Can we improve the targeting of respiratory syncytial virus (RSV) prophylaxis in infants born 32–35 weeks’ gestational age with more informed use of risk factors?

Objective: To evaluate the key risk factors for respiratory syncytial virus (RSV) hospitalisation in 32–35 weeks’ gestational age (wGA) infants.

Methods: Published risk factors were assessed for predictive accuracy (area under the receiver operating characteristic curve [ROC AUC]) and for number needed to treat (NNT).

Results: Key risk factors included: proximity of birth to the RSV season; having siblings; crowding at home; day care; smoking; breast feeding; small for GA; male gender; and familial wheezing/eczema. Proximity of birth to the RSV season appeared the most predictive. Risk factors models from Europe and Canada were found to have a high level of predictive accuracy (ROC AUC both >0.75; NNT for European model 9.5). A model optimised for three risk factors (birth ±10 weeks from start of RSV season, number of siblings ≥2 years and breast feeding for ≤2 months) had a similar level of prediction (ROC AUC: 0.776; NNT: 10.2). An example two-risk factor model (day care attendance and living with ≥2 siblings <5 years old) had a lower level of predictive accuracy (ROC AUC: 0.55; NNT: 26).

Conclusions: An optimised combination of risk factors has the potential to improve the identification of 32–35 wGA infants at heightened risk of RSV hospitalisation.     

European risk factors' model to predict hospitalization of premature infants born 33–35 weeks' gestational age with respiratory syncytial virus: validation with Italian data

Objectives.?A model for predicting respiratory syncytial virus hospitalization in infants born 33–35 weeks' gestational age (wGA) has been developed from the Spanish FLIP study risk factors. The model correctly classified 71% of cases and the area under the receiver operating characteristic (ROC) curve was 0.791. To assess its applicability in Italy, the model was validated against data from the Osservatorio VRS study.

Methods.?Discriminant function analysis was used to validate the model by (a) using the predictive variables identified in FLIP to generate a function from the Italian data and (b) applying the coefficients from the FLIP calculations to the Italian data.

Results.?The function calculated from the Italian data provided 77% accurate classification (ROC: 0.773). Applying the FLIP coefficients to the Italian data resulted in correctly classifying 68% of cases and a ROC of 0.760. The number needed to treat to prevent hospitalization of 80% of at risk infants was 13.4, based on a hospitalization rate of 5% and 80% treatment efficacy.

Conclusions.?The Italian data confirm the predictive ability of the model, which could be used to target palivizumab prophylaxis in Italian infants born 33–35 wGA.     

A 4-year survey on palivizumab respiratory syncytial virus (RSV)-prophylaxis: How can compliance be improved?

Objective. To identify compliance-influencing factors and to suggest strategies for overcoming barriers in a preventive medicine program.

Methods. A survey was conducted to evaluate compliance in children receiving palivizumab prophylaxis for respiratory syncytial virus (RSV) infections. Demographics, neonatal variables, and parental attitudes capable of influencing the outcome of prophylaxis were studied in 216 children over a four-year period.

Results. The overall compliance rate with all recommended doses of palivizumab was 87%. Among the neonatal characteristics, low birth weight and a younger age at the beginning of the program were significantly associated with good compliance (p < 0.05). The strongest factor influencing poor compliance was being foreign-born or a non-native speaker (p < 0.01).

Conclusions. Compliance to RSV infection prophylaxis is reduced in infants born to foreign-born or non-native speakers. In order to enhance compliance, parents should be provided with adequate information in their own language explaining the advantages of the palivizumab prophylaxis program for RSV infections.     

Early neonatal morbidities and associated modifiable and non-modifiable risk factors in a cohort of infants born at 34–35 weeks of gestation

Objective: To ascertain the most common early morbidities in a cohort of infants born at 34–35 weeks gestation and to identify the risk factors associated with these morbidities.

Methods: Retrospective analysis of data collected prospectively for all 235 infants born at 34–35 weeks of gestation during an eight-month period at a single tertiary medical center. Study group infants (SG) were compared with 470 term infants (TI), matched both for gender and for mode of delivery.

Results: Jaundice requiring phototherapy (32%), respiratory disease (19.1%) and cyanotic episodes (15.7%) were the most frequent early morbidities, followed by hypoglycemia, temperature instability and feeding intolerance. The risk of having a complication was 13.3-times higher in the SG compared with the TI group (95% CI 8.9–19.6, p?0.001). Modifiable interventions associated with these morbidities were antenatal steroids, MgSO₄ and mode of delivery. Non-modifiable factors were maternal age, parity, twins and gender.

Conclusions: Jaundice requiring phototherapy, respiratory disease and cyanotic episodes are the most frequent early morbidities among infants born at 34–35 weeks. Medically modifiable factors were found to be associated with the above morbidities. Whether specific recommendations for the care of these infants will affect early morbidities needs to be studied in controlled prospective studies.     

The impact of advanced maternal age (≥40 years) on birth outcomes among triplets: a population study

Objective The objective was to determine the impact of advanced maternal age on the birth outcomes of triplet gestations.Study design A retrospective cohort study on 15,795 triplets born in the United States from 1995 to 1997. The generalized estimating equations framework was used to generate relative risks after capturing the effect of sibling correlations within triplet clusters.Results There was a 40% higher likelihood for stillbirths among older gravidas (40 years) as compared to younger mothers (20–29 years) although this was statistically non-significant. By contrast, we noted a significantly lower level of neonatal mortality (OR=0.36, 95% CI=0.19–0.67), perinatal mortality (OR=0.53; 95% CI=0.32–0.89) and infant mortality (OR=0.37; 95% CI=0.20–0.67) among older mothers.Conclusion Our findings demonstrate a shifting phenomenon whereby a higher level of intra-uterine demise was compensated by a higher rate of extra-uterine survival among triplets born to older mothers.     

In resource limited areas complete enteral feed in stable very low birth weight infants (1000–1500 g) started within 24 h of life can improve nutritional outcome

Objective: To evaluate feasibility of complete enteral feed (CEF) in stable very low birth weight neonates weighing 1000–1500?g.

Subjects and interventions: One hundred and three stable very low birth weight (vlbw) neonates (1000–1500?g) irrespective of gestational age (GA) were randomized to receive either CEF with expressed breast milk (EBM) (n?=?51) or minimal enteral feed (MEF) supplemented with intravenous fluid (IVF). (MEF) (n?=?52). Feed volume was increased progressively. Primary outcome measures were feed intolerance (FI) and necrotizing enterocolitis (NEC) in first 21 days of life or discharge from NICU, whichever was earlier. Secondary outcome measures were the time taken to reach calorie intake of 110?kcal/kg/D and regain of birthweight.

Results: FI was observed in n?=?12 (23.53%) in CEF group versus n?=?6 (11.53%) in MEF group (p?=?0.1264). NEC was observed in 4 (7.8%) in CEF group versus 1(1.9%) in MEF group (p?=?0.16) and results were comparable in both groups. Birthweight regain (10.6?±?1.6 days versus 11.8?±?1.6 days, p?=?0.038), NICU discharge (11.7?±?2.6 days versus 13.0?±?3.45 days, p?=?0.038) and time to reach 110?kcal/kg/day (9.571?±?1.458 days versus 10.833?±?1.655 days, p?=?0.001) were significantly earlier in CEF compared to MEF group.

Conclusion: Complete enteral feeds started within 24?h of life is feasible in vlbw neonates.     

Long-term outcome at age 7–10 years after extreme prematurity – a prospective,two centre cohort study of children born before 25 completed weeks of gestation (1999–2003)

Abstract

Objective: We aimed to determine the long-term neurodevelopmental outcome in extremely preterm infants of 22–23 completed weeks’ gestation as compared to infants of 24 weeks with immediate postnatal life support born in two German tertiary perinatal centres between 1999 and 2003.

Methods: Children were assessed for cognitive and neurological outcomes at the age of 7–10 years. The test battery included a neurological examination, the Wechsler Intelligence Scale for children (WISC-IV) and the Frostigs Developmental Test of Visual Perception (DTVP-2). Gross motor function was classified according to the GMFCS and functional activity was assessed with the Lincoln Oseretzky Motor Development Scale (LOS KF 18).

Results: Outcome data were available for 79/105 children. 75.9% of the entire study cohort showed no or mild impairment. There was no difference seen between the two gestational age groups. Risk factors for moderate or severe impairment were an intracerebral haemorrhage >II° and/or periventricular leukomalacia or a retinopathy of prematurity >II°. Neither the gestational age (GA) nor the birth weight was associated with long-term outcome.

Conclusions: Gestational age was not a predictor for long-term impairment of preterm infants born <25 completed weeks’ GA. Other prognostic factors should be taken into account for counselling in the grey zone of viability.