Heated, Humidified High-Flow Nasal Cannula Therapy: Yet Another Way to Deliver C-PAP?

OBJECTIVE.

The goal was to estimate the level of delivered continuous positive airway pressure by measuring oral cavity pressure with the mouth closed in infants of various weights and ages treated with heated, humidified high-flow nasal cannula at flow rates of 1–5 L/minute. We hypothesized that clinically relevant levels of continuous positive airway pressure would not be achieved if a nasal leak is maintained.

METHODS.

After performing bench measurements and demonstrating that oral cavity pressure closely approximated levels of traditionally applied nasal continuous positive airway pressure, we successfully measured oral cavity pressure during heated, humidified, high-flow nasal cannula treatment in 27 infants. Small (outer diameter: 0.2 cm) cannulae were used for all infants, and flow rates were left as ordered by providers.

RESULTS.

Bench measurements showed that, for any given leak size, there was a nearly linear relationship between flow rate and pressure. The highest pressure achieved was 4.5 cmH2O (flow rate: 8 L/minute; leak: 3 mm). In our study infants (postmenstrual age: 29.1–44.7 weeks; weight: 835–3735 g; flow rate: 1–5 L/minute), no pressure was generated with the mouth open at any flow rate. With the mouth closed, the oral cavity pressure was related to both flow rate and weight. For infants of 1500 g, there was a linear relationship between flow rate and oral cavity pressure.

CONCLUSIONS.

Oral cavity pressure can estimate the level of continuous positive airway pressure. Continuous positive airway pressure generated with heated, humidified, high-flow nasal cannula treatment depends on the flow rate and weight. Only in the smallest infants with the highest flow rates, with the mouth fully closed, can clinically significant but unpredictable levels of continuous positive airway pressure be achieved. We conclude that heated, humidified high-flow nasal cannula should not be used as a replacement for delivering continuous positive airway pressure. (Zuzanna J. Kubicka, Joseph Limauro, et al. Pediatrics 121: 82-88.)

Decreased Incidence of BPD

After Early Management Changes, Including Surfactant and Nasal CPAP Treatment at Delivery, Lowered Oxygen Saturation Goals, and Early Amino Acid Administration

OBJECTIVE.

The goal was to investigate the clinical impact of 3 early management practice changes for infants of 1000 g.

METHODS.

We performed an historical cohort study of appropriately sized, preterm infants without congenital anomalies who were born between January 2001 and June 2002 (pre–early management practice change group; n = 87) and between July 2004 and December 2005 (post–early management practice change group; n = 76).

RESULTS.

Only 1 (1%) of 87 infants in the pre–early management practice change group received continuous positive airway pressure treatment in the first 24 hours of life, compared with 61 (80%) of 76 infants in the post–early management practice change group. The proportions of infants who required any synchronized intermittent mandatory ventilation during their hospital stays were 98.8% and 59.5%, respectively. The mean durations of synchronized intermittent mandatory ventilation were 35 days and 15 days, respectively. The combined incidence rates of moderate and severe bronchopulmonary dysplasia at corrected gestational age of 36 weeks were 43% and 24%, respectively. The use of vasopressor support for hypotension in the first 24 hours of life decreased from 39.1% (before early management practice changes) to 19.7% (after practice changes), the cumulative days of oxygen therapy decreased from 77 ± 52 days to 56 ± 47 days, and the proportions of infants discharged with home oxygen therapy decreased from 25.7% to 10.1%; the incidence of patent ductus arteriosus requiring surgical ligation increased from 1% to 10%.There were no differences in rates of death, intraventricular hemorrhage, periventricular leukomalacia, pneumothorax, necrotizing enterocolitis, or retinopathy of prematurity.

CONCLUSIONS.

Successful early management of extremely preterm infants with surfactant treatment followed by continuous positive airway pressure treatment at delivery, lowered oxygen saturation goals, and early amino acid supplementation is possible and is associated with reductions in the incidence and severity of bronchopulmonary dysplasia.(Cara Geary, Melinda Caskey, et al. Pediatrics 121(January 2008) : 89-96)

Impact of PDA and Subsequent Therapy With Indomethacin on Cerebral Oxygenation in Preterm Infants

OBJECTIVES.

A hemodynamically important patent ductus arteriosus is a common problem in the first week of life in the preterm infant. Although patent ductus arteriosus induces alterations in organ perfusion, scarce information is available of the impact of patent ductus arteriosus and its subsequent treatment on the oxygen supply and oxygen extraction of the brain. We investigated the impact of patent ductus arteriosus and its treatment with indomethacin on regional cerebral oxygen saturation and fractional tissue oxygen extraction by using near-infrared spectroscopy.
 
PATIENTS AND METHODS. Twenty infants with patent ductus arteriosus (gestational age: <32 weeks), subsequently treated with indomethacin, were monitored for mean arterial blood pressure, arterial oxygen saturation, near-infrared spectroscopy–determined regional cerebral oxygen saturation, and fractional tissue oxygen extraction ([arterial oxygen saturation – regional cerebral oxygen saturation]/arterial oxygen saturation). Ten-minute periods were selected and averaged during patent ductus arteriosus, at 10, 20, 30, 60, and 120 minutes, and at 6,12, 24, and 36 hours after starting indomethacin treatment (to ductal closure) for mean arterial blood pressure, arterial oxygen saturation, regional cerebral oxygen saturation, and fractional tissue oxygen extraction. The patients with patent ductus arteriosus were matched for gestational age, birth weight, postnatal age, and severity of respiratory distress syndrome with infants without patent ductus arteriosus, who served as control subjects.

RESULTS. Mean arterial blood pressure and regional cerebral oxygen saturation were significantly lower and fractional tissue oxygen extraction significantly higher compared with the control infants during patent ductus arteriosus (mean arterial blood pressure: 33 ± 5 vs 38 ± 6 mmHg; regional cerebral oxygen saturation: 62% ± 9% vs 72% ± 10%; fractional tissue oxygen extraction: 0.34 ± 0.1 vs 0.25 ± 0.1, respectively). Regional cerebral oxygen saturation and fractional tissue oxygen extraction were lower and higher, respectively, up to 24 hours after the start of indomethacin but normalized to control values afterward. Indomethacin had no additional negative effect on cerebral oxygenation.

CONCLUSIONS.

A hemodynamically significant patent ductus arteriosus has a negative effect on cerebral oxygenation in the premature infant. Subsequent and adequate treatment of a patent ductus arteriosus may prevent diminished cerebral perfusion and subsequent decreased oxygen delivery, which reduces the change of damage to the vulnerable immature brain. (Petra M. A. Lemmers, Mona C. Toet, et al. Pediatrics 121(January 2008): 142-147)

Hematologic Profile of Sepsis in Neonates: Neutrophil CD64 as a Diagnostic Marker

OBJECTIVE.

The goal was to determine the utility of neutrophil CD64 as a diagnostic marker for sepsis in neonates.
METHODS. A prospective study that enrolled consecutive infants with suspected sepsis was performed. Complete blood count with differential, blood culture, and CD64 index measurement were performed, and neutrophil CD64 indices were correlated with the diagnoses of confirmed and suspected sepsis.

RESULTS.

There were 293 episodes of sepsis evaluations for 163 infants. Infants with sepsis episodes (confirmed or suspected; n = 40) were of greater gestational age (34.7 ± 0.9 weeks), compared with those (n = 123) with no sepsis (32.6 ± 0.5 weeks), but had similar birth weights (2325 ± 200 vs 1969 ± 94 g) and Apgar scores at 1 and 5 minutes. There was no difference in the duration of hospitalization for the 2 groups. As expected, the hematologic profiles of sepsis episodes (n = 128) were characterized by higher white blood cell counts, absolute neutrophil counts, absolute band counts, and immature/total neutrophil ratios but lower platelet counts. Sepsis episodes had higher neutrophil CD64 indices (5.61 ± 0.85 vs 2.63 ± 0.20). For all sepsis episodes, the CD64 index had an area under the curve, in receiver operating characteristic analysis, of 0.74; with a cutoff value of 2.30, the CD64 index in combination with the absolute neutrophil count had the highest negative predictive value (93%) for ruling out sepsis and 95% sensitivity for diagnosing sepsis. For culture-positive sepsis episodes, the CD64 index had the highest area under the curve (0.852) of all hematologic variables, with a sensitivity of 80% and a specificity of 79%, with a cutoff value of 4.02.

CONCLUSIONS.

Neutrophil CD64 is a highly sensitive marker for neonatal sepsis. Prospective studies incorporating CD64 into a sepsis scoring system are warranted. (Vineet Bhandari, Chao Wang, BS, et al. Pediatrics 121(January 2008): 129-134)

Comparison between rectal and infrared skin temperature in the newborn

The reliability of measurement of body temperature using a new infrared skin thermometer was evaluated in 107 newborns. The use of the device was associated with low operator-related variability and acceptable limits of agreement with the temperature measured with a rectal mercury thermometer. Use of the infrared skin thermometer is a comfortable and reliable way of measurement of body temperature in newborns. (Mario De Curtis, Flaminia Calzolari, et al. Arch. Dis. Child. Fetal Neonatal Ed. 2008 93: F55-F57

Therapeutic Hypothermia Changes the Prognostic Value of Clinical Evaluation of Neonatal Encephalopathy

Objective

To evaluate whether therapeutic hypothermia alters the prognostic value of clinical grading of neonatal encephalopathy.

Study design

This study was a secondary analysis of a multicenter study of 234 term infants with neonatal encephalopathy randomized to head cooling for 72 hours starting within 6 hours of birth, with rectal temperature maintained at 34.5°C ± 0.5°C, followed by re-warming for 4 hours, or standard care at 37.0°C ± 0.5°C. Severity of encephalopathy was measured pre-randomization and on day 4, after re-warming, in 177 infants; 31 infants died before day 4, and data were missing for 10 infants. The primary outcome was death or severe disability at 18 months of age.

Results

Milder pre-randomization encephalopathy, greater improvement in encephalopathy from randomization to day 4, and cooling were associated with favorable outcome in multivariate binary logistic regression. Hypothermia did not affect severity of encephalopathy at day 4, however, in infants with moderate encephalopathy at day 4, those treated with hypothermia had a significantly higher rate of favorable outcome (31/45 infants, 69%, P = .006) compared with standard care (12/33, 36%).

Conclusion

Infants with moderate encephalopathy on day 4 may have a more favorable prognosis after hypothermia treatment than expected after standard care. (Alistair J. Gunn, John S. Wyatt,et al. The Journal of Pediatrics, Volume 152, Issue 1, Pages 55-58.e1 (January 2008)

Comments:

There have now been two large trials demonstrating that 72h of hypothermia may improve the neurodevelopment outcomes of infants with neonatal encephalopathy. Only infants with moderate encephalopathy after birth seem to benefit. Few infants with mild encephalopathy have long-term deficits and the severe cases appear to have no benefit. There are ongoing trials, which will better inform us about this therapy, but multiple questions will remain. For example, there is no information in humans about the interval from birth to initiation of cooling that can protect the brain, the optimal temperature, or the optional duration of cooling. Trials of cooling for neonatal encephalopathy are very difficult. Most of these infants are born outside level 3 units capable of providing hypothermia, and the clinical assessments for the hypothermia, consent, and initiation of therapy within 6h of birth limits enrollment in trials. Careful in-depth analysis of the limited available data can provide some information to guide clinical care. In this issue of The Journal, Gunn et al provide a secondary analysis of the Cool Cap Trial, which demonstrates that the degree of encephalopathy is not altered by hypothermia on day 4. This information indicates that a therapeutic response cannot be evaluated by the clinical exam. As previously reported, infants with moderate encephalopathy are most likely to benefit. (Hypothermia for neonatal encephalopathy - a refinement Alan H. Jobe, MD, PhD, Volume 152, Issue 1, Page A3 (January 2008)

Chest expansion for assessing tidal volume in premature newborn infants on ventilators

J Pediatr (Rio J). 2007;83(4):329-34: Premature neonates, mechanical ventilation, tidal volume, chest expansion, lung injury, volutrauma, bronchopulmonary dysplasia.

Objectives:

To investigate whether clinical observation of chest expansion predicts tidal volume in neonates on mechanical ventilation and whether observer experience interferes with results.

Methods:

An observational study that enrolled less experienced physicians in the first year of pediatric residency, moderately experienced (second year pediatric residency, first year of neonatology or pediatric intensive care specialization) or who were already experienced (second year neonatology specialization, graduate students or primary physician supervisors with minimum experience of 4 years in neonatology). These professionals observed the chest expansion of newborn infants on mechanical ventilation and estimated the tidal volume being supplied to the babies. True tidal volume given was calculated, indexed by the patient’s current weight, and considered adequate between 4 and 6 mL/kg, insufficient below 4 mL/kg and excessive over 6 mL/kg. Results were analyzed using chi-square test.

Results: One hundred and eleven assessments were carried out with 21 newborn infants and the estimates given were in agreement with measured volume in 23.1, 41.3 and 65.7% for less, moderate and experienced physicians, respectively. These results are evidence that the three groups are not statistically equal (p = 0.013) and that the group of fully-experienced physicians have a better level of agreement than those with little or moderate experience (p = 0.007).

Conclusions:

Clinical analysis of chest expansion by physicians with less or moderate experience exhibit a low level of agreement with the tidal volume given to newborn infants on mechanical ventilation. Although increased experience did result in higher levels of agreement, chest expansion must still be interpreted with caution.

Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks’ gestation

Objective:

To investigate the effects of umbilical cord milking on the need for red blood cell (RBC) transfusion and morbidity in very preterm infants.

Patients and Methods: 40 singleton infants born between 24 and 28 weeks’ gestation were randomly assigned to receive umbilical cord clamped either immediately (control group, n = 20) or after umbilical cord milking (milked group, n = 20). Primary outcome measures were the probability of not needing transfusion, determined by Kaplan–Meier analysis, and the total number of RBC transfusions. Secondary outcome variables were haemoglobin value and blood pressure at admission.

Results:

There were no significant differences in gestational age and birth weight between the two groups. The milked group was more likely not to have needed red cell transfusion (p = 0.02) and had a decreased number (mean (SD)) of RBC transfusions (milked group 1.7 (3.0) vs controls 4.0 (4.2); p = 0.02). The initial mean (SD) haemoglobin value was higher in the milked group (165 (14) g/l) than in the controls (141 (16) g/l); p<0.01). Mean (SD) blood pressure at admission was significantly higher in the milked group (34 (9) mm Hg) than in the controls 28 (8) mm Hg; p = 0.03). There was no significant difference in mortality between the groups. The milked group had a shorter duration of ventilation or supplemental oxygen than the control group.

Conclusion:

Milking the umbilical cord is a safe procedure, reducing the need for RBC transfusions, and the need for circulatory and respiratory support in very preterm infants. (S Hosono, H Mugishima, et al. Arch. Dis. Child. Fetal Neonatal Ed. 2008 93: F14-F19)

Delayed cord clamping in preterm infants delivered at 34–36 weeks’ gestation: a randomised controlled trial

Background:

Even mild iron deficiency and anaemia in infancy may be associated with cognitive deficits. A delay in clamping the cord improves haematocrit levels and results in greater vascular stability and less need for packed cell transfusions for anaemia in the first period after birth. Follow-up data on haemoglobin levels after the neonatal period were not available.

Objective:

To provide neonatal and follow-up data for the effects of early or delayed clamping of the cord.
Methods: 37 premature infants (gestational age 34 weeks, 0 days–36 weeks, 6 days) were randomly assigned to one of two groups in the first hour after birth, and at 10 weeks of age. In one group the umbilical cord was clamped within 30 seconds (mean (SD) 13.4 (5.6)) and in the other, it was clamped at 3 minutes after delivery. In the neonatal period blood glucose and haemoglobin levels were determined. At 10 weeks of age haemoglobin and ferritin levels were determined.

Results:

The late cord-clamped group showed consistently higher haemoglobin levels than the early cord-clamped group, both at the age of 1 hour (mean (SD) 13.4 (1.9) mmol/l vs 11.1 (1.7) mmol/l), and at 10 weeks (6.7 (0.75) mmol/l vs 6.0 (0.65) mmol/l). No relationship between delayed clamping of the umbilical cord and pathological jaundice or polycythaemia was found.

Conclusion:
(Keith J. Barrington, and Neil
Immediate clamping of the umbilical cord should be discouraged. (C A Ultee, J van der Deure, et al. Arch. Dis. Child. Fetal Neonatal Ed. 2008 93: F20-F23)

Inhaled Nitric Oxide for Preterm Infants: A Systematic Review

OBJECTIVE.

Our goal was to determine whether, for preterm newborn infants with respiratory disease, inhaled nitric oxide reduced the rates of death, bronchopulmonary dysplasia, intracranial hemorrhage, or neurodevelopmental disability.
METHODS. We searched Medline, Embase, Healthstar, and the Cochrane Central Register of Controlled Trials using the search terms "nitric oxide," "clinical trial," and "newborn" and covering 1985–2006. We also searched abstracts of the Pediatric Academic Societies.

RESULTS.

Eleven randomized, controlled trials of inhaled nitric oxide therapy for preterm infants were found. The trials were grouped into 3 categories according to the entry criteria, that is, entry in the first 3 days of life on the basis of oxygenation criteria (early rescue), enrollment after 3 days on the basis of elevated risk of bronchopulmonary dysplasia, and routine use for intubated preterm infants. Early rescue treatment based on oxygenation criteria did not seem to affect mortality or bronchopulmonary dysplasia rates. Routine use for intubated preterm infants showed a barely significant reduction in the incidence of the combined outcome of death or bronchopulmonary dysplasia (relative risk [RR]: 0.91 [95% confidence limits (CLs): 0.84, 0.99]). Later treatment based on the risk of bronchopulmonary dysplasia showed no significant effect on this outcome. Early rescue treatment showed a trend toward increased incidence of severe intracranial hemorrhage, whereas routine use for intubated preterm infants seemed to show a reduction in the incidence of either severe intracranial hemorrhage or periventricular leukomalacia (RR: 0.70 [95% CLs: 0.53, 0.91]).

CONCLUSIONS.
 
Inhaled nitric oxide as rescue therapy for very ill preterm infants undergoing ventilation does not seem to be effective and may increase severe intracranial hemorrhage. Later use of inhaled nitric oxide to prevent bronchopulmonary dysplasia does not seem to be effective. Early routine use of inhaled nitric oxide for mildly sick, preterm infants seems to decrease the risk of serious brain injury and may improve rates of survival without bronchopulmonary dysplasia. (Keith J. Barrington, and Neil N. Finer. Pediatrics 120: 1088-1099.)

Maternal Factors in ELBW Infants Who Develop Spontaneous Intestinal Perforation

BACKGROURND.Spontaneous intestinal perforation of the extremely low birth weight infant ( 1000 g) is associated with a high incidence of Candida and coagulase-negative Staphylococcus sepsis. Little is known about prenatal risk factors, and histopathologic examination of placentas in infants with spontaneous intestinal perforation has not been reported.

OBJECTIVES.

Our objective was to investigate maternal factors and specific placental findings in a sample of infants with spontaneous intestinal perforation. We compared the maternal factors and clinical outcomes to a matched control group.

PATIENTS AND METHODS.

This single-center, retrospective cohort study was conducted between January 2001 and December 2005. The records of extremely low birth weight infants with spontaneous intestinal perforation were reviewed (n = 16). Study infants were matched to 2 infants in the control group; any twin of a study patient was also included as a control subject (n = 35). Histopathologic examination of placentas included standard hematoxylin and eosin and methenamine silver stains.

RESULTS.

Infants with spontaneous intestinal perforation were more likely than control subjects to have severe placental chorioamnionitis with fetal vascular response (40% vs 12%); 2 placentas also tested positive for yeast versus none in the control subjects. Mothers of infants with spontaneous intestinal perforation were more likely than control subjects to have received antibiotics before or at delivery (93% vs 57%). Fifty percent of the infants had Candida, and 31% in the spontaneous intestinal perforation group had coagulase-negative Staphylococcus sepsis versus 6% in the control subjects. Finally, infants with spontaneous intestinal perforation had delayed enteral feeding (64 ± 30 vs 31 ± 10 days) and prolonged hospitalization (155 ± 48 vs 108 ± 36 days).

CONCLUSIONS.

Spontaneous intestinal perforation in the extremely low birth weight infant is a neonatal disease related to placental inflammation. We alert practitioners to the importance of placental findings, because they may be positive for yeast. (Pediatrics 120: e1458-e1464)

"Late-Preterm" Infants: A Population at Risk

Late-preterm infants, defined by birth at 34 through 36 weeks' gestation, are less physiologically and metabolically mature than term infants. Thus, they are at higher risk of morbidity and mortality than term infants. The purpose of this report is to define "late preterm," recommend a change in terminology from "near term" to "late preterm," present the characteristics of late-preterm infants that predispose them to a higher risk of morbidity and mortality than term infants, and propose guidelines for the evaluation and management of these infants after birth. (Pediatrics 120: 1390-1401.)

Cerebrospinal Fluid Xanthochromia in Newborns Is Related to Maternal Labor Before Delivery

OBJECTIVE.

The purpose of this work was to investigate whether xanthochromia in newborns is related to maternal labor before delivery.

METHODS.

We reviewed the medical charts of all of the infants 30 days of age who had a lumbar puncture performed in a single pediatric emergency department between 2003 and 2005. Xanthochromia was detected by the hospital laboratory using the qualitative visual inspection method. We used logistic regression to determine the relationship between maternal labor before birth and the presence of cerebrospinal fluid xanthochromia, adjusting for factors known to be associated with xanthochromia.

RESULTS.

Of the 478 newborns who had a lumbar puncture performed during the study period, 134 (28%) had xanthochromia. Of the 449 infants with delivery method recorded in the medical chart, 332 (74%) were born via vaginal delivery, 24 (5%) via cesarean section after maternal labor, and 93 (21%) via cesarean section without maternal labor. After excluding patients with hyperbilirubinemia (total bilirubin 15 mg/dL) and adjusting for factors known to be associated with xanthochromia (cerebrospinal fluid red blood cells 20000 cells per mL and cerebrospinal fluid protein 150 mg/dL), infants born after maternal labor had a higher rate of cerebrospinal fluid xanthochromia than infants born without any labor.

CONCLUSIONS.

Xanthochromia is a common finding in the cerebrospinal fluid of newborns and is associated with maternal labor preceding delivery.( Pediatrics 120: e1212-e1216)

Effect of prone position without PEEP on oxygenation and complacency in an experimental model of lung injury

Pediatr (Rio J). 2007;83(4):343-8: Prone position, ARDS, PEEP
.
Objective:

To observe the effects of the prone position and the need for positive end-expiratory pressure (PEEP) to improve oxygenation.

Methods:

Sixteen rats were anesthetized and ventilated at a tidal volume of 8 mL/kg, respiratory rate of 60 rpm and PEEP = 0 cmH2O (ZEEP), in the supine position for 30 minutes. Lung injury was then induced by means of intratracheal instillation of hydrochloric acid. Once the injury was established, rats were placed in the prone position for a further 30 minutes and randomized into two groups: in group 1 PEEP = 5 cmH2O was added; while group 2 was kept on ZEEP. Measurements of pulmonary mechanics, arterial blood gas analysis and mean arterial pressure were taken at the end of each phase.

Results:

In group 1, oxygen partial pressure increased significantly from 98.7±26.5 to 173.9±58.4 mmHg between injury and prone phases; in group 2 it was unchanged, varying from 99.6±15.4 to 100.5±24.5 mmHg. Group 1 also exhibited significant improvement in complacency, from 0.20±0.01 to 0.23±0.02 mL/cmH2O, while, once more, group 2 did not exhibit improvement, going from 0.21±0.02 to 0.22±0.01 mL/cmH2O. Mean arterial blood pressure measurements did not change significantly in either group at any point during the experiment.

Conclusions:

The prone position only resulted in improved oxygenation and respiratory mechanics when combined with PEEP = 5 cmH2O. The prone position did not cause hemodynamic compromise with or without PEEP = 5 cmH2O.

Use of Medications for Gastroesophageal Reflux at Discharge Among ELBW Infants

OBJECTIVES.

Our goals were (1) to determine the use of medications to treat gastroesophageal reflux in extremely low birth weight infants (birth weight of <1000 g) at discharge; (2) to identify risk factors associated with the use of medications to treat gastroesophageal reflux at discharge; and (3) to assess the contribution of gastroesophageal reflux medication use at discharge to growth and development at corrected ages of 18 to 22 months.

METHODS.

This retrospective cohort analysis included extremely low birth weight infants enrolled at National Institute of Child Health and Human Development Neonatal Research Network Centers between 2002 and 2003 who survived to follow-up evaluations at corrected ages of 18 to 22 months. Analyses were used to identify factors associated with discharge with antireflux medications and poor growth or neurodevelopmental impairment after discharge.

RESULTS. A total of 1598 infants were included in the analyses; 24.8% were discharged from the hospital with medications to treat gastroesophageal reflux. A total of 19.3% of the 1287 infants discharged at postmenstrual age of 42 weeks were discharged with antireflux medications. For those infants, center, lower gestational age, and race had significant effects on the use of antireflux medications at discharge. A total of 47.6% of the 311 infants discharged at postmenstrual age of >42 weeks were discharged with antireflux medications. For those infants, no tested variables were associated with treatment with antireflux medications at discharge. Use of antireflux medications at discharge was not associated with either poor growth or neurodevelopmental impairment at corrected ages of 18 to 22 months.
 
CONCLUSIONS.

Use of antireflux medications at the time of discharge seems to be common for extremely low birth weight infants, especially those discharged at postmenstrual age of >42 weeks, but does not seem to have effects on growth or development at the time of follow-up evaluations. (William F. Malcolm, Marie Gantz, et al. Pediatrics 121(January 2008): 22-27.)

Antireflux Medications for infants

(Khoshoo V, Edell D, Aaron Thompson A, et al. Are We Overprescribing Antireflux Medications for Infants With Regurgitation? Pediatrics 2007 120:946-949.)

Objective.

Our goal was to evaluate the diagnosis and treatment of infants with persistent regurgitation who were referred to a pediatric gastroenterology service.

Methods.

The records of 64 infants with persistent regurgitation and without any neurodevelopmental abnormalities, underlying illness, or cigarette smoke exposure were evaluated for diagnostic workup and treatment. Forty-four infants underwent extended esophageal pH monitoring.

Results.

Only 8 of 44 pH studies showed abnormal acid reflux. Forty-two of these 44 infants were already on antireflux medications. Other etiologies included hypertrophic pyloric stenosis (4) and renal tubular acidosis (1). Discontinuation of medication did not result in worsening of symptoms in most infants with normal pH studies.
Conclusions. The majority of infants who were prescribed antireflux drugs did not meet diagnostic criteria for gastroesophageal reflux disease.

Comments.

The finding of this study is based on evaluating 44 infants which I believe that the sample size is too small to draw a significant conclusion. The authors excluded those who were born at preterm. This is considered as a biased selection for the studied population. As it has been confirmed in several studies that gastroesophageal reflux (GER) occurs commonly in premature infants and if they were included in the study I believe that the difference will be insignificant. In addition, mild GER typically is a developmental process that resolves with maturation and in many occasions, antireflux medications are not required. Although the esophageal pH monitoring is used as a diagnostic test for GER disease in infants, previous studies reported substantial variability among patients due to the difficulty in controlling and standardizing the feeding regimen. See also the study by T I Omari, G P Davidson (Archives of Disease in Childhood Fetal and Neonatal Edition 2003). Finally, GER is common but it is difficult to diagnose. I might agree with the authors that anti-reflux medications are over-used however this needs to be well studied. (Saleh Al-Alaiyan In NeoNotes journal club available at: http://www.fsneo.org/JourClub/9-001.htm )

Additional Comments:

Editors Note:

As I have said in the past, GER is one of the most over-diagnosed and over-treated conditions in premature babies. The fact is that almost all premature babies (and probably most term babies) have some degree of GE reflux that you will be able to demonstrate if you look hard enough. This reflux is usually not the cause of the apnea, bradycardia or desaturation episodes that we frequently see in premature babies. Treating the reflux with medications that block release of stomach acids may interfere with digestion, and may predispose to fungal infections. The use of prokinetic agents (such as metoclopramide) to improve GI motility and reduce feeding intolerance may be helpful in some premature infants with or without GE reflux. For further discussion of the diagnosis and treatment of GER in infants, see 3-011, 3-012, 5-011, 5-030, 6-041, and 7-033. Andrew B. Kairalla in NeoNotes Journal Club, Available at: http://www.fsneo.org/JourClub/9-001.htm)

Sildenafil for Pulmonary Hypertension associated with Congenital Heart Defect


Background: Pulmonary hypertension (PH) when associated with congenital heart defects (CHD) carries high post-operative mortality. Various pulmonary vasodilators have been used in such a situation. Our experience of using sildenafil, an affordable option in resource – limited setting, is described in this study.

Objective:

To study pulmonary artery pressure (PAP) before and after siladenafil in cases of CHD.

Study design: A case series observational in nature.

Methods:

The subjects were 12 neonates and 11 infants. Their mode of presentation was studied. Echocardiography was performed before and after treatment. Sildenafil was administered in a dose of 0.5 mg / kg / dose / 6h, through an orogastric tube.

Results:

Sixteen patients presented with respiratory distress, three with oxygen dependence, three had hypoxaemia disproportionate to pulmonary or cardiac problem and one was asymptomatic. In seven cases, PH was detected during echo performed for suspected CHD. After sildenafil, PAP normalized in six cases, substantially declined in eight, and remained unchanged in nine. The response was better among babies less than two months old.

Conclusion:

Sildenafil is effective in the treatment of PH associated with CHD. Oral availability and low cost are valuable considerations in resource-limited setting.(S.R. Daga, Chhaya Valvi, et al. : Sildenafil for Pulmonary Hypertension associated with Congenital Heart Defect. The Internet Journal of Pediatrics and Neonatology. 2007. Volume 7 Number 2.)

Preterm birth: what can be done?

Preterm birth (birth before 37 weeks of gestational age) is the leading cause of perinatal mortality (defined here as stillbirth at gestational age >28 weeks and death within 7 days of birth) in developed countries. Although improvements in neonatal care have increased survival for preterm infants, prevention research and knowledge to date have not managed to reduce the rate of premature births. The frequency of preterm birth is high—12–13% in the USA and 5–9% in many other developed countries—and the incidence is increasing.

With more preterm babies surviving into adulthood, clinicians and health-care providers will have to be prepared to meet their long-term health problems, which can include cerebral palsy, language and learning disabilities, and poor growth. Follow-up of preterm survivors into middle age is also needed to establish any other later-emerging health risks.

The causes of preterm birth are multifactorial and complex and include infection and inflammation, vascular disease, and stress. Disturbing disparities exist between different racial groups in the prevalence of preterm birth, with African-American and Afro-Caribbean women in the USA and UK being two to three times more likely to deliver early than white women. However, not all of this difference can be explained by socioeconomic factors (eg, access to prenatal care) and maternal behaviour (eg, drug and alcohol use)—gene–environment interactions also have a part to play.

Elucidating the underlying mechanisms by which known risk factors, such as black race, lead to early birth is the most important task ahead for perinatal researchers. Only with serious commitment and investment in this area can clinicians begin to develop interventions to bring down the unacceptably high rates of premature births and the infant death and disability associated with it. (The Lancet 2008; 371:2 (January 5, 2008

Preterm birth Epidemiology and causes of preterm birth