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.

PREOPERATIVE BLOOD TRANSFUSION NOT BENEFICIAL FOR SURGERY IN NEONATES

 PBT independently associated with increased morbidity and mortality in neonates undergoing surgery

WEDNESDAY, Oct. 28, 2020 (HealthDay News) -- For neonates undergoing surgery, preoperative blood transfusions (PBTs) are associated with increased 30-day morbidity and mortality, according to a study published online Oct. 21 in Pediatrics.

Katerina Dukleska, M.D., from the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, and colleagues identified all neonates who underwent surgery using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric Participant Use Data Files from 2012 to 2015. Mortality and composite morbidity (defined as any postoperative complication) were compared for neonates who did and those who did not receive a PBT within 48 hours of surgery.

The researchers found that 9.9 percent of the 12,184 neonates identified received a PBT. Compared with those who did not receive a transfusion, neonates who received a PBT had higher rates of preoperative comorbidities and worse postoperative outcomes (composite morbidity: 46.2 versus 16.2 percent). PBTs were independently associated with 30-day morbidity and mortality in a multivariate regression analysis (odds ratios, 1.90 and 1.98, respectively). The associations persisted in a propensity score-matched analysis (odds ratios, 1.53 and 1.58, respectively).

"In some cases, blood transfusions may be doing more harm than good when used before surgery in our most critically ill infants," a coauthor said in a statement. "Giving a transfusion in anticipation of blood loss may seem prudent, but our findings suggest that a 'wait and see' approach to giving infants blood during surgery may reduce surgical complications and the risk of death."

Abstract/Full Text (subscription or payment may be required)

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.

BATHING BABIES MORE THAN ONCE A WEEK NEARLY DOUBLES ECZEMA RISK

Bathing Babies More Than Once a Week Nearly Doubles Eczema Risk

Ingrid Hein

June 23, 2020

Bathing an infant more than once a week nearly doubles the risk for eczema, and each additional bath increases the risk for skin-barrier dysfunction, according to new research.

"More bathing results in higher transdermal water loss," said investigator Thomas Marrs, PhD, from King's College London.

Maybe we are only meant to bath weekly, he told Medscape Medical News.

Previous studies have looked at bathing frequency in infants with eczema, but this is the first time investigators have looked at bathing in a general population of infants at a time when eczema typically develops, he said.

"Different professionals advise differently. Wash less? Wash more? There's a wide range of difference in awareness of the importance of this," he said. And although this is an observational study, it "tells us there is a relationship between bathing and skin dryness."

Marrs presented results from a recent study on the link between bathing, skin-barrier dysfunction, and eczema at the European Academy of Allergy and Clinical Immunology 2020 Digital Congress.

For their study, he and his colleagues assessed babies from England and Wales who were part of the Enquiring About Tolerance (EAT) study, which evaluated the early introduction of food and allergy development.

Parents completed a questionnaire when their 3-month-old infants were enrolled in EAT, and again at 12 months. They were asked about the use of moisturizer, shampoo, soap, bubble baths, bath oil, and baby wipes, bathing frequency, and their assessment of how dry the baby's skin was.

Infants were assessed at 3 months and 12 months for eczema, using the International Study of Asthma and Allergies in Childhood (ISAAC) protocol, and for transdermal water loss on the left forearm skin.

The risk for eczema at 3 months was significantly higher in babies bathed more than once weekly than in those bathed less often (adjusted odds ratio [aOR], 1.69; P = .03).

Risk for Atopic Dermatitis
Baths per Week	Prevalence of Eczema, %
≤1	14.6
2–4	26.9
5–6	25.2
≥7	23.2

"In the first few months of life, there's a pride in routine, in bath, story, bed," Marrs said. However, "I would caution against a daily bathing routine; once a week is enough for a young baby, particularly if they have risk factors for developing eczema."

But for babies who have eczema, bathing should perhaps be done more frequently to avoid infection. For these infants, "this is more complicated," he explained. "Eczema gets more angry when it is left to be infected. The more staph on the skin, the more inflamed. So it may be important to wash more, but we don't know where the balance lies."

At 3 months, skin-barrier dysfunction — transdermal water loss of at least 15 g/m² per h — was higher in the 317 infants (24.4%) who had eczema than in the 986 who did not (15.7 vs 12.4 g/m² per h; P < .001).

And each additional bath per week was independently associated to skin-barrier dysfunction after adjustment for family history of eczema, inherited filaggrin mutation, and family reporting of dry skin and use of emollients (aOR, 1.21; P < .001).

Skin-barrier dysfunction was seen in 14.6% of those bathed no more than once a week, 26.4% in those bathed two to four times a week, 30.4% of those bathed five or six times a week, and 44.0% of those bathed at least daily.

The association between bathing frequency and eczema was lost at 12 months.

"This is really an observational study showing an association in early life," Marrs said. "We need a more robust study. Bathing wasn't absolutely stable from 3 to 12 months of age."

Food Sensitization and Bathing

Although less bathing improved transdermal water loss and eczema, it did not improve rates of food sensitization. I

n fact, at 12 months, food sensitization scores were better in frequent bathers.

On skin-prick tests, sensitization was reduced in frequent bathers for peanut (≥3 mm; aOR, 0.22; P = .004) and egg (≥3 mm; aOR, 0.43; P = .04), even after correction for the presence of eczema at 3 months.

"What struck me is that while there was a big decrease in skin sensitization, it wasn't there when we looked in the blood. We can't say there's cause and effect without a clinical trial," Marrs said. "These results were a surprise. It may be that the skin acts as a physical barrier, and if it's dry it's more permeable and more allergens can disrupt skin, which makes it more likely to get sensitization."

The strongest known risk factor of atopic dermatitis is a family history of atopic disease.

"We need to look further at this," he added. Although the study was not powered to look at this, it's "a very good thought teaser."

Around the world, eczema is on the rise, said Umit Sahiner, MD, from Hacettepe University in Ankara, Turkey, during his presentation on causes and current treatment approaches for eczema in children.

"The strongest known risk factor of atopic dermatitis is a family history of atopic disease," he said. "If one or both of the parents have it, the risk for the child is five- or sixfold."

In urban settings, ultraviolet exposure, a dry climate, a diet high in sugars, repeat use of antibiotics, and higher education have all been associated with increased risk for eczema, he said. To date, bathing has not been considered as a risk factor.

Marrs and Sahiner have disclosed no relevant financial relationships.

European Academy of Allergy and Clinical Immunology (EAACI) 2020 Digital Congress.

https://www.medscape.com/viewarticle/932836

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

WIRELESS MONITORING IN THE NICU

Wireless Monitoring in the NICU

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.

METH, OPIOID USE IN PREGNANCY ON RISE

THURSDAY, Nov. 29, 2018 (HealthDay News) -- Methamphetamine and opioid use has soared among pregnant American women, putting the health of baby and mother at risk, a new study finds. 

While addiction among pregnant women has dramatically increased across the country, it disproportionally affects women living in rural America, where access to addiction treatment and prenatal care is limited, the researchers added.

"Use of both substances represents worsening public health crises," said lead researcher Dr. Lindsay Admon, an assistant professor of obstetrics and gynecology at the University of Michigan in Ann Arbor.

Although government efforts to curb methamphetamine use have been effective in the past, its use has spiked once more, she said.

Some data suggests that stopping amphetamine use in pregnancy can improve outcomes, Admon said. "But as clinicians, we need clear guidance on how to best promote cessation among pregnant patients with amphetamine use disorders."

Moreover, doctors need ways to guide patients to treatment services, particularly in rural areas where obstetric and addiction treatment services may be harder to access. In addition, addicted women may not tell their doctors about their drug use for fear of the legal consequences, Admon noted.

Another women's health expert agreed with the findings.

"This study confirms what I have been hearing clinically from providers and patients in the West that there is an unrecognized problem with amphetamines, and that the opioid crisis is now coupled with an amphetamine crisis that desperately needs monetary, treatment and recovery infrastructure support to reduce it," said Hendree Jones, a professor of obstetrics and gynecology at the University of North Carolina in Chapel Hill.

Furthermore, the study provides compelling data that underscores the lack of addiction treatment resources for women of childbearing age, said Jones, who wasn't involved with the research.

For the study, Admon and colleagues collected data on 47 million births in U.S. hospitals over 12 years. 

They found that the number of births among women addicted to amphetamine, mostly methamphetamine, doubled from 2008 to 2015, from 1.2 per 1,000 births to 2.4 per 1,000 births.

In addition, opioid use more than quadrupled from 1.5 per 1,000 births between 2004 and 2005 to 6.5 per 1,000 between 2014 and 2015. 

Using amphetamine during pregnancy increases the odds of moms dying or having serious medical complications by nearly two times of that of women using opioids, the researchers found. 

Also the risk of preterm delivery, preeclampsia or eclampsia, heart failure or heart attack, and the need for a blood transfusion were higher among moms using amphetamine, compared with those using opioids, according to the study. 

The main risk to infants born to addicted mothers is neonatal abstinence syndrome. Basically, the infants are born addicted to the drug mom was using and they go through withdrawal, much as an adult does when they stop taking the drug.

Symptoms such as body shakes, tremors, breathing problems, diarrhea or throwing up and fever and sweating can last up to six months, according to the March of Dimes. 

Often these babies need to be in neonatal intensive care units for an extended period.

Between 2014 and 2015, amphetamine use caused delivery complications in roughly 1 percent of all births in the rural West (11 per 1,000 deliveries), which was higher than the number of complications among women using opioids in most areas. 

Opioid use during pregnancy was highest in rural areas of the Northeast, causing complications in nearly 3 percent of all births (29 per 1,000 deliveries).

Poor, white women on public assistance were the ones most likely to be using amphetamine and opioids, the researchers found.

In addition to using amphetamine and opioids, many of these women are also using marijuana and tobacco, said Dr. Rahul Gupta, chief medical and health officer at the March of Dimes.

"It's very troubling that of all the times in the lifecycle of an individual during pregnancy, women who are using opioids are also using tobacco," he said. "That almost seals the fate of the infant, as well as the health of the mother and the ability of the mother to take care of the child," Gupta said.

The report was published Nov. 29 in the American Journal of Public Health

Full article here