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Frontiers in Pediatrics 2022The present review considers some controversial management practices during extremely premature perinatal transition. We focus on perinatal prevention and treatment of... (Review)
Review
The present review considers some controversial management practices during extremely premature perinatal transition. We focus on perinatal prevention and treatment of respiratory distress syndrome (RDS) in immature infants. New concerns regarding antenatal corticosteroid management have been raised. Many fetuses are only exposed to potential adverse effects of the drug. Hence, the formulation and the dosage may need to be modified. Another challenge is to increase the fraction of the high-risk fetuses that benefit from the drug and to minimize the harmful effects of the drug. On the other hand, boosting anti-inflammatory and anti-microbial properties of surfactant requires further attention. Techniques of prophylactic surfactant administration to extremely immature infants at birth may be further refined. Also, new findings suggest that prophylactic treatment of patent ductus arteriosus (PDA) of a high-risk population rather than later selective closure of PDA may be preferred. The TREOCAPA trial (Prophylactic treatment of the ductus arteriosus in preterm infants by acetaminophen) evaluates, whether early intravenous paracetamol decreases the serious cardiorespiratory consequences following extremely premature birth. Lastly, is inhaled nitric oxide (iNO) used in excess? According to current evidence, iNO treatment of uncomplicated RDS is not indicated. Considerably less than 10% of all very premature infants are affected by early persistence of pulmonary hypertension (PPHN). According to observational studies, effective ventilation combined with early iNO treatment are effective in management of this previously fatal disease. PPHN is associated with prolonged rupture of fetal membranes and birth asphyxia. The lipopolysaccharide (LPS)-induced immunotolerance and hypoxia-reperfusion-induced oxidant stress may inactivate NO-synthetases in pulmonary arterioles and terminal airways. Prospective trials on iNO in the management of PPHN are indicated. Other pulmonary vasodilators may be considered as comparison drugs or adjunctive drugs. The multidisciplinary challenge is to understand the regulation of pregnancy duration and the factors participating the onset of extremely premature preterm deliveries and respiratory adaptation. Basic research aims to identify deficiencies in maternal and fetal tissues that predispose to very preterm births and deteriorate the respiratory adaptation of immature infants. Better understanding on causes and prevention of extremely preterm births would eventually provide effective antenatal and neonatal management practices required for the intact survival.
PubMed: 35620146
DOI: 10.3389/fped.2022.862038 -
Pediatrics and Neonatology Oct 2014For premature infants with advanced acute abdomen, creating a temporary enterostomy is believed to be an appropriate surgical management. However, there is no consensus...
BACKGROUND
For premature infants with advanced acute abdomen, creating a temporary enterostomy is believed to be an appropriate surgical management. However, there is no consensus regarding the timing of enterostomy reversal. The aim of this study was to determine the optimal timing for enterostomy closure (EC) by analyzing EC-related complications.
METHODS
This was a retrospective study of preterm infants who underwent enterostomy for suspected acute abdomens and subsequent closure.
RESULTS
EC-related complications occurred in 35 of 54 infants (65%). A univariate analysis determined the following risk factors for EC-related complications: lower weight and younger age at the time of EC and a shorter stoma duration. In a multiple logistic regression analysis, the only significant risk factor was a weight under 2660 g at the time of the closure operation. Infants with EC-related complications were ventilated longer, were administered more vasopressors, and were more likely to undergo reoperation. Additionally, these infants required parenteral nutrition for a longer duration, had a longer length of hospital stay after EC, and had a significantly lower weight and height at a corrected age of 7-10 months than infants without EC-related complications.
CONCLUSION
Body weight may be one of the most important factors to consider for minimizing EC-related complications.
Topics: Abdomen, Acute; Age Factors; Enterostomy; Female; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Infant, Premature, Diseases; Length of Stay; Male; Parenteral Nutrition; Postoperative Complications; Retrospective Studies; Time Factors
PubMed: 24582165
DOI: 10.1016/j.pedneo.2014.01.001 -
Pediatrics Nov 2003Patent ductus arteriosus (PDA), a common finding among premature infants, is conventionally treated by intravenous indomethacin. Intravenous ibuprofen was recently shown...
OBJECTIVE
Patent ductus arteriosus (PDA), a common finding among premature infants, is conventionally treated by intravenous indomethacin. Intravenous ibuprofen was recently shown to be as effective and to have fewer adverse reactions in preterm infants. If equally effective, then oral ibuprofen for PDA closure would have several important advantages over the intravenous route. This study was designed to determine whether oral ibuprofen treatment is efficacious and safe in closure of a PDA in premature infants with respiratory distress syndrome.
METHODS
Twenty-two preterm newborns (gestational age: 27.5 +/- 1.75 [range: 23.9-31 weeks]; weight: 979 +/- 266 [range: 380-1500 g]) with PDA and respiratory distress syndrome were studied prospectively. They received oral ibuprofen suspension 10 mg/kg/body weight for the first dose, followed at 24-hour intervals by 2 additional doses of 5 mg/kg each, if needed, starting on the second day of life. Echocardiography was performed before treatment and 24 hours after each dose. Every child underwent cranial ultrasonography before and after each ibuprofen dose. The rate of ductal closure, the need for additional treatment, side effects, complications, and the infants' clinical courses were recorded.
RESULTS
Ductal closure was achieved in all newborns except for 1 (95.5%), in whom clinically nonsignificant ductal shunting persisted. No infant required surgical ligation of the ductus. There was no reopening of the ductus after closure had been achieved. Fourteen newborns were treated with 1 dose of ibuprofen, 6 were treated with 2 doses, and the remaining 2 were treated with 3 doses. The survival rate at 1 month was 86.4% (19 of 22). Three (13.6%) infants died from the following causes: 1 who was born at 24 weeks' gestation with a birth weight of 380 g died as a result of extreme prematurity complications, necrotizing enterocolitis, and low birth weight; 1 died as a result of Candida sepsis; and the third died as a result of Klebsiella sepsis. Intraventricular hemorrhage was observed in 7 infants. The classification was changed from grade 2 to grade 3 in 1 and from grade 0 to grade 1 or higher in 3 others. The rate of survival to discharge was 86.4% (19 of 22). No bronchopulmonary dysplasia was observed in the study group, and there was no case of tendency to bleed. There were no significant differences in the levels of serum creatinine before and after treatment with oral ibuprofen.
CONCLUSIONS
Oral ibuprofen suspension may be an effective and safe alternative for PDA closure in premature infants with PDA. However, larger comparative studies are warranted.
Topics: Administration, Oral; Cerebral Hemorrhage; Drug Evaluation; Ductus Arteriosus, Patent; Gestational Age; Humans; Ibuprofen; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Leukomalacia, Periventricular; Pilot Projects; Prospective Studies; Respiratory Distress Syndrome, Newborn; Safety; Suspensions; Treatment Outcome; Ultrasonography
PubMed: 14595076
DOI: 10.1542/peds.112.5.e354 -
Catheterization and Cardiovascular... Oct 2017The advent of Amplatzer Duct Occluder II additional Size (ADOIIAS) provided the potential to close hemodynamic significant patent ductus arteriosus (HSPDA) and to...
OBJECTIVES
The advent of Amplatzer Duct Occluder II additional Size (ADOIIAS) provided the potential to close hemodynamic significant patent ductus arteriosus (HSPDA) and to analyze the feasibility, safety and efficacy of the device.
BACKGROUND
Treatment of a patent ductus arteriosus (PDA) in very premature neonates is still a dilemma for the neonatalogist who has to consider its significance and has to choose among different treatment options. Because surgical ligation and medical therapy both have their drawbacks, interventional catheterization might provide an alternative means of closing HSPDA.
MATERIAL AND METHODS
Between September 2013 and June 2015, 32 premature infants with complications related to HSPDA defined by ultrasound (US) underwent transcatheter closure. The procedure was performed in the catheterization laboratory by venous cannulation without angiography. The position of the occluder was directed by X-ray and US. In particular we looked at procedural details, device size selection, complications, and short and mid-term outcomes.
RESULTS
Thirty two premature infants, all of whom had clinical complications related to HSPDA, born at gestational ages ranging between 23.6 and 36 weeks (mean ± standard deviation 28 ± 3 weeks) underwent attempted transcatheter PDA closure using the ADOIIAS. Their mean age and weight at the time of procedure was 25 days (range 8-70 days) and 1373 g (range 680-2480 g), respectively. Ten infants weighed ≤1,000g. All ducts were tubular. The mean PDA and device waist diameters were 3.2 ± 0.6mm (range 2.2-4) and 4.4 ± 0.6 mm, respectively, and the mean PDA and device lengths 5.2 ± 2.0 mm (range 2-10) and 3.4 ± 1.3 mm. Median fluoroscopy and procedural times were 11 min (range 3-24) and 28 min (range 10-90), respectively. Complete closure was achieved in all but one patient. There was no device migration. A left pulmonary artery (LPA) obstruction developed in one patient. Five infants died. Four deaths were related to complications of prematurity and one death in a 680 g infant was related to the procedure.
CONCLUSIONS
It is feasible to close HSPDA in relative safety in premature infants who have severe and complex disease. Success requires perfect selection of the occluder and exact positioning by US. © 2017 Wiley Periodicals, Inc.
Topics: Birth Weight; Cardiac Catheterization; Ductus Arteriosus, Patent; Echocardiography, Doppler, Color; Gestational Age; Hemodynamics; Humans; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Prosthesis Design; Radiography, Interventional; Septal Occluder Device; Treatment Outcome
PubMed: 28471089
DOI: 10.1002/ccd.27091 -
Pediatric Cardiology Mar 2021Transcatheter patent ductus arteriosus closure (TCPC) is an emerging treatment for low birth weight extremely premature neonates (EPNs). Left pulmonary artery (LPA) and...
Transcatheter patent ductus arteriosus closure (TCPC) is an emerging treatment for low birth weight extremely premature neonates (EPNs). Left pulmonary artery (LPA) and descending aorta (DAO) obstruction are described device-related complications, however, data on mid- and long-term vascular outcomes are lacking. A retrospective analysis of EPNs who underwent successful TCPC at our institution from 03/2013 to 12/2018 was performed. Two-dimensional echocardiography and spectral Doppler velocities from various time points before and after TCPC were used to identify LPA and DAO flow disturbances. A total of 44 EPNs underwent successful TCPC at a median (range) procedural weight of 1150 g (755-2500 g). Thirty-two (73%) patients were closed with the AVP II and 12 (27%) with the Amplatzer Piccolo device. LPA and DAO velocities on average remained within normal limits and improved spontaneously in long-term follow up (26.1 months, range 1-75 months). One patient, who had concerning LPA flow characteristics immediately after device implant (peak velocity 2.6 m/s) developed progressive LPA stenosis requiring stent placement 3 months post-procedure. In the remaining infants, including 7 (16%) who developed LPA and 3 (7%) who developed DAO flow disturbances (range 2-2.4 m/s), all had progressive normalization of flow velocities over time. TCPC can be performed safely in EPNs with a low incidence of LPA and DAO obstruction. In the absence of significant progressive vascular obstruction in the early post-procedure period, mild increases in LPA and DAO flow velocities tend to improve spontaneously and normalize in long-term follow-up.
Topics: Aorta, Thoracic; Cardiac Catheterization; Ductus Arteriosus, Patent; Female; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Male; Pulmonary Artery; Retrospective Studies; Risk Factors; Stenosis, Pulmonary Artery; Treatment Outcome
PubMed: 33394112
DOI: 10.1007/s00246-020-02523-8 -
The Journal of Craniofacial Surgery Sep 2023The purpose of this study was to characterize a novel type of calvarial thickening and provide objective measurements of skull thickness and calvarial suture morphology...
PURPOSE
The purpose of this study was to characterize a novel type of calvarial thickening and provide objective measurements of skull thickness and calvarial suture morphology in patients with bronchopulmonary dysplasia.
METHODS
Infants with severe bronchopulmonary dysplasia who also had undergone computed tomography (CT) scans were identified from the neonatal chronic lung disease program database. Thickness analysis was performed using Materialise Mimics.
RESULTS
The chronic lung disease team treated 319 patients during the study interval of which, 58 patients (18.2%) had head CT available. Twenty-eight (48.3%) were found to have calvarial thickening. The rate of premature suture closure in the study population was 36.2% (21 of 58 patients), with 50.0% of affected cohort having evidence of premature suture closure on the first CT scan. Multivariate logistic regression identified 2 risk factors, requiring invasive ventilation at 6 months of age and fraction of inspired oxygen requirement at 6 months of age. Increased head circumference at birth protected against the development of calvarial thickening.
CONCLUSIONS
We have described a novel subset of patients with chronic lung disease of prematurity who have calvarial thickening with remarkably high rates of premature closure of cranial sutures. The exact etiology of the association is unknown. In this patient population with radiographic evidence of premature suture closure, operative decision should be made after considering unequivocal evidence of elevated intracranial pressure or dysmorphology and balanced against the risk of the procedure.
Topics: Humans; Child; Infant, Newborn; Bronchopulmonary Dysplasia; Craniosynostoses; Skull; Cranial Sutures; Phenotype
PubMed: 37431930
DOI: 10.1097/SCS.0000000000009528 -
The Journal of Pediatrics Oct 2016To study the biologic effect of paracetamol, an inhibitor of prostaglandin synthase, on early closure of ductus arteriosus, and to evaluate possible adverse effects... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To study the biologic effect of paracetamol, an inhibitor of prostaglandin synthase, on early closure of ductus arteriosus, and to evaluate possible adverse effects associated with the drug.
STUDY DESIGN
In a controlled, double-blind, phase I-II trial, very low gestational age (<32 weeks) infants requiring intensive care were randomly assigned to intravenous paracetamol or placebo (0.45% NaCl). A loading dose of 20 mg/kg was given within 24 hours of birth, followed by 7.5 mg/kg every 6 hours for 4 days. Daily cardiac ultrasound examinations of ductal calibers were performed before the first dose, and until 1 day after the last dose. The main outcome was a decrease in the ductal caliber without side effects.
RESULTS
Of 63 screened infants, 48 were randomized: 23 were assigned to paracetamol and 25 to placebo. Before the intervention, their ductal calibers were similar. During the intervention, the ductus closed faster in the paracetamol group (hazard ratio 0.49, 95% CI 0.25-0.97, P = .016). The mean (95% CI) postnatal ages for ductal closure were 177 hours (31.1-324) for the paracetamol-treated vs 338 hours (118-557) for controls (P = .045). Paracetamol serum levels were within the therapeutic range, and no adverse effects were evident.
CONCLUSIONS
Prophylactic paracetamol induced early closure of the ductus arteriosus without detectable side effects. Further trials are required to determine whether intravenous paracetamol may safely prevent symptomatic patent ductus arteriosus.
TRIAL REGISTRATION
ClinicalTrials.gov: NCT01938261; European Clinical Trials Database: EudraCT 2013-008142-33.
Topics: Acetaminophen; Administration, Intravenous; Analgesics, Non-Narcotic; Double-Blind Method; Ductus Arteriosus, Patent; Female; Gestational Age; Humans; Infant, Newborn; Infant, Premature; Infant, Very Low Birth Weight; Male; Premature Birth; Treatment Outcome
PubMed: 27215779
DOI: 10.1016/j.jpeds.2016.04.066 -
Echocardiographic parameters predicting spontaneous closure of ductus arteriosus in preterm infants.Frontiers in Pediatrics 2023To evaluate the value of echocardiographic parameters in predicting early spontaneous closure of ductus arteriosus in premature infants.
OBJECTIVE
To evaluate the value of echocardiographic parameters in predicting early spontaneous closure of ductus arteriosus in premature infants.
METHODS
222 premature infants admitted to the neonatal ward of our hospital were selected, and patent ductus arteriosus was detected by echocardiography 48 h after birth. On the 7th day, whether the ductus arteriosus was closed naturally in this cohort was observed. The infants whose ductus arteriosus were not closed were identified as the PDA group ( = 109), and the other infants were included in the control group ( = 113). The echocardiographic parameters of the two groups of premature infants at 48 h after birth were single-factor statistically and Pearson correlation analyzed, and the parameters with statistically significant differences in single-factor analyzed were selected for multivariate logistic stepwise regression analysis.
RESULTS
The ductus arteriosus shunt velocity and the pressure difference between the descending aorta and the pulmonary artery (ΔPs) in the PDA group were lower than those in the control group ( < 0.05). The pulmonary artery pressure (PASP) in the PDA group was higher than that in the control group ( < 0.05). According to the multivariate logistic stepwise regression analysis, only the maximum shunt velocity of ductus arteriosus was correlated with early spontaneous closure of ductus arteriosus in 48 h first echocardiographic parameters ( = 0.049). The receiver operating characteristic (ROC) curve indicates the optimal critical point of echocardiographic ductus arteriosus shunt velocity in premature infants 48 h after birth was 1.165 m/s.
CONCLUSION
Echocardiographic parameters are of great value in predicting the early spontaneous closure of ductus arteriosus in premature infants. In particular, the ductus arteriosus shunt velocity is correlated with the early spontaneous closure of ductus arteriosus.
PubMed: 37397143
DOI: 10.3389/fped.2023.1198936 -
Developmental Pharmacology and... 1988Patent ductus arteriosus (PDA) in premature infants is a current challenge to pediatricians. Pharmacological closure of PDA with indomethacin, a prostaglandin synthetase... (Review)
Review
Patent ductus arteriosus (PDA) in premature infants is a current challenge to pediatricians. Pharmacological closure of PDA with indomethacin, a prostaglandin synthetase inhibitor is an effective drug therapy, along with usual medical treatment. Administration of indomethacin may decrease mortality and morbidity (e.g. bronchopulmonary dysplasia) among very small premature infants (less than 1,000 g). Co-administration of furosemide with indomethacin may lessen the transient renal side effects of indomethacin. The therapeutic efficacy of indomethacin in closure of PDA depends largely on understanding and manipulation of the pharmacokinetic characteristics of the drug in preterm infants. Maintaining a therapeutic level of the drug in plasma is essential to achieve an optimal therapeutic response. Compared to surgical ligation, indomethacin is a noninvasive, less expensive and safer therapy for ductus closure.
Topics: Ductus Arteriosus, Patent; Humans; Indomethacin; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature
PubMed: 3066603
DOI: 10.1159/000457690 -
Taiwanese Journal of Obstetrics &... Jul 2021Spina bifida (SB) is a congenital birth defect defined as a failure of the neural tube formation during the embryonic development phase. Fetoscopic repair of SB is a... (Review)
Review
OBJECTIVE
Spina bifida (SB) is a congenital birth defect defined as a failure of the neural tube formation during the embryonic development phase. Fetoscopic repair of SB is a novel treatment technique that allows to close spinal defect early and prevent potential neurological and psychomotor complications.
CASE REPORT
We present a case report of a 32-year-old-multigravida whose fetus was diagnosed with lumbosacral myelomeningocele at 23rd week. Fetoscopic closure of MMC was performed at 26 weeks. At 32 weeks, due to premature amniorrhexis and placental abruption, an emergency C-section was performed. Newborn's psychomotor development was within normal limits.
CONCLUSION
Although intrauterine treatment has an increased risk of premature labor, placental abruption, prenatal closure is associated with improved postnatal psychomotor development. Prenatal surgery decreases the risk of Arnold-Chiari II malformation development and walking disability. Fetoscopic closure of SB is becoming a choice for treatment with beneficial outcomes for mother and fetus.
Topics: Abruptio Placentae; Adult; Cesarean Section; Female; Fetal Membranes, Premature Rupture; Fetoscopy; Humans; Infant, Newborn; Lumbosacral Region; Meningomyelocele; Pregnancy; Pregnancy Trimester, Second; Spinal Dysraphism
PubMed: 34247822
DOI: 10.1016/j.tjog.2021.05.032