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

Objectives: We assessed whether an infusion of normal saline volume during chest compression resuscitation, compared with standard intravenous epinephrine, would increase diastolic blood pressure, achieve return of spontaneous circulation (ROSC) and maintain physiological stability after ROSC.

Methods: Near-term fetal lambs were asphyxiated until mean blood pressure reached 10-12 mm Hg and heart rate was <60 beats per minute. Resuscitation was commenced with ventilation and chest compressions. Lambs were randomly allocated to: standard care (20 µg/kg intravenous epinephrine; n=8) or volume infusion (20 mL/kg over 2 min; n=10). After two allocated treatment doses, rescue intravenous epinephrine was administered if ROSC was not achieved by 8 min. Lambs achieving ROSC were monitored for 60 min. Cerebral histology was assessed for micro-haemorrhages.

Results: Blood pressure and cerebral blood flow during chest compressions was higher in volume infusion lambs. ROSC occurred in 8/8 standard care lambs. Of the volume infusion lambs, 5/10 achieved ROSC in response to allocated treatment, and despite increased diastolic pressure, 3/10 required rescue epinephrine and 2/10 did not achieve ROSC. For 2 min after ROSC, blood pressure, heart rate and arterial partial pressure of arterial oxygen (PaO₂) was higher in standard care lambs compared with volume infusion lambs. The number of periventricular white matter micro-haemorrhages was higher in volume infusion lambs.

Conclusions: Volume infusion with saline improved blood pressure stability during and after cardiopulmonary resuscitation but was inferior to intravenous epinephrine in achieving ROSC and reducing cerebral micro-haemorrhages. The use of volume infusion during resuscitation in moderately asphyxiated euvolaemic newborns is unlikely to have clinical benefit.

Background: Targeted testing for cytomegalovirus (CMV) in preterm infants <21 days has two benefits: timely congenital CMV (cCMV) diagnosis, and differentiation between cCMV and postnatal CMV (pCMV). We present an audit of targeted testing for cCMV alongside rates of clinically suspected pCMV in preterm infants.

Methods: We collected data on CMV testing from 2016 to 2023 in infants born <30 weeks gestation during admission to a tertiary London neonatal centre.

Results: Of all infants, 77% (899/1162) were tested for CMV during their admission with 74.6% tested <21 days of age. CMV infection was confirmed in 58 infants, 4 cases of cCMV (0.4%) and 54 cases of pCMV (6.0%). One infant with cCMV died, and all were symptomatic: microcephaly, thrombocytopenia, leucopenia, white matter hyperintensity on brain imaging, but none had hearing loss. Most pCMV cases (92.6%) were symptomatic, with bone-marrow suppression (92.6%), sepsis-like syndrome (50%), respiratory (31.5%) and gastrointestinal symptoms (29.6%). All infants with cCMV and 38.9% of infants with pCMV received treatment. Overall, 6% (54/899) had symptomatic CMV disease, 16.7% of infants with CMV died during their neonatal intensive care unit admission, and 42.6% were discharged on home oxygen.

Conclusions: CMV causes a substantial disease burden in infants born <30 weeks gestation, whereby 6% have symptomatic CMV disease. We show the feasibility and value of targeted cCMV and opportunistic pCMV testing. In the absence of universal screening, targeted birth testing for cCMV in infants <30 weeks gestational age should be considered.

Objective: To determine whether extending caffeine therapy through 43 weeks' postmenstrual age (PMA) decreases intermittent hypoxia (IH) in convalescing preterm infants. Secondary objectives were to assess caffeine effects on changes in inflammation-related plasma biomarkers and brain MRI.

Design: Multicentre masked randomised trial.

Setting: 16 US hospitals.

Patients: Infants at <30 weeks + 6 days gestational age on caffeine between 32 weeks and 36+5 days PMA in room air with routine caffeine discontinuation prior to 36 weeks +6 days.

Intervention: Randomisation to caffeine or placebo and treated through 42 completed weeks. Pulse oximetry was recorded from enrolment through 1 week after stopping study drug. Blood for 12 inflammation-related biomarkers obtained at enrolment and 38 weeks' PMA and brain imaging after enrolment or <3 days of randomisation, and study end.

Main outcome measure: Seconds/hour of oxygen saturation <90% from randomisation to study end.

Results: Randomised 160 subjects, 78 placebo, 82 caffeine. IH was less at every PMA with caffeine treatment from 34 (172.7 (123.4, 241.7); 84.7 (64.4, 111.4, p<0.01) through 41 weeks (73.0 (51.3, 103.7); 26.6 (18.5, 38.2, p<0.001). Adjusted TNF-α levels were 23% lower at follow-up in the caffeine group compared with placebo (p<0.02), without other biomarker differences. Paired brain imaging found no significant differences.

Conclusions: Extended caffeine reduced the burden of IH in very preterm infants and may reduce inflammation. Further study is needed to determine if this effect of caffeine is associated with reduced risk of adverse outcomes.

Trial registration number: NCT03321734.

Objective: The introduction of quality improvement projects has been reported to be associated with a reduced rate of intraventricular haemorrhage (IVH) rate in some neonatal intensive care units.

Methods: In this retrospective single-centre study of 1675 preterm infants <1500 g, we analysed the frequency of overall IVH and severe IVH before and after the introduction of a first (2010) and a second (2019) quality improvement bundle.

Results: After the introduction of a first bundle of interventions in 2010, we were able to show a significant reduction of the rate of IVH from 22.2% to 10.5% (p=0002), mainly related to a reduction of severe IVH in the subgroup of infants below 26 weeks of gestational age. By continuous monitoring and implementation of a second intervention bundle in 2019 according to new identified risk factors, we could maintain a low rate of IVH over a 14 year period. With the reduction of the IVH rate, we observed improved long-term neurodevelopmental outcome as indicated by a lower rate of cerebral palsy and improved psychomotor development scores.

Conclusion: Our data suggest that implementing an intervention bundle of measures targeted to avoid risk factors may be associated with a significant reduction in IVH rate. By constant monitoring of the effects of the intervention and individual measures and refining the care bundle based on new evidence becoming available, a reduced IVH rate may be maintained despite annual fluctuations in the incidence of IVH. These intensified efforts are justified as IVH is not an inevitable event.

Objective: To evaluate the prevalence of acute peripartum twin-to-twin transfusion syndrome (TTTS) in vaginally born monochorionic (MC) twin pregnancies, comparing early cord clamping (ECC) to delayed cord clamping (DCC).

Design, setting and patients: Single-centre retrospective cohort study including vaginally born MC twins at our institution between January 2020 and April 2025. Acute peripartum TTTS was defined as intertwin haemoglobin (Hb) difference >8 g/dL within 12 hours after birth, without signs of chronic TTTS or twin anaemia polycythaemia sequence. Twins were categorised to the ECC and DCC group if cord clamping occurred ≤60 s or >60 s after birth of the first twin, respectively.

Results: Thirty-five twin pregnancies were included (n=17 in the ECC group; n=18 in the DCC group). Acute peripartum TTTS occurred in 0% (0/17) in the ECC group compared with 17% (3/18) in the DCC group (p<0.01). In the ECC group, no cases of severe brain injury were observed, whereas 8% (3/36) of infants in the DCC group, all with acute peripartum TTTS, showed severe brain injury (p<0.01). DCC time of the first born infant was associated with larger intertwin Hb difference (β=0.01, p=0.04). Potential risk factors for acute TTTS included interval between birth and cord clamping of the first infant (OR 1.02, 95% CI 1.00 to 1.03, p<0.03) and total combined diameter of bidirectional placental anastomoses (OR 1.34, 95% CI 0.97 to 1.84, p=0.07).

Conclusion: DCC in MC twin pregnancies may be associated with a higher prevalence of acute peripartum TTTS and severe brain injury and is therefore not recommended.

Objectives: While antibiotics save lives in infants with sepsis, up to 12.0% of non-infected term and late preterm infants are exposed to antibiotics underscoring diagnostic challenges in early onset sepsis (EOS).This study aimed to assess whether serial physical examination (SPE) in neonatal intensive care units (NICUs) could safely reduce early antibiotic exposure in infants born at ≥34 weeks' gestation at risk for EOS.

Design: A population-based, multicentre interventional study from 2018 throughout 2021.

Setting: Six Norwegian tertiary and secondary level NICUs.

Patients: In total, 54 713 liveborn infants were eligible for inclusion.

Interventions: Infants at risk for EOS (mild/transient clinical signs, chorioamnionitis-exposed or group B streptococcus sepsis in a sibling) were clinically monitored with SPE for 24-48 hours. Infants with no/transient clinical signs did not receive antibiotics, whereas treatment was initiated without delay if signs indicated severe EOS, clinical condition deteriorated despite intervention or vital signs failed to improve.

Main outcome measures: Comparative statistics were used to evaluate changes after implementing SPE, including percentage of infants exposed to antibiotics, incidence of EOS, NICU and safety outcomes (time from birth to antibiotics administration in EOS, infection-related deaths and re-admissions for infection). A statistical process control chart was used to evaluate antibiotic exposure over time.

Results: Infants exposed to antibiotics were reduced by 50%, from 1.8% (95% CI 1.6% to 2.0%) to 0.9% (95% CI 0.8% to 1.1%).Incidence of culture-positive EOS, NICU admission rates and safety outcomes remained unchanged.

Conclusion: SPE reduced antibiotic exposure in infants ≥34 weeks' gestation without compromising safety.

Objective: Recommendations on nasal intubation depths in term or preterm newborns are scarce, although this is the preferred route in some countries. Postmenstrual age (PMA) and weight-based recommendations were recently published by our group.

Design: A prospective quality assurance study SETTING: Single-centre study (University Children's Hospital Tübingen) PATIENTS: All nasally intubated term and preterm infants between August 2021 and August 2023 INTERVENTIONS: Physicians were free to choose the method of orientation for the insertion depth (our recommendations vs other's (eg, endotracheal tube (ETT) tip markers)). Subsequently, chest X-rays were performed. Correct ETT placement was defined as the tip visible between thoracic vertebrae 1-3. X-ray investigators were blinded to the method of orientation.

Main outcome measures: Main outcome was the rate of correct ETT placements using our previous recommendation compared with other orientations. Secondary, a subgroup analysis for infants <1000 g and a comparison of PMA-based orientations by European Resuscitation Council (ERC) guidelines were performed.

Results: 114 intubations/infants were analysed (39 weight-based; 26 PMA-based; 49 others). Median PMA (IQR) was 30 0/7 weeks (26 6/7-35 0/7), weight 1310 g (793-2300). Correct ETT placement was in 74% following our recommendations versus 55% in others (p=0.046). No difference was seen between PMA-based and weight-based recommendations (77 vs 69%; p=0.57). 48 infants <1000 g showed even clearer results; based on ERC guideline, correct placement would have been 27%.

Conclusions: Our previously published recommendations for nasal intubation depths are applicable in routine care leading to a more accurate ETT placement than with other orientations.

Objective: The first hour after birth is a sensitive period for the mother-newborn dyad and, according to evidence-based routines, should be respected and protected. However, a gap exists between the strive for zero separation and current practices. Therefore, our aim was to investigate mothers' experiences of mother-infant separation directly after birth.

Design, setting and participants: A qualitative study based on open-ended questions from a survey. The sample was drawn from an ongoing national cohort study (Mom2B, N=∼9000). Data was extracted from responses of participants (n=441) during the period 2023-2025. We included mothers who had been separated from their newborns directly after birth and who had completed the open-ended questions about separation and their related experiences. Thematic analysis was conducted.

Results: One overarching theme emerged: 'Separation, an experience beyond the mother's control'. This theme referred to the healthcare system being organised in such a way that two individuals in need of care from different units could not stay together, even when the individuals were mothers and their newborn. The mothers and their newborns were often separated, even if only one of them needed care, due to existing routines and organisation. Mothers questioned the reasons for separation and described it as anxiety-inducing and traumatic.

Conclusion: The mothers' experiences and reasons for separation highlight structural obstacles within a healthcare system that need to be addressed to minimise the significant burden of such separation.