Packed Red Blood Cell Transfusion as a Predictor of Moderate-Severe Bronchopulmonary Dysplasia: A Comparative Cohort Study of Very Preterm Infants.

OBJECTIVE: Bronchopulmonary dysplasia (BPD) is a leading cause of morbidity and mortality in neonatal intensive care units. Our aim was to evaluate association between packed red blood cell transfusion and the development of BPD in very preterm infants. STUDY DESIGN: This retrospective study of very preterm infants (mean gestational age: 27.1 ± 2.4 weeks, birth weight: 970 ± 271 g) was conducted at Biruni University (Turkey) between July 2016 and December 2020. RESULTS: BPD developed in 107 of the 246 enrolled neonates, including 47 (43.9%), 27 (25.3%), and 33 (30.8%) diagnosed with mild, moderate, and severe BPD, respectively. A total of 728 transfusions were administered. The increased number (4 transfusions [2-7] vs. 1 [1-3], p = 0.001) and volume of transfusions (75 mL/kg volume [40-130] vs. 20 [15-43], p = 0.001) were significantly higher in infants with BPD compared to those without BPD. The transfusion volume cut-off for the prediction of BPD by receiver operating characteristic curve analysis was 42 mL/kg (sensitivity 73.6%; specificity 75%; area under the receiver-operating characteristic curve: 0.82). In multivariate analysis, multiple transfusions and larger transfusion volume were independent risk factors for moderate-severe BPD. CONCLUSION: The increased number and volume of transfusions were associated with BPD in very preterm infants. A packed red blood cell transfusion volume ≥42 mL/kg was a statistically significant predictor of the development of BPD at a postmenstrual age of 36 weeks. KEY POINTS: · Transfusions were found to be an important risk factor for BPD development in very premature infants.. · Number and volume of transfusion were associated with the severity of BPD.. · Optimal cut point volume of transfusion for prediction of BPD was 42 mL/kg body weight..

Factors Affecting Metabolic Bone Disease of Prematurity: Is Hypothyroxinemia Included?

Objectives: The association between transient hypothyroxinemia of prematurity (THOP) and metabolic bone disease of prematurity (MBD) is not clearly known. We aimed to evaluate the effects of THOP and other risk factors on MBD in very low birth weight infants. Methods: This study included infants born at <30 weeks gestational age and <1500 g birth weight who were hospitalized between July 2016 and December 2019. The following information was obtained from medical records: Demographic characteristics; clinical follow-up data; morbidities; initial thyroid function tests; and calcium (Ca), phosphorus (P), and alkaline phosphatase (ALP) levels at postnatal 4-6 weeks. Newborns with an ALP level >500 IU/L were diagnosed with MBD. Patients without MBD were defined as Group 1 and patients with MBD were defined as Group 2. Results: Our study enrolled 145 infants who met the inclusion criteria. The incidences of MBD and THOP were 16.5% and 56.5%, respectively. Gestational age and birth weight were significantly lower in Group 2 than in Group 1. It was observed that these infants received total parenteral nutrition for a longer period of time and had a longer transition period to full enteral feeding. In addition, duration of non-invasive mechanical ventilation, duration of oxygen treatment, frequencies of moderate-severe bronchopulmonary dysplasia, and postnatal steroid use were found to be significantly higher in babies in Group 2 compared to babies in Group 1. There was no significant difference between the groups in terms of THOP. However, multivariate logistic regression analysis revealed no risk factors for the development of MBD. The presence of MBD and Ca, P, and ALP levels did not differ significantly between patients with and without THOP. Conclusion: Our study reveals that MBD is a multifactorial disease and THOP is not a risk factor for the development of MBD.

The long-term impacts of preterm birth and associated morbidities on bone health in preschool children: a prospective cross-sectional study from Turkey.

OBJECTIVE: To evaluate the impact of preterm birth on bone health in preschool children. METHODS: A total of 166 preschool children (aged 7-8 years) born preterm (n = 86, <37-week gestation) and at term (n = 80, ≥37 weeks of gestation) in our hospital were included in this prospective cross-sectional study. Data on antenatal, perinatal, and early postnatal characteristics and maternal obstetric history were obtained from medical records. Bone densitometry data including total bone mineral content (BMC), bone mineral density (BMD; total, lumbar, and femoral), z-scores, and bone loss were collected for each participant. RESULTS: Current height, weight, and BMI values were significantly lower in the preterm group (p < .001). Serum calcium, phosphorus and alkaline phosphatase (ALP) levels did not differ among groups, whereas VitD3 levels were significantly higher in the preterm group (p = .039). The mean total BMC, total BMD, lumbar (L2-L4) BMD, femur BMD, total z-score, and L2-L4 z-score values were significantly lower for the preterm group, whereas the total, lumbar, and femoral bone loss were significantly higher (p < .001), regardless of the severity of prematurity. Intraventricular hemorrhage (IVH) and retinopathy were significantly associated with lower total BMC (p = .004, p = .012, respectively). Fortified breastfeeding was associated with lumbar bone loss (p = .043), and formula feeding was associated with both femur and lumbar bone loss (p = .006, p = .012, respectively). CONCLUSIONS: Our findings revealed long-term adverse effects of preterm birth on bone health, with significantly lower anthropometric values (weight, height, and BMI), lower scores for total BMC, BMD (total, lumbar, femoral), and z-scores (total, femur), along with higher bone loss (total, lumbar, femoral) and higher rates of osteopenia and osteoporosis in preschool children born preterm (whether moderate or very preterm) compared with those born at term. Exclusive breastfeeding appears to reduce the likelihood of long-term bone loss in preterm infants.

Relationship Between the Respiratory Severity Score and Extubation Failure in Very-Low-Birth-Weight Premature Infants.

OBJECTIVE: The objective of the study is to investigate the utility of the respiratory severity score (RSS), an easy-to-use, non-invasive respiratory failure assessment tool that does not require arterial blood sampling, for predicting extubation failure in very-low-birth-weight premature infants. METHODS: Demographic characteristics, clinical course, and neonatal morbidities were retrospectively analyzed. Data were obtained from the files of infants who were admitted to our unit between February 2016 and September 2020, were born before 30 weeks' gestation, and had a birth weight <1250 g. Extubation success was defined as no need for reintubation for 72 h after extubation. RSS and RSS/kg values before each patient's first planned extubation were calculated. RSS values before extubation and risk factors for extubation failure were compared between infants in the successful and failed extubation groups. RESULTS: Our study enrolled 142 infants who met the inclusion criteria. The extubation failure rate was 30.2% (43/142). Early gestation, low birth weight, male sex, high RSS, grade ≥3 intraventricular hemorrhage, late-onset sepsis, low weight at the time of extubation, and postmenstrual age at the time of extubation were identified as risk factors for extubation failure. In the logistic regression analysis including these risk factors, RSS/kg remained a significant risk factor, along with late-onset sepsis (OR 25.7 [95% CI: 5.70-115.76]; p<0.001). In the receiver operating characteristic analysis of RSS values, at a cutoff value of 2.13 (area under the curve: 82.5%), RSS/kg had 77% sensitivity and 78% specificity (p<0.001). The duration of mechanical ventilation and hospital stay were prolonged in infants with extubation failure. The incidence rates of stage ≥3 retinopathy of prematurity and stage ≥2 necrotizing enterocolitis were also higher. CONCLUSIONS: High RSS and RSS/kg values were closely associated with extubation failure and can be used as a non-invasive assessment tool to support clinical decision-making, and thus reduce the rate of extubation failure.

Associations of Respiratory Distress Syndrome Severity and Other Factors With Transient Hypothyroxinemia of Prematurity.

Aim This study examined the associations of respiratory distress syndrome (RDS) severity and other factors on thyroid hormone levels in very low birth weight (VLBW) infants. Methods The demographic characteristics, clinical course, morbidity, and initial thyroid function test results of VLBW infants diagnosed with RDS between July 2016 and September 2018 were obtained retrospectively. RDS severity was determined according to the requirement for multiple surfactants. Patients were divided into groups without and with hypothyroxinemia, and variables of interest were compared between the two groups. Results Our study involved 98 infants meeting the inclusion criteria; the incidence of hypothyroxinemia was 56.1%. Free T4 (fT4) levels were found to be negatively correlated with gestational week (p < 0.001) and birth weight (p < 0.001). The fT4 levels were significantly lower in infants requiring multiple surfactant doses. In infants with hypothyroxinemia, the duration of invasive mechanical ventilation and oxygen treatment was longer and hemodynamically significant patent ductus arteriosus, grade ≥ 3 intraventricular hemorrhage, and moderate to severe bronchopulmonary dysplasia were more common. Multiple pregnancy (odds ratio (OR) = 5.616, 95%; confidence interval (CI): 1.765-17.874) and the duration of invasive mechanical ventilation (OR = 1.05, 95%; CI: 1.005-1.096) were significant risk factors for the development of hypothyroxinemia in logistic regression analysis. Conclusions Transient hypothyroxinemia of prematurity is associated with RDS severity and early morbidities of prematurity. In the presence of multiple pregnancy, patients should be followed up more closely due to the possibility of hypothyroxinemia.

Comparison of Alternative Lipid Emulsions on Morbidities in Very-Low-Birth-Weight Preterms.

OBJECTIVE: To compare clinical outcomes of using different alternative lipid emulsions for longer durations in babies who are at high risk for preterm morbidities. METHODS: Preterm infants born ≤ 30 wk receiving SMOFlipid versus Clinoleic with longer durations (≥ 14 d) were included in this retrospective study. The authors compared demographic features, clinical applications, and morbidities between epochs: epoch 1 (Clinoleic, July 2017-June 2018) versus epoch 2 (SMOFlipid, July 2018-June 2019). RESULTS: A total of 91 infants were included in the study. In bivariate analysis; moderate bronchopulmonary dysplasia (BPD) (p = 0.000) and composite outcome [BPD, retinopathy of prematurity (ROP) needed treatment, cholestasis and late-onset sepsis and/or mortality] rates were significantly higher (p = 0.043) in Clinoleic group. In multivariate logistic regression analysis, it was found that the type of lipid emulsion used had no significant effect on these morbidities. CONCLUSIONS: Since both groups had comparable morbidity and mortality, both lipid emulsions are equally safe in preterm babies requiring parenteral nutrition.

The Ideal Timing of Bedside Surgical Ligation of Patent Ductus Arteriosus in Premature Babies Less Than 30 Gestational Weeks.

OBJECTIVE: The aim of our study is to determine the relationship between exposure to hemodynamically significant patent ductus arteriosus and morbidities in premature babies, the optimal number of pharmacologic treatment cycles, and ideal ductus ligation timing. MATERIALS AND METHODS: The study was a retrospective single-center study conducted in a 3-year period between July 2017 and June 2020. Premature babies, born ≤30 weeks of gestation and transferred to our unit for bedside ductus ligation, were included in the study. The subjects were divided into 2 groups; Group A consisted of the patients who received ≥3 pharmacologic treatment cycles, and group B consisted of the patients who received ≤2 cycles. The groups were compared according to preoperative and postoperative features. The main outcome of the study was the presence of severe bronchopulmonary dysplasia. The secondary outcomes were specified as the length of stay in the neonatal intensive care unit and the duration of invasive mechanical ventilation (MV). RESULTS: The study group consisted of 24 patients. There were 10 patients in group A and 14 patients in group B. The mean gestational week and the mean birthweight were found to be 26,7 ± 2.2 weeks and 928 ± 190 g, respectively. The incidence of severe bronchopulmonary dysplasia was significantly higher in group A (70% vs. 14.3%; P = .019). Post-ligation invasive MV, duration, and length of stay in the intensive care unit were found to be significantly longer in group A. None of the patients had hemodynamic disturbances or complications during and after the operation. CONCLUSIONS: Bedside surgical ductus ligation is a safe procedure. Prolonging pharmacologic treatment in order to avoid surgery increases the risk of severe bronchopulmonary dysplasia and prolongs hospital stay.

Comparison of Early Nasal Intermittent Positive Pressure Ventilation and Nasal Continuous Positive Airway Pressure in Preterm Infants with Respiratory Distress Syndrome.

AIMS: To compare the effect of early nasal intermittent positive pressure ventilation (nIPPV) and nasal continuous positive airway pressure (nCPAP) in terms of the need for endotracheal ventilation in the treatment of respiratory distress syndrome (RDS) in preterm infants born between 24 and 32 gestational weeks. METHODS: This is a randomized, controlled, prospective, single-centered study. Forty-two infants were randomized to nIPPV and 42 comparable infants to nCPAP (birth weight 1356 ± 295 and 1359 ± 246 g and gestational age 29.2 ± 1.7 and 29.4 ± 1.5 weeks, respectively). RESULTS: The need for endotracheal intubation and invasive mechanical ventilation was significantly lower in the nIPPV group than the nCPAP group (11.9% and 40.5%, respectively, p < 0.05). There were no differences in the duration of total nasal respiratory support, duration of invasive mechanical ventilation, bronchopulmonary dysplasia or other early morbidities. CONCLUSION: nIPPV compared with nCPAP reduced the need for endotracheal intubation and invasive mechanical ventilation in premature infants with RDS.

A comparison of the effects of invasive mechanic ventilation/surfactant therapy and non-invasive nasal-continuous positive airway pressure in preterm newborns.

AIMS: This study compared the early-term outcomes of mechanical ventilation (MV)/surfactant treatment with nasal-continuous positive airway pressure (nCPAP) in preterm infants with respiratory distress syndrome (RDS). MATERIALS AND METHODS: Data from newborns born between ≥24 and ≤32 weeks of gestation, hospitalized at our newborn intensive care unit, and diagnosed with RDS between January 2009 and February 2012 were analyzed. RESULTS: Of 193 newborns with RDS who were enrolled in the study, 113 were treated with nCPAP and 80 with MV at a level of 57.5% of nCPAP. Within the study group, 46.3% of the infants were female. The mean gestation of the continuous positive airway pressure (CPAP) group was 29.07 ± 1.99 weeks; that of the MV group was 28.61 ± 2.01 weeks. The birth weight was 1321.1 ± 325.4 g and 1240.3 ± 366.1 g; however, the difference between the two groups was not significant. MV was not required in 54.9% of the patients with nCPAP treatment. Bronchopulmonary dysplasia (BPD) developed in 20 (18.7%) patients in the nCPAP group and 18 (24.4%) patients in the MV group; the difference was not significant (p = .351). Between 2009 and 2012, nCPAP was used at a rate of 33.9, 70.8, 68.4, and 69%. The risk factors for developing BPD were low gestation week, duration of intubation, and proven sepsis (p = .0001, p = .004, and p = .011, respectively). CONCLUSIONS: Early nCPAP treatment in preterm infants (≤32 weeks of gestation) decreases both the need for MV and the use of surfactant, but without a significant effect on BPD development. (No. 2016/324).

Factors Affecting the Target Oxygen Saturation in the First Minutes of Life in Preterm Infants.

Background: The aim of this study was to describe the effect of factors on time to reach a pulse oxygen saturation (SpO2) level of 90% in preterm infants in the delivery room. Methods: Preterm (<35 gestational age) infants who did not require supplemental oxygen were included in the study. Continuous recordings were taken by pulse oximetry during the first 15 min of life. Results: Of 151 preterm infants, 79 (52.3%) were female and 126 (83.5%) were delivered by cesarean section. Target saturation level (≥90%) was achieved faster in preductal measurements. Mean times taken to have a preductal and postductal SpO2 level of 90% were significantly lower in preterm babies born by vaginal delivery, with umbilical arterial pH ≥ 7.20 and whose mothers were non-smokers during pregnancy. Conclusions: Differences in achievement of target saturation level were influenced by multiple factors (birth way, probe location, maternal smoking and umbilical blood gas pH) in the delivery room during resuscitation of preterm babies.

Agreement of Mixed Venous Carbon Dioxide Tension (PvCO2) and Transcutaneous Carbon Dioxide (PtCO2) Measurements in Ventilated Infants.

BACKGROUND: Noninvasive transcutaneous carbon dioxide monitoring has been shown to be accurate in infants and children, limited data are available to show the usefulness and limitations of partial transcutaneous carbon dioxide tension (PtCO2) value. OBJECTIVES: The current study prospectively determines the effectiveness and accuracy of PtCO2 measurements in newborns. MATERIALS AND METHODS: Venous blood gas sampling and monitoring of the PtCO2 level (TCM TOSCA, Radiometer) were done simultaneously. All measurements are performed on mechanically ventilated infants. Partial venous carbon dioxide tension (PvCO2) values divided into three groups according to hypocapnia (Group 1: < 4.68 kPa), normocapnia (Group 2: 4.68-7.33 kPa), hypercapnia (Group 3: > 7.33 kPa) and then PvCO2 and PtCO2 data within each group were compared separately. RESULTS: A total of 168 measurements of each PvCO2 and PtCO2 data were compared in three separated groups simultaneously (13 in Group 1, 118 in Group 2, and 37 in Group 3). A bias of more than ± 0.7 kPa was considered unacceptable. PtCO2 was related to PvCO2 with acceptable results between the two measurements in hypocapnia (mean difference 0.20 ± 0.19 kPa) and normocapnia (0.002 ± 0.30 kPa) groups. On the other hand in hypercapnia group PtCO2 values were statistically significant (P < 0.001) and lower than PvCO2 data (mean difference 0.81 ± 1.19 kPa). CONCLUSIONS: PtCO2 measurements have generally good agreement with PvCO2 in hypocapnic and normocapnic intubated infants but there are some limitations especially with high level of CO2 tension. Monitoring of PtCO2 is generally a useful non-invasive indicator of PvCO2 in hypocapnic and normocapnic infants.

Assessment of the place of tubular reabsorption of phosphorus in the diagnosis of osteopenia of prematurity.

AIM: In this study, we aimed to investigate the utility of tubular reabsorption of phosphorus in the diagnosis of osteopenia of prematurity in addition to biochemical markers. MATERIALS AND METHOD: Premature babies with a gestational age of ≤32 weeks and/or a birth weight of ≤1 500 g who were hospitalized in the neonatal intensive care unit between June 2009 and March 2011 were included in the study. These babies were evaluated at the 40th gestational week and serum calcium, phosphorus, alkaline phosphatase, urea, creatinine, urinary calcium and phosphorus levels were measured and tubular reabsorption of phosphorus was determined. The subjects who had bone graphy findings and/or an alkaline phosphatase level of >400IU/L and a phosphorus value of <3.5 mg/dL were considered osteopenic. The levels of tubular reabsorption of phosphorus of the osteopenic patients were compared with the ones of the non-osteopenic patients. The study was initiated after obtaining ethics committee approval (date: 04.29.2009/213). RESULTS: During the study period, a total of 698 premature babies were hospitalized in our neonatology unit. A diagnosis of osteopenia of prematurity was made in 24 of 190 subjects who met the study criteria. The level of tubular reabsorption of phosphorus was compared with the serum calcium, phosphorus and alkaline phosphatase levels measured at the 40th gestational week and alkaline phosphatase was found to be significantly increased in the group with a high tubular reabsorption of phosphorus (≥%95). When the subjects with a phosphorus level of <3.5 mg/dL and an alkaline phosphatase level of >499 IU were compared with the newborns who were found to have a tubular reabsorption of phosphorus of ≥%95 for the objective of evaluating the specificity and sensitivity of tubular reabsorption of phosphorus, the sensitivity, specificity, positive predictive value and negative predictive value of tubular reabsorption of phosphorus in the diagnosis of osteopenia were found to be 27%, 82%, 17% and 89%, respectively. When the osteopenic and non-osteopenic patients were compared in terms of the levels of tubular reabsorption of phosphorus, no statistically significant difference was found. CONCLUSIONS: It was thought that it was not appropriate to use tubular reabsorption of phosphorus alone in the diagnosis of osteopenia of prematurity.

Comparison of anti-D immunoglobulin, methylprednisolone, or intravenous immunoglobulin therapy in newly diagnosed pediatric immune thrombocytopenic purpura.

This study aimed to evaluate the efficacy, cost, and effects of anti-D immunoglobulin (anti-D Ig), methylprednisolone, or intravenous immunoglobulin (IVIG) therapy on the development of chronic disease in children who are Rh-positive with diagnosed immune thrombocytopenic purpura (ITP). Children with newly diagnosed ITP and platelet count <20,000/mm(3) were prospectively randomized to treatment with anti-D Ig (50 µg/kg), methylprednisolone (2 mg/kg/day), or IVIG (0.4 g/kg/day, 5 days). Sixty children with a mean age of 6.7 years were divided into three equal groups. No difference was observed between platelet counts before treatment and on day 3 of treatment. However, platelet counts at day 7 were lower in the methylprednisolone group than in the IVIG group (P = 0.03). In the anti-D Ig group, hemoglobin and hematocrit levels were significantly lower at the end of treatment (P < 0.05). Chronic ITP developed in 30% of the anti-D Ig group, 35% of the methylprednisolone group, and 25% of the IVIG group, but no significant difference was noted among the groups. The cost analysis revealed that the mean cost of IVIG was 7.4 times higher than anti-D Ig and 10.9 times higher than methylprednisolone. In the treatment of ITP in childhood, one 50 µg/kg dose of anti-D Ig has similar effects to IVIG and methylprednisolone. Among patients who were treated with anti-D Ig, serious anemia was not observed, and the cost of treatment was less than that of IVIG treatment.