Ventilation in Extremely Preterm Infants and Respiratory Function at 8 Years.

BACKGROUND: Assisted ventilation for extremely preterm infants (<28 weeks of gestation) has become less invasive, but it is unclear whether such developments in care are associated with improvements in short-term or long-term lung function. We compared changes over time in the use of assisted ventilation and oxygen therapy during the newborn period and in lung function at 8 years of age in children whose birth was extremely premature. METHODS: We conducted longitudinal follow-up of all survivors of extremely preterm birth who were born in Victoria, Australia, in three periods - the years 1991 and 1992 (225 infants), 1997 (151 infants), and 2005 (170 infants). Perinatal data were collected prospectively, including data on the duration and type of assisted ventilation provided, the duration of oxygen therapy, and oxygen requirements at 36 weeks of age. Expiratory airflow was measured at 8 years of age, and values were converted to z scores for age, height, ethnic group, and sex. RESULTS: The duration of assisted ventilation rose substantially over time, with a large increase in the duration of nasal continuous positive airway pressure. Despite the increase in the use of less invasive ventilation over time, the duration of oxygen therapy and the rate of oxygen dependence at 36 weeks rose, and airflows at 8 years of age were worse in 2005 than in earlier periods. For instance, for 2005 versus 1991-1992, the mean difference in the z scores for the ratio of forced expiratory volume in 1 second to forced vital capacity was -0.75 (95% confidence interval [CI], -1.07 to -0.44; P<0.001), and for 2005 versus 1997 the mean difference was -0.53 (95% CI, -0.86 to -0.19; P=0.002). CONCLUSIONS: Despite substantial increases in the use of less invasive ventilation after birth, there was no significant decline in oxygen dependence at 36 weeks and no significant improvement in lung function in childhood over time. (Funded by the National Health and Medical Research Council of Australia and the Victorian Government's Operational Infrastructure Support Program.).

Doppler manifestations of ductal steal: role in decision making.

Patent ductus arteriosus in extremely premature babies is associated with major neonatal morbidities such as necrotizing enterocolitis and intraventricular haemorrhage. Altered systemic blood flow and end-organ hypoperfusion are known associates of a haemodynamically significant ductus arteriosus where descending aorta blood flow profiles may reveal abnormal diastolic retrograde flow. A preterm neonate was noted to have a large symptomatic patent ductus arteriosus with reversal of diastolic flow in the superior mesenteric vessels. Treatment with indomethacin led to ductal closure and concomitant restoration of diastolic flow and resolution of symptoms. Doppler studies of systemic vessels may help improve our understanding of the systemic impact of a haemodynamically significant ductus arteriosus.

Survey of management of neonatal haemolytic jaundice in Australasia.

BACKGROUND: Haemolytic jaundice is an important entity in neonatal clinical practice. Because of the decrease in rhesus isoimmunisation since the advent of anti-D immunoglobulin and improved antenatal management strategies, its management in the neonatal period has become less intensive and exchange transfusions rarely performed. AIM: We planned to review the practice of Australasian perinatal units in light of recent advances and recommendations. METHODS: An electronic survey was sent to the directors of all 25 tertiary-level perinatal units across Australasia. The questionnaire comprised 20 questions dealing with the management of haemolytic jaundice. RESULTS: Twenty out of the 25 neonatal units responded. Most were aware of the recent American Academy of Pediatrics guidelines, but only eight (40%) based their practice on it. Fifty per cent of neonatal units had written protocols to manage such infants, but almost all had written guidelines for performing exchange transfusions. Seven (35%) units started prophylactic phototherapy; however, the criteria used for early exchange were variable, most related to cord haemoglobin or rate of rise of bilirubin. Few units used high-dose intravenous immunoglobulin in haemolytic jaundice. Average exchange rates (based on the last 2 years) were 3.5/year (0-10). CONCLUSION: Variable practice was noted across the Australasian units. Written protocols form the backbone of management of jaundice in such babies. The use of intravenous immunoglobulin is minimal, and the information available on its use needs to be critically appraised.

Bilious vomiting in the newborn: 6 years data from a Level III Centre.

BACKGROUND: Bilious vomiting in the newborn is an urgent condition that frequently requires neonatal and paediatric surgical involvement. Investigations involve abdominal X-ray and contrast imaging in most cases. We aimed to describe the prevalence of surgical intervention in this cohort and assess the reliability of contrast imaging in accurate prediction of underlying condition. METHODS: A retrospective audit of data from December 2001 to October 2007 was undertaken. Data on newborns admitted to a level III unit with bilious vomiting was extracted. Infants with bilious aspirates but no vomiting were excluded. RESULTS: Sixty-one infants were admitted to the unit during the period with bilious vomiting. Most of them were out born (83.6%). Mean (and standard deviation) gestation was 38.3 weeks (+/-3.2); weight was 3173.5 grams (+/-717.6); day of admission was 3.68 days (1-28); and length of stay in the unit was 9.96 days (1-48). There were 52 (85.2%) abnormal X-rays and 21 (34.4%) abnormal contrast studies. Sixteen (26.6%) babies had laparotomies of which 6 were malrotations with volvulus, 2 small bowel obstructions, 2 meconium ileus, 2 Hirschsprung's disease, 2 other findings, while 2 were normal. Positive predictive value (number of accurate predictions of surgical findings) for barium contrast studies was 85.7% in this series. CONCLUSION: Bile stained vomiting is a surgical emergency and prompt investigation is the key in the management. Contrast studies still form the backbone of such investigations.

Developmental Disability at School Age and Difficulty Obtaining Follow-up Data.

BACKGROUND: The relationship of developmental disability rates with difficulty obtaining follow-up data is unclear. With this study, we aimed to determine if children who attended research follow-up assessments with more difficulty had more disability at school age, compared with those who attended with less difficulty, and to establish the relationship between follow-up and disability rates. METHODS: Two groups, comprising 219 consecutive survivors born at <28 weeks' gestation or at <1000 g birth weight in the state of Victoria, Australia, in 2005, and 218 term-born, normal birth weight controls were assessed at 8 years of age for neurodevelopmental disability (any of IQ <-1 SD, cerebral palsy, blindness, or deafness). Children were classified as either more or less difficult to get to attend by research nurses involved in the study. RESULTS: The follow-up rate was 87% for both groups. Overall, children who attended with more difficulty had higher rates of neurodevelopmental disability (42%; 19 of 45) than those who attended with less difficulty (20%; 66 of 328) (odds ratio: 3.09, 95% confidence interval: 1.58 to 6.01; P = .001). As the follow-up rate rose among the 3 individual hospitals involved in the assessments, so did the rate of neurodevelopmental disability (P = .025). CONCLUSIONS: Children who attend with more difficulty have higher rates of neurodevelopmental disability at school age than those who attend with less difficulty, and disability rates rise with higher follow-up rates. Rates of neurodevelopmental disability will be underestimated if researchers are not persistent enough to obtain high follow-up rates.

Changing Neurodevelopment at 8 Years in Children Born Extremely Preterm Since the 1990s.

BACKGROUND AND OBJECTIVE: Survival of extremely preterm (EP; <28 weeks' gestation) infants has increased over the last 2 decades. Equivalent reductions in developmental morbidity in early childhood have not been consistently reported. The aim of this study was to determine trends in neurodevelopmental outcomes at 8 years of age of children born EP (22-27 completed weeks' gestation) over the past 2 decades. METHODS: Population-based cohorts of all EP survivors born in the state of Victoria, Australia in 1991-1992, 1997, and 2005 were recruited at birth. At 8 years of age, general intelligence (IQ), academic achievement, and neurosensory status were assessed. Major neurosensory disability was defined as any of moderate or severe cerebral palsy, IQ <-2 SD relative to term controls, blindness, or deafness. RESULTS: Rates of major neurosensory disability were similar in all eras (1991-1992, 18%; 1997, 15%; 2005, 18%), as were rates of IQ <-2 SD, cerebral palsy, blindness, and deafness. Mean z scores for IQ were similar across eras, but there was some evidence that scores for academic achievement were lower in 2005 than in 1997, and the odds of having academic problems were higher in 2005 than in both earlier eras. These outcomes were not explained by differences in known perinatal care or sociodemographic variables between eras. CONCLUSIONS: Contrary to expectations, rates of major neurosensory disability have not improved, and academic performance is poorer at early school age in 2005 than in earlier eras for EP children born in the state of Victoria, Australia.

Clearance of infant vancomycin-resistant Enterococcus faecium carriage after a neonatal inpatient outbreak.

A follow-up cohort study was undertaken to document clearance of fecal vancomycin-resistant Enterococcus faecium carriage in 19 infants colonized during a hospital outbreak. By the conclusion of the 14-month study period, all participants had returned terminal negative fecal specimens, supporting the hypothesis that carriage is transient in this population.

Outbreak of vanB vancomycin-resistant Enterococcus faecium colonization in a neonatal service.

OBJECTIVE: To describe successful termination of an outbreak of vancomycin-resistant Enterococcus faecium (VREfm) colonization within a neonatal service. SETTING: Multisite neonatal intensive care unit and special care nurseries within a single health care service. PARTICIPANTS: Forty-four cases of VREfm-colonized neonatal inpatients-including 2 clinical isolates (eye swab and catheter-urine specimen) and 42 screening isolates. INTERVENTIONS: Active surveillance cultures, patient isolation, contact precautions, enhanced environment cleaning, and staff and parent education. Whole genome sequencing and multilocus sequence typing were used to characterize the outbreak and refine infection control procedures. RESULTS: Peak prevalence of VREfm colonization across all sites was 31% upon discovery of the outbreak. Subsequent to the intervention, transmission was halted within 8 weeks and no further isolates of the outbreak strain have been detected as of 12 months following outbreak cessation. Environmental swabs revealed VREfm colonization of baby-weighing scales, a baby bath, and a pharmacy refrigerator within the neonatal intensive care unit. All isolates were of a single multilocus sequence type (sequence type 796) and highly clonal at the core genome level. CONCLUSIONS: Bundled infection control interventions were effective in rapidly terminating a clonal outbreak of sequence type 796 VREfm colonization within a neonatal inpatient service. Strain-typing and active surveillance cultures were critical in guiding the management of this outbreak. The closed environment of a neonatal unit likely facilitated eradication of the patient and environment reservoirs of VREfm colonization.

Growth of extremely preterm survivors from birth to 18 years of age compared with term controls.

OBJECTIVES: To determine changes in height, weight, and BMI of extremely preterm (EPT; gestational age <28 completed weeks) survivors from birth to 18 years of age, compared with term controls. METHODS: Birth, discharge, and follow-up at ages 2, 5, 8, and 18 years of consecutive EPT survivors and contemporaneous term controls born in 1991-1992 in Victoria, Australia. Weight, height, and BMI were converted to z scores and compared between groups. Height z scores at age 2 and midparental height z scores were examined as predictors of height z score at age 18 years. RESULTS: Follow-up rates were >90% until 18 years, when 166 (74%) of 225 EPT subjects and 153 (60%) of 253 controls were assessed. EPT subjects had lower weight z scores than controls at birth, with a much greater difference at discharge, which reduced progressively until age 18 years. EPT children were shorter than controls at all ages, and this difference did not alter greatly over time. BMI z scores were lower in EPT children at younger ages, but by age 18 were similar between groups. Height at age 2 was a better predictor of height at age 18 in EPT participants, compared with midparental height. CONCLUSIONS: EPT survivors were substantially lighter than term controls from birth to late adolescence, although the gap in weight steadily decreased over time from a peak at the time of discharge. The height disadvantage in EPT children compared with controls remained constant over time and BMI scores were similar at age 18 years.

Procedural training opportunities for basic pediatric trainees during a 6-month rotation in a level III perinatal centre in Australia.

OBJECTIVE: We aimed to evaluate the procedural training opportunities for basic paediatric trainees in a large tertiary perinatal centre in Australia, to facilitate a realistic expectation of the procedural skills acquired during a 6-month training period. METHODS: A prospective study in which all neonatal registrars and fellows anonymously documented their opportunities for procedural practice (including IV cannulation, intubation, umbilical lines insertion etc) for each shift during a calender month. Based on the averaged number of each shift type worked in a 6-month rotation, the total exposure to each procedure for one 6-month rotation was calculated. RESULTS: During a 6-month period, the registrars had the largest number of exposures on IV cannulation (140.54), venous blood sampling (26.78), bag and mask ventilation (17.38), intubation (7.1) and lumbar puncture (6.68). For the fellows, the largest number of exposure was IV cannulation (127.92) followed by intubation (16.53) then venous blood sampling (21.02). Procedural skills to which registrars had little exposure included chest drains, chest compressions, peripherally inserted central vascular lines and placement of oro-gastric tubes. CONCLUSION: There are ample training opportunities for registrars during a 6-month period. Simulation/animal models for rare procedures will be helpful to increase the trainee's procedural competency.