Changes in ventilation modes in the last decade and their impact on the prevalence of bronchopulmonary dysplasia in preterm infants.

BACKGROUND: Less invasive forms of ventilation have evolved aiming to decrease bronchopulmonary dysplasia (BPD) morbidity. It is unclear whether changes in ventilation practices have been associated with improvements in respiratory outcomes. OBJECTIVE: To examine the changes in ventilation modes in preterm neonates between two periods during the last decade and their impact on BPD prevalence. METHODS: A retrospective chart review of very low birth weight infants and those born at less than 32 weeks gestation hospitalized during two periods: the years 2012-2013 and 2018-2019. The primary outcome was the prevalence of BPD. Study variables included the mode and duration of ventilation, duration of oxygen need, and perinatal clinical parameters. RESULTS: Four hundred eighty-one infants were enrolled. Between the two study periods, a significant increase was observed in invasive (33%-47%, p = 0.002), and noninvasive ventilation rates (44%-72%, p < 0.001). The average duration of noninvasive ventilation increased significantly (from 9.24 to 14.08 days, p = 0.016). The total duration of respiratory support remained unchanged. The overall prevalence of moderate and severe BPD at 36 weeks corrected age remained approximately 40% in preterm infants born at less than 28 weeks gestation. CONCLUSION: The increasing use of non-invasive ventilation was not accompanied by a reduction in the use of invasive ventilation, nor by a reduced prevalence of BPD. The high prevalence of BPD remains a significant problem in extreme prematurity. Other interventions, in addition to less aggressive ventilation, need to be explored.

Rescue antenatal corticosteroids and neonatal outcomes in twin gestation.

OBJECTIVE: Although repeated antenatal corticosteroids (ACS) courses are not recommended, a single rescue ACS course has been shown to decrease neonatal morbidity among preterm singletons. However, little is known regarding the effects of rescue ACS course in twin pregnancies. METHODS: A retrospective cohort study conducted during 2015-2017 at a tertiary-care center including all twins delivered between 24-34 weeks of gestation who received at least one course of ACS. RESULTS: Overall, 162 (70.4%) twins were exposed to a single ACS course and 68 (29.6%) to an additional rescue ACS course. Rescue ACS course was associated with lower rates of respiratory distress syndrome (7.4% vs. 19.1%, p = .03), surfactant use (7.4% vs 18.5%, p = .04) and bronchopulmonary dysplasia (0 vs 8.6%, p = .01) as compared to a single ACS course. In the rescue ACS group, compared to the single ACS group, the rates of composite respiratory adverse outcome (10.3% vs 22.2%, OR [95% CI]: 0.40 (0.17-0.95), p = .04) and any adverse neonatal outcome (13.2% vs 26.5%, OR [95% CI]: 0.42 (0.19-0.92), p = .04) were significantly lower. Hospital stay was also shorter among neonates born to mothers receiving a rescue ACS course (median 23 vs. 30 days, p = .01). No differences were noted in neonatal birthweight, head circumference and the rate of neonatal hypoglycemia. CONCLUSION: Rescue ACS course was associated with improved respiratory and neonatal outcomes in twin gestations. Further studies are warranted to confirm our findings and better delineate the optimal regimen of rescue ACS in this setting.

Factors associated with the development of neonatal hypoglycemia after antenatal corticosteroid administration: It's all about timing.

OBJECTIVE: To determine the factors associated with neonatal hypoglycemia among neonates exposed to antenatal corticosteroid (ACS). METHODS: A retrospective study conducted during 2017-2019 at a tertiary-care center including all neonates delivered between 24 and 34 weeks of gestation after ACS administration. The primary outcome was neonatal hypoglycemia (<40 mg/dl). RESULTS: Overall, 362 early preterm neonates, including 205 singletons and 157 twins, were exposed to ACS before delivery and constituted the study group. Of them, 275 (76.0%) were exposed to a single ACS course and 87 (24.0%) to an additional rescue ACS course. Neonatal hypoglycemia occurred in 84 (23.2%) neonates. The incidence of neonatal hypoglycemia was significantly higher in those delivered between 24 and 48 h after ACS administration compared with those delivered outside this time interval (10/25, 40.0% vs 74/337, 21.9%; P = 0.049). In multivariate analysis, after adjusting for neonatal birth weight and gestational age, delivery within 24-48 h after ACS administration was the only independent risk factor associated with neonatal hypoglycemia (adjusted odds ratio 2.41, 95% confidence interval 1.03-5.68; P = 0.044). CONCLUSION: Neonatal hypoglycemia occurred in over one-fifth of those exposed to ACS, and was independently associated with delivery between 24 and 48 h after ACS administration.

[APNEA OF PREMATURITY - PATHOPHYSIOLOGY, TREATMENT & PROGNOSIS].

INTRODUCTION: Apnea of prematurity affects the majority of infants born before 34 weeks of complete gestation. Significant recurrent apnea of prematurity is associated with both short and long term complications and is a risk factor for increased mortality and neurodevelopmental disability. The current review discusses the recent advances in the understanding of the pathophysiology of apnea of prematurity, as well as the clinical questions relevant to physicians and staff treating infants with apnea of prematurity. Finally, we discuss monitoring and discharge decisions, and present recommendations following discharge from the neonatal intensive care unit.

Prematurity as a Risk Factor of Sleep-Disordered Breathing in Children Younger Than Two Years: A Retrospective Case-Control Study.

STUDY OBJECTIVES: Sleep-disordered breathing (SDB) is a highly prevalent condition affecting 2% to 4% of children. However, the prevalence and characteristics of SDB in children younger than 2 years and the effect of prematurity as a risk factor remains unclear. METHODS: Children younger than 24 months referred for PSG at two medical centers between the years 2014 to 2018 were included in this retrospective analysis. We excluded children with genetic syndromes. Polysomnography (PSG) was performed and scored according to American Academy of Sleep Medicine guidelines. RESULTS: Ninety-eight children were included (age 14.1 ± 6.4 [2-23] months), with 31 born prematurely (PRETERM; 24 to 34 weeks gestational age). PRETERM had increased odds of SDB (age and sex adjusted), using a cutoff of AHI ≥ 5 events/h with an odds ratio of 4.3 (95% confidence interval 1.5-12.9). Gestational age was the only significant predictor for SDB in this cohort, every additional week of gestation reducing the odds of SDB by 12.5%. PRETERM SDB was also characterized by more severe nocturnal hypoxemia, increased frequency of central apnea, and altered sleep architecture. CONCLUSIONS: Current findings underscore the importance of prematurity antecedents as a risk factor for SDB in young symptomatic children younger than 2 years referred for a PSG. Future studies focused on improved estimates of the prevalence of SDB among nonreferral young children appear warranted.

Giant lung cysts following necrotizing pneumonia: Resolution with conservative treatment.

RATIONALE: Necrotizing pneumonia is characterized by destruction and liquefaction of the lung tissue and loss of the normal pulmonary parenchymal architecture. During the course of resolution areas of hyperlucency are formed, sometimes with the development of giant lung cysts that can be a field with fluid resembling lung abscess. There is no consensus on the management of these abnormalities. OBJECTIVE: To assess the prevalence of giant lung cysts as a complication of necrotizing pneumonia and to report our experience with conservative treatment that achieved complete resolution. METHODS: Medical chart reviews of all children aged 0 to 18 years hospitalized with necrotizing pneumonia in a single tertiary center from 2015 to 2017, demographic data, and clinical course during and after hospitalization as well as serial chest imaging were collected. RESULTS: During the study period, 761 children were diagnosed with community-acquired pneumonia, 16 of 761 (2.3%) had necrotizing pneumonia and 6 of 16 (37.5%) with necrotizing pneumonia complicated by a giant lung cyst or lung abscess. All were closely observed and showed complete clinical and radiographic resolution with antibiotic treatment. CONCLUSIONS: Treatment of giant lung cyst formation following necrotizing pneumonia by a conservative approach with prolonged antibiotics results in complete recovery with no need for invasive procedures.

Predictors of Prolonged Hospitalizations in Pediatric Complicated Pneumonia.

BACKGROUND: Pediatric community-acquired complicated pneumonia (PCACP) is characterized by a prolonged clinical course, but this may be highly variable. METHODS: A multicenter observational study was conducted to develop and validate a clinical prediction tool for prolonged hospitalizations in PCACP. The derivation and validation cohorts consisted of 144 and 169 patients with PCACP, respectively, hospitalized between the years 1997 and 2017 in three tertiary care hospitals. Logistic regression analyses were used to identify parameters associated with a prolonged hospitalization and to develop and validate a prediction model for constructing a useful clinical tool. RESULTS: Higher levels of lactate dehydrogenase (LDH) (P < .026) and lower levels of glucose (P = .018) in pleural fluid were significantly associated with prolonged hospitalization. A predictive stepwise logistic regression model was developed and applied to the validation cohort. The area under the receiver operating characteristic curve (AUROC) constructed indicated that the model retained good predictive value (AUROC for the derivation vs validation data, [0.77 (95% CI, 0.66-0.87) vs 0.82 (95% CI, 0.72-0.91)], respectively). From these data, a clinical tool was derived; the combination of pleural LDH >1,000 units/L and pleural glucose levels < 1 mmol/L or pleural LDH levels > 2,000 units/L and pleural glucose levels < 2 mmol/L or pleural LDH levels > 3,000 units/L and pleural glucose < 3 mmol/L predict prolonged hospitalization with positive and negative predictive values of 78% (95% CI, 0.71-0.85) and 73% (95% CI, 0.59-0.85), respectively. CONCLUSIONS: In children, pleural fluid LDH and glucose levels are useful parameters for assessing the severity of PCACP. The model developed in this study accurately predicts patients who will have prolonged hospitalization.

Neonatal characteristics and perinatal complications in neonates with Down syndrome.

The annual rate of Down syndrome (DS) births in Jerusalem is stable, regardless of prenatal screening, and diagnostic measures. We aimed to evaluate our historical cohort for obstetrical characteristics and the neonatal course and complications. We reviewed computerized medical files of neonates with the diagnosis of DS born in the four main hospitals in Jerusalem between the years 2000 and 2010 and evaluated for maternal history and primary neonatal hospitalization. A total of 403 neonates were diagnosed with DS. The average maternal age was 35.6 years, 73% were born via spontaneous vaginal delivery. In all gestational ages, the mean birth weight and head circumference percentiles were significantly lower than the general population (P < 0.001 for both) and at each week the HC percentile was lower than the weight percentile (P < 0.0001), worse among males. Mortality during the primary hospitalization was 3.7%. The most common anomalies were cardiac (79%) with either congenital defects or functional abnormalities, neither influenced the length of hospitalization. The main reasons for prolonged hospitalization were prematurity and anomalies of other (non-cardiac) organs. Common perinatal complications included respiratory failure or need for oxygen supplementation (32%), hyperbilirubinemia (23%), sepsis (6.4%), and feeding difficulties (13%). About 84% were fed by human milk; of those, two thirds were exclusively breast-fed and one third were supplemented with infant formula. In conclusion, infants with DS were small for gestational age with relatively reduced head circumference. Despite the increased rate of congenital anomalies and perinatal complications, most infants were discharged home in good medical condition and were exclusively breastfed.

Complicated community acquired pneumonia in childhood: Different types, clinical course, and outcome.

The incidence of pediatric community acquired complicated pneumonia (PCACP) is increasing. Questions addressed: Are different types of PCACP one disease? How do different treatment protocols affect the outcome? METHODS: Retrospective analysis of medical records of PCACP hospitalizations in the three major hospitals in Jerusalem in the years 2001-2010 for demographics, clinical presentation, management, and outcome. RESULTS: Of the 144 children (51% aged 1-4 years), 91% of Jewish origin; 40% had para-pneumonic effusion (PPE), 40% empyema (EMP), and 20% necrotizing pneumonia (NP). Bacterial origin was identified in 42% (empyema 79%, P = 0.009), most common S. pneumoniae (32%), group A streptococcus (9%). Patients with EMP, compared to PPE and NP, were less likely to receive prior antibiotic treatment (35% vs. 57% and 59%, respectively, P = 0.04). Mean hospitalization was longer in patients with NP followed by EMP and PPE (16.4 ± 10.6, 15.2 ± 7.9, and 12.7 ± 4.7 days, respectively), use of fibrinolysis was not associated with the outcome. All children had recovered to discharge regardless of antibiotic therapy or fibrinolysis. ANSWER: NP is a more severe disease with prolonged morbidity and hospitalization in spite of prior antibiotic treatment. All types had favorable outcome regardless of treatment-protocol. Complicated pneumonia has an ethnic predominance. Pediatr Pulmonol. 2017;52:247-254. © 2016 Wiley Periodicals, Inc.

Thyroxine-Based Screening for Congenital Hypothyroidism in Neonates with Down Syndrome.

OBJECTIVE: To ascertain whether thyroxine (T4)-based screening programs for congenital hypothyroidism (initial measurement of total T4 [tT4] followed by thyroid stimulating hormone [TSH] measurement in patients with tT4 <10th percentile) identifies congenital hypothyroidism in all neonates with Down syndrome. STUDY DESIGN: Retrospective cohort study of 159 neonates with Down syndrome, born during the period 1998-2007 were included. Screening test results were compared with those of the general population. All primary care physicians of these infants were contacted and infants' thyroid status verified. RESULTS: tT4 concentrations in children with Down syndrome were significantly lower, and TSH higher than those in the general population; tT4 concentrations did not correlate with screening TSH concentrations. Twenty children with Down syndrome were treated with L-thyroxin within the first month of life although only 10 babies had been identified by the routine screening test. CONCLUSIONS: T4-based screening does not identify many cases of congenital hypothyroidism in neonates with Down syndrome. We recommend that neonates with Down syndrome be screened by simultaneous measurements of both tT4 and TSH.