NEW STUDY: CANNULAS WITH LONG NARROW TUBING SIGNIFICANTLY LESS COMMON NASAL TRAUMA

Cannulas with long, narrow tubing noninferior to short binasal prongs in preterm infants

November 30, 2020 

Use of cannulas with long and narrow tubing was noninferior to short binasal prongs and masks for providing nasal intermittent positive pressure ventilation in preterm infants, according to a study published in JAMA Pediatrics.

There was significantly less nasal trauma with use of the cannulas with long and narrow tubing, researchers reported.

“There is concern that this long, thin interface delivers reduced and suboptimal pressure transmission, tidal volume and support compared with short binasal prongs and masks, especially when leak at the nose is more than minimal,” Ori Hochwald, MD,senior physician in the neonatal ICU at Rambam Medical Center in Haifa, Israel, and colleagues wrote. “Despite its widespread use, the clinical efficacy of cannulas with long and narrow tubing was not thoroughly studied.”

The randomized, controlled, unblinded, prospective, noninferiority trial included 166 preterm infants born between 24 and 33 weeks and 6 days’ gestation who presented with respiratory distress syndrome requiring noninvasive ventilatory support as initial treatment after birth or following first extubation. Preterm infants were recruited from two tertiary neonatal ICUs from December 2017 to December 2019.

The primary outcome was intubation requirement within 72 hours after nasal intermittent positive pressure ventilation treatment began. Researchers defined the noninferiority margin as 15% or less absolute difference.

Preterm infants were randomly assigned to use of cannulas with long and narrow tubing (n = 83) or short binasal prongs and masks (n = 83). In the cannula tubing group, mean gestational age was 29.3 weeks and mean birth weight was 1,237 g; in the short binasal prongs and masks group, it was 29.2 weeks and 1,254 g, respectively.

In the cannula tubing group, the primary endpoint was reached in 12 (14%) infants compared with 15 (18%) in the short binasal prongs and masks group (risk difference = –3.6%; 95% CI, –14.8 to 7.6; P = .53).

Moderate to severe nasal trauma caused by ventilation was significantly less common in the cannula tubing group in four infants compared with 17 infants in the short binasal prongs and masks group (P = .01). Researchers observed no differences in other adverse events during hospitalization.

The researchers reported no differences in other adverse events between the two groups.

“Further larger studies are needed to establish the noninferiority and possible advantage of performing initial nasal intermittent positive pressure ventilation with cannulas with long and narrow tubing in the group of infants with lower gestational age and more severe respiratory distress syndrome,” the researchers wrote.

Article found here.

MOST NEWBORNS OF COVID-19-INFECTED MOMS FARE WELL

Article found here

MONDAY, Sept. 28, 2020 (HealthDay News) -- Babies born to mothers with COVID-19 only rarely suffer from effects of the virus, a new study suggests. 

These newborns generally do well in the six to eight weeks after birth, but more are admitted to the neonatal intensive care unit (NICU) if their mothers had COVID-19 in the two weeks before delivery. 

Of more than 200 babies studied, complications including preterm birth and NICU admission didn't differ among mothers with and without COVID-19. No pneumonia or lower respiratory infections were reported through 8 weeks of age.

"The babies are doing well, and that's wonderful," said lead author Dr. Valerie Flaherman, an associate professor of pediatrics at the University of California, San Francisco (UCSF).

"When coronavirus first hit, there were so many strange and unfortunate issues tied to it, but there was almost no information on how COVID-19 impacts pregnant women and their newborns. We didn't know what to expect for the babies, so this is good news," Flaherman said in a university news release. 

Of 263 infants, 44 were admitted to a NICU, but no pneumonia or lower respiratory tract infections were reported. Among 56 infants assessed for upper respiratory infection, this type of infection was reported in two babies born to COVID-19-positive mothers and one born to a COVID-19-negative mother. 

According to senior study author Dr. Stephanie Gaw, "Overall, the initial findings regarding infant health are reassuring, but it's important to note that the majority of these births were from third-trimester infections." Gaw is an assistant professor of obstetrics, gynecology and reproductive sciences at UCSF. 

Two infants born to mothers who tested positive in the third trimester had birth defects. One had heart, kidney, lung and vertebral abnormalities. The other had facial, genital, kidney, brain and heart issues. 

One mother who tested negative delivered an infant with gastrointestinal, kidney and heart issues, the researchers noted. 

The findings were published online Sept. 22 in the journal Clinical Infectious Diseases.

Long-Term Neurodevelopmental Impacts of Prenatal Opioid Exposure

Amit Akirov, MD 

February 7, 2020

Article published here

Opioid use disorder is on the rise among women of reproductive age, contributing markedly to the opioid epidemic and increasing the incidence of adverse health outcomes in pregnant women and children. It is estimated that up to 14.4% of pregnant women have opioids dispensed during pregnancy. Perinatal exposure to opioids may have significant immune, neural, and behavioral effects that can alter central nervous system (CNS) development, as well as induce long-term changes in brain structure and function, according to a preclinical animal model study published in Brain, Behavior, and Immunity.

In light of the marked increase in the use of prescription opioids among women of childbearing age, there is evidence for a rapid increase in the rates of opioid use disorder during pregnancy and the risk for neonatal opioid withdrawal syndrome. Opioid exposure includes the use and misuse of various opioids, including oxycodone, morphine, codeine, illicit opioids, and medications used to manage opioid use disorders, such as methadone and buprenorphine.

Limited data are available on the direct effects of perinatal opioid exposure on developing neural circuitry and neurodevelopment outcomes. Because opioids rapidly cross the placenta, perinatal opioids can have a direct impact on the CNS.

The researchers completed a literature review to assess the effects of opioids on the developing brain. They used an animal model that included 200 male and female rat pups; 86 saline-exposed and 114 methadone-exposed offspring were used for outcome measures.

Similar to what was previously observed in human neonates after methadone exposure, rat pups of both sexes born to methadone-exposed mothers with methadone exposure in utero, and continuing through the perinatal and neonatal periods, had significantly reduced body weight. Methadone concentration in the urine also increased proportionally to maternal dose.

Methadone was found to induce systemic inflammatory response syndrome that persisted for weeks postnatally, with evidence for increased inflammatory proinflammatory cytokines in peripheral circulation, including a 19-fold (1954%) increase in interleukin (IL)-1β, 36% increase in tumor necrosis factor (TNF)-α, and more than 2-fold (225%) increase in IL-6 at approximately 17 days of methadone exposure. Although at a later time point there was no difference in TNFα, IL-6, and CXCL1, levels of IL-1β remained significantly increased (188%), compared with the saline-exposed pups.

Compared with peripheral bone marrow cells (PMBCs) from saline-exposed pups, PMBCs from methadone-exposed pups hypersecreted proinflammatory cytokines, including TNF-α and IL-1β. These findings support enhanced immune activation and lymphocyte hyperreactivity after methadone exposure. This sustained peripheral immune hyperreactivity was blocked by pretreatment of PMBCs with naloxone.

Perinatal methadone exposure leads to an increase in several cerebral molecular and cellular inflammatory mediators, including a 42% increased cerebral cortical Toll-like receptor 4 (TLR4) mRNA expression and an 87% increased MyD88 mRNA expression in the brains of methadone-exposed pups, compared with saline-exposed rats. Furthermore, there was an increase in cortical IL-1β and cortical CXCL1 among methadone-exposed rats, but brain levels of TNFα and IL-6 were unchanged with methadone exposure.  Perinatal methadone exposure was also associated with increased microglial activation.  

Regarding structural effects of methadone exposure in the CNS, there was a significant reduction in axonal integrity and myelin expression in methadone-exposed pups compared with saline-exposed pups. Diffusion tensor imaging was used to examine the brain ex vivo, with evidence for decreased fractional anisotropy in methadone-exposed rat offspring compared with saline-exposed pups, an indication for abnormal diffusion in the corpus callosum and external capsule.

After the data pointed to structural and microstructural brain injury, the researchers used a touchscreen operant platform to assess cognition and executive function. Methadone exposure during the perinatal period was associated with widespread associative learning and executive control dysfunction among adult rats. Importantly, these impairments were not secondary to sensorimotor-related problems or lack of motivation, as the data showed normal response reaction times and reward retrieval latencies.

The researchers acknowledged several study limitations, including lack of power to assess for sex differences in outcome measures and limitations secondary to the use of an ELISA kit to perform urinalysis for methadone levels.

“We provide evidence that methadone exposure in the perinatal period leads to a unique immune, neural and behavioral phenotype, associated with a systemic pro-inflammatory signature indicative of widespread brain and immune system injury. This signature reflects a significantly altered cerebral and immune microenvironment concomitant with dysregulated developmental homeostasis in the perinatal period,” concluded the researchers.

Reference

Jantzie LL, Maxwell JR, Newville JC, et al. Prenatal opioid exposure: the next neonatal neuroinflammatory disease[published online ahead of print, 2019 Nov 22]. Brain Behav Immun. doi: 10.1016/j.bbi.2019.11.007

Study into skin collection of blood chemistry from babies aims to replace invasive blood tests

Scientists at the University of Strathclyde are researching a system to measure and monitor blood chemistry levels in premature and sick babies through their skin, which if successful, could eventually replace the need for invasive blood tests.

When babies are born early or sick there is a medical need to track levels of electrolytes such as glucose, lactate, sodium and potassium in their bodies, as the balance of these can be critical.

The levels are currently measured by heel stick blood tests or blood taken from a vein, which can be distressing and risk depleting the blood at the time when the infants in the neonatal intensive care unit are already vulnerable.

For full article, click here.

STUDY: LIBERAL PLATELET USE IN PRETERM INFANTS AND IVH

1. For preterm infants with echocardiographically-confirmed patent ductus arteriosus (PDA) within the first 14 days of life, there was no significant difference in the timing of PDA closure between infants who received liberal versus restrictive platelet transfusions.

2. Infants in the liberal transfusion group had significantly higher rates of intraventricular hemorrhage (IVH) of any grade compared to the restrictive group. There was no significant difference between groups for IVH grade III-IV. The cumulative volume of platelet transfusion was a significant risk factor in developing any grade IVH.

Evidence Rating: Level 1 (Excellent)

Liberal platelet transfusion does not expedite patent ductus arterious closure

April 2, 2019 | Matthew Lin, MD and Leah H. Carr, MD

Study Rundown: Prospective data has supported a positive association between thrombocytopenia and PDA. One theory, based on animal studies, is that platelet accumulation within the PDA may lead to thrombus formulation and vascular remodeling, resulting in PDA closure. The purpose of this randomized controlled trial was to evaluate whether maintaining a platelet count of >100 000/uL in thrombocytopenic preterm infants with PDA identified in the first 14 days of life would result in the primary outcome of earlier PDA closure. Preterm infants with PDA were randomized into a “liberal” versus “restrictive” platelet transfusion group. Researchers found no statistically significant difference between groups for time to closure of the PDA. Significant secondary outcomes included higher volume of platelets transfused and higher rates of any grade IVH in the liberal group. However, there was no difference between groups for IVH grades III-IV. Follow-up analyses showed that cumulative volume of platelets received was a significant risk factor for any grade IVH. This study is limited by an inability to account for potential platelet dysfunction, which may explain why groups had similar outcomes. For neonatologists, these data suggest that liberal use of platelets in preterm infants with PDAs in the first 14 days of life will not increase time to closure and may increase risk of any grade of IVH.

Click to read the study, published today in Pediatrics

REASSURING DATA ON TRIPLET NEONATAL OUTCOMES

"Reassuring" Data on Neonatal Outcomes of Triplets

NEW YORK (Reuters Health) - A large retrospective study provides reassuring data on neonatal outcomes of very preterm and very low birth weight triplets.

"Our results identified that, when matched by country of birth, gestational age and sex, the outcomes of preterm triplets were similar to those of singletons, meaning that their risk of mortality and illnesses common to preterm neonates are similar," Dr. Prakesh Shah of Mount Sinai Hospital, part of Sinai Health System, in Toronto, Canada, told Reuters Health by email.

"The literature on this topic of outcome of triplets vs. singletons is marred by small, single-center studies and some showing that the outcomes are worse and some showing they are similar," Dr. Shah explained.

He and his colleagues compared neonatal outcomes of more than 6,000 triplets born between 24 to 32 weeks' gestation or weighing 500 to 1,499 g at birth with that of three times as many singletons from 11 high-income countries.

"This is the largest set of premature triplets studied in the world," Dr. Shah said.

The results showed no difference in the primary outcome (a composite of mortality or severe neonatal morbidity (severe neurologic injury, treated retinopathy of prematurity, and bronchopulmonary dysplasia) between triplets and singletons (23.4% vs. 24.0%).

The odds ratio was 0.91 in a model adjusted for maternal hypertension and birth weight z-score and 1.00 in a model adjusted for these factors plus cesarean birth and antenatal steroid use.

There were also no significant between-group differences in rates of severe neonatal morbidities. The results were also similar for a subsample of 1,648 triplets and 4,944 matched singletons born at 24 to 28 weeks' gestation.

"Our findings from a large cohort of neonates can be used to provide reassuring results for families and care providers that although triplets do incur strain to already resource-limited neonatal units, their outcomes are similar to those of singletons," the authors conclude.

The study had no commercial funding and the authors have declared no relevant conflicts of interest.

SOURCE: https://bit.ly/2R3jJOv

Pediatrics 2018.

EARLY EPO AND NEUROPROTECTION FOR PREEMIES

Early EPO Offers Neuroprotection for Preemies: Meta-analysis

By Reuters Staff

April 10, 2017

NEW YORK (Reuters Health) - Early prophylactic administration of recombinant human erythropoietin (rhEPO) improves neurodevelopmental outcomes in very preterm babies, a meta-analysis of randomized controlled trials confirms.  However, more work is needed to figure out optimal dosing and timing of administration, the authors say in a report online April 7 in Pediatrics. Improving neurodevelopmental outcomes is a “major goal” in neonatology, especially with regard to the increasing survival rate of very premature infants, and rhEPO is one of the most promising agents to accomplish this, they point out.

Dr. Christof Dame and colleagues from the neonatology department at Charite University Medical Center in Berlin did a pooled analysis of four randomized controlled trials that investigated the use of rhEPO in preterm infants (<= 32 weeks' gestational age) and reported neurodevelopmental outcomes at 18 to 24 months' corrected age. The studies were mostly of high methodological quality with a low risk of bias, they say.

Their analysis showed a significant reduction in the incidence of a Mental Developmental Index (MDI) score lower than 70 on the Bayley Scales of Infant Development with prophylactic rhEPO administration. “The beneficial effect of prophylactic rhEPO on the incidence of MDI lower than 70 at 18 to 24 months' corrected age was consistent across all studies. With an absolute risk reduction from 15.7% to 8.4% and a number needed to treat of 14 patients, the estimated effect is clinically relevant. The observed benefits of rhEPO are robust, because they are in agreement with available evidence from longer-term follow-up studies, which also reported improved cognitive outcomes,” the authors say.

Full article may be accessed at link below.

SOURCE: http://bit.ly/2oIBNTR

Pediatrics 2017.

Reuters Health Information © 2017 

Cite this article: Early EPO Offers Neuroprotection for Preemies: Meta-analysis - Medscape - Apr 07, 2017.