Risk assessment of survival and morbidity of infants born at <24 completed weeks of gestation.

BACKGROUND: Infants born at the threshold of viability have a high risk of mortality and morbidity. The British Association of Perinatal Medicine (BAPM) provided updated guidance in 2019 advising a risk-based approach to balancing decisions about active versus redirected care at birth. AIMS: To determine survival and morbidity of infants born between 22 and 24 completed weeks of gestation. To develop a scoring system to categorise infants at birth according to risk for mortality or severe adverse outcome. METHODS: A retrospective, single centre observational study of infants who received neonatal care from 2011 to 2021. Data were collected on mortality, morbidity and two-year neurodevelopmental outcomes. Each infant was risk categorised utilising the proposed tools in the BAPM (2019) framework. A composite adverse score for either dying or surviving with severe impairment was created. RESULTS: Four infants born at 22 weeks, 49 at 23 weeks and 105 at 24 weeks of gestation were included. The mortality rate was 23.4 %. Following risk categorisation there were 8 (5.1 %) extremely high risk, 44 (27.8 %) high risk and 106 (67.1 %) moderate risk infants. The rate of dying or surviving with severe impairment for extremely high risk, high risk and moderate risk were 100 %, 88.9 % and 53 % respectively. The proportions with the composite adverse outcome differed significantly according to the risk category (p < 0.001). CONCLUSIONS: When applying a scoring system to risk categorise infants at birth, high rates of dying or surviving with severe impairment were found in infants born at 22 or 23 weeks of gestation.

Diaphragmatic ultrasound and patent ductus arteriosus in the newborn: A retrospective case series.

Background: Patent ductus arteriosus (PDA) and diaphragmatic dysfunction are frequently seen in newborn infants but their relationship remains unknown. We aimed to use point of care ultrasound to compare diaphragmatic kinetics in infants with a PDA compared to in those without a PDA. Methods: M-mode ultrasonography was used to measure the mean inspiratory velocity (V I) in newborn infants with and without a haemodynamically significant PDA admitted in the Neonatal Unit at King's College Hospital during a three month period. Results: Seventeen diaphragmatic ultrasound studies were reviewed from 14 infants with a median (IQR) gestational age of 26.1 (25.8-30.6) weeks, birth weight of 780 (660-1385) gr at a postnatal age of 18 (14-34) days. Eight scans had evidence of a PDA. The median (IQR) VI was significantly lower in scans with a PDA [1.01 (0.78-1.86) cm/s] compared to the ones without a PDA [3.21 (2.80-3.59) cm/s, p < 0.001]. The median (IQR) gestational age was lower in infants with a PDA [25.8 (25.6-27.3) weeks] compared to infants without a PDA [29.0 (26.1-35.1) weeks, p = 0.007]. Using multivariable linear regression analysis the VI was independently associated with a PDA (adjusted p < 0.001) but not with the gestational age (adjusted p = 0.659). Conclusions: Patent ductus arteriosus was associated with a lower mean inspiratory velocity in neonates and this effect was independent of gestational age.

Respiratory function monitoring during early resuscitation and prediction of outcomes in prematurely born infants.

OBJECTIVES: Over the last decade, there has been increased use of end-tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) monitoring during resuscitation of prematurely born infants in the delivery suite. Our objectives were to test the hypotheses that low end-tidal carbon dioxide (ETCO2) levels, low oxygen saturations (SpO2) and high expiratory tidal volumes (VTE) during the early stages of resuscitation would be associated with adverse outcomes in preterm infants. METHODS: Respiratory recordings made in the first 10 min of resuscitation in the delivery suite of 60 infants, median GA 27 (interquartile range 25-29) weeks were analysed. The results were compared of infants who did or did not die or did or did not develop intracerebral haemorrhage (ICH) or bronchopulmonary dysplasia (BPD). RESULTS: Twenty-five infants (42%) developed an ICH and 23 (47%) BPD; 11 (18%) died. ETCO2 at approximately 5 min after birth was lower in infants who developed an ICH, this remained significant after adjusting for gestational age, coagulopathy and chorioamnionitis (p=0.03). ETCO2 levels were lower in infants who developed ICH or died compared to those that survived without ICH, which remained significant after adjustment for gestational age, Apgar score at 10 min, chorioamnionitis and coagulopathy (p=0.004). SpO2 at approximately 5 min was lower in the infants who died compared to those who survived which remained significant after adjusting for the 5-min Apgar score and chorioamnionitis (p=0.021). CONCLUSIONS: ETCO2 and SpO2 levels during early resuscitation in the delivery suite were associated with adverse outcomes.

Diaphragmatic electromyography during a spontaneous breathing trial to predict extubation failure in preterm infants.

BACKGROUND: Premature attempts at extubation and prolonged episodes of ventilatory support in preterm infants have adverse outcomes. The aim of this study was to determine whether measuring the electrical activity of the diaphragm during a spontaneous breathing trial (SBT) could predict extubation failure in preterm infants. METHODS: When infants were ready for extubation, the electrical activity of the diaphragm was measured by transcutaneous electromyography (EMG) before and during a SBT when the infants were on endotracheal continuous positive airway pressure. RESULTS: Forty-eight infants were recruited (median (IQR) gestational age of 27.2 (25.6-30.4) weeks). Three infants did not pass the SBT and 13 failed extubation. The amplitude of the EMG increased during the SBT [2.3 (1.5-4.2) versus 3.5 (2.1-5.3) µV; p < 0.001]. In the whole cohort, postmenstrual age (PMA) was the strongest predictor for extubation failure (area under the curve (AUC) 0.77). In infants of gestational age <29 weeks, the percentage change of the EMG predicted extubation failure with an AUC of 0.74 while PMA was not associated with the outcome of extubation. CONCLUSIONS: In all preterm infants, PMA was the strongest predictor of extubation failure; in those born <29 weeks of gestation, diaphragmatic electromyography during an SBT was the best predictor of extubation failure. IMPACT: Composite assessments of readiness for extubation may be beneficial in the preterm population. Diaphragmatic electromyography measured by surface electrodes is a non-invasive technique to assess the electrical activity of the diaphragm. Postmenstrual age was the strongest predictor of extubation outcome in preterm infants. The change in diaphragmatic activity during a spontaneous breathing trial in extremely prematurely born infants can predict subsequent extubation failure with moderate sensitivity and specificity.

Acute kidney injury in infants with congenital diaphragmatic hernia.

OBJECTIVES: To assess the incidence of acute kidney injury (AKI) in infants with congenital diaphragmatic hernia (CDH), including those who had fetoscopic endoluminal tracheal occlusion (FETO), and the effect of AKI on mortality and length of stay. STUDY DESIGN: Ten-year retrospective review of infants admitted with CDH to a tertiary perinatal centre. RESULT: Ninety-four infants with median gestational age of 38+1 weeks were included. Fifty-nine (62.8%) infants had AKI. Compared to infants without AKI, infants with AKI, had a similar incidence of mortality (p = 0.989). In survivors, AKI was not independently associated with a longer adjusted median length of stay [23 versus 15 days (p = 0.194)]. FETO was associated with an increased risk of AKI (p = 0.005), but neither the mortality nor length of stay of FETO infants who had AKI was increased. CONCLUSION: AKI was present in the majority of infants with CDH and most common in those who had undergone FETO.

Outcomes following less-invasive-surfactant-administration in the delivery-room.

BACKGROUND: Less invasive surfactant administration (LISA) on the neonatal unit reduces the need for mechanical ventilation and bronchopulmonary dysplasia (BPD). AIMS: To assess the immediate and longer-term efficacy of LISA to prematurely born infants in the delivery-room. STUDY DESIGN: A case control study with inborn historical controls matched for gestational age, birthweight and gender to each LISA infant. SUBJECTS: Infants born between 26+0 weeks and 34+6 weeks of gestational age. OUTCOME MEASURES: Respiratory function monitoring before and after LISA and need for mechanical ventilation within 72 h of birth. RESULTS: Ninety-nine infants, median gestational age of 32+4(range:27+0-34+6) weeks, were prospectively recruited. The respiratory rate and inspired oxygen (FiO2) decreased two minutes after LISA and there was a reduction in the FiO2 requirement at two hours post birth. Compared to historical controls, LISA administration was associated with a reduction in the need for mechanical ventilation within 72 h after birth (20.2% versus 56.6% p < 0.001) the incidence of moderate to severe BPD (8.2% versus 20.2%, p = 0.02) and the median costs of neonatal intensive care stay (£1218 versus £2436, p = 0.03) and total neonatal unit stay (£12,888 versus £17,240, p = 0.04). A high FiO2 in the delivery-room pre-LISA (median 0.75 versus 0.60, p = 0.02) was associated with LISA failure, that is mechanical ventilation within 72 h of birth. CONCLUSIONS: LISA to prematurely born infants in the delivery-room was associated with reductions in the need for mechanical ventilation and costs of care, but was less successful in those with initial, more severe respiratory disease.

Pulmonary hypertension in infants with bronchopulmonary dysplasia: risk factors, mortality and duration of hospitalisation.

OBJECTIVES: Pulmonary hypertension (PH) is a complication of bronchopulmonary dysplasia (BPD) and associated with increased mortality and morbidity. Our aim was to identify, in infants with BPD, the effect of PH on health-care utilisation and health related cost of care. METHODS: An electronic data recording system was used to identify infants ≤32 weeks of gestation who developed BPD. PH was classified as early (≤28 days after birth) or late (>28 days after birth). RESULTS: In the study period, 182 infants developed BPD; 22 (12.1%) developed late PH. Development of late PH was associated with a lower gestational age [24.6 (23.9-26.9) weeks, p=0.001] and a greater need for positive pressure ventilation on day 28 after birth (100%) compared to infants without late PH (51.9%) (odds ratio (OR) 19.5, 95% CI: 2.6-148), p<0.001. Late PH was associated with increased mortality (36.4%) compared those who did not develop late PH (1.9%) after adjusting for gestational age and ventilation duration (OR: 26.9, 95% CI: 3.8-189.4), p<0.001. In infants who survived to discharge, late PH development was associated with a prolonged duration of stay [147 (118-189) days] compared to the infants that did not develop late PH [109 (85-149) days] (p=0.03 after adjusting for gestational age). Infants who had late PH had a higher cost of stay compared to infants with BPD who did not develop late PH (median £113,494 vs. £78,677, p=0.016 after adjusting for gestational age). CONCLUSIONS: Development of late PH was associated with increased mortality, a prolonged duration of stay and higher healthcare cost.