Inhaled corticosteroids in ventilated preterm neonates: a non-randomized dose-ranging study.

BACKGROUND: Inhaled corticosteroids (ICS) offer targeted treatment for bronchopulmonary dysplasia (BPD) with minimal systemic effects compared to systemic steroids. However, dosing of ICS in the management of infants at high-risk of developing BPD is not well established. The objective of this study was to determine an effective dose of ICS for the treatment of ventilator-dependent infants to facilitate extubation or reduce fractional inspired oxygen concentration. METHODS: Forty-one infants born at < 32 weeks gestational age (GA) or < 1250 g who were ventilator-dependent at 10-28 days postnatal age were included. A non-randomized dose-ranging trial was performed using aerosolized inhaled beclomethasone with hydrofluoralkane propellant (HFA-BDP). Four dosing groups (200, 400, 600 and 800 µg twice daily for 1 week) with 11, 11, 10 and 9 infants in each group, respectively, were studied. The primary outcome was therapeutic efficacy (successful extubation or reduction in FiO2 of > 75% from baseline) in ≥60% of infants in the group. Oxygen requirements, complications and long-term neurodevelopmental outcomes were also assessed. RESULTS: The median age at enrollment was 22 (10-28) postnatal days. The primary outcome, therapeutic efficacy as defined above, was not achieved in any group. However, there was a significant reduction in post-treatment FiO2 at a dose of 800 µg bid. No obvious trends were seen in long-term neurodevelopmental outcomes. CONCLUSIONS: Therapeutic efficacy was not achieved with all studied doses of ICS. A significant reduction in oxygen requirements was noted in ventilator-dependent preterm infants at 10-28 days of age when given 800 µg of HFA-BDP bid. Larger randomized trials of ICS are required to determine efficacy for the management of infants at high-risk for development of BPD. TRIAL REGISTRATION: This clinical trial was registered retrospectively on clinicaltrials.gov. The registration number is NCT03503994 .

The Power of a Parent's Touch: Evaluation of Reach and Impact of a Targeted Evidence-Based YouTube Video.

Despite strong evidence that skin-to-skin contact and breast-feeding are effective pain-relieving interventions for infants undergoing painful procedures, they remain underutilized in clinical practice. Given the important contribution of parents, there is a need to find innovative ways to assist parents to become actively involved in their infant's care. We developed a YouTube video to disseminate evidence-based information on the effectiveness of skin-to-skin contact and breast-feeding for infant pain management. The 2-minute 39-second video launched on December 2, 2014, and was promoted through Web-based and in-person communication and YouTube advertisements. Data were collected using YouTube analytics and an online survey. Post-18 months from its launch, the video had a reach of 157 938 views from 154 countries, with most viewers watching an average of 73% of the video (1 minute 56 seconds). Parents (n = 32) and healthcare providers (n = 170) completed the survey. Overall, both reported that they liked the video, found it helpful, felt more confident, and were more likely to use skin-to-skin contact (16% and 12%) and breast-feeding (3% and 11%), respectively, during future painful procedures. Despite the high-viewing patterns, alternative methods should be considered to better evaluate the impact on practice change.

Striving for Optimum Noise-Decreasing Strategies in Critical Care: Initial Measurements and Observations.

To identify baseline sound levels, patterns of sound levels, and potential barriers and facilitators to sound level reduction. The study setting was neonatal and pediatric intensive care units in a tertiary care hospital. Participants were staff in both units and parents of currently hospitalized children or infants. One 24-hour sound measurements and one 4-hour sound measurement linked to observed sound events were conducted in each area of the center's neonatal intensive care unit. Two of each measurement type were conducted in the pediatric intensive care unit. Focus groups were conducted with parents and staff. Transcripts were analyzed with descriptive content analysis and themes were compared against results from quantitative measurements. Sound levels exceeded recommended standards at nearly every time point. The most common code was related to talking. Themes from focus groups included the critical care context and sound levels, effects of sound levels, and reducing sound levels-the way forward. Results are consistent with work conducted in other critical care environments. Staff and families realize that high sound levels can be a problem, but feel that the culture and context are not supportive of a quiet care space. High levels of ambient sound suggest that the largest changes in sound levels are likely to come from design and equipment purchase decisions. L10 and Lmax appear to be the best outcomes for measurement of behavioral interventions.

Congenital methemoglobinaemia due to Hb F-M-Fort Ripley in a preterm newborn.

Methemoglobinaemia is a rare cause of cyanosis in newborns. Congenital methemoglobinaemias due to M haemoglobin or deficiency of cytochrome b5 reductase are even rarer. We present a case of congenital methemoglobinaemia presenting at birth in a preterm infant. A baby boy born at 29 weeks and 3 days of gestation had persistent central cyanosis immediately after delivery, not attributable to a respiratory or cardiac pathology. Laboratory methemoglobin levels were not diagnostic. Cytochrome b5 reductase levels were normal and a newborn screen was unable to pick up any abnormal variants of fetal haemoglobin. Genetic testing showed a γ globin gene mutation resulting in the M haemoglobin, called Hb F-M-Fort Ripley. The baby had no apparent cyanosis at a corrected gestational age of 42 weeks. Although rare, congenital methaemoglobin aemia should be considered in the differential in a preterm with central cyanosis and investigated with genetic testing for γ globin chain mutations if other laboratory tests are non-conclusive.

Is Preterm Premature Rupture of Membranes Latency Influenced by Single Versus Multiple Agent Antibiotic Prophylaxis in Group B Streptococcus Positive Women Delivering Preterm?

OBJECTIVE: To evaluate the influence of antibiotic regimen on the duration of latency (time from preterm pre-labour rupture of membranes [PPROM] to delivery) and significant infectious neonatal morbidity from rupture of membranes to delivery < 37 weeks' gestational age in women known to be group B Streptococcus (GBS) positive. METHODS: We obtained data from the Nova Scotia Atlee Perinatal Database. In a retrospective, cohort, population-based study, we included pregnancies complicated by PPROM but excluded pregnancies in this group requiring immediate delivery. The cohort was categorized by antibiotic regimen (single vs. multiple agents) and we compared latency and adverse neonatal outcomes according to antibiotic regimen used. Summary characteristics were compared using chi-square analysis with significance < 0.05. Logistic regression was used to estimate adjusted odds ratios, 95% confidence intervals, and mean differences for all outcomes and to account for confounding variables. RESULTS: From 1988 to 2011, the potential study population was 119 158 pregnancies. In total, 3435 deliveries were identified to be PPROM (3%). Of these, 303 mother-baby pairs (9%) were known to be GBS positive by urine or swab culture. Adjusted comparisons of latency and neonatal sepsis showed no difference according to antibiotic regimen (P > 0.05). CONCLUSION: The 2013 SOGC guideline on GBS prophylaxis recommends antibiotic therapy in women with PPROM for both latency and prevention of GBS-related neonatal sepsis. This clinically relevant evaluation in a select preterm group demonstrated that type of antibiotic regimen did not influence either latency with PPROM and GBS positive culture or rates of neonatal sepsis. Ongoing evaluation of serious neonatal outcomes is essential in view of this new recommendation.

Objectif : Évaluer l'influence d'un schéma antibiotique sur la durée de la latence (période séparant la rupture prématurée des membranes préterme [RPMP] et l'accouchement) et la présence d'une morbidité infectieuse néonatale considérable, entre la rupture des membranes et l'accouchement à < 37 semaines d'âge gestationnel, chez des femmes ayant obtenu des résultats positifs au dépistage des streptocoques du groupe B (SGB). Méthodes : Nous avons tiré des données de la Nova Scotia Atlee Perinatal Database. Dans le cadre d'une étude populationnelle de cohorte rétrospective, nous avons inclus les grossesses compliquées par la RPMP, mais nous avons exclu les grossesses de ce groupe qui nécessitaient un accouchement immédiat. La cohorte a été catégorisée en fonction du schéma antibiotique (un seul agent vs de multiples agents) et nous avons comparé la latence et les issues néonatales indésirables en fonction du schéma antibiotique utilisé. Les caractéristiques sommaires ont été comparées au moyen d'une analyse du chi carré (signification < 0,05). Une régression logistique a été utilisée pour estimer les rapports de cotes corrigés, les intervalles de confiance à 95 % et les différences moyennes pour toutes les issues et pour tenir compte des variables parasites. Résultats : Entre 1988 et 2011, la population d'étude potentielle s'élevait à 119 158 grossesses. Au total, 3 435 accouchements ont été identifiés comme présentant une RPMP (3 %). La présence de SGB avait été déterminée par uroculture ou par mise en culture d'écouvillonnages chez 303 paires mère-enfant (9 %) de ce groupe. Les comparaisons corrigées de la latence et de la septicémie néonatale n'ont indiqué aucune différence en fonction du schéma antibiotique (P > 0,05). Conclusion : La directive de 2013 de la SOGC sur la prophylaxie anti-SGB recommande la mise en œuvre d'une antibiothérapie chez les femmes qui présentent une RPMP, et ce, tant pour la latence que pour la prévention de la septicémie néonatale attribuable aux SGB. Cette évaluation pertinente sur le plan clinique auprès d'un groupe sélectionné d'accouchements prétermes a démontré que le type de schéma antibiotique n'influençait ni la latence (en présence d'une RPMP et de résultats positifs à la suite de la mise en culture des SGB) ni les taux de septicémie néonatale. La poursuite de l'évaluation des issues néonatales graves s'avère essentielle à la lumière de cette nouvelle recommandation.

Preterm prelabour rupture of membranes: effect of latency on neonatal and maternal outcomes.

OBJECTIVES: To compare risks of infection and prematurity-related outcomes according to latency periods among women with preterm prelabour rupture of membranes (PPROM). METHODS: Women with PPROM occurring between 24+0 and 36+6 weeks of gestation were identified from a provincial population-based perinatal database in Nova Scotia. The primary outcomes included composite variables for serious maternal and neonatal infectious morbidity and neonatal prematurity-related morbidity. Logistic regression was used to quantify the relationship between latency period (< 24 hours, 24 hours to < 48 hours, 48 hours to < 7 days, and ≥ 7 days) and maternal and neonatal outcomes. Separate analyses were conducted for gestational age groups 24+0 to 33+6 weeks and 34+0 to 36+6 weeks. RESULTS: There were 4329 women included in the cohort. The composite variables representing serious maternal or neonatal infectious morbidity were not significantly associated with latency for either gestational age group. For PPROM occurring at gestational ages of 24+0 to 33+6 weeks, the odds of neonatal prematurity-related morbidity were significantly decreased at the latency periods of 48 hours or more compared with < 24 hours latency. For PPROM at 34+0 to 36+6 weeks of gestation, the odds of prematurity-related morbidity at 48 hours to < 7 days latency was decreased compared with latencies < 24 hours (OR 0.4; 95% CI 0.2 to 0.8). CONCLUSION: Postponing delivery following PPROM may contribute to less prematurity-related morbidity, even close to term, without putting mother or neonate at substantial risk for serious infectious morbidity. Generalization of these findings to other obstetric populations should be informed by the underlying risk of infection.

Objectifs : Comparer les risques d'infection et les issues associées à la prématurité en fonction des périodes de latence chez les femmes qui présentent une rupture prématurée des membranes préterme (RPMP). Méthodes : Les femmes qui ont présenté une RPMP se manifestant entre 24+0 et 36+6 semaines de gestation ont été identifiées au sein d'une base de données périnatale en population générale provinciale, en Nouvelle-Écosse. Parmi les critères d'évaluation primaires, on trouvait des variables composites représentant la morbidité infectieuse maternelle et néonatale grave, et la morbidité néonatale liée à la prématurité. Une régression logistique a été utilisée pour quantifier la relation entre la période de latence (< 24 heures, de 24 heures à < 48 heures, de 48 heures à < 7 jours et ≥ 7 jours) et les issues maternelles et néonatales. Des analyses distinctes ont été menées pour ce qui est des groupes d'âge gestationnel allant de 24+0 à 33+6 semaines et de 34+0 à 36+6 semaines. Résultats : La cohorte comptait 4 329 femmes. Les variables composites représentant la morbidité infectieuse maternelle ou néonatale grave n'ont pas été associées de façon significative à la latence dans l'un ou l'autre des groupes d'âge gestationnel. Pour ce qui est de la RPMP se manifestant aux âges gestationnels situés entre 24+0 et 33+6 semaines de gestation, la probabilité d'une morbidité néonatale liée à la prématurité était considérablement amoindrie en présence de périodes de latence de 48 heures ou plus, par comparaison avec la latence < 24 heures. Pour ce qui est de la RPMP se manifestant aux âges gestationnels situés entre 34+0 et 36+6 semaines de gestation, la probabilité d'une morbidité liée à la prématurité en présence d'une période de latence se situant entre 48 heures et < 7 jours était amoindrie, par comparaison avec les latences < 24 heures (RC, 0,4; IC à 95 %, 0,2 - 0,8). Conclusion : Le report de l'accouchement à la suite d'une RPMP pourrait contribuer à amoindrir la morbidité liée à la prématurité, même près du terme, sans exposer la mère ou le nouveau-né à un risque substantiel de morbidité infectieuse grave. La généralisation de ces constatations à d'autres populations obstétricales devrait tenir compte du risque sous-jacent d'infection.

Neonatal outcomes in spontaneous versus obstetrically indicated late preterm births in a nova scotia population.

OBJECTIVE: To examine the indications for late preterm delivery in Nova Scotia and to compare the short-term outcomes by type of labour (spontaneous, induced, none). METHODS: We conducted a population-based retrospective cohort study of late preterm births (34+0 to 36+6 weeks' gestation) between 1988 and 2009 using the Nova Scotia Atlee Perinatal Database. The association between labour type and neonatal outcomes was examined with logistic regression to estimate odds ratios with 95% confidence intervals. RESULTS: Of the 10 315 late preterm births, 6228 followed spontaneous labour, 2338 followed induction of labour, and 1689 followed Caesarean section with no labour. Babies born following induction were at higher risk of developing hyperbilirubinemia (OR 1.14; 95% CI 1.03 to 1.27) and needing total parenteral nutrition (OR 1.52; 95% CI 1.15 to 1.99) than those born spontaneously. Those born without labour were at higher risk of needing resuscitation (OR 2.43; 95% CI 1.84 to 3.21) and total parenteral nutrition (OR 2.54; 95% CI 1.93 to 3.33) and developing transient tachypnea of the newborn (OR 1.43; 95% CI 1.10 to 1.85), hypoglycemia (OR 1.97; 95% CI 1.63 to 2.39), respiratory distress syndrome (OR 2.33; 95% CI 1.89 to 2.88), necrotizing enterocolitis (OR 3.20; 95% CI 1.07 to 9.53), and apneic spells (OR 1.29; 95% CI 1.05 to 1.59). When adjusted for maternal and fetal factors, odd ratios were only slightly attenuated. CONCLUSION: Among late preterm babies, those born by Caesarean section without labour are at increased risk of many adverse outcomes, while those born following induction of labour are at increased risk of few of the outcomes studied. Maternal and fetal factors other than those for which adjustment was made may contribute to the differences in outcome by labour type.

Outcomes in a population of healthy term and near-term infants with serum bilirubin levels of >or=325 micromol/L (>or=19 mg/dL) who were born in Nova Scotia, Canada, between 1994 and 2000.

OBJECTIVE: The goal was to study the incidence of kernicterus, developmental delay, autism, cerebral palsy, and hearing loss in infants with peak total serum bilirubin levels of >or=325 micromol/L (>or=19 mg/dL), compared with infants with less-severe or no hyperbilirubinemia, in a population of healthy term and late preterm infants. METHODS: Prospectively gathered, standardized, maternal and neonatal data for infants at >or=35 weeks of gestation who were born between January 1, 1994, and December 31, 2000, were extracted from the Nova Scotia Atlee Perinatal Database. Infants with Rh factor isoimmunization, significant congenital or chromosomal abnormalities, or severe peripartum asphyxia were excluded. Comparisons were made on the basis of peak total serum bilirubin levels. Diagnoses were obtained through data linkage with the Medical Services Insurance Database for office visits and the Canadian Institute for Health Information Database for hospital admissions. The registration file provided information allowing calculation of follow-up times, which were determined for each separate outcome. Follow-up periods ranged from 2 to 9 years, with the end point being the first time the diagnostic code was encountered in either database. Cox proportional-hazards regression analyses were used to examine the relationships between outcomes and total serum bilirubin levels. RESULTS: Of 61238 infants included in the study cohort, 4010 (6.7%) did not have linkage data, which left 56019 infants for analysis. There were no cases of kernicterus and no significant differences in rates of cerebral palsy, deafness, developmental delay, or visual abnormalities between the groups. There were suggestions of associations with attention-deficit disorder in the severe hyperbilirubinemia group and with autism in the combined moderate and severe hyperbilirubinemia group. CONCLUSIONS: There was no increase in adverse effects reported previously to be associated with bilirubin toxicity. Associations with developmental delay, attention-deficit disorder, and autism were observed.

A randomized trial of aggressive versus conservative phototherapy for hyperbilirubinemia in infants weighing less than 1500 g: Short- and long-term outcomes.

OBJECTIVE: Treatment regimens for hyperbilirubinemia vary for very low birth weight infants. The present study seeks to determine whether the initiation of conservative phototherapy is as effective as aggressive phototherapy in reducing peak bilirubin levels without increasing adverse effects. STUDY DESIGN: The present randomized, controlled study included infants with birth weights between 500 g and 1500 g, stratified into two birth weight groups. In one group, aggressive phototherapy was commenced by 12 h of age, while in the other group, conservative phototherapy was commenced if serum bilirubin levels exceeded 150 mumol/L. The primary outcome variables were peak serum bilirubin levels and hours of phototherapy. Secondary outcomes were age at peak bilirubin levels, number of infants with rebound hyperbilirubinemia, and number of adverse short- and long-term outcomes. RESULTS: Of 174 eligible infants, 95 consented to participate -49 in the conservative arm and 46 in the aggressive arm. Ninety-two infants completed the study. There was no significant difference in peak bilirubin levels except in infants who weighed less than 1000 g -171.2+/-26 mumol/L (conservative) versus 139.2+/-46 mumol/L (aggressive); P<0.02. There was no difference in duration of phototherapy or rebound hyperbilirubinemia. There were no differences in short-term adverse outcomes. Of the 87 infants who survived until hospital discharge, 82 (94%) had some follow-up and 75 (86%) attended follow-up until 18 months corrected age. The incidence of cerebral palsy, abnormal mental developmental index at 18 months corrected age, or combined outcome of cerebral palsy and death did not significantly differ between the two groups. CONCLUSIONS: In infants weighing less than 1000 g, peak bilirubin levels were significantly higher using conservative phototherapy regimens and there was a tendency for poor neurodevelopmental outcome.

Fetal and neonatal outcomes of diabetic pregnancies.

OBJECTIVE: To estimate whether the incidences of adverse fetal and neonatal outcomes in infants of mothers with preexisting types 1 and 2 diabetes 1) differ from infants of nondiabetic mothers in Nova Scotia (NS); and 2) have changed between 1988 and 2002. METHODS: Population-based cohort study using the NS Atlee Perinatal Database, a well-validated source of standardized clinical information. RESULTS: A total of 516 infants of diabetic mothers and 150,589 infants of nondiabetic mothers from singleton pregnancies were studied. Infants of diabetic mothers had significantly higher rates of perinatal mortality (17.4/1,000 compared with 5.9/1,000, relative risk [RR] 3.01, 95% confidence interval [CI] 1.55-5.84), major congenital anomaly (9.1% compared with 3.1%, RR 2.97, 95% CI 2.25-3.90), and large for gestational age birth (LGA, more than 90th percentile weight for gestational age) (45.2% compared with 12.6%, RR 3.59, 95% CI 3.26-3.95) than infants of nondiabetic mothers. In infants of diabetic mothers, there was no improvement in perinatal mortality (23.4/1,000 in 1988-1995 compared with 11.5/1000 in 1996-2002, P = .340), incidence of LGA (48.0% in 1988-1995 compared with 42.3% in 1996-2002, P = .237), or rate of major congenital anomaly (8.2% in 1988-1995 compared with 10.0% in 1996-2002, P = .560). Diabetes remained an independent risk factor for LGA infants and major congenital anomaly after adjusting for possible confounders. CONCLUSION: Rates of adverse neonatal outcomes are 3-9 times greater in infants of diabetic mothers compared with those of nondiabetic mothers. There were no significant improvements in rates of perinatal mortality, congenital anomaly, or LGA birth in infants of diabetic mothers in 1996-2002 compared with 1988-95.

Changes in maternal characteristics in Nova Scotia, Canada from 1988 to 2001.

BACKGROUND: Maternal characteristics such as age, parity, smoking status, pre-pregnancy weight and pregnancy weight gain have changed in many industrialized countries in recent years. Many of these changes have not been adequately described at a population level. The purpose of this study was to describe recent trends in selected maternal characteristics in Nova Scotia. METHODS: Data from a population-based perinatal database were used to examine changes in maternal age, parity, smoking, pre-pregnancy weight, delivery weight and pregnancy weight gain among all deliveries between 1988 and 2001. RESULTS: The proportion of deliveries to women > or = 35 years increased by 84% over the study period from 7.0% in 1988-1991 to 12.9% in 1998-2000, while deliveries to women > or = 40 years increased by more than 100%. The number of nulliparous women > or = 35 years also increased significantly. The overall prevalence of smoking decreased from 32.7% in 1988-1991 to 25.1% in 1998-2001, however the prevalence of smoking among women <20 years did not change over the study period and was almost 50%. The proportion of women with a pre-pregnancy weight of > or = 90 kilograms (kg) increased by 165% from 4.1% in 1988-1991 to 10.7% in 1998-2001. The proportion of women with pregnancy weight gain of < 7 kg and > or =18 kg increased by 37% and 13%, respectively. CONCLUSION: Dramatic changes have occurred in several important maternal characteristics and there is evidence of ongoing change. Continuation of these trends is likely to impact on future obstetric practice and perinatal health.