Multi-component lipid emulsion vs soy-based lipid emulsion for very low birth weight preterm neonates: A pre-post comparative study.

OBJECTIVE: To examine the effectiveness of soybean oil-medium chain triglycerides-olive oil-fish oil lipid emulsion (SMOF-LE) on clinical outcomes of very-low-birth-weight neonates. STUDY DESIGN: We conducted a pre-post comparative study of very-low-birth-weight neonates, dividing them according to lipid emulsion received: Intralipid (soy-based; n = 680) or SMOF-LE (n = 617). Primary outcomes were mortality, chronic lung disease, severe retinopathy, infection, and necrotising enterocolitis. Secondary outcomes were cholestasis, osteopenia, time to full feeds, and time to regain birthweight. RESULTS: Baseline characteristics between groups were comparable. Primary outcomes did not differ significantly between groups, although any retinopathy was significantly lower in the SMOF-LE group. SMOF-LE group had lower odds of cholestasis, osteopenia, and lipid interruption, and reduced times to full feeds and to regain birthweight. CONCLUSIONS: Compared with Intralipid, SMOF-LE was not associated with differences in mortality and major morbidities but was associated with lower odds of any retinopathy, cholestasis, and osteopenia; and improved lipid tolerance.

Complete recovery in Wernicke's encephalopathy complicating hyperemesis gravidarum.

Wernicke's encephalopathy (WE) is an uncommon neurological complication in pregnancies complicated with hyperemesis due to thiamine deficiency. In women with hyperemesis, inadvertent glucose administration prior to thiamine supplementation triggers the development of neurological manifestations. Delay in the diagnosis can lead to maternal morbidity, and in one-third of cases may lead to persistence of some neurological deficit. With early recognition and thiamine supplementation, complete recovery is reported. We report a case of WE complicating a case of triplet pregnancy with hyperemesis gravidarum, which highlights the importance of early recognition and treatment, resulting in complete recovery as in the index case.

Early treatment versus expectative management of patent ductus arteriosus in preterm infants: a multicentre, randomised, non-inferiority trial in Europe (BeNeDuctus trial).

BACKGROUND: Much controversy exists about the optimal management of a patent ductus arteriosus (PDA) in preterm infants, especially in those born at a gestational age (GA) less than 28 weeks. No causal relationship has been proven between a (haemodynamically significant) PDA and neonatal complications related to pulmonary hyperperfusion and/or systemic hypoperfusion. Although studies show conflicting results, a common understanding is that medical or surgical treatment of a PDA does not seem to reduce the risk of major neonatal morbidities and mortality. As the PDA might have closed spontaneously, treated children are potentially exposed to iatrogenic adverse effects. A conservative approach is gaining interest worldwide, although convincing evidence to support its use is lacking. METHODS: This multicentre, randomised, non-inferiority trial is conducted in neonatal intensive care units. The study population consists of preterm infants (GA < 28 weeks) with an echocardiographic-confirmed PDA with a transductal diameter > 1.5 mm. Early treatment (between 24 and 72 h postnatal age) with the cyclooxygenase inhibitor (COXi) ibuprofen (IBU) is compared with an expectative management (no intervention intended to close a PDA). The primary outcome is the composite of mortality, and/or necrotising enterocolitis (NEC) Bell stage ≥ IIa, and/or bronchopulmonary dysplasia (BPD) defined as the need for supplemental oxygen, all at a postmenstrual age (PMA) of 36 weeks. Secondary outcome parameters are short term sequelae of cardiovascular failure, comorbidity and adverse events assessed during hospitalization and long-term neurodevelopmental outcome assessed at a corrected age of 2 years. Consequences regarding health economics are evaluated by cost effectiveness analysis and budget impact analysis. DISCUSSION: As a conservative approach is gaining interest, we investigate whether in preterm infants, born at a GA less than 28 weeks, with a PDA an expectative management is non-inferior to early treatment with IBU regarding to the composite outcome of mortality and/or NEC and/or BPD at a PMA of 36 weeks. TRIAL REGISTRATION: This trial is registered with the Dutch Trial Register NTR5479 (registered on 19 October 2015), the registry sponsored by the United States National Library of Medicine Clinicaltrials.gov NCT02884219 (registered May 2016) and the European Clinical Trials Database EudraCT 2017-001376-28 .

Indirect neonatal hyperbilirubinemia in hospitalized neonates on the Thai-Myanmar border: a review of neonatal medical records from 2009 to 2014.

BACKGROUND: Indirect neonatal hyperbilirubinemia (INH) is a common neonatal disorder worldwide which can remain benign if prompt management is available. However there is a higher morbidity and mortality risk in settings with limited access to diagnosis and care. The manuscript describes the characteristics of neonates with INH, the burden of severe INH and identifies factors associated with severity in a resource-constrained setting. METHODS: We conducted a retrospective evaluation of anonymized records of neonates hospitalized on the Thai-Myanmar border. INH was defined according to the National Institute for Health and Care Excellence guidelines as 'moderate' if at least one serum bilirubin (SBR) value exceeded the phototherapy threshold and as 'severe' if above the exchange transfusion threshold. RESULTS: Out of 2980 records reviewed, 1580 (53%) had INH within the first 14 days of life. INH was moderate in 87% (1368/1580) and severe in 13% (212/1580). From 2009 to 2011, the proportion of severe INH decreased from 37 to 15% and the mortality dropped from 10% (8/82) to 2% (7/449) coinciding with the implementation of standardized guidelines and light-emitting diode (LED) phototherapy. Severe INH was associated with: prematurity (< 32 weeks, Adjusted Odds Ratio (AOR) 3.3; 95% CI 1.6-6.6 and 32 to 37 weeks, AOR 2.2; 95% CI 1.6-3.1), Glucose-6-phosphate dehydrogenase deficiency (G6PD) (AOR 2.3; 95% CI 1.6-3.3), potential ABO incompatibility (AOR 1.5; 95% CI 1.0-2.2) and late presentation (AOR 1.8; 95% CI 1.3-2.6). The risk of developing severe INH and INH-related mortality significantly increased with each additional risk factor. CONCLUSION: INH is an important cause of neonatal hospitalization on the Thai-Myanmar border. Risk factors for severity were similar to previous reports from Asia. Implementing standardized guidelines and appropriate treatment was successful in reducing mortality and severity. Accessing to basic neonatal care including SBR testing, LED phototherapy and G6PD screening can contribute to improve neonatal outcomes.

Effects of Probiotics on Necrotizing Enterocolitis, Sepsis, Intraventricular Hemorrhage, Mortality, Length of Hospital Stay, and Weight Gain in Very Preterm Infants: A Meta-Analysis.

Probiotics are increasingly used as a supplement to prevent adverse health outcomes in preterm infants. We conducted a systematic review, meta-analysis, and subgroup analysis of findings from randomized controlled trials (RCTs) to assess the magnitude of the effect of the probiotics on health outcomes among very-low-birth-weight (VLBW) infants. Relevant articles from January 2003 to June 2017 were selected from a broad range of databases, including Medline, PubMed, Scopus, and Embase. Studies were included if they used an RCT design, involved a VLBW infant (birthweight <1500 g or gestational age <32 wk) population, included a probiotic intervention group, measured necrotizing enterocolitis (NEC) as a primary outcome, and measured sepsis, mortality, length of hospital stay, weight gain, and intraventricular hemorrhage (IVH) as additional outcomes. The initial database search yielded 132 potentially relevant articles and 32 (n = 8998 infants) RCTs were included in the final meta-analysis. Subgroup analysis was used to evaluate the effects of the moderators on the outcome variables. In the probiotics group, it was found that NEC was reduced by 37% (95% CI: 0.51%, 0.78%), sepsis by 37% (95% CI: 0.72%, 0.97%), mortality by 20% (95% CI: 0.67%, 0.95%), and length of hospital stay by 3.77 d (95% CI: -5.94, -1.60 d). These findings were all significant when compared with the control group. There was inconsistent use of strain types among some of the studies. The results indicate that probiotic consumption can significantly reduce the risk of developing medical complications associated with NEC and sepsis, reduce mortality and length of hospital stay, and promote weight gain in VLBW infants. Probiotics are more effective when taken in breast milk and formula form, consumed for <6 wk, administered with a dosage of <109 CFU/d, and include multiple strains. Probiotics are not effective in reducing the incidence of IVH in VLBW infants.

[Delayed umbilical cord clamping in preterm infants born before 37 weeks of gestation: A prospective observational study]. / Clampage tardif du cordon ombilical chez les enfants prématurés nés avant 37 semaines d'aménorrhée : étude observationnelle prospective.

INTRODUCTION AND OBJECTIVES: Many international studies have demonstrated that delayed umbilical cord clamping reduces neonatal morbidity. However, in France, delayed umbilical cord clamping is still not performed in many neonatal units. The aims of this study were to evaluate the feasibility of developing a protocol of delayed umbilical cord clamping in the maternity ward of the Toulouse university hospital and to evaluate the impact of this new protocol on neonatal mortality. METHODS: We conducted a prospective observational study including 123 preterm infants born before 37 weeks of gestation between June 2012 and June 2013 and hospitalized at birth. Delayed cord clamping was performed for at least 30s after birth; otherwise, it was evaluated as early cord clamping. We excluded twin-to-twin transfusion syndrome, congenital abnormalities, alloimmunization, and perinatal asphyxia. We analyzed the reasons why delayed umbilical cord clamping was not performed and then neonatal morbidity in our population. RESULTS: Delayed umbilical cord clamping was performed on 79 infants and 44 infants had early umbilical cord clamping. The two groups had similar baseline characteristics. Preterm infants in the delayed cord-clamping group had a higher level of hemoglobin during the first 24h of life (17.9g/dL versus 16.6g/dL, P=0.005), fewer of them required transfusion (14% versus 35%, P=0.03), and fewer presented late-onset sepsis (8% versus 26%, P=0.02) or bronchopulmonary dysplasia (9% versus 26%, P=0.03). There was no statistically significant increase of hyperbilirubinemia requiring phototherapy. DISCUSSION AND CONCLUSION: Implanting a new protocol of delayed umbilical cord clamping in our maternity ward proved to be possible without difficulty. The advantages of delayed umbilical cord clamping were observed in this prospective study. Today, delayed cord clamping has become a common practice in our maternity unit.

Vitamin A supplementation to prevent mortality and short- and long-term morbidity in very low birth weight infants.

BACKGROUND: Vitamin A is necessary for normal lung growth and the integrity of respiratory tract epithelial cells. Preterm infants have low vitamin A status at birth and this has been associated with an increased risk of developing chronic lung disease. OBJECTIVES: To evaluate supplementation with vitamin A on the incidence of death or neonatal chronic lung disease and long-term neurodevelopmental disability in very low birth weight (VLBW) infants compared with a control (placebo or no supplementation), and to consider the effect of the supplementation route, dose, and timing. SEARCH METHODS: For the original review and subsequent updates, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE, Science Citation Index, and the Oxford Database of Perinatal Trials. The reference lists of relevant trials, paediatric and nutrition journals, and conference abstracts and proceedings were handsearched up to 2010.For the 2016 update, we used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 4), MEDLINE via PubMed (1 May 2016), EMBASE (1 May 2016), and CINAHL (1 May 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Randomised controlled trials comparing vitamin A supplementation with a control (placebo or no supplementation) or other dosage regimens in VLBW infants (birth weight ≤ 1500 grams or less than 32 weeks' gestation). DATA COLLECTION AND ANALYSIS: Two review authors screened the search results, extracted data, and assessed the trials for risk of bias. Results were reported as risk ratios (RR), risk differences (RD), and number needed to treat to benefit (NNTB), all with 95% confidence intervals (CI). Trialists were contacted for additional data. MAIN RESULTS: Eleven trials met the inclusion criteria. Ten trials (1460 infants) compared vitamin A supplementation with a control and one (120 infants) compared different regimens of vitamin A supplementation. Compared to the control group, vitamin A appeared to have a small benefit in reducing the risk of death or oxygen requirement at one month of age (typical RR 0.93, 95% CI 0.88 to 0.99; typical RD -0.05, 95% CI -0.10 to -0.01; NNTB 20, 95% CI 10 to 100; 6 studies, 1165 infants) and the risk of chronic lung disease (oxygen requirement) at 36 weeks' postmenstrual age (typical RR 0.87, 95% CI 0.77 to 0.99; typical RD -0.07, 95% CI -0.13 to -0.01; NNTB 11, 95% CI 6 to 100; 5 studies, 986 infants) (moderate-quality evidence). There was a marginal reduction of the combined outcome of death or chronic lung disease (typical RR 0.92, 95% CI 0.84 to 1.01; typical RD -0.05, 95% CI -0.11 to 0.01; 4 studies, 1089 infants). Neurodevelopmental assessment of 88% of the surviving infants in the largest trial showed no difference between the groups at 18 to 22 months of age, corrected for prematurity (low-quality evidence). There is no evidence to support different vitamin A dosing regimens. No adverse effects of vitamin A supplementation were reported, but it was noted that intramuscular injections of vitamin A were painful. AUTHORS' CONCLUSIONS: Whether clinicians decide to utilise repeat intramuscular doses of vitamin A to prevent chronic lung disease may depend upon the local incidence of this outcome and the value attached to achieving a modest reduction in the outcome balanced against the lack of other proven benefits and the acceptability of the treatment. Information on long-term neurodevelopmental status suggests no evidence of either benefit or harm from the intervention.

Aspectos clínicos, epidemiológicos, supervivencia, mortalidad y morbilidad de recién nacidos pretérmino de muy bajo peso al nacer periodo enero 2012 a octubre 2014 en el Hospital San Juan de Dios de Ayaviri Puno Perú / Clinical aspects, epidemiological, survival, mortality and morbidity in preterm newborn with very low birth weight, period January 2012 to October 2014 in the Hospital San Juan de Dios in Ayaviri, Puno, Peru

Conocer si existe diferencias en los aspectos clínicos y epidemiológicos de los recién nacidos prematuros con peso al nacer entre 600 - 749 g, 750 - 999 g, 1000 - 1249 g y 1250 - 1499 g del servicio de Neonatología del Hospital San Juan de Dios de Ayaviri durante enero 2012 a octubre 2014. Material y métodos: El estudio fue de tipo descriptivo, transversal de casos y controles. La muestra estuvo constituida por 48 neonatos cuyo peso fue de 1250 - 1499 g y por 30 neonatos cuyo peso fue de 1000 - 1249 g en el periodo que corresponde al estudio. Se usó una ficha de datos la cual fue validada por los Médicos Asistentes del servicio de Neonatología del Hospital San Juan de Dios de Ayaviri. Para el análisis de datos se utilizó el programa SPSS versión 21. Resultados: Hubo asociación de recién nacidos con peso entre 1000 a 1249gr relacionados con morbilidad cardiorespiratoria (80 por ciento), y requerimiento de oxigeno (90 por ciento). Asimismo los recién nacidos entre 1250 a 1499gr tuvieron una mayor frecuencia de fototerapia en los recién nacidos prematuros entre 1250 a 1499 hubo 18,8 por ciento de mortalidad, y en los neonatos de 1000 a 1249 la frecuencia de mortalidad fue del 10 por ciento, no existiendo diferencias estadísticas. La tasa de mortalidad global fue del 15,4 por ciento (12/78). Encontramos que de los pacientes que fallecieron el 50 por ciento tuvo afección pulmonar. Conclusiones: Las patologías asociadas a mortalidad de mayor frecuencia fueron los problemas respiratorios. Encontramos asociación de la edad materna, primiparidad, morbilidad neonatal, y requerimiento de oxigeno en neonatos cuyo peso fluctuó entre 1000 a 1249g. La tasa de mortalidad global fue del 15,4 por ciento...

A Comparison of the Short-term Morbidity and Mortality Between Late Preterm and Term Newborns.

INTRODUCTION: Late preterm babies are defined as those born between 34 to 36 completed weeks. There has been a recent increased awareness that this group of babies has a higher incidence of morbidity as compared to term babies. The aim of this study was to evaluate the short-term morbidities occurring in this group of babies managed in the neonatal unit at Singapore General Hospital (SGH). MATERIALS AND METHODS: A retrospective study was done of babies managed in the neonatal unit at SGH from January 2005 to December 2008. Maternal, perinatal and neonatal data were obtained from the departmental database. The outcomes of late preterm infants were compared with term infants. RESULTS: A total of 6826 babies were admitted. Ten percent (681 out of 6826) of babies were late preterm babies, making up 63% (681 out of 1081) of all preterm babies. Late preterm babies had significantly greater need for resuscitation at birth. They also had statistically significant increased risks of developing hyaline membrane disease (2.5% vs 0.1%), transient tachypnoea of the newborn (TTN) (8.1% vs 1.7%), pneumonia (7.0% vs 2.8%), patent ductus arteriosus (PDA) (4.3% vs 1.1%), hypotension (0.7% vs 0%), apnoea (3.7% vs 0%), gastrointestinal (GI) bleeding (1.5% vs 0.3%), polycythaemia (2.2% vs 1.0%), anaemia (3.4% vs 1.2%), thrombocytopenia (3.2% vs 0.6%), hypoglycaemia (6.6% vs 1.7%), neonatal jaundice requiring phototherapy (41.1% vs 12.2%) and sepsis (1.7% vs 0.6%). CONCLUSION: Late preterm infants are indeed a vulnerable group of infants with significant morbidities that need to be addressed and treated. Despite their relatively large size and being almost term, the understanding that late preterm infants are not similar to term infants is important to both obstetricians and neonatologists.

[Correlation between antenatal corticosteroid therapy, resuscitation and mortality in very low birth weight infants]. / Correlação entre o uso de corticoterapia antenatal, a reanimação e a mortalidade de recém-nascidos prematuros de muito baixo peso.

PURPOSE: To evaluate the correlation between the use of antenatal corticosteroid therapy (AC), the frequency of resuscitation in delivery room and mortality of newborn infants under 1,500 g and gestational age less than or equal to 34 weeks. METHODS: A cohort study was conducted on all newborn infants under 1,500 g and with a gestational age less than or equal to 34 weeks admitted at the neonatal ICU between January 2006 and December 2011. Newborns who had congenital anomalies, genetic syndromes, congenital infections and those who were transferred to or came from other institutions were excluded. The studied infants were divided into 2 groups: those who received (n=182) and those who did not receive (n=38) AC. The main outcomes studied were the necessity of neonatal resuscitation, the presence of the main neonatal diseases and mortality during hospitalization. The means of the variables were compared using Student's t-test or non-parametric test and frequencies were compared by χ2test with Fisher's correction. The variables that presented difference between groups were assessed by logistic regression. The Statistical Package for the Social Sciences (SPSS) 16.0 was used and the significance level was set at 0.05. RESULTS: In this study, 220 patients were evaluated. The groups were similar concerning birth weight, gestational age and the presence of the main neonatal morbidity during hospitalization. The infants who received antenatal corticosteroids showed lower mortality (OR=3.0; 95%CI 1.4-6.5) and required less resuscitation (OR=2.4; 95%CI 1.1-5.0). Besides, they required less advanced resuscitation procedures, such as tracheal cannula (OR=3.7; 95%CI 1.7-7.6), cardiac massage (OR=5.7; 95%CI 2.0-16.5) and medications (OR=8.9; 95%CI 2.0-39.4). CONCLUSIONS: The use of antenatal corticosteroids reduced the need for resuscitation in delivery room, especially advanced procedures, and reduced the mortality in the studied groups.

Correlação entre o uso de corticoterapia antenatal, a reanimação e a mortalidade de recém-nascidos prematuros de muito baixo peso / Correlation between antenatal corticosteroid therapy, resuscitation and mortality in very low birth weight infants

OBJETIVO: Avaliar a correlação entre o uso de corticoterapia antenatal (CAN), a frequência de reanimação em sala de parto e a evolução ao óbito de recém-nascidos menores de 1.500 g e idade gestacional menor ou igual a 34 semanas. MÉTODOS: Estudo de coorte no qual foram acompanhados, desde a internação até a idade gestacional corrigida de 34 semanas, todos os recém-nascidos admitidos na UTI neonatal de janeiro de 2006 a dezembro de 2011. Foram excluídos os recém-nascidos que apresentaram malformações, síndromes genéticas, infecções congênitas e os transferidos de ou para outras instituições. Os recém-nascidos foram separados em 2 grupos: os que receberam (n=182) e os que não receberam (n=38) corticosteroide antenatal. Os principais desfechos estudados foram a necessidade de reanimação neonatal, a presença das principais morbidades neonatais e a evolução ao óbito durante a internação. As médias das variáveis foram comparadas utilizando-se o teste t de Student ou teste não paramétrico e as frequências foram comparadas pelo teste do χ2, com correção de Fisher. Todas as variáveis que se apresentaram diferentes entre os grupos foram avaliadas por regressão logística. Foi utilizado o pacote estatístico Statistical Package for the Social Sciences (SPSS) 16.0 e a significância foi considerada 0,05. RESULTADOS: Foram avaliados 220 pacientes. Não houve diferença entre os grupos quanto ao peso de nascimento, à idade gestacional e à presença das principais patologias neonatais. O grupo de recém-nascidos que recebeu CAN apresentou mortalidade 3 vezes menor (IC95% 1,4-6,5) e necessitou 2,4 vezes menos de reanimação (IC95% 1,1-5,0). Além disso, houve diminuição ...

PURPOSE: To evaluate the correlation between the use of antenatal corticosteroid therapy (AC), the frequency of resuscitation in delivery room and mortality of newborn infants under 1,500 g and gestational age less than or equal to 34 weeks. METHODS: A cohort study was conducted on all newborn infants under 1,500 g and with a gestational age less than or equal to 34 weeks admitted at the neonatal ICU between January 2006 and December 2011. Newborns who had congenital anomalies, genetic syndromes, congenital infections and those who were transferred to or came from other institutions were excluded. The studied infants were divided into 2 groups: those who received (n=182) and those who did not receive (n=38) AC. The main outcomes studied were the necessity of neonatal resuscitation, the presence of the main neonatal diseases and mortality during hospitalization. The means of the variables were compared using Student's t-test or non-parametric test and frequencies were compared by χ2test with Fisher's correction. The variables that presented difference between groups were assessed by logistic regression. The Statistical Package for the Social Sciences (SPSS) 16.0 was used and the significance level was set at 0.05. RESULTS: In this study, 220 patients were evaluated. The groups were similar concerning birth weight, gestational age and the presence of the main neonatal morbidity during hospitalization. The infants who received antenatal corticosteroids showed lower mortality (OR=3.0; 95%CI 1.4-6.5) and required less resuscitation (OR=2.4; 95%CI 1.1-5.0). Besides, they required less advanced resuscitation procedures, such as tracheal cannula (OR=3.7; 95%CI 1.7-7.6), cardiac massage (OR=5.7; 95%CI 2.0-16.5) and medications (OR=8.9; 95%CI 2.0-39.4). CONCLUSIONS: The use of antenatal corticosteroids reduced the need for resuscitation in delivery room, especially advanced procedures, and reduced the mortality in the studied groups. .

[Antenatal corticosteroid therapy and late preterm infant morbidity and mortality]. / Corticoterapia prenatal y morbimortalidad del prematuro tardío: estudio prospectivo.

INTRODUCTION: Late preterm infants (34-36 weeks gestation) have a morbidity rate significantly higher than those born at term. However, few interventions have been undertaken to reduce this increased morbidity and mortality. Antenatal corticosteroid administration could be an effective preventive measure. OBJECTIVE: The aim of this study was to describe the morbidity associated with late prematurity in our institution, and determine if there are differences between those who received antenatal corticosteroids. PATIENTS AND METHODS: A prospective observational study was conducted on late preterm infants born in a tertiary hospital from October 2011 until September 2012. Two groups were formed according to whether or not they had received antenatal steroids. The rates of morbidity and mortality for each of the groups were analysed and compared. RESULTS: There was a total of 4127 live newborns during the study period, of whom 3795 were term and 332 were preterm (the overall prematurity rate was 8.04%). There were 247 late preterm deliveries, representing 6% of live born infants, and 74.4% of all premature infants. Of late preterm infants, 63.2% were admitted to the Neonatal Unit and 29.6% had received antenatal steroids. The incidence of admission to the Neonatal Unit and Neonatal Intensive Care, transient tachypnea, need for respiratory support in the form of continuous positive pressure airway and oxygen therapy, incidence of hypoglycemia, feeding difficulty, and jaundice requiring phototherapy were significantly higher (P<.05) in the late preterm group that did not receive antenatal steroids. CONCLUSIONS: Our finding suggests that the administration of antenatal corticosteroids to patients at risk of 34-36 weeks delivery could significantly reduce the cost and acute morbidity associated with late preterm birth.

Efficacy and safety of probiotics in preterm infants.

Probiotics are live microbial feed supplements that beneficially affect the recipient by improving intestinal balance. In an updated systematic review, nineteen trials randomizing more than 2800 infants were included. In a meta-analysis of trial data, enteral probiotic supplementation significantly reduced the incidence of severe necrotizing enterocolitis (typical RR 0.35, 95% CI 0.24 to 0.52) and mortality (typical RR 0.55, 95% CI 0.40 to 0.74). There was no evidence of significant reduction of nosocomial sepsis (typical RR 0.89, 95% CI 0.77 to 1.03). The included trials reported no systemic infection with - supplemented probiotics. Recent data in addition to a report by the European Society for Pediatric Gastroenterology (ESPGAN) concluded probiotics could be generally considered safe.

[Health insurance expenses for children in the first five years of life - a cohort-based analysis]. / Ausgaben einer Krankenkasse für Kinder in den ersten fünf Lebensjahren - eine kohortenbasierte Analyse.

INTRODUCTION: The development of paediatrics is characterised by several changes in the past few years, concerning, in particular holistic treatments or preventive check-ups, but also the transfer of treatment from the inpatient to the outpatient sector. There are no reference values for assessing emerging health insurance expenses. The aim of this study was to obtain a frame of reference for the costs of the treatment for neonates, infants, and young children using the example of the expenditures of one health insurance fund. METHODS: The individual health insurance expenditures were analysed for the first five years of life of children insured with the AOK PLUS in Saxony, Germany, in 2005. Costs of hospital treatment, ambulatory care, remedies, tools, medicines and care were included. RESULTS: The costs per insured child and year amounted to approximately 1,277 Euro (N = 11,147), with the highest costs arising in the first two years. 858 Euro were spent annually for an "average" child; 5,691 Euro per year incurred for a child with special medical needs. DISCUSSION: The present cost analysis describes both the height and structure of a health insurance's spendings on children within the first five years of their life in consideration of regional medical care offers. The question of whether this analysis provides valid reference values for other health insurances or other service areas will have to be answered by other analyses.

Zinc supplementation reduces morbidity and mortality in very-low-birth-weight preterm neonates: a hospital-based randomized, placebo-controlled trial in an industrialized country.

BACKGROUND: Zinc plays a pivotal role in the pathogenesis of many diseases and in body growth. Preterm neonates have high zinc requirements. OBJECTIVE: The objective of the study was to investigate the efficacy of zinc supplementation in reducing morbidity and mortality in preterm neonates and to promote growth. DESIGN: This was a prospective, double-blind, randomized controlled study of very-low-birth-weight preterm neonates randomly allocated on the seventh day of life to receive (zinc group) or not receive (control group) oral zinc supplementation. Total prescribed zinc intake ranged from 9.7 to 10.7 mg/d in the zinc group and from 1.3 to 1.4 mg/d in the placebo control group. The main endpoint was the rate of neonates with ≥ 1 of the following morbidities: late-onset sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, periventricular leucomalacia, and retinopathy of prematurity. Secondary outcomes were mortality and body growth. RESULTS: We enrolled 97 neonates in the zinc group and 96 in the control group. Morbidities were significantly lower in the zinc group (26.8% compared with 41.7%; P = 0.030). The occurrence of necrotizing enterocolitis was significantly higher in the control group (6.3% compared with 0%; P = 0.014). Mortality risk was higher in the placebo control group (RR: 2.37; 95% CI: 1.08, 5.18; P = 0.006). Daily weight gain was similar in the zinc (18.2 ± 5.6 g · kg⁻¹ · d⁻¹) and control (17.0 ± 8.7 g · kg⁻¹ · d⁻¹) groups (P = 0.478). CONCLUSION: Oral zinc supplementation given at high doses reduces morbidities and mortality in preterm neonates. This trial was registered in the Australian New Zealand Clinical Trial Register as ACTRN12612000823875.

Newborn mortality and fresh stillbirth rates in Tanzania after helping babies breathe training.

BACKGROUND: Early neonatal mortality has remained high and unchanged for many years in Tanzania, a resource-limited country. Helping Babies Breathe (HBB), a novel educational program using basic interventions to enhance delivery room stabilization/resuscitation, has been developed to reduce the number of these deaths. METHODS: Master trainers from the 3 major referral hospitals, 4 associated regional hospitals, and 1 district hospital were trained in the HBB program to serve as trainers for national dissemination. A before (n = 8124) and after (n = 78 500) design was used for implementation. The primary outcomes were a reduction in early neonatal deaths within 24 hours and rates of fresh stillbirths (FSB). RESULTS: Implementation was associated with a significant reduction in neonatal deaths (relative risk [RR] with training 0.53; 95% confidence interval [CI] 0.43-0.65; P ≤ .0001) and rates of FSB (RR with training 0.76; 95% CI 0.64-0.90; P = .001). The use of stimulation increased from 47% to 88% (RR 1.87; 95% CI 1.82-1.90; P ≤ .0001) and suctioning from 15% to 22% (RR 1.40; 95% CI 1.33-1.46; P ≤ .0001) whereas face mask ventilation decreased from 8.2% to 5.2% (RR 0.65; 95% CI 0.60-0.72; P ≤ .0001). CONCLUSIONS: HBB implementation was associated with a significant reduction in both early neonatal deaths within 24 hours and rates of FSB. HBB uses a basic intervention approach readily applicable at all deliveries. These findings should serve as a call to action for other resource-limited countries striving to meet Millennium Development Goal 4.

Vitamin A supplementation to prevent mortality and short- and long-term morbidity in very low birthweight infants.

BACKGROUND: Vitamin A is necessary for normal lung growth and the integrity of respiratory tract epithelial cells. Preterm infants have low vitamin A status at birth, and this has been associated with increased risk of developing chronic lung disease. OBJECTIVES: To evaluate vitamin A supplementation on the incidence of death and/or neonatal chronic lung disease and long-term neurodevelopmental disability in very low birthweight infants (VLBW); and to consider the effect of the supplementation route, dose, and timing. SEARCH STRATEGY: In August 2011, the Cochrane Central Regsiter of Controlled Trials (Central, The Cochrane Library), MEDLINE, Science Citation Index and the Oxford Database of Perinatal Trials were searched. The reference lists of relevant trials, paediatric and nutrition journals, and conference abstracts and proceedings were handsearched up to 2007. SELECTION CRITERIA: Randomised controlled trials comparing vitamin A supplementation with a control (placebo or no supplementation) or other dosage regimens in VLBW infants (birthweight ≤ 1500 g or < 32 weeks' gestation). DATA COLLECTION AND ANALYSIS: Both review authors screened the search results, extracted data, and assessed the trials' risk of bias. Results were reported as risk ratios (RR), risk differences (RD), and number needed to treat to benefit (NNTB), all with 95% confidence intervals (CI). Trialists were contacted for additional data. MAIN RESULTS: Nine trials met the inclusion criteria, eight compared vitamin A supplementation with a control (1291 infants), and one compared different regimens (120 infants). Compared to the control group, vitamin A appears to be beneficial in reducing death or oxygen requirement at one month of age (RR 0.93, 95% CI 0.88 to 0.99; RD -0.05, 95% CI -0.10 to -0.01; NNTB 20, 95% CI 10 to 100; 1165 infants) and oxygen requirement at 36 weeks' postmenstrual age (RR 0.87, 95% CI 0.77 to 0.98; RD -0.08, 95% CI -0.14 to -0.01; NNTB 13, 95% CI 7 to 100; 824 infants). A trend towards a reduction in death or oxygen requirement at 36 weeks' postmenstrual age was also noted (RR 0.91, 95% CI 0.82 to 1.00; 1001 infants). Neurodevelopmental assessment of 88% of surviving infants in the largest trial showed no differences between the groups at 18 to 22 months of age, corrected for prematurity. The different dosage vitamin A regimens showed similar results. AUTHORS' CONCLUSIONS: Whether clinicians decide to utilise repeat intramuscular doses of vitamin A to prevent chronic lung disease may depend upon the local incidence of this outcome and the value attached to achieving a modest reduction in this outcome, balanced against the lack of other proven benefits and the acceptability of treatment. Information on long-term neurodevelopmental status suggests no evidence of either benefit or harm from the intervention.

High mortality rates for very low birth weight infants in developing countries despite training.

OBJECTIVE: The goal was to determine the effect of training in newborn care and resuscitation on 7-day (early) neonatal mortality rates for very low birth weight (VLBW) infants. The study was designed to test the hypothesis that these training programs would reduce neonatal mortality rates for VLBW infants. METHODS: Local instructors trained birth attendants from 96 rural communities in 6 developing countries in protocol and data collection, the World Health Organization Essential Newborn Care (ENC) course, and a modified version of the American Academy of Pediatrics Neonatal Resuscitation Program (NRP), by using a train-the-trainer model. To test the impact of ENC training, data on infants of 500 to 1499 g were collected by using a before/after, active baseline, controlled study design. A cluster-randomized, controlled trial design was used to test the impact of the NRP. RESULTS: A total of 1096 VLBW (500-1499 g) infants were enrolled, and 98.5% of live-born infants were monitored to 7 days. All-cause, 7-day neonatal mortality, stillbirth, and perinatal mortality rates were not affected by ENC or NRP training. CONCLUSIONS: Neither ENC nor NRP training of birth attendants decreased 7-day neonatal, stillbirth, or perinatal mortality rates for VLBW infants born at home or at first-level facilities. Encouragement of delivery in a facility where a higher level of care is available may be preferable when delivery of a VLBW infant is expected.

Phase 1 trial of 4 thyroid hormone regimens for transient hypothyroxinemia in neonates of <28 weeks' gestation.

BACKGROUND: Transiently low levels of thyroid hormones occur in approximately 50% of neonates born 24-28 weeks' gestation and are associated with higher rates of cerebral palsy and cognitive impairment. Raising hormone levels shows promise for improving neurodevelopmental outcome. OBJECTIVE: To identify whether any of 4 thyroid hormone supplementation regimens could raise T(4) and FT(4) without suppressing TSH (biochemical euthyroidism). METHODS: Eligible subjects had gestational ages between 24 07 and 2767 weeks and were randomized <24 hours of birth to one of six study arms (n = 20-27 per arm): placebo (vehicle: 5% dextrose), potassium iodide (30 microg/kg/d) and continuous or bolus daily infusions of either 4 or 8 microg/kg/d of T(4) for 42 days. T(4) was accompanied by 1 microg/kg/d T(3) during the first 14 postnatal days and infused with 1 mg/mL albumin to prevent adherence to plastic tubing. RESULTS: FT(4) was elevated in the first 7 days in all hormone-treated subjects; however, only the continuous 8 microg/kg/d treatment arm showed a significant elevation in all treatment epochs (P < .002 versus all other groups). TT(4) remained elevated in the first 7 days in all hormone-treated subjects (P < .05 versus placebo or iodine arms). After 14 days, both 8 microg/kg/d arms as well as the continuous 4 microg/kg/d arm produced a sustained elevation of the mean and median TT(4), >7 microg/dL (90 nM/L; P < .002 versus placebo). The least suppression of THS was achieved in the 4 microg/kg/d T(4) continuous infusion arm. Although not pre-hypothesized, the duration of mechanical ventilation was significantly lower in the continuous 4 microg/kg/d T(4) arm and in the 8 microg/kg/d T(4) bolus arm (P < .05 versus remaining arms). ROP was significantly lower in the combined 4 thyroid hormone treatment arms than in the combined placebo and iodine arms (P < .04). NEC was higher in the combined 8 microg/kg/d arms (P < .05 versus other arms). CONCLUSIONS: Elevation of TT(4) with only modest suppression of TSH was associated with trends suggesting clinical benefits using a continuous supplement of low-dose thyroid hormone (4 microg/kg/d) for 42 days. Future trials will be needed to assess the long-term neurodevelopmental effects of such supplementation.