Neonatal Intra-Ventricular-Hemorrhage Prevention in Premature at < 30 Weeks Gestational Age

Introduction: Intraventricular Hemorrhage (IVH) is a devastating condition mostly in preterm infants at &lt; 30 weeks GA with large morbidities and mortality usually in the first 72 hours after birth. Prevention seems to be the only way to completely deal with this problem. The IVH prevention in this age group has been studied and includes some strategies such as prenatal corticosteroids, cesarean delivery, careful extraction among others, but still, it has an unacceptably high incidence in this population.Objective: To measure the application of a quality improvement project develop from the "Drive to Zero IVH Prevention Project" presented in a Epiclatino lecture in our unit.Material and method: We design a before and after observational study and measured the incidence of IVH before and after October 2017 when a minimum manipulation protocol was implemented at the Cl&iacute;nica del Country (CDC) unit. We also compare these findings to those of other units in the EpicLatino network. All patients born &lt;30 weeks GA with less than 2 days of age, who survived at least 3 days, and had a neuroimaging taken were included. We compared demographics, diagnosis, and frequency of IVH cases, before Nov 2017 and after from CDC and the from 2018-2019 EpicLatino registry using a bivariate analysis. Results: We collected data from 46 cases before, 40 after implementation, and 203 cases from the EpicLatino registry. Demographic characteristics were very similar in the post-intervention with few statistically significant differences in antenatal steroid use (97.5% post, 96% before and 79.3% Epilatino, p=0.016), prolonged rupture of membranes (15% post, 4% before and 15% EpicLatino, p &lt;0.001), vaginal deliveries (7.5% post, 10.9% before and 24.1% Epilatino, p=0.01), suspended chorioamnionitis (12.5% post, 6% before and 20.2% Epiclatino). We found a significant reduction in IVH after the protocol was implemented with only 5 (7.5%) cases post-intervention compared to 19 (29.4%) case before, and when compared to the 81 (39.1%) cases in the registry, p&lt; 0.001. Most of the cases that occurred in the post-intervention occurred before admission to the unit due to obstetric trauma.Discussion: If a well-controlled delivery minimizing obstetric trauma is achieved, a minimal manipulation protocol appears to significantly decrease the incidence of HIV. Controlled, multicenter studies are still required to confirm these findings.

Association of Antenatal Corticosteroid Exposure and Infant Survival at 22 and 23 Weeks

Objective In 2014, the leading obstetric societies published an executive summary of a joint workshop to establish obstetric interventions to be considered for periviable births. Antenatal corticosteroid administration between 220/7 and 226/7 weeks was not recommended given existing evidence. We sought to evaluate whether antenatal steroid exposure was associated with improved survival among resuscitated newborns delivered between 22 and 23 weeks of gestation. Study Design We conducted a population-based cohort study of all resuscitated livebirths delivered between 220/7 and 236/7 weeks of gestation in the United States during 2009 to 2014 utilizing National Center for Health Statistics data. The primary outcome was rate of survival to 1 year of life (YOL) between infant cohorts based on antenatal steroid exposure. Multivariable logistic regression estimated the association of antenatal steroid exposure on survival outcomes. Results In the United States between 2009 and 2014, there were 2,635 and 7,992 infants who received postnatal resuscitation after delivery between 220/7 to 226/7 and 230/7 to 236/7 weeks of gestation, respectively. Few infants born at 22 (15.9%) and 23 (26.0%) weeks of gestation received antenatal corticosteroids (ANCS). Among resuscitated neonates, survival to 1 YOL was 45.2 versus 27.8% (adjusted relative risk [aRR]: 1.6, 95% confidence interval [CI]: 1.2–2.1) and 57.9 versus 47.7% (aRR: 1.3, 95% CI: 1.1–1.5) for infants exposed to ANCS compared with those not exposed at 22 and 23 weeks of gestation, respectively. When stratified by 100 g birth weight category, ANCS were associated with survival among neonates weighing 500 to 599 g (aRR: 1.9, 95% CI: 1.3–2.9) and 600 to 699 g (aRR: 1.7, 95% CI: 1.1–2.6) at 22 weeks. Conclusion Exposure to ANCS was associated with higher survival rates to 1 YOL among resuscitated infants born at 22 and 23 weeks. National guidelines recommending against ANCS utilization at 22 weeks should be re-evaluated given emerging evidence of benefit. Key Points

Necrotising enterocolitis, late-onset sepsis and mortality after routine probiotic introduction in the UK

ObjectiveTo compare necrotising enterocolitis (NEC), late-onset sepsis (LOS), focal intestinal perforation (FIP) and mortality in infants from a single neonatal unit before and after probiotic introduction.DesignRetrospective review of infants <32 weeks admitted January 2009–December 2012 (no probiotic) and January 2013–December 2017 (routine probiotics). Infants included were admitted before day 3, and not transferred out before day 3. NEC, LOS and FIP were defined with standard definitions.Patients1061 infants were included, 509 preprobiotic and 552 postprobiotic. Median gestation, birth weight and antenatal steroid use did not differ, and proportions of extremely low birthweight infants were similar (37% and 41%).ResultsOverall unadjusted risk of NEC (9.2% (95% CI 7.1 to 12.1) vs 10.6% (95% CI 8.2 to 13.4), p=0.48), LOS (16.3% (95% CI 13.2 to 19.6) vs 14.1% (95% CI 11.5 to 17.4), p=0.37) and mortality (9.2% (95% CI 7.1 to 12.1) vs 9.7% (95% CI 7.6 to 12.6), p=0.76) did not differ, nor proportion of surgical NEC. In multiple logistic regression, accounting for gestation, birth weight, antenatal steroid, maternal milk, chorioamnionitis and sex, probiotic receipt was not significantly associated with NEC (adjusted OR (aOR) 1.08 (95% CI 0.71 to 1.68), p=0.73), LOS or mortality. In subgroup (645 infants) >28 weeks, aOR for NEC in the probiotic cohort was 0.42 (95% CI 0.2 to 0.99, p=0.047). FIP was more common in the probiotic cohort (OR 2.3 (95% CI 1.0 to 5.4), p=0.04), not significant in regression analysis (2.11 (95% CI 0.97 to 4.95), p=0.05).ConclusionsProbiotic use in this centre did not reduce overall mortality or rates of NEC, LOS or FIP but subgroup analysis identified NEC risk reduction in infants >28 weeks, and LOS reduction <28 weeks.

Predictors of mortality in premature babies with respiratory distress syndrome treated by early rescue surfactant therapy

OBJECTIVE: To determine the predictors of mortality following early rescue surfactant therapy in preterm babies with respiratory distress syndrome. STUDY DESIGN: Prospective cohort study enrolling babies between 28 weeks to 34 weeks with respiratory distress syndrome requiring early rescue surfactant therapy. For statistical analysis babies were further divided into two subgroups: survivors and non-survivors. Maternal and neonatal variables were compared between the two groups to find out the predictors of mortality. RESULTS: Out of total 110 babies, 72 (65.45%) survived. The mean birth weight and mean gestational age of the study population was 1614.36 (±487.86) g and 31.40 (±2.0)1 weeks, respectively. Birth weight < 1500 g, gestational age < 32 weeks, primiparity, vaginal delivery, prolonged rupture of membranes, lack of antenatal steroid cover, bag and mask ventilation at birth, sepsis, apneic episodes and mechanical ventilation were significantly associated with death on univariate analysis. On multivariate analysis, very low birth weight, vaginal delivery, lack of antenatal steroid cover, bag and mask ventilation at birth and mechanical ventilation were found to be independent predictors of mortality. CONCLUSIONS: Some of the identified predictors of mortality are modifiable and can be used to draw up a screening tool to predict the clinical severity and mortality among these babies.

A Question of Timing: 10-year Retrospective Analysis on the Use of Antenatal Steroids for Imminent Preterm Birth

Objective Antenatal steroids improve the neonatal outcome if they are administered within a therapeutic window of seven days before preterm birth. The aim of this study was to evaluate the timing of antenatal steroids for imminent preterm birth at a single center in Germany. Material and Methods A 10-year retrospective analysis of 843 preterm births between 24/0 and 33/6 weeks was performed from January 2008 to December 2017 at a German university hospital. We evaluated the timing of antenatal steroids according to the indication for their application. Descriptive statistics and binomial regression were performed to analyze factors influencing the timing of antenatal steroid administration. Results Of 843 preterm births below 34 weeks included in our study, 752 pregnant women received antenatal steroids (89.2%). Only 301/843 women (35.7%) gave birth within the optimal window of 7 days after antenatal steroids. 91/843 women (10.8%) did not receive steroids. 130/843 women (15.4%) only received one dose, 76/843 (9.0%) gave birth within 8 to 14 days, and 245/843 (29.1%) more than 14 days later. In a binomial regression model, preterm premature rupture of membranes (OR 3.40, 95% CI 1.81 to 6.39, p<0.001), fetal growth restriction (OR 3.27, 95% CI 1.63 to 6.58, p=0.001), and preeclampsia (OR 2.83, 95% CI 1.37 to 5.83, p=0.005) were positively associated with optimal timing. Conclusion Two thirds of women with preterm birth before 34 weeks received antenatal steroids outside the optimal therapeutic window. Further research is needed to achieve an optimal effect of antenatal steroids on neonatal outcome and to reduce untimely as well as unnecessary interventions.

The Controversy Persists: Is There a Qualification Criterion to Utilize Inhaled Nitric Oxide in Pre-term Newborns?

Inhaled nitric oxide (iNO) use in premature newborns remains controversial among clinicians. In 2014, the American Academy of Pediatrics, Committee on Fetus and Newborn released a statement that the available data do not support routine iNO use in pre-term newborns. Despite the absence of significant benefits, 2016 California data showed that clinicians continue to utilize iNO in pre-term infants. With studies as recent as January 2017, the Cochrane review confirmed no major advantages of iNO in pre-term newborns. Still, it recognized that a subset of pre-term infants with pulmonary hypertension (PHTN) had not been separately investigated. Furthermore, recent non-randomized controlled trials have suggested that iNO may benefit specific subgroups of pre-term newborns, especially those with PHTN, prolonged rupture of membranes, and antenatal steroid exposure. Those pre-term infants who showed a clinical response to iNO had increased survival without disability. These findings underscore the need for future studies in pre-term newborns with hypoxemic respiratory failure and PHTN. This review will discuss the rationale for using iNO, controversies regarding the diagnosis of PHTN, and additional novel approaches of iNO treatment in perinatal asphyxia and neonatal resuscitation in the pre-term population &lt; 34 weeks gestation.

Antenatal Steroid Utilization in Ethiopia

Background. Administration of antenatal corticosteroids to pregnant mothers is one of the most effective interventions to decrease preterm neonatal mortality. In this study we assessed antenatal steroid utilization by the mother and its effect on preterm babies. Method. Two years prospective, multicenter, observational study was conducted in selected hospitals of Ethiopia. Significance of the study outcomes was tested by chi-square and binary logistic regression. Result. Out of 4919 participants, 1575 preterm babies whose gestational ages were below 35 weeks were included in the study. Use of antenatal dexamethasone was 37.5% among study participants. The risk of early onset neonatal sepsis 235 (40.4%) was higher in preterm babies whose mother took antenatal dexamethasone ( P-value .002) than those who did not. Conclusion. Antenatal dexamethasone use in our study was comparable with other low and middle-income countries. Risk of early onset neonatal sepsis was higher among infants whose mother took antenatal dexamethasone.