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

Objective: To compare the duration of mechanical ventilation between preterm infants receiving closed-loop automated oxygen control (CLAC) or manual oxygen control.

Design: Randomised controlled trial.

Setting: Tertiary neonatal unit in London, UK.

Patients: Infants (n=69) with a median (IQR) gestational age of 27.0 (25.6-29.0) weeks studied at a corrected postmenstrual age of 27.6 (25.9-29.1) weeks.

Interventions: Infants were randomised to CLAC or manual oxygen control within 48 hours of initiation of mechanical ventilation if less than 7 days of age until successful extubation.

Main outcome measures: Duration of mechanical ventilation.

Results: The CLAC infants (n=34) compared with those who received manual control had a shorter duration of mechanical ventilation (median (range): 11 (1-57) vs 40 (3-134) days, p=0.027), a shorter duration of supplemental oxygen (median (range): 33 (0-100) vs 47 (3-335) days, p=0.031), a lower incidence of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (55% vs 83.9%, p=0.015) and fewer required home oxygen (26.5% vs 51.4%, p=0.016). In the CLAC infants, the time spent in the target oxygen range (91%-95%) was increased (p<0.001) and the times spent in hypoxaemia (peripheral oxygen saturation level (SpO₂)<85%) and hyperoxaemia (SpO₂>95%) were reduced (p<0.001).

Conclusions: Use of CLAC in preterm, ventilated infants was associated with improved achievement of oxygen saturation targets, shorter durations of mechanical ventilation and supplemental oxygen treatment and a lower incidence of BPD. These results need to be replicated in larger multicentre studies before any change in routine practice could be recommended.

Trial registration number: NCT05030337.

Background: It has traditionally been considered that mother-infant ABO incompatibility only causes mild haemolytic disease of the newborn (HDN). However, this view is inconsistent with clinical practice, and large-scale population-based data are lacking to investigate its effects on neonates.

Methods: Differences in hospitalisation rates and incidence rates of neonatal hyperbilirubinaemia (NHB) and anaemia among 47 679 Chinese liveborn neonates with different mother-infant ABO combinations, differences in the incidence of ABO-incompatible HDN (ABO-HDN) among neonates with O-B versus O-A mother-infant ABO incompatibility, and the contributions of ABO-HDN to the development of NHB and neonatal anaemia were analysed.

Results: Of the 47 679 liveborn neonates, neonates with mother-infant ABO incompatibility had higher rates of hospitalisation and incidence of NHB and anaemia. The hierarchy of the risk of mother-infant ABO incompatibility to the neonate was O-B > O-A > non-O-A/O-B incompatibility. Among neonates with O-B and O-A mother-infant ABO incompatibility, the ABO-HDN incidence rates were 15.27% (513/3359) and 11.33% (417/3680), respectively (95% CI 1.41 (1.23 to 1.62)), and the severe ABO-HDN incidence rates were 2.05% (69/3359) and 1.14% (42/3680), respectively (95% CI 1.82 (1.23 to 2.67)). Among the 7039 neonates with O-A/O-B mother-infant ABO incompatibility, ABO-HDN was an independent aetiological factor in 41.11% (666/1620) of the neonates with NHB, 70.27% (52/74) of the neonates with severe NHB, 42.34% (163/385) of the neonates with anaemia and 18.28% (17/93) of the neonates with severe anaemia.

Conclusions: Mother-infant ABO incompatibility often leads to severe HDN and is a dominant cause of NHB and neonatal anaemia, leading to significantly higher neonatal hospitalisation rates.

Objective: To understand why surgical decision-making in necrotising enterocolitis (NEC) is challenging and to explore what is required to optimise this.

Design: Three semi-structured in-person focus groups exploring surgical decision-making in NEC. Reflexive thematic analysis of the focus group transcript was undertaken.

Participants: 22 consultant participants (15 paediatric surgeons and 7 neonatologists).

Main outcome measures: Themes addressing what informs, the challenges of and how to improve surgical decision-making in NEC.

Results: 10 themes addressed what informs decision-making in NEC, 6 themes addressed why this is challenging and 5 themes explained what is required to address the challenges of decision-making. Themes regarding challenges of decision-making were: diagnostic uncertainty, variable threshold for referral/transfer, lack of continuity of care, absence of clear criteria for surgery, uncertainty surrounding surgery and fear. Subthemes regarding fear were fear of (1) poor clinical outcome, (2) criticism from colleagues and (3) undertaking unnecessary surgery.Themes in all three areas were related to infant, clinician and system-based factors. These included themes regarding indications for surgical intervention, indications for referral and transfer of infants, and reducing variability in practice.

Conclusions: This study identified themes that illuminate the difficulties experienced by neonatologists and surgeons regarding surgical decision-making in NEC. Clinicians of both specialties would welcome changes to current practice focused particularly around standardisation of practice and greater objectivity around several aspects of surgical decision-making. These insights can be used to focus further research and implement practice change around surgical decision-making in NEC with the ultimate aim of facilitating early and accurate decision-making.

Objective: Definitive guidance regarding the duration of antibiotics for neonatal sepsis is lacking. We hypothesised that a 7-day antibiotic course is non-inferior to a 14-day course for treating culture-proven sepsis.

Design: Randomised, controlled, non-inferiority trial with masked outcome assessment in eight centres in a low and middle-income country.

Patients: Neonates with a birth weight (BW) ≥1000 g and blood culture-proven sepsis were randomised on day 7 of sensitive antibiotic therapy provided sepsis had clinically remitted.

Exclusions: Staphylococcus aureus or fungal sepsis, and infections requiring prolonged antibiotics. We planned to enrol 350 per group, assuming 10% rate of primary outcome, +7% non-inferiority margin, one-sided 5% alpha, 90% power, 10% loss to follow-up.

Intervention: 7 days (no further treatment); comparison: 14 days (7 days postrandomisation).

Outcomes: Primary: relapse (definite or probable) within day 21 postantibiotic completion.

Secondary outcomes: composite of mortality or definite/probable/secondary sepsis and duration of hospitalisation. One interim analysis (per protocol (PP)) was planned.

Results: 126 and 135 subjects were recruited in 7-day and 14-day groups, respectively, with mean (SD) birth weight (BW) 2250.9 (741.1) and 2187.8 (718.8) g. The trial was terminated early, based on interim PP analysis. 2/125 and 6/130 subjects had the primary outcome in 7-day and 14-day groups, respectively (risk difference (RD)=-3.0% (99.5% CI -9.2%, +3.1%), below non-inferiority margin). The composite secondary outcome also favoured the 7-day regimen (RD: -3.7% (99.5% CI -12.4% to +5.1%)). Duration of hospitalisation was shorter in 7-day group (median difference: -4 days (95% CI -5 to -3)).

Conclusions: A 7-day course of antibiotics may be non-inferior to a 14-day course for uncomplicated bacterial neonatal sepsis.

Trial registration number: NCT03280147.

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: 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: During perinatal transition, compromised cerebral oxygenation may contribute to neonatal morbidity and mortality. Near-infrared spectroscopy measures cerebral regional tissue oxygen saturations (crSO₂) and may guide delivery room respiratory management. This review evaluated whether crSO₂ monitoring in addition to routine assessment (clinical assessment, pulse oximetry +/- ECG) compared with routine assessment alone improves neonatal outcomes.

Design: Systematic review and meta-analysis based on Ovid MEDLINE, Embase, and Cochrane CENTRAL searches (16 February and 5 November 2024).

Setting: Delivery room.

Patients: Newborn infants of all gestations, born via any mode, receiving continuous positive airway pressure and/or intermittent positive pressure ventilation during stabilisation/resuscitation.

Intervention: crSO₂ monitoring with a dedicated treatment guideline in addition to routine assessment compared with routine assessment alone.

Main outcome measures: Survival without neurodevelopmental impairment, survival, severe intraventricular haemorrhage and periventricular leukomalacia (infants <34 weeks); and crSO₂ <10th percentile.

Results: Among 566 articles, 3 articles reporting outcomes from 2 randomised controlled trials (RCTs) (667 preterm infants) were identified. No data were found for survival without neurodevelopmental impairment. We could not exclude benefit or harm from delivery room monitoring of crSO₂ for survival (relative risk (RR) 1.02, 95% CI 0.99 to 1.05), severe intraventricular haemorrhage (RR 0.76, 95% CI 0.38 to 1.54), periventricular leukomalacia (RR 1.93, 95% CI 0.66 to 5.70) (n=667; two RCTs) and crSO₂ <10th percentile (RR 1.00, 95% CI 0.78 to 1.29) (n=60; one RCT).

Conclusions: The limited evidence could not exclude benefit or harm from delivery room monitoring of crSO₂ with a dedicated treatment guideline in preterm infants.