Neonatology最新文献

Introduction: Neonatal care in low-resource settings is hindered by shortages of trained staff, inadequate infrastructure, and limited equipment and medications that compromise the management of common neonatal conditions and reduce the quality of care. Our aim was to describe the collaborative efforts between the Italian Agency for Development Cooperation (AICS), the Union of European Neonatal and Perinatal Societies (UENPS), Doctors with Africa CUAMM, the Ethiopian Paediatric Society (EPS), and the Ethiopian Federal Ministry of Health (FMoH) to assess resuscitation and respiratory care practices in Ethiopian NICUs, identify gaps, and guide targeted interventions.

Methods: A 50-item survey was distributed to 48 Ethiopian NICUs. Based on the survey results, a national workshop in Addis Ababa and a neonatal resuscitation 'Train the Trainers' course were scheduled. In parallel, funds were allocated to initiate renovations and equipment upgrade at two selected sites.

Results: The survey showed that most units lacked essential resuscitation equipment. Non-invasive respiratory support mainly relied on homemade CPAP systems; mechanical ventilators were available in <40% of units. Caffeine was rarely used, and surfactant was unavailable. The national workshop led to a document shared with the FMoH outlining priorities for subsequent training and resource strengthening. Newly trained instructors conducted four local neonatal resuscitation courses, training 150 healthcare providers. Facility upgrades addressed water, power, medical gas systems, and refurbishment of deteriorated areas.

Conclusions: The survey revealed major gaps in neonatal care in Ethiopia. Collaborative efforts by AICS, UENPS, CUAMM, EPS, and FMoH helped reinforce key infrastructures, and promote delivery room and respiratory care.

Introduction: Neonatal jaundice is a leading cause of early post-discharge referrals. Community follow-up commonly relies on visual assessment and clinic-based evaluation, generating avoidable visits. Scalable home pathways that maintain safety are needed. We evaluated a nurse-led, home pathway that integrates transcutaneous bilirubin (TcB) screening with targeted pediatric teleconsultation.

Methods: Prospective before-after study within routine nurse-led home visits for eligible infants (firstborn and preterm) ≥35 weeks' gestation. A 3-month pre-intervention phase (usual visual assessment) was compared with a 9-month intervention using TcB-guided thresholds and teleconsultation via a secure digital platform. The primary analysis targeted infants who, under usual care, would be referred ("baseline-eligible"), estimating the absolute difference in referral at the home visit. Secondary outcomes were agreement between clinical cues and TcB, teleconsultation utilization, and phototherapy requirement.

Results: 1,236 infants were enrolled (157 pre-intervention; 1,079 intervention). Among baseline-eligible infants (n=840), 152 (18.1%) were referred; thus 688/840 (81.9%) potential referrals were avoided (absolute reduction 81.9%; 95% CI 79.2-84.4; NNR 1.22, 95% CI 1.19-1.26). TcB identified all infants requiring phototherapy (4/1,079; 0.4%) within 14 days. Agreement between clinical cues and TcB-defined need for follow-up was slight (weighted κ=0.075; 95% CI 0.059-0.091). The reduction in referrals corresponded to an absolute decrease of 0.67 visits per infant.

Conclusions: A nurse-led, digitally supported home pathway that integrates TcB screening and targeted teleconsultation substantially reduces unnecessary neonatal referrals, with no missed cases requiring phototherapy. This pragmatic precision-triage model is implementable within existing community services and can relieve post-discharge system burden while preserving safety.

Objective: To conduct an overview of systematic reviews of RCTs assessing the effects of perinatal/neonatal interventions in reducing IVH among preterm infants.

Methods: PUBMED, EMBASE, Cochrane database for systematic reviews, and systematic review repositories were searched for meta-analyses of RCTs involving preterm infants or women at high risk of preterm birth and reporting on IVH. Metaumbrella package of R software was used to pool outcome data for each intervention. Quality of the systematic reviews were assessed using AMSTAR 2 tool. Certainty of evidence (COE) was reported using GRADE recommendations.

Results: A total of 148 systematic reviews (110 Cochrane vs 38 non-Cochrane) were included. Postnatal interventions were reported in 118 reviews. Severe IVH was reported in 100/148 reviews that included 39483 infants and 20400 antenatal women. 78% (n=116) of the reviews were rated high or moderate quality on AMSTAR -2 assessment. Antenatal corticosteroids and magnesium sulphate for imminent preterm birth, volume targeted ventilation, early rescue surfactant administration through thin catheter, prophylactic indomethacin significantly reduced the rates of severe IVH (moderate COE). Use of respiratory function monitors and heated humidified respiratory gases in the delivery room and early prophylactic erythropoietin supplementation for preterm infants may reduce the rates of severe IVH (Very Low COE).

Conclusion and relevance: Antenatal steroids and magnesium sulphate administration and early neonatal lung protective strategies reduce the rates of IVH in preterm neonates. Adequately powered RCTs evaluating IVH care bundles with long-term follow up are required.

Introduction: We aimed to evaluate the effect of Family Integrated Care (FICare) in single family rooms (SFR) on infant outcomes, compared with standard neonatal care (SNC) in open bay units (OBU).

Methods: A prospective cohort study was conducted in three Dutch level II neonatal units. Preterm infants hospitalized ≥7 days were included between 2017 and 2020. The intervention site provided FICare in SFR; control sites provided SNC in OBU. Predefined secondary outcomes included length of stay (LOS), breastfeeding, growth, late-onset sepsis, days with tube feeding (TF), respiratory support and intravenous access, discharge with TF, and readmissions. Linear mixed models accounting for multiple births, and exploratory mediation analyses, were used.

Results: A total of 358 infants were included (169 FICare; 189 SNC; median gestational age 33+3 weeks [interquartile range 30+5-35+0]). FICare was associated with a 9% reduction in LOS (adjusted mean ratio [aMR] 0.91 ≈ 2 days, 95% CI 0.84-0.99). Infants in the FICare group were more likely to be discharged with TF (adjusted odds ratio 5.77, 95% CI 2.25-14.79) and had fewer days with TF in hospital (aMR 0.79, 95% CI 0.66-0.94) and intravenous access (adjusted incidence rate ratio 0.55, 95% CI 0.39-0.76), while maintaining similar growth and readmission rates. Days with TF and intravenous access fully mediated the effect on LOS (adjusted total indirect effect 0.91, 95% CI 0.85-0.97). Other outcomes did not differ.

Conclusions: FICare in SFR was associated with decreased LOS, mediated by acquiring feeding skills. Further research should include robust study designs, including diverse parental populations.

Objective To determine if episodes of desaturation, either with or without bradycardia, are associated with cerebral and abdominal hypoxemia in preterm infants. Study Design Secondary analysis of a single center pilot randomized clinical trial including preterm infants <29 weeks' gestation on positive pressure respiratory support. Rates of cerebral hypoxemia (<55% for ≥10 seconds) and abdominal hypoxemia (<40% for ≥10 seconds) on near-infrared spectroscopy corresponding with episodes of desaturation (oxygen saturations (SpO2) <85% for ≥10 seconds) either with or without bradycardia (<100 bpm for ≥10 seconds) were compared using a generalized estimating equation to address repeated events from the same subject. Results Twenty-five infants with a gestational age (mean+SD) of 24w 6d±11d and birth weight 645±142 grams were included. Desaturations with and without bradycardia were both associated with cerebral hypoxemia and abdominal hypoxemia (all p<0.05). Cerebral hypoxemia was more strongly associated with desaturations with bradycardia compared to episodes without bradycardia (adjusted odds ratio (aOR), 95% confidence intervals (CI): 0.34, 0.25-0.47; p<0.001). There were also more episodes of abdominal hypoxemia during desaturations with bradycardia versus desaturations with no bradycardia (aOR, 95% CI: 0.35, 0.26-0.46; p<0.001). The rate of concurrent cerebral and abdominal hypoxemia was also higher during desaturations with bradycardia. Conclusions Desaturations, whether occurring with or without bradycardia, are associated with cerebral and abdominal hypoxemia in very preterm infants. Cerebral and abdominal hypoxemia are more likely during episodes of desaturation with bradycardia than during episodes without bradycardia.

Background: In congenital diaphragmatic hernia (CDH), infants with left heart disease are at highest risk of extracorporeal membrane oxygenation (ECMO) and mortality, but the association between maternal-fetal environmental characteristics and these adverse post-natal outcomes is unknown.

Methods: Maternal-fetal dyads with CDH enrolled in a single-center Birth Defects Biorepository who were also enrolled in comprehensive post-natal echocardiographic studies from 2019-2023 were included in a retrospective analysis. Geocoded census tract was used to generate maternal neighborhood characteristics from conception to birth from the American Community Survey (ACS), Childhood Opportunity Index, Air Quality Index (AQI) and Food and Drug Administration percent food insecurity. Infant characteristics including ECMO and survival were abstracted from the biorepository. Quantification of left heart hypoplasia and/or left ventricular (LV) dysfunction was performed on post-natal echocardiograms. Disease-specific and neighborhood characteristics were compared by ECMO/mortality status and by presence of left heart disease.

Results: Seventy-seven patients (58% male, 82% left CDH, 68% liver herniation) were included. Twenty-four (31%) required ECMO, 61 (77%) had left heart hypoplasia or LV dysfunction, and 19 (25%) received pulmonary vasodilators. ECMO utilization was higher in patients with left heart disease. Worse neighborhood air quality by AQI was identified in patients who required ECMO and/or died and in patients with left heart disease. A higher percentage of female-headed households was seen in patients who required ECMO and/or died.

Conclusions: Maternal neighborhood characteristics may impact outcomes in CDH. Future study of these environmental factors may inform individualized treatment strategies.

Introduction Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is used in preterm infants as a synchronized and proportional mode of non-invasive ventilation. Finding the ideal NAVA level to support preterm infants remains challenging. Methods A single-center prospective interventional study was conducted to study the effect of increasing NAVA levels on tidal ventilation measured with electrical impedance tomography (EIT). Preterm infants supported with NIV-NAVA were included. After a baseline registration and following a predefined titration protocol, NAVA levels were progressively increased by 0.5 cmH2O/µV up to a NAVA level of 3 cmH2O/µV. Before and during the titration procedure the evolution of (EIT) parameters (end-expiratory lung impedance (EELI), end-inspiratory lung impedance (EILI), silent spaces (SS) and center of ventilation (CoV)) and respiratory parameters (electrical diaphragm activity (Edi) peak and minimum (Edimin) and peak inspiratory pressure (PIP)) were measured. Results 16 patients with a mean (standard deviation (SD)) gestational age (GA) at birth 26.7 (1.2) weeks and birth weight (BW) of 838 (205) grams were included for analysis. EIT parameters did not change significantly with titration of NAVA levels. PIP increased significantly with each increase in NAVA level and Edi peak decreased significantly from NAVA level 1 tot 1.5 cmH2O/µV. Edi min and transcutaneous CO2 (TcCO2) remained constant during the titration procedure. Conclusion There was no effect of increasing NAVA levels on regional ventilation parameters. PIP increased with each increase in NAVA level, whereas Edi peak largely remained stable.

The latest American Academy of Pediatrics guidelines for managing jaundice in late preterm and term neonates have increased the bilirubin thresholds to start phototherapy. This was considered safe based on expert consensus but its cost-effectiveness has not yet been evaluated. We found that implementing the new guidelines decreased hospitalisations due to phototherapy by 68.7%, 70.2%, and 60% for the total population and the late preterm and term subgroups, respectively (p<0.001 for the three analyses). The hospitalisation costs were decreased from €1,289,040 to €423,120 (i.e. an absolute saving of €865,920, or 68%, for the entire population composed by late preterm and term neonates). Implementing the new treatment threshold nationwide would entail an estimated cost reduction of €191,964,324. In conclusion, the new jaundice guidelines significantly decreased the use of phototherapy and associated healthcare costs.

Introduction: Multi-morbidity is a known cause of adverse outcomes and resource utilization in adults. Our objective was to describe the co-occurrence of neonatal morbidities and their association with neurodevelopmental outcomes in preterm neonates.

Methods: We included 17,438 preterm neonates of <29 weeks' gestation admitted to Canadian NICU between 2010 and 2020, of whom 7,943 children had neurodevelopmental information. Neonatal outcomes were mortality, late-onset sepsis, necrotizing enterocolitis, and severe neurological injury. The outcomes were neurodevelopmental impairments, with significant impairment defined as any of: Bayley-III score <70, cerebral palsy with GMFCS ≥3, hearing amplification, or bilateral visual impairment; and severe impairment defined as any of: Bayley-III score <55, cerebral palsy with GMFCS 4-5, or bilateral blindness.

Results: The mean (SD) gestational age was 26.1 (1.6) weeks and 54.5% were male. Any neonatal mortality/morbidity occurred in 40.1% of children. Among survivors, 16.3% had significant neurodevelopmental impairment and 5.8% had severe neurodevelopmental impairment. However, 51% of children with significant impairment and 43% with severe neurodevelopmental impairment and had no neonatal morbidities. Late-onset sepsis (aOR 1.60, 95%CI 1.36, 1.88), necrotizing enterocolitis (aOR 1.91, 95% CI 1.36, 2.69) and severe neurological injury (aOR 3.54, 95%CI 2.85, 4.38) were associated with significant neurodevelopmental impairment among survivors. An increase in the count of neonatal morbidities correlated with a rise in the count of neurodevelopmental impairments.

Conclusions: Sixty percent of infants <29 weeks' gestation experienced no adverse neonatal outcomes and the majority were free of significant neurodevelopmental impairment. Neonatal morbidities had a direct and combined association with neurodevelopmental impairment.