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

Objective: To evaluate if postnatal treatment with betamethasone in extremely preterm infants was associated with neurodevelopmental impairment (NDI) at 6.5 years of age.

Design: Prospective cohort study.

Setting: Extremely Preterm Infants in Sweden Study (gestational age <27 weeks, born 2004-2007).

Patients: 428 children born extremely preterm were assessed at 6.5 years of age, 115 treated with betamethasone and 313 not treated.

Main outcome measures: NDI at 6.5 years of age. Evaluation at 6.5 years included cognitive testing with the Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), neurological examination and a medical record review.

Exposure: Treatment with postnatal betamethasone.

Main outcome: Moderate to severe NDI at 6.5 years of age, defined as a composite including cerebral palsy, and/or impairment in cognition, hearing and vision.

Results: Moderate to severe NDI was more prevalent in children treated with postnatal betamethasone (49% treated vs 26% not treated, p<0.001). Betamethasone-treated children had worse cognitive development with mean WISC-IV score of 75 (SD 13.7) vs 87 (SD 14.0, p<0.001). The effect was dose dependent: 1.35 mg/kg vs 1.0 mg/kg (p=0.01) in betamethasone-treated children with moderate to severe versus no or mild NDI, respectively. The differences remained after adjustment for potential confounders with logistic regression (adjusted OR (aOR) 1.80, 95% CI 1.14 to 3.21). The difference in NDI also remained after propensity score matching, with crude OR 2.82 (95% CI 1.42 to 5.61, p=0.003) and aOR 2.17 (95% CI 1.07 to 4.69, p=0.04).

Conclusion: Postnatal treatment with betamethasone is associated with increased risk of NDI at 6.5 years.

Background and aim: Unplanned extubation (UE) is an adverse event that can occur for neonates that are intubated and mechanically ventilated. UE is recognised as an important quality measure in the neonatal intensive care unit (NICU) due to the negative impact these events may have on the neonate. We aimed to use quality improvement (QI) methodology to reduce the rate of UE to the global standard of <1/100 ventilation days.

Methods: A 12-month retrospective audit on mechanically ventilated neonates in our NICU identified a mean UE rate of 1.78/100 ventilation days. A clinical guideline focusing on best practice was introduced with key interventions identified by a review of the literature as those which were thought to reduce UE rates. The key interventions in the clinical guideline were introduced sequentially. UE rates were analysed monthly using control charts and the reported cause of each UE event was analysed. Three 12-month periods were included: preintroduction of QI interventions (period 1), during introduction of QI interventions (period 2), and after introduction of QI interventions (period 3).

Results: The introduced interventions reduced the mean rate of UE from 1.78/100 ventilation days in period 1 to 0.8/100 ventilation days in period 3 of the QI project.

Conclusions: The key interventions introduced in this QI project were successful in reducing rates of UE by 55%, allowing achievement of the global standard of <1/100 ventilation days.

Objective: Following very preterm birth, some children require ongoing intensive care after the neonatal period and transition directly from neonatal units (NNUs) to paediatric intensive care units (PICUs) around term-corrected age.We aimed to understand, at a national level, characteristics and outcomes of children born very preterm who transitioned directly from NNUs to PICUs.

Design: Retrospective cohort study, using data linkage of National Neonatal Research Database, Paediatric Intensive Care Audit Network and Office for National Statistics datasets.

Setting: All NNUs and PICUs in England and Wales.

Patients: Children born <32 gestational weeks between 1 January 2013 and 31 December 2018, admitted to NNUs, and who transitioned directly to PICU without return to NNU at ≥36 weeks corrected gestation age were included.

Main outcome measures: Mortality, length of PICU stay, invasive ventilation in PICU (including via tracheostomy), PICU readmission until 2 years of age.

Results: Direct NNU-to-PICU transitions occurred in 276 babies during the study period. An increasing yearly trend was observed: 36 transitions of babies born in 2013, 65 in 2018.Of this cohort, 22% of children died before their second birthday, 59% of survivors had ≥1 PICU readmission, 33% of children had long stays in PICU (≥28 days) and 25% received tracheostomy ventilation.

Conclusions: An increasing number of very preterm children require ongoing intensive care at the end of their neonatal stay, with high rates of mortality and morbidity. Multidisciplinary involvement and planning around the time of transition from NNU to PICU, informed by national guidance, may be beneficial.

Objective: To conduct a methodological systematic review of multicentre trials of premature infants to (1) determine if and how multiple births have been considered in the design, analysis and reporting of recent trials and (2) assess whether there has been an improvement since the last review was conducted 10 years ago.

Design: A systematic search was conducted in PubMed on 28 June 2023 for articles published between June 2018 and June 2023. Articles were eligible for inclusion if they were a multicentre randomised trial of infants born preterm and reported the results of a primary outcome that was measured on an infant or could be attributed to an infant.

Results: We reviewed 62/74 trials (80%), after determining it was unclear if multiple births were present in the other 20%. 87% of trials (54/62) did not account for multiple births in their sample size calculations and 48% (30/62) did not account for clustering due to multiple births in their analyses. Problems were not limited to lower-ranked journals. No trials reported the intraclass correlation coefficient for any outcomes, indicating the degree of clustering present.

Conclusions: Persistent problems remain with the design and analysis of multicentre trials of premature infants due to ignoring the complexity that comes with the inclusion of multiple births, despite methods available to address this. Trialists should consider the impact of multiple births in their trial design and analysis. Readers of neonatal trials should be aware of these issues, particularly those who peer review papers.

Objectives: (1) To assess how main pulmonary artery peak Doppler velocity (MPAVpeak) correlates with right ventricular output (RVO) and superior vena cava flow (SVCf), (2) to assess the reproducibility of MPAVpeak and (3) to test the prognostic accuracy of MPAVpeak to predict high-grade intraventricular haemorrhage (IVH) or death at seventh day of life.

Design: Prospective cohort study.

Setting: Nine third-level neonatal units in Spain.

Patients: Preterm infants <33 weeks of gestational age who had standardised measurements of MPAVpeak, RVO and SVCf at 6, 12 and 24 hours of life.

Main outcome measures: High-grade IVH or death at seventh day of life.

Results: One hundred and ninety preterm infants with a median (IQR) gestational age and birth weight of 29.7 weeks (27.1-31.8) and 1152 g (892-1491), respectively, were included. High-grade IVH or death at seventh day of life occurred in 24 (12.6%). MPAVpeak was strongly correlated with RVO (Spearman rho 0.826-0.843). MPAVpeak discriminated well for low RVO (<120 mL/kg/min) at 6 (AUROC, area under the receiver operating characteristic curve=0.90), 12 (AUROC 0.94) and 24 hours (AUROC 0.86). Observer reproducibility was better for MPAVpeak (inter-observer limits of agreement ±8.4%) compared with RVO (±18.8%) and SVCf (±32.2%). The prognostic accuracy of MPAVpeak to predict high-grade IVH or death was good (AUROC >0.75) and non-inferior to RVO and SVCf (DeLong's test p>0.05).

Conclusions: MPAVpeak is an adequate marker of systemic blood flow with high reproducibility and acceptable prognostic accuracy in preterm infants below 33 weeks of gestational age during the first day of life.

Context: Knowledge gaps exist on the incidence and risk factors for developing pulmonary hypertension (PH) in preterm infants with bronchopulmonary dysplasia (BPD) and its impact on outcomes.

Objective: To systematically review and meta-analyse the incidence, risk factors and short- and long-term outcomes of BPD-PH in preterm infants.

Design: PubMed, Embase, Cochrane CENTRAL and CINAHL were searched for studies including infants<37 weeks gestational age (GA) or birth weight<2500 g with BPD-PH versus BPD-no PH from inception until 5 April 2023.

Main outcome measures: Incidence, risk factors and short- and long-term outcomes.

Results: 44 observational studies evaluating 7677 preterm infants were included. The incidence of PH in mild, moderate and severe BPD was 5%, 18% and 41%, respectively. Small for GA (25 studies; N=5814; OR 1.8; 95% CI 1.3, 2.5), necrotising enterocolitis (22 studies; N=3387; OR 1.6; 95% CI 1.3, 2.2), early PH (four studies; N=820 OR 2.2; 95% CI 1.5, 3.3) and severe BPD (20 studies; N=2587; OR 5.4; 95% CI 3.2, 9.1) were significant risk factors for BPD-PH. Compared with BPD-no PH, the BPD-PH group had significantly higher mortality (22 studies; N=4882; OR 6.4; 95% CI 4.7, 8.6), longer duration of mechanical ventilation, oxygen supplementation, length of hospital stay, need for home oxygen and tracheostomy requirement. The BPD-PH infants also had a significantly higher risk of neurodevelopmental impairment in the motor domain.

Conclusions: PH increases across the severity of BPD and is associated with higher odds of mortality and adverse short-term and neurodevelopmental outcomes.

Prospero registration number: CRD42023413119.

Objective: This study aimed to investigate whether distractions during simulated neonatal resuscitation impact mask leakage and visual gaze patterns during positive pressure ventilation (PPV) of a newborn manikin.

Study design: In this observational, simulation-based study, medical students and paediatric residents managed a neonate requiring resuscitation alongside a standardised team and executed PPV on a leak-free manikin. The scenario incorporated distractions such as chest compressions, preparation and insertion of an umbilical vein catheter, administering fluids and interpreting venous blood gas. Ventilation parameters were monitored using a respiratory function monitor, and participants were equipped with eye-tracking glasses to assess visual gaze patterns. Additionally, they self-assessed their level of distractions and estimated performance. Measures included dwell time, mask leak, minute volume and respiratory rate to determine whether PPV parameters and distractors were associated during times of interest (TOI).

Results: We included 30 participants and observed statistically significant differences in the delivery of PPV parameters between TOIs with distractions compared with TOIs without distractions, as reflected in mask leak (31.0 vs 15.9 %), minute volume (202.0 vs 253.0 mL/kg/min) and respiratory rate (29.0 vs 33.0/min). Results on alterations in gaze behaviour showed a significant gaze shift from the infant's chest and airway to instruments and other areas of interest when distractions were present. During the venous blood gas interpretation, participants rated their performance worse than during other TOIs. Participants generally overrated their ventilation quality.

Conclusion: This study showed a significant impact of distractions on PPV parameters and visual attention during simulated neonatal resuscitation.

In perinatal medicine, the number of babies with life-limiting or life-threatening conditions is increasing and the benefits of providing palliative care with a holistic, interdisciplinary approach are well documented. It can be particularly challenging, however, to integrate palliative care into routine care where there exists uncertainty about a baby's diagnosis or potential outcome.This framework, developed collaboratively by the British Association of Perinatal Medicine (BAPM) and the Association of Paediatric Palliative Medicine (APPM), offers supportive guidance for all healthcare professionals working in perinatal medicine across antenatal and neonatal services. It explicitly acknowledges that palliative care is not just for babies who are dying or who will certainly die in early life; incorporating a palliative approach into antenatal and neonatal care for all babies with an uncertain outcome can be particularly valuable. The framework provides guidance on recognising babies who may benefit from palliative care and outlines the key elements of perinatal palliative care: holistic family support, empowering parents to be parents, parallel planning, symptom management and loss and bereavement care. It provides recommendations for the delivery of palliative care services, advocating for a unified approach that involves all members of the perinatal team, supported by specialist services as needed.This framework calls for a shift in the philosophy and practice of perinatal care to integrate palliative care into the everyday and to recognise and embrace the challenge of uncertain prognosis.