Retinopathy of prematurity — Risk factors

Objective: Improved survival of low birth weight, premature babies have increased the incidence of retinopathy of prematurity. This hospital-based, prospective, study was undertaken to determine its incidence and risk factors in our neonatal unit.Methods: Neonates with gestational age ≤ 35 weeks and/or birth weight ≤ 1500 gm born over a one-year period were examined by indirect ophthalmoscopy between 2 to 4 weeks after birth, and followed up till retinal vascularisation was complete. Maternal and neonatal risk factors were noted and data analyzed by statistical package SPSS-10.0.Results: Sixty babies were thus examined. The incidence of retinopathy was 21.7% in the cohort, 33.3% in babies ≤32 weeks gestation and 36.4% in babies weighing ≤1250 gm. Oxygen (p=0.01), sepsis (p=0.04) and apnoea (p=0.02) were independent risk factors. Retinopathy was significantly more severe in babies with hyaline membrane disease (p=0.02) and lower birth weight (p=0.02). Severe disease was never seen before 6.5 weeks of age.Conclusion: Indirect ophthalmoscopy should be performed at 4 weeks of post natal age in all preterm babies with birth weight ≤ 1500 gm, and intensified in the presence of risk factors like oxygen administration, apnoea and septicemia.     

Are there predictors for proliferative retinopathy of prematurity and is supplemental oxygen a useful conservative treatment option?

BACKGROUND: Especially very immature preterm babies develop retinopathy of prematurity (ROP). This study aims at analysing risk factors for proliferative ROP and realizing the efficiency of supplemental oxygen therapy. PATIENTS: 180 preterm babies with birth weight < or = 1 500 grams were included retrospectively. METHODS: To determine potential predictors all preterm babies with ROP grade > or = 3 were matched to pairs with similar immature babies with ROP 1 or 2. Additionally we examined the influence of supplemental oxygen therapy on the coagulation rate of high grade retinopathy. RESULTS: 44 % of the preterm babies showed ROP. A longer duration of ventilation (21 vs. 33 days), a longer duration of oxygen supplementation (59 vs. 78 days), relapsing sepsis (10 vs. 19 babies with sepsis > 2 times), a large total volume of transfusions (median: 150 mL vs. 105 mL), chronic lung disease (CLD) (6 vs. 15 babies with oxygen requirements at 36 weeks post-menstrual age), a duration of intubation for more than 28 days (13 vs. 6 babies) and the lack of phototherapy (21 vs. 9 babies) were risk factors associated with ROP > or = 3 using univariate analysis [p < 0.05]. Only the both last criteria correlated with high grade ROP after logistic regression. The supplemental oxygen therapy showed no influence on the coagulation rate of high grade ROP. Possibly this therapy influences the frequency of surgical treatment of amotio- and of putting on a cerclage, but this remains still speculative because of the low case number. We saw no negative effect on the frequency of CLD and on the survival of the babies. CONCLUSIONS: Especially measures against long duration of intubation could help to prevent high grade ROP. The supplemental oxygen therapy may have a positive effect on course.     

Metabolic bone disease of prematurity – an overview

With improved survival of extreme preterm and very low birth weight infants, there has been an increased incidence of metabolic bone disease (MBD). The last couple of decades have seen better awareness of the condition which in turn has led to improvement in the management and prevention of MBD. MBD occurs because there is difficulty in matching intrauterine mineral accretion rate after birth. The lack of a single specific and sensitive diagnostic test frustrates early diagnosis in many babies. Investigations like dual energy X-ray absorptiometry (DEXA) and quantitative ultrasound scanning are helpful in establishing a diagnosis but currently used mostly in research studies. A pragmatic approach for paediatricians is to pre-empt the formal diagnosis and supplement those at risk with adequate minerals and vitamin D, whilst monitoring the blood markers of MBD. Despite the noticeable short-term complications and stunting effect on childhood height, the prognosis of MBD is generally good. The aim of this article is to provide the reader with an improved understanding of the aetiopathogenesis, and offer some practical guidance on when and how to investigate and manage the metabolic bone disease of prematurity.     

Can screening for retinopathy of prematurity be reduced?

BACKGROUND: As screening for retinopathy of prematurity (ROP) is costly, time-consuming for the ophthalmologist and discomforting for the neonate, the minimum number of infants should be screened for ROP, without missing infants with severe ROP, at risk for threshold ROP. OBJECTIVES: To develop a diagnostic screening guideline for ROP that would safely reduce the number of ROP screening funduscopies in our department. METHODS: Data of 275 infants admitted between 1996 and 2000 and screened for ROP according to our Dutch National guideline were studied. Significant risk factors for ROP were calculated, using logistic regression analysis and used to develop a guideline. The discriminative power of the guideline was evaluated using the area under the curve for the receiver operating characteristic curve. RESULTS: Significant risk factors for ROP were: gestational age, birth weight and number of erythrocyte transfusions within the first 4 weeks of life. The combination of these 3 factors resulted in the highest area under the curve: 0.793. Using these 3 factors, a diagnostic screening guideline for ROP was developed: if birth weight + 2 x (gestational age - 20) - 6 x erythrocyte transfusion value within the first 4 weeks of life >or=34, no screening for ROP is necessary. Using this guideline, 22.2% of the infants of the study group could have been excluded from screening; 3.8% of the infants with ROP stages 1-2 would have been missed. CONCLUSION: In our department, ROP screening can be safely reduced using our diagnostic screening guideline.     

Epidemiology of prematurity – How valid are comparisons of neonatal outcomes?

Direct comparisons of neonatal outcomes at any level (unit, regional or international), require detailed validation and standardisation to ensure 'like for like' evaluation. Reported variation in neonatal performance may be either real or the result of one or more artefacts of the data collection. These issues need to be understood in order for an accurate interpretation to be made. Such artefacts are a particular feature of national data collection systems and can lead to serious misinterpretation. For example, very preterm deliveries have a major impact on neonatal mortality rates in developed countries with births before 33 weeks of gestation accounting for between 35% and 70% of neonatal deaths. Variation in the rate of very preterm delivery rates and differing practices regarding registration of these infants can have a major effect on the recorded neonatal mortality rate. At a more local level the validity of neonatal comparisons often depends upon whether the question being raised is appropriately matched to the data obtained to answer it. Problems arise when the question being addressed has been poorly framed or the data used to answer it has been inappropriately chosen. Comparisons using questions based on clearly defined standardised outcome measures and good quality prospective data collection are a much better way to proceed.     

Is Pacific race a retinopathy of prematurity risk factor?

BACKGROUND: Black race affords some protection from retinopathy of prematurity (ROP), but more ROP was previously found in another darkly pigmented race, the Alaskan natives. DESIGN: From fall 1989 through summer 2003, all Alaskan infants with a birth weight of 1500 g or less were examined, documenting mother's stated race, prenatal care, and neonatal intensive care unit course. RESULTS: Retinopathy of prematurity was classified as to predefined threshold for peripheral ablative treatment (region of avascular retina and fibrovascular ridge and vessel tortuosity) in 873 infants. Threshold ROP was more prevalent in Alaskan natives (24.9%) and Asians (15.9%) (10% overall), with no significant difference between Alaskan natives and Asians (P = .24). Alaskan native males had more threshold ROP (69%) compared with non-Alaskan native males (51%). Compared with threshold nonnatives, Alaskan native threshold infants had greater birth weights (829 +/- 222 vs 704 +/- 186 g), required less time on ventilation (46 +/- 22 vs 70 +/- 75 days), and progressed to treatment at a younger age (35.5 +/- 2.2 vs 36.2 +/- 2.6 weeks' gestational age) (data are given as mean +/- SD). CONCLUSIONS: In this limited study, we find increased risk of threshold ROP in 2 northern Pacific races. Threshold Alaskan natives had similar or better prenatal and neonatal intensive care unit variables than did threshold nonnatives; however, Alaskan native males were still at a greater risk.     

Screening for retinopathy of prematurity: is it painful?

BACKGROUND: Screening programmes for retinopathy of prematurity have shown to reduce unfavourable visual outcome and to be cost-effective. Following present recommendations, almost 1% of all newborn babies should therefore be screened and undergo at least one ophthalmologic examination. This is a skilled procedure that requires drug instillation and manipulation of the ocular globe with scleral indentation. The objective of this study is to describe the side effects of this ophthalmic exam with special focus on the occurrence of pain. METHODS: This was an observational study with a before-after analysis where all neonates undergoing an ophthalmologic exam during a 4-month period in a third level hospital were included. CRIES pain score was determined before the exam, 5 min after and 24 h after the screening manoeuvre. Blood pressure and pulse rate were determined in addition to the mentioned measurements 30 min after the ophthalmologic examination.Minimum oxygen saturation, apnoeas, gastrointestinal side effects (like vomiting and gastric aspirates), the need for respiratory assistance or for intensive care unit admission were recorded within 24 h before and after the procedure. RESULTS: 27 preterm neonates underwent an ophthalmologic examination and were included in the study. CRIES pain score was significantly higher 5 min after and 24 h after the screening procedure than before. This difference was also observed after stratification for birth weight and gestational age. No other study variable modified this time effect. No significant changes in blood pressure and pulse rate were shown after the ophthalmic exam. Vomiting was present in 4% of the newborns, gastric aspirates in 22% and apnoeas in 41% after the examination. Ten percent of the explored preterm babies needed increased respiratory assistance and 4% had to be transferred from the intermediate care unit to the intensive care because of severe apnoeas. COMMENTS: An increase in pain score was shown after retinopathy of prematurity screening examination. Physiologic variable changes do not last long enough to evaluate the impact of certain procedures. Multivariate pain scores (like CRIES) should be used in everyday practice. It seems that the ophthalmologic examination in preterm babies might be painful and further studies should identify the best strategy to prevent pain during the retinopathy of prematurity screening manoeuvre.     

Application of topical gentamicin—a new era in the treatment of genodermatosis

Background The clinical use of gentamicin always lies in its antimicrobial activity in the past as an aminoglycoside antibi-otic.However,in the past decade,ther...     

Retinopathy of Prematurity in a Rural Neonatal Intensive Care Unit in South India—A Prospective Study

Objective  

To report the incidence, spectrum and treatment outcome of Retinopathy of Prematurity (ROP) in a rural neonatal nursery.     

New developments in neonatology: less severe retinopathy of prematurity?

PURPOSE: To determine the effects of surfactant replacement therapy (SRT), high-frequency oscillatory ventilation (HFOV), and general improvements in quality of care on the incidence of severe retinopathy of prematurity (ROP). METHODS: Retrospective comparison of the incidence and severity of ROP in two groups of preterm infants admitted to our neonatal intensive care unit (NICU) in two consecutive 5-year periods (1986-1995) and screened for ROP. During the second study period, natural surfactant was introduced in the treatment of respiratory distress syndrome (RDS) and HFOV was used for treatment of respiratory insufficiency of any origin. The effects of these developments and general improvements on the incidence of severe ROP were analyzed with stepwise logistic regression. RESULTS: The overall incidence of ROP from 1986-1990 was not significantly different from the incidence of ROP from 1991-1995. The incidence of severe ROP (ROP stage 3 or greater) was significantly lower in the second period (15.7% versus 6.4%, P=.015). For infants <1000 g, the incidence of overall ROP was increased significantly during the second study period (47.6% versus 60.1 %, P=.045), although the incidence of severe ROP remained unchanged. Only SRT was associated with a decreased risk for severe ROP; HFOV and general improvements in quality of care had no influence on the outcome. In patients with RDS, the incidence of severe ROP decreased significantly during the second period. CONCLUSION: Of the recent new developments in neonatology, only SRT was associated with a decreased risk for severe ROP.     

Does early erythropoietin therapy decrease transfusions in anemia of prematurity ?

Objective. To investigate the effect of early erythropoietin treatment on induction of erythropoiesis and the need for transfusion in Very Low Birth Weight (VLBW) infants with acute neonatal problems.Methods. The study group consisted of 14 VLBW prematures with gestational ages less than 32 weeks who were given subcutaneous erythropoietin (600 U/kg per week) and oral iron (3 mg/kg per day) during the first 7–8 weeks of their life, while 13 other VLBW prematures that were given placebo constituted the control group. Weekly hemotocrit, (Hct) reticulocyte (Ret) values and the volume of blood drawn and transfused were recorded in the both groups.Results. The groups were comparable regarding with birth weights and gestational ages. The volume of the blood drawn (76.8 ± 42.5 and 37.0 ± 15.2) was higher and the volume of the transfusions (51.84 ± 49.30 and 68.84 ± 41.2) was lower in the study group but the differences between the groups were not significant (p>0.05). The hemotocrit, the reticulocyte and the ferritin values were similar in both the groups at the end of the therapy.Conclusion. Under the neonatal intensive care circumstances of developing countries where blood volumes needed for laboratory analysis are still very high, phlebotomy losses can not be avoided. Thus early erythropoietin and iron therapy at these doses are not effective in decreasing the need for transfusion and induction of endogenous erythropoiesis.     

Pediatric palliative care—when quality of life becomes the main focus of treatment

Pediatric palliative care (PPC) focuses on children and adolescents with life-limiting diseases. It may be initiated at various points of the disease trajectory, if possible early enough to support living with the best possible quality of life despite a limited lifespan. From birth to adolescence, children with a broad spectrum of diseases may benefit from PPC. Since 50% of deaths in childhood occur within the first year of life, PPC is just as relevant to neonatology. Causes of death in the neonate and young infant are due to perinatal conditions such as preterm birth and congenital disorders and syndromes; in older children, external causes, such as traumatic injuries, outweigh disease-related causes of death. PPC may last from a few hours or days for neonates to many years for children with complex chronic conditions. For neonates, PPC often has the character of end-of-life (EOL) care followed by bereavement care for the family. For older children, PPC can clearly be differentiated from EOL care; its indications include progress or deterioration of disease, marked instability of the child’s condition, increase in the need for technical or medical support, increase in suffering, or failure of treatment. If a child’s need for palliative care is established, useless and potentially harmful treatments may be withheld and informed choices can be made about treatment, care, and the remaining life of the child. Conclusion This review aims to provide knowledge for clinicians who care for children and adolescents at risk of dying from their disease. PPC can improve the child’s remaining lifetime by focusing on quality of life and goals that are defined by the child and his or her family.     

Do recombinant human erythropoietin and iron supplementation increase the risk of retinopathy of prematurity?

Comparing a group of infants treated with recombinant erythropoietin and iron supplementation to a group of control infants, no difference was observed concerning the transfusion need. The incidence of retinopathy of prematurity was significantly higher in the treated group. These data need to be confirmed in randomized controlled studies.