

Objective: Investigate whether enteral supplementation with arachidonic acid (AA) and docosahexaenoic acid (DHA), from birth to term-equivalent age (TEA), promotes brain maturation as a prespecified secondary outcome of a multicentre randomised controlled trial.

Participants: 206 infants born at 22-28 weeks gestational age (GA) were randomised into intervention or control groups from three university hospitals in Sweden.

Intervention: The intervention group received an oil with AA (100 mg/kg/d) and DHA (50 mg/kg/d) starting at birth until 40 weeks postmenstrual age (PMA) in addition to standard nutrition. Standard-of-care infants received standard nutrition according to national guidelines.

Main outcome and measures: MRI volumetrics were defined a priori as a secondary outcome of the trial and included total brain, white and cortical grey matter, central structures and cerebellum. Univariable and multivariable linear regression models were used for comparisons.

Results: MRI data in 117 infants had sufficient quality for inclusion (n=58 intervention). Birth weight, GA at birth, sex distribution, and PMA at MRI were similar in the groups. Infants receiving intervention had significantly larger white-matter volume at TEA, as compared with standard of care, in models adjusted for GA at birth, sex, study centre and PMA at MRI (β=6.8 cm³, 95% CI 0.7 to 12.9, p=0.028). The contribution of the intervention to white-matter volume corresponded to 10 days of prolonged gestation.

Conclusion and relevance: Our findings in this hypothesis-generating study suggest that AA+DHA promotes white matter growth, which may protect the developing brain in this vulnerable population.

Trial registration number: NCT03201588.

Objective: To compare feeding strategies on preterm infants' growth during hospitalisation, neonatal morbidities, mortality and neurodevelopmental outcome (NDO) at 18-26 months corrected age.

Methods: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension statement for network meta-analysis . We searched five medical databases for randomised controlled trials comparing different feeding approaches in preterm infants and their effects on growth, neonatal morbidities, mortality and NDO. The Cochrane Collaboration's tool was used to assess the risk of bias. We used a random-effects model. Pooled mean differences (MD) or risk ratios with 95% CIs were calculated.

Results: Ninety-five studies (9663 infants) were included.Human milk (HM) with bovine milk fortifier (BMF) (adjusted according to blood urea nitrogen) achieved the best length increment (MD=0.56 cm/week; 95% CI 0.19 to 0.93). Notably, HM+BMF (3.5 gm/kg/d protein) showed the best head circumference growth (MD 0.46 cm/week; 95% CI 0.10 to 0.81) but no significant difference in weight gain. There were no significant differences in neonatal morbidities/mortality. While MOM|+PTF (supp) displayed significantly lower NDO delay in the domain of mild cognitive delay.

Conclusion: Overall, there is a lack of strong evidence to support a specific enteral feeding strategy and further high-quality research is required. Targeted HM fortification appears to improve head growth, while adjusted fortification enhances length. Given the significant inconsistency detected, which may compromise the reliability of the network estimates, these results must be interpreted carefully.

Objective: To identify the location of the left ventricle (LV) and identify the structures below the lower third of the sternum when chest compressions (CCs) are performed using transthoracic echocardiography.

Design: Prospective observational cohort study.

Setting: The Lois Hole Hospital for Women and the Grey Nuns Community Hospital, Edmonton, Alberta, Canada.

Patients: Newborn infants born between 37 and 41⁺⁶ weeks' gestation admitted to postnatal unit. Newborns of diabetic mothers, large or small for gestational age and with known congenital anomalies were excluded.

Interventions: Transthoracic echocardiogram to obtain views as per the American Society of Echocardiography guidelines including (1) parasternal long axis, (2) parasternal short axis, (3) apical four chamber and (4) subcostal view.

Main outcome measures: To assess the positions of the right ventricle and LV and their perception on the chest wall when CCs are performed.

Results: A total of 50 newborn infants were recruited with a mean (SD) gestational age of 39 (1) weeks and birth weight of 3409 (347) g. The LV was located at the third left sternal border in one (2%) newborn infant. In 22 (44%) infants, the LV was located at the fourth left sternal border, in 25 (50%) infants the LV was located at the fifth and in 2 (4%) infants, it was located at the sixth left sternal border.

Conclusions: In newborn infants, CC delivered at the currently recommended lower third of the sternum is likely to compress the right heart, great veins and aorta and not the LV.

Introduction: Children born preterm often have anatomical and functional visual abnormalities, even in the absence of retinopathy of prematurity. This includes suboptimal visual acuity (VA), defined as binocular VA between 5-6.3/10 and 8/10. We examine relationships between suboptimal VA and neurodevelopment in children born preterm.

Methods: Secondary analysis of the French EPIPAGE-2 cohort with children born between 24+0 weeks and 31+6 weeks of gestation, eligible for follow-up at 5.5 years. Children were classified into three VA groups: 5-6.3/10, 8/10 and 10/10 as reference group. Neurodevelopment was assessed with the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition, the Movement Assessment Battery for Children-II (MABC-2) and the Strengths and Difficulties Questionnaire (SDQ). Comparisons between groups were adjusted for neonatal and socioeconomic characteristics using generalised estimating equations models.

Results: Among 1787 included children, 62% had suboptimal VA. Compared with the 10/10 VA group, the mean full-scale IQ decreased by -3.09 (95 % CI -4.75 to -1.42) and -4.97 (95 % CI -6.47 to -3.46) points, the mean MABC-2 total score by -0.66 (95 % CI -0.71 to -0.61) and -1.06 (95 % CI -1.09 to -1.00), and the mean total SDQ scores increased by 0.40 (95 % CI -0.16 to 0.94) and 0.60 (95 % CI 0.10 to 1.1) in groups with VA groups at 8/10 and 5-6.3/10, respectively.

Discussion: In this French population-based cohort of children born preterm, suboptimal VA was frequent and associated with increased risk of neurodevelopmental difficulties. A comprehensive neurodevelopmental and neurovisual assessment is warranted in children born preterm with suboptimal VA.

Objective: To assess the economic consequences of initiating full milk feeds from birth compared with intravenous fluids with gradual feeding in infants born preterm.

Design: Within-trial economic evaluation alongside a prospective, multicentre, randomised controlled trial (Fluids Exclusively Enteral from Day 1). A cost-consequence approach was used (revised from the planned cost-effectiveness analysis to avoid double counting length of stay within costs).

Setting: 46 UK National Health Service (NHS) neonatal units.

Patients: Preterm infants born at 30+0to 32+6 weeks' gestation.

Interventions: Infants were allocated to either full milk feeds or gradual feeding with intravenous support within 3 hours of birth.

Main outcome measure: Resource use and costs were captured from birth to 6 weeks' corrected age. Costs were assessed from an NHS and personal social services perspective. The primary clinical outcome was length of hospital stay.

Results: 2088 infants were enrolled. There was no statistically significant difference in mean (95% CI) length of hospital stay between groups (-0.050 days (-0.638 to 0.538)). Mean total costs were £670 lower in the full milk group (95% CI: -£1562 to £223; p=0.141). Subgroup analyses suggested lower costs among infants born at 30 weeks' gestation and those below the 10th birth weight centile; no evidence of interaction was found.

Conclusions: Initiating full milk feeds from birth was associated with a modest reduction in costs compared with gradual feeding. While overall hospital stays and costs were not significantly reduced, early full feeding may offer economic advantages in selected subgroups. Further research is needed to assess long-term outcomes.

Trial registration number: ISRCTN89654042.

Objective: Currently, retinopathy of prematurity (ROP) screening requires a full retinal examination. To reduce the screening burden, we assessed whether a single optic nerve-centred image could detect treatment-requiring ROP. The objective is to investigate the use of a single image centred around the optic disc to detect treatment-requiring ROP, to reduce the burden of ROP screening with the same security of a full retinal examination.

Design: Retrospective case series.

Setting: Tertiary referral centre.

Population: Premature infants screened for ROP in a tertiary referral centre.

Main outcome: Vascular dilation and tortuosity on a scale from 1 to 5 were blindly labelled by three independent ROP experts using a 8 by 8 mm optic nerve-centred images. Images were automatically generated from images of the routine screening examinations.

Results: A total of 278 patients (556 eyes) with a mean gestational age of 28.4±2.0 weeks and a mean birth weight of 1059.7±324.0 g were included. Treatment was needed in 49 eyes (8.8%) of 25 patients. A total of 1510 image sets centred on the optic disc were obtained and analysed. When the cut-off of the vascular dilatation and tortuosity rating was fixed at 3 (equivalent to a severe preplus disease), sensitivity and specificity for the detection of prethreshold type 1 ROP were 100% and 88.9%, respectively.

Conclusions: ROP screening using a single posterior pole image could reduce stress in premature infants without degrading the quality of screening, compare to iterative dilated complete fundus examination.

Objective: To assess the contribution of rare coding genetic variants to idiopathic neonatal arterial ischaemic stroke (NAIS).

Design: Observational genetic study using trio-based whole-exome sequencing (WES).

Setting: Multicentre study.

Patients: 23 newborns diagnosed with idiopathic NAIS and their biological parents.

Interventions: WES-trio with a customised workflow for filtering and interpreting variants in de novo autosomal dominant and recessive inheritance models.

Main outcome measures: Identification of pathogenic (P) or likely pathogenic (LP) variants potentially associated with NAIS.

Results: We identified 28 unique rare de novo variants in 28 genes across 23 newborns with NAIS. Under the autosomal recessive model, no candidate genes were identified. No common P/LP variant across the 23 newborns was detected. In-silico predictors and comprehensive knowledge-driven analysis highlighted PIK3CD (p.Gln431Arg) as a candidate gene in one patient with perforant stroke. However, no more cases were identified with PIK3CD variants, and functional studies are warranted to assess its pathogenicity impact.

Conclusions: Trio-based WES did not identify a monogenic cause for idiopathic NAIS. Coding variants therefore appear unlikely to explain the underlying genetic base of the disease. Furthermore, PIK3CD (p.Gln431Arg) may contribute to perforant stroke, although it requires further association evidence. As the potential role of non-coding or structural variants in NAIS remains possible, genome-wide long-read sequencing approaches may provide further insights into the genetic architecture of this condition.