Randomised controlled trial of an aggressive nutritional regimen in sick very low birthweight infants

AIMS—To improve energy intake in sick very low birthweight (VLBW) infants; to decrease growth problems, lessen pulmonary morbidity, shorten hospital stay, and avoid possible feeding related morbidity. Morbidity in VLBW infants thought to be associated with parenteral and enteral feeding includes bronchopulmonary dysplasia, necrotising enterocolitis, septicaemia, cholestasis and osteopenia of prematurity.METHODS—A prospective randomised controlled trial (RCT) comparing two types of nutritional intervention was performed involving 125 sick VLBW infants in the setting of a regional neonatal intensive care unit. Babies were randomly allocated to either an aggressive nutritional regimen (group A) or a control group (group B). Babies in group B received a conservative nutritional regimen while group A received a package of more aggressive parenteral and enteral nutrition. Statistical analysis was done using Student''s t test, the Mann-Whitney U test, the χ² test and logistic regression.RESULTS—There was an excess of sicker babies in group A, as measured by initial disease severity (P <0.01), but mean total energy intakes were significantly higher (P <0.001) in group A at days 3 to 42 while receiving total or partial parenteral nutrition. Survival and the incidences of bronchopulmonary dysplasia, septicaemia, cholestasis, osteopenia and necrotising enterocolitis were similar in both groups. Growth in early life and at discharge from hospital was significantly better in babies in group A. There were no decreases in pulmonary morbidity or hospital stay.CONCLUSION—Nutritional intake in sick VLBW infants can be improved without increasing the risk of adverse clinical or metabolic sequelae. Improved nutritional intake resulted in better growth, both in the early neonatal period and at hospital discharge, but did not decrease pulmonary morbidity or shorten hospital stay.     

International randomised controlled trial of patient triggered ventilation in neonatal respiratory distress syndrome

AIM—To compare the effects of patient triggered ventilation (PTV) with conventional ventilation (IMV) in preterm infants ventilated for respiratory distress syndrome (RDS).METHODS—Nine hundred and twenty four babies from 22 neonatal intensive care units were assessed. They were under 32 weeks of gestation and had been ventilated for respiratory distress syndrome (RDS) for less than 6 hours within 72 hours of birth. The infants were randomly allocated to receive either PTV or IMV. Analysis was on an "intention to treat" basis. Death before discharge home or oxygen therapy at 36 weeks of gestation; pneumothorax while ventilated; cerebral ultrasound abnormality nearest to 6 weeks; and duration of ventilation in survivors were the main outcome measures.RESULTS—There was no significant difference in outcome between the two groups. Unadjusted rates for death or oxygen dependency at 36 weeks of gestation were 47.4% and 48.7%, for PTV and IMV, respectively; for pneumothorax these were 13.4% and 10.3%; and for cerebral ultrasound abnormality nearest to 6 weeks these were 35.4% and 36.9%. Median duration of ventilation for survivors in both groups was 6 days. Overall, 79% of babies received only their assigned ventilation. PTV babies were more likely to depart from their intended ventilation (27% vs 15%). The trend towards higher pneumothorax rates with PTV occurred only in infants below 28 weeks of gestation (18.8% vs 11.8%).CONCLUSIONS—There was no observed benefit from the use of PTV, with a trend towards a higher rate of pneumothorax under 28 weeks of gestation. Although PTV has a similar outcome to IMV for treatment of RDS in infants of 28 weeks or more gestation, within 72 hours of birth, it was abandoned more often. It cannot be recommended for infants of less than 28 weeks'' gestation with the ventilators used in this study.     

Randomised,controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g

AIM—To determine whether extubation to nasal continuous airway pressure (NCPAP) results in a greater proportion of infants remaining free of additional ventilatory support for one week after extubation compared with those extubated directly to headbox oxygen.METHODS—A randomised, controlled, clinical trial was conducted at the neonatal intensive care unit of the Royal Women''s Hospital, Melbourne, of infants with birthweights between 600 and 1250 g, ventilated via an endotracheal tube for more than 12 hours, requiring less than 50% oxygen, a ventilator rate ? 20/minute, considered by the clinical management team to be ready for extubation. Infants were randomly allocated either to NCPAP or to oxygen administered via a headbox. Success was defined by no requirement for additional ventilatory support over the week following extubation. Failure criteria were (i) apnoea; (ii) absolute increase in oxygen requirement greater than 15% above that required before extubation; or (iii) respiratory acidosis (pH<7.25 with pCO₂ >6.67 kPa).RESULTS—Thirty one of 47 (66%) infants were successfully extubated to NCPAP compared with 18 of 45 (40%) for headbox oxygen. The increase in failure rate in the headbox group was due primarily to increased oxygen requirements in this group. Of the 27 who failed headbox oxygen, 26 were given a trial of NCPAP and 13 did not require endotracheal reintubation. There was no significant difference between the groups in the total number of days of assisted ventilation or the duration of inpatient stay.CONCLUSIONS—NCPAP applied prophylactically after endotracheal extubation reduces the incidence of adverse clinical events that lead to failure of extubation in the seven days after extubation. This reduction is clinically important. The benefits of NCPAP do not seem to be associated with an increased incidence of unwanted side effects.     

Randomised trial of dopamine compared with hydrocortisone for the treatment of hypotensive very low birthweight infants

AIM—To compare the efficacy of hydrocortisone with dopamine for the treatment of hypotensive, very low birthweight (VLBW) infants.METHODS—Forty infants were randomly allocated to receive either hydrocortisone (n=21) or dopamine (n=19).RESULTS—All 19 infants randomised to dopamine responded; 17 of 21 (81%) did so in the hydrocortisone group. Three of the four non-responders in the hydrocortisone group had clinically significant left to right ductal shunting. The incidence of bronchopulmonary dysplasia, retinopathy of prematurity, intraventricular haemorrhage, necrotising enterocolitis, symptomatic patent ductus arteriosus, hyperglycaemia, sepsis (bacterial or fungal) or survival did not differ between groups. The adrenocorticotrophic hormone (ACTH) stimulated plasma cortisol activity, either before or after treatment, did not differ between the two groups of infants. Although a significant difference in efficacy between dopamine and hydrocortisone was not noted (P = 0.108), there were four treatment failures in the hydrocortisone group, compared with none in the dopamine group.CONCLUSION—Both hydrocortisone and dopamine are effective treatments for hypotension in very low birthweight infants.     

Outcome at 5-6 years of prematurely born children who received morphine as neonates

AIM—To assess outcome at 5-6 years in a cohort of very preterm infants (<34 weeks of gestation) who had been randomly allocated within a controlled clinical trial to receive morphine or non-morphine treatment in the neonatal period.METHODS—Assessments were made on 87 children at 5-6 years who had been recruited in the neonatal period to two sequential controlled studies (1989-92). Infants requiring mechanical ventilation had been randomly allocated to receive either morphine (n=62) or other (n=33) solutions starting on the first day of life. Each child was seen by a single experienced observer and assessed at 5-6 years using the WPPSI-R, Movement ABC, and the Child Behaviour Checklist. The performance of children exposed to morphine was compared with that of those in the non-morphine group. Blood samples for thyroid stimulating hormone (TSH) measurement were obtained from children whose parents gave consent.RESULTS—There was no significant difference in any of the three test scales between infants in the two groups, but there was a trend towards better performance in all three tests in the morphine group. Assessment of TSH values in a subgroup of the survivors showed no difference in thyroid function between the two groups.CONCLUSION—Exposure to morphine in the neonatal period to facilitate mechanical ventilation does not seem to have any adverse effects on intelligence, motor function, or behaviour when these children are assessed at 5-6 years of age.     

Growth and neurodevelopmental outcome of VLBW infants at 1 year corrected age

Objectives

To evaluate growth and neurodevelopmental outcome of very low birth weight infants (VLBW) and compare with term normal birth weight infants (NBW) till 12 months corrected age.

Design

A prospective cohort study

Setting

Tertiary care neonatal unit in northern India

Subjects

37 VLBW infants and 35 NBW infants born between January 2007 and December 2007.

Interventions

Anthropometric measurements were recorded and Z-scores were computed serially at birth, discharge, 40 weeks post menstrual age (PMA), and at 1, 3, 6 and 12 months of corrected age. Developmental quotient (DQ) at 12 months corrected age was assessed.

Results

Z-scores for weight, length and head circumference (HC) at birth were ?1.21(±0.92), ?0.98(±1.32) and ?0.70(±1.14), respectively for VLBW infants and ?0.37(±0.72), ?0.11(±0.96) and 0.05(±0.73) respectively for NBW infants. VLBW infants had a significant drop in all Z-scores by discharge (P<0.001). There was a catch up to birth scores by 12 month age. VLBW infants had significantly lower Z-scores for weight, length and HC at one year corrected age as compared to NBW infants (P =0.01, 0.04 and 0.001, respectively). DQ at 12 months was significantly lower in VLBW infants (91.5+7.8) than NBW infants (97.5±5.3) (P <0.001). DQ of small for gestational age (SGA) and appropriate for gestational age (AGA) VLBW infants was comparable.

Conclusion

VLBW infants falter in their growth during NICU stay with a catch-up later during infancy. In comparison to NBW infants, they continue to lag in their physical growth and neurodevelopment at 1 year of corrected age.     

Early administration of Bifidobacterium breve to preterm infants: randomised controlled trial

AIM—To investigate the colonisation with Bifidobacterium breve of the bowels of very low birthweight (VLBW) infants.METHODS—The adverse effects of B breve were examined in 66 VLBW infants (preliminary study). A prospective randomised clinical study of 91 VLBW infants was also completed and these infants were followed up for three years. Precise viable bacterial counts of serial stool specimens were examined for the first eight weeks after birth in 10 infants. The colonisation rates of administered bacteria were examined using immunohistochemical staining of stool specimens with a B breve specific monoclonal antibody.RESULTS—In the preliminary study there were no side effects attributable to the bacteria. Immunohistochemical staining of stool specimens showed that the colonisation rates of the administered bacteria were 73% at 2 weeks of age, but only 12% in the control group. Early administration of B breve significantly decreased aspirated air volume from the stomach and improved weight gain.CONCLUSIONS—B breve can colonise the immature bowel very effectively and is associated with fewer abnormal abdominal signs and better weight gain in VLBW infants, probably as a result of stabilisation of their intestinal flora and accelerated feeding schedules.     

Randomised controlled trial of eutectic mixture of local anaesthetics cream for venepuncture in healthy preterm infants

AIM—To assess the safety and efficacy of EMLA cream (eutectic mixture of local anaesthetics) used to induce surface anaesthesia for venepuncture in healthy preterm infants.METHODS—Nineteen infants, median gestational age 31 weeks (range 26-33 weeks) were assessed in a randomised, double blind, placebo controlled, cross-over trial. Changes in physiological variables (heart rate, blood pressure, oxygen saturation) and behavioural responses (neonatal facial coding system score, crying time) before and after venepuncture with EMLA cream were compared with those obtained with a placebo cream to assess efficacy. Toxicity was assessed by comparing methaemoglobin concentrations at 1 hour and 8 hours after application.RESULTS—There was no significant difference in efficacy between EMLA and placebo creams in physiological and behavioural responses. There was no significant difference in methaemoglobin concentrations one hour after the cream had been applied. At eight hours, however, concentrations were significantly higher after EMLA than placebo (p=0.016). There was no evidence of clinical toxicity.CONCLUSION—This study does not support the routine use of EMLA for venepuncture in healthy preterm infants.     

Plasma vitamin A levels in the very low birthweight infant — relationship to respiratory outcome

Objective: To examine the association between plasma vitamin A levels and outcome measures in very low birthweight (VLBW) infants, including meta-analysis of all observational studies. Design: A prospective observational longitudinal study of plasma vitamin A levels measured in the cord blood; maternal blood in the first 48 h after delivery; and the infants' blood at 48 h, 7 days and 28 days of age and correlated with antenatal and postnatal events. A meta-analysis of all published observational studies on the association of vitamin A with respiratory outcome in the VLBW infant was undertaken. Patients: Fifty-seven infants (88% of all eligible) VLBW infants (<1500 g) admitted from January through October 1993 to one of two regional neonatal intensive care units in the South Island of New Zealand. Results: Exposure to antenatal steroids led to a significant increase in infant cord plasma vitamin A levels (P=0.003), but no influence on infant plasma vitamin A levels at any other time. Exposure to postnatal steroids produced a significant rise in infant plasma vitamin A levels between 7 and 28 days (P=0.008). After controlling for gestational age, antenatal and postnatal steroid exposure, low vitamin A levels at 48 h increased the risk of developing chronic lung disease (odds ratio for 50 μg/l decrease: 2.04, 95% CI 1.19–5.77) and bronchopulmonary dysplasia (odds ratio 1.96, 95% CI 1.14–6.87). On combining our results in meta-analysis with those of other published prospective observational studies, infants with chronic lung disease had lower plasma vitamin A levels at all times. Conclusions: Our results support an association between low plasma vitamin A levels and adverse outcome in the VLBW infant.     

Tachypnoea is a good predictor of hypoxia in acutely ill infants under 2 months

OBJECTIVE—To evaluate the respiratory rate as an indicator of hypoxia in infants < 2 months of age.SETTING—Pediatric emergency unit of an urban teaching hospital.SUBJECTS—200 infants < 2 months, with symptom(s) of any acute illness.METHODS—Respiratory rate (by observation method), and oxygen saturation (SaO₂) by means of a pulse oximeter were recorded at admission. Infants were categorised by presence or absence of hypoxia (SaO₂ ? 90%).RESULTS—The respiratory rate was ? 50/min in 120 (60%), ? 60/min in 101 (50.5%), and ? 70/min in 58 (29%) infants. Hypoxia (SaO₂? 90%) was seen in 77 (38.5%) infants. Respiratory rate and SaO₂ showed a significant negative correlation (r = ?0.39). Respiratory rate ? 60/min predicted hypoxia with 80% sensitivity and 68% specificity.CONCLUSION—These results indicates that a respiratory rate > 60/min is a good predictor of hypoxia in infants under 2 months of age brought to the emergency service of an urban hospital for any symptom(s) of acute illness.     

Diaphragmatic paralysis among very low birth weight infants following ligation for patent ductus arteriosus

Management of diaphragmatic paralysis (DP) among newborn infants remains controversial, especially for very low birth weight (VLBW) infants following ligation for patent ductus arteriosus (PDA). This study aimed to characterize the impact of DP after PDA ligation among VLBW infants. Clinical characteristics of DP cases treated with either diaphragmatic plication or conservative methods were described as well. The medical records of VLBW infants who underwent PDA ligation in Chang Gung Memorial Hospital between January 2000 and December 2011 were retrospectively reviewed, and DP was suspected if postligation chest X-rays showed an elevation of the left diaphragm as confirmed by a chest ultrasonograph. For each DP case, three other infants that received PDA ligation with proximate birth dates and who were closely matched in terms of gestational age (±1?week) and birth weight (±10?%) were selected as the control group. A total of eight preterm infants were diagnosed as having DP and 24 infants were selected as the control group. The affected infants usually presented with respiratory distress and extubation failure. The study demonstrated that, among our patient population, DP was associated with a significantly longer duration of ventilator dependency (56.1?±?16.0 vs. 29.8?±?17.7?days, p?=?0.001) and a higher incidence of severe bronchopulmonary dysplasia (87.5 vs. 23?%, p?=?0.002). For selective infants with DP-related ventilatory failure after PDA ligation, surgical plication may facilitate extubation. Diaphragmatic paralysis should be evaluated carefully among VLBW infants receiving PDA ligation because of its adverse impact on ventilator dependency and correlation to a higher incidence of severe bronchopulmonary dysplasia.     

Lung Function and Respiratory Health at School Age in Ventilated Very Low Birth Weight Infants

Objective

To investigate respiratory health and lung function in school-aged children without broncho-pulmonary dysplasia (BPD), who were very low birth weight (VLBWi) and randomized at birth to high frequency oscillatory ventilation (HFOV) or volume guarantee (VG) ventilation for severe respiratory distress syndrome (RDS).

Methods

In this observational study, 7-y-old ex-preterm infants with severe RDS, randomly assigned at birth to receive assisted/control ventilation?+?VG (Vt?=?5 mL/kg, PEEP?=?5 cmH₂O)(VG group; mean GA 27?±?2 wk; mean BW 1086?±?158 g) or HFOV (HFOV group; mean GA: 27?±?2; mean BW: 1090?±?139 g) (both groups were ventilated with Drager Babylog 8000 plus) were recalled. Neonatal clinical data and outcome were known. Actual outcomes were investigated with an interview; lung function was measured by whole-body plethysmography.

Results

Twenty five children were studied (VG group, n?=?13 vs. HFOV group, n?=?12). There were no differences in anthropometric data, drugs (steroids/bronchodilators and antibiotics) or hospital readmission for respiratory disorders. Compliance to the test was adequate. The authors found a similar obstructive deficit (elevated values: airway resistance (RAW), residual volume (RV), total lung capacity (TLC) with near-normal spirometry) in both groups suggesting a persistent airflow limitation even in absence of BPD.

Conclusions

VLBW infants even in absence of BPD, need long term respiratory follow-up, because they frequently show an impairment of lung function, independent from initial respiratory support, even if at birth the choice is a lung protective approach (e.g., HFOV or VG ventilation).     

Racial differences in respiratory-related neonatal mortality among very low birth weight infants

OBJECTIVE: To examine racial differences in the secular trends in respiratory-related neonatal mortality among very low birth weight (VLBW) infants in the United States, temporally associated with surfactant availability. DESIGN: Comparison of time trends in African American and non-Hispanic white (NHW) VLBW infants of cause-specific neonatal mortality and neonatal and infant mortality for 2 consecutive 3-year periods. RESULTS: From 1985 to 1988 there was no racial difference in the rate of decline of each mortality outcome. From 1988 to 1991 rates of decline in neonatal mortality caused by respiratory distress syndrome and by all respiratory causes were significantly greater for NHWs compared with African Americans. However, the rate of decline in nonrespiratory neonatal mortality was similar for African Americans and NHWs. Compared with African American VLBW infants, NHWs had a greater rate of decline in both neonatal (31% vs 20%; P <.01) and infant mortality (32% vs 21%; P <.01) during this period. CONCLUSIONS: Between 1988 and 1991, declines in neonatal mortality risks caused by respiratory distress syndrome and all respiratory causes were greater for NHW infants than for African American VLBW infants. The decline in nonrespiratory mortality risk showed no racial differences. These findings suggest possible racial disparities in timely access or racial differences in the efficacy of respiratory treatments for VLBW infants.     

两种无创呼吸支持治疗极低出生体重儿呼吸窘迫综合征疗效分析

目的 探讨早期应用经鼻间歇正压通气（NIPPV）与加温湿化经鼻导管高流量通气（HHHFNC）治疗极低出生体重呼吸窘迫综合征（RDS）早产儿的临床疗效。方法 89例极低出生体重RDS早产儿依据初始呼吸支持治疗方式随机分为NIPPV组（46例）和HHHFNC组（43例）。分析两组患儿初始治疗失败率、肺表面活性物质（PS）使用率、呼吸支持治疗相关数据及各种并发症的发生率。结果 NIPPV组治疗72 h内气管插管率、PS使用率、有创辅助通气时间、无创辅助通气时间及总用氧时间、严重呼吸暂停发生率、肺炎发生率与HHHFNC组的差异无统计学意义（P > 0.05）;NIPPV组支气管肺发育不良、颅内出血、早产儿视网膜病、坏死性小肠结肠炎、动脉导管未闭、气漏的发生率与HHHFNC组的差异均无统计学意义（P > 0.05）;NIPPV组鼻损伤的发生率高于HHHFNC组（P < 0.05）。结论 对于极低出生体重RDS早产儿的初始呼吸支持治疗,HHHFNC与NIPPV疗效相当,是可供临床选择的另一种安全和有效的无创辅助通气治疗方式。     

Glutamine-enriched enteral nutrition in very low birth weight infants. Design of a double-blind randomised controlled trial [ISRCTN73254583]

Background

Enteral feeding of very low birth weight (VLBW) infants is a challenge, since metabolic demands are high and administration of enteral nutrition is limited by immaturity of the gastrointestinal tract. The amino acid glutamine plays an important role in maintaining functional integrity of the gut. In addition, glutamine is utilised at a high rate by cells of the immune system. In critically ill patients, glutamine is considered a conditionally essential amino acid. VLBW infants may be especially susceptible to glutamine depletion as nutritional supply of glutamine is limited in the first weeks after birth. Glutamine depletion has negative effects on functional integrity of the gut and leads to immunosuppression. This double-blind randomised controlled trial is designed to investigate the effect of glutamine-enriched enteral nutrition on feeding tolerance, infectious morbidity and short-term outcome in VLBW infants. Furthermore, an attempt is made to elucidate the role of glutamine in postnatal adaptation of the gut and modulation of the immune response.

Methods

VLBW infants (gestational age <32 weeks and/or birth weight <1500 g) are randomly allocated to receive enteral glutamine supplementation (0.3 g/kg/day) or isonitrogenous placebo supplementation between day 3 and 30 of life. Primary outcome is time to full enteral feeding (defined as a feeding volume ≥ 120 mL/kg/day). Furthermore, incidence of serious infections and short-term outcome are evaluated. The effect of glutamine on postnatal adaptation of the gut is investigated by measuring intestinal permeability and determining faecal microflora. The role of glutamine in modulation of the immune response is investigated by determining plasma Th1/Th2 cytokine concentrations following in vitro whole blood stimulation.

     

Inhaled salbutamol for wheezy infants: a randomised controlled trial

BACKGROUND—Salbutamol is frequently used as a bronchodilator for infants who wheeze. Many single dose studies have questioned its effectiveness.AIMS—To investigate the response of wheezy infants to salbutamol over an extended time period in order to elucidate either symptomatic relief or a protective effect.METHODS—Eighty infants under 1 year, with persistent or recurrent wheeze and a personal or family history of atopy, were recruited to a randomised, double blind, cross over, placebo controlled trial. Salbutamol (200 µg three times daily) or placebo were administered regularly over two consecutive treatment periods of four weeks via a spacer and mask. Symptoms of wheeze and cough were recorded in a diary. At the end of the study pulmonary function tests were performed before and after salbutamol (400 µg).RESULTS—Forty eight infants completed the diary study; 40 infants underwent pulmonary function testing. No difference in mean daily symptom score was observed between the salbutamol and placebo periods. There was no difference in the number of symptom free days. Compliance and forced expiratory flows remained unchanged and resistance increased following salbutamol. There was no relation between the response measured by symptom score or pulmonary function in individual patients.CONCLUSION—In wheezy infants with an atopic background, there was no significant beneficial effect of salbutamol on either clinical symptoms or pulmonary function. Clinical effects could not be predicted from pulmonary function tests. Salbutamol cannot be recommended as the bronchodilator of choice in this age group.     

Comparison of neonatal outcome for inborn and outborn very low-birthweight preterm infants

Background:  The aim of the present study was to compare the neonatal outcome of very low-birthweight (VLBW) preterm infants with regard to inborn and outborn status in a medical center of Southern Taiwan, where short-distance neonatal transport is the rule and maternal transport was not well established.
Methods:  This retrospective study included outborn VLBW preterm infants admitted to the neonatal intensive care unit of Chang Gung Memorial Hospital at Kaohsiung after neonatal transport during the period from 1999 through 2003. An equal number of inborn preterm infants matched for gender and birthweight were included as controls. Infants with lethal congenital anomalies or who died in the delivery room were excluded. Data were collected from reviewing medical charts.
Results:  A total of 34 inborn VLBW infants and 34 outborn VLBW infants with neonatal transport were included. Chronic lung disease (CLD) was significantly more frequent in the outborn group according to McNemar test ( P  = 0.0124) and logistic regression. Logistic regression also showed that outborn status ( P  = 0.0173) and birthweight ( P  = 0.0024) were the two most important risk factors for development of CLD.
Conclusion:  Well-trained short distance neonatal transport is useful and valuable for VLBW infants with gestation age of 27–34 weeks in Southern Taiwan. The respiratory outcome, however, was poor in the outborn group in terms of incidence of CLD. To improve the respiratory outcome, further modification of respiratory care during transportation or antenatal maternal transport is crucial.     

早期或晚期使用枸橼酸咖啡因防治极低出生体重儿呼吸暂停的临床分析

目的 比较早期或晚期使用枸橼酸咖啡因防治极低出生体重儿呼吸暂停的临床效果。方法 选取2015年6月至2017年5月于新生儿重症监护室住院治疗的极低出生体重儿共82例为研究对象,按开始使用枸橼酸咖啡因的日龄分为早期治疗组（日龄 < 3 d）（n=22）和晚期治疗组（3 d ≤ 日龄<10 d）（n=60）,回顾性收集并比较两组患儿围产期的基本情况、治疗过程情况及临床结局。结果 早期治疗组的出生体重明显低于晚期治疗组（P=0.004）;早期治疗组机械通气时间及吸氧时间明显短于晚期治疗组（P < 0.05）;早期治疗组支气管肺发育不良（BPD）的发生率明显低于晚期治疗组（P=0.032）。其余基本情况、治疗过程情况及临床结局在两组间比较差异均无统计学意义（P > 0.05）。结论 早期使用枸橼酸咖啡因可改善极低出生体重儿的预后。     

Respiratory support practices in infants born at term in the United Kingdom

Infants born at term requiring mechanical ventilation suffer significant mortality and morbidity, yet few studies have tried to identify the optimum respiratory support for such infants. We, therefore, hypothesised that practice would vary, particularly between different levels of neonatal care provision. The lead clinicians of all 212 UK neonatal units were asked to complete an electronic web-based survey regarding respiratory support practices for term-born infants. Survey questions included the level of neonatal care provided, number of term-born infants ventilated per annum, initial and rescue ventilation modes and whether surfactant or inhaled nitric oxide (NO) were used. The overall response rate was 82?%. A greater proportion of neonatal intensive care units (NICUs) compared to local neonatal units (LNUs) stated that they used volume-targeting, particularly for infants with RDS (p?=?0.0006) or congenital pneumonia (p?=?0.0005). High-frequency oscillatory ventilation was stated as initial mode by a greater proportion of NICUs compared to LNUs and special care units (SCUs), particularly for respiratory distress syndrome (p?<?0.0001) or persistent pulmonary hypertension of the newborn (p?<?0.001). Continuous mandatory ventilation was stated to be the rescue mode by a greater proportion of LNUs/SCUs compared to NICUs (p?<?0.0001). Surfactant was stated to be most commonly given for respiratory distress syndrome (79?% of units) and MAS (61?% of units); surfactant use was lowest in SCUs (p?<?0.0001); inhaled NO was infrequently used by LNUs and SCUs. Conclusions There was considerable variation in respiratory support practices for term-born infants, particularly between different levels of neonatal care provision.     

No relationship between mode of delivery and neonatal mortality and neurodevelopment in very low birth weight infants aged two years

Background

To compare neonatal mortality and neurodevelopmental outcomes at two years of age in very low birth weight infants (≤1500 g) born by cesarean with those by vaginal delivery.

Methods

In this retrospective, case-control study, we evaluated neonatal mortality, medical conditions and neurodevelopmental outcomes at two years of corrected age in 710 very low birth weight (VLBW) infants born between January 2005 and December 2010. Of the 710 infants, 351 were born by the cesarean and 359/710 by vaginal route.

Results

There were no significant differences in neonatal mortality between the cesarean delivery group and vaginal delivery group [56/351 (15.9%) vs. 71/359 (19.8%), P=0.20]. VLBW infants delivered by the cesarean procedure had a higher incidence of respiratory distress syndrome than those born by the vaginal route [221/351 (63.0%) vs. 178/359 (49.6%), P<0.001]. There were no differences in other neonatal morbidities, including intraventricular hemorrhage [126/351 (35.9%) vs. 134/359 (37.3%), P=0.69], bronchopulmonary dysplasia [39/351 (11%) vs. 31/359 (8.6%), P=0.38] and necrotising enterocolitis [40/351 (11.4%) vs. 32/359 (8.9%), P=0.32] between the two groups. The incidence of poor neurodevelopment after cesarean delivery was similar to that after vaginal delivery [105/351 (29.9) vs. 104/359 (29.0%), P=0.78].

Conclusions

In neither neurodevelopment nor neonatal mortality did cesarean birth offered significant advantages to VLBW infants. Moreover, the operation might be associated with an increased risk of respiratory distress syndrome for VLBW infants. The mode of delivery of VLBW infants should be largely based on obstetric indications and maternal considerations rather than perceived better outcomes for the neonate.