Patent Ductus Arteriosus Response to Treatment by Course and Associations with Perinatal and Clinical Factors.

OBJECTIVE: The objective of this study is to examine patent ductus arteriosus (PDA) response by treatment course and investigate associations with postmenstrual age (PMA), chronological age (CA), gestational age (GA), antenatal steroid exposure (ANS), birthweight (BW), weight at treatment initiation (WT), and PDA/left pulmonary artery (LPA) ratio. STUDY DESIGN: This is a single-center retrospective cohort study of preterm infants less than 37 weeks' GA born January 1, 2016 to December 31, 2018 who received acetaminophen and/or indomethacin for PDA treatment. Cox proportional hazards regression models were used to determine whether factors of interest were associated with PDA response to medical treatment. RESULTS: In total, 289 treatment courses were administered to 132 infants. Thirty-one (23%) infants experienced treatment-associated PDA closure. Ninety-four (71%) infants had evidence of PDA constriction following any treatment course. Ultimately, 84 (64%) infants experienced definitive PDA closure. For each 7-day increase in CA at the time of treatment initiation, the PDA was 59% less likely to close (p = 0.04) and 42% less likely to respond (i.e., constrict or close) to treatment (p < 0.01). PDA/LPA ratio was associated with treatment-associated PDA closure (p = 0.01). For every 0.1 increase in the PDA/LPA ratio, the PDA was 19% less likely to close in response to treatment. CONCLUSION: In this cohort, PDA closure is independent of PMA, GA, ANS, BW, and WT; however, CA at treatment initiation predicted both treatment-associated PDA closure and PDA response (i.e., constriction or closure), and PDA/LPA ratio was associated with treatment-associated closure. Most infants experienced PDA constriction rather than closure, despite receiving up to four treatment courses. KEY POINTS: · Detailed PDA responses for up to four treatment courses provide a novel perspective.. · Chronological age at the start of treatment predicted treatment-associated PDA closure and response.. · For each 7-day increase in chronological age, the PDA was 59% less likely to close..

A quality improvement initiative to standardize time to initiation of enteral feeds after non-surgical necrotizing enterocolitis using a consensus-based guideline.

BACKGROUND: Recent evidence demonstrates that earlier feeding may be beneficial after non-surgical necrotizing enterocolitis (NEC). We aimed to decrease time to reach full enteral feeds by 20% post-NEC by standardizing time to reinitiate feeds. METHODS: We implemented a consensus-based guideline for earlier feeding post-NEC. Outcome measures included days to initiate enteral feeds and reach full enteral feeds. Central venous line days and length of stay were also evaluated. Balancing measures were NEC recurrence and post-NEC stricture. Statistical analysis used process control methodology and standard comparison statistical testing. RESULTS: Average days infants with Stage II NEC began feeding decreased from 9.4 to 5.1 days and average days to reach full feeds was decreased by 35% from 24.0 to 15.7 days. We observed no change in our balancing measures. CONCLUSION: A multidisciplinary consensus-based NEC earlier feeding guideline decreased time to reach full enteral feeds and reduced central line days without adverse events.

Dexamethasone Alters Tracheal Aspirate T-Cell Cytokine Production in Ventilated Preterm Infants.

Postnatal corticosteroids improve respiratory status and facilitate respiratory support weaning in preterm infants with bronchopulmonary dysplasia (BPD). Older literature describes characteristic cytokine profiles in tracheal aspirates (TA) of BPD patients which are altered with corticosteroids. Corticosteroids also influence peripheral blood T-cell presence. However, little is known regarding TA T-cell phenotype and cytokine production before or after exogenous corticosteroids. We hypothesized that postnatal dexamethasone alters the TA T-cell cytokine profiles of preterm infants. TA samples were collected from 14 infants born from 23 0/7 to 28 6/7 weeks who were mechanically ventilated for at least 14 days. Samples were collected up to 72 h before a ten-day dexamethasone course and again 1 to 3 calendar days after dexamethasone initiation. The primary outcome was change in T cell populations present in TA and their intracellular cytokine profile after dexamethasone treatment, ascertained via flow cytometry. Following dexamethasone treatment, there were significant decreases in respiratory severity score (RSS), percent CD4+IL-6+ cells, CD8+IL-6+ cells, CXCR3+IL-6+ cells, and CXCR3+IL-2+ cells and total intracellular IFN-γ in TA. RSS significantly correlated with TA percent CD4+IL-6+ cells. To our knowledge, this is the first study demonstrating that dexamethasone reduced T-cell IL-6 and this reduction was associated with improved RSS in pre-term infants with evolving BPD.

Earlier re-initiation of enteral feeding after necrotizing enterocolitis decreases recurrence or stricture: a systematic review and meta-analysis.

OBJECTIVE: To assess the effects of earlier vs. later re-initiation of enteral feeds after necrotizing enterocolitis (NEC). STUDY DESIGN: We reviewed the literature to assess timing of enteral feeding after NEC using fixed effects models. RESULTS: Three studies met inclusion criteria; no randomized trials. After removal of Bell's Stage I infants, the earlier refeeding group (<5-7 or median 4 days) included 79 infants and later refeeding group (≥5-7 or median 10 days) included 119 infants. Pooled analysis revealed earlier re-initiation reduced the incidence in the composite outcome of recurrent NEC and/or post-NEC stricture (OR = 0.27; 95% Cl = 0.10-0.75; p = 0.012). Individually, NEC recurrence (pooled OR = 0.34; 95% Cl = 0.09-1.29; p = 0.112) or stricture (OR = 0.34; 95% Cl = 0.09-1.26; p = 1.06) did not differ between groups. CONCLUSIONS: There was no increase in negative outcomes with earlier refeeding after NEC. Earlier initiation of enteral feeds resulted in a significantly lower risk for the combined outcome of recurrent NEC and/or post-NEC stricture.