Adverse cardiovascular events are common during dexmedetomidine administration in neonates and infants during intensive care.

AIM: This study aimed to assess the safety of a commonly used sedative, dexmedetomidine in neonates and infants during intensive care. METHODS: A retrospective cohort study was conducted in the paediatric intensive care unit at Oulu University Hospital. The study population consisted of all children from birth up to 6 months of age who received dexmedetomidine during 2010-2016. Adverse cardiovascular outcomes were defined as abnormal heart rates or blood pressure values according to the Paediatric Early Warning Score. RESULTS: Of the 172 infants, 56% had congenital malformation, and 48% had undergone surgery. Neonates and 1-3-month-olds experienced bradycardia (86% vs. 73% in 1-3-month-olds and 50% in 3-6-month-olds, p = 0.001) and severe bradycardia (17% vs. 14% in 1-3-month-olds and 0% in 3-6-month-olds, p = 0.005) more often than older patients. The median maximum rate of dexmedetomidine infusion was 0.86 µg/kg/h (IQR = 0.60-1.71 µg/kg/h). A dose-dependent increase in bradycardia and severe hypotension was found. Adverse cardiovascular events were managed with additional fluid boluses and discontinuation of the infusion. CONCLUSION: Adverse cardiovascular events were common during dexmedetomidine administration in neonates and infants. Lower dexmedetomidine doses may be required in sedating neonates.

National survey revealed variable practices in paediatric procedural sedation and patient monitoring.

Paediatric procedures requiring sedation are increasingly being performed off site, but there are no national guidelines for paediatric procedural sedation in Finland or studies on it. Therefore, the aim of this survey was to assess national practices for paediatric procedural sedation outside operation rooms and intensive care units in terms of indications, sedative medication, treatment facilities, patient safety and training of the personnel. An online survey including single- and multiple-choice questions and open-ended questions was sent to Finnish paediatricians, paediatric surgeons and paediatric anaesthesiologists via the electronic mailing lists of national societies in December 2019. A total of 71 responses were received. Lumbar puncture (41%), intra-articular injections (38%) and MRI (17%) were the most common procedures that required routine sedation. Benzodiazepines were the most frequently used sedatives during both painful procedures (80%) and imaging (61%). Pulse oximetry monitoring was reported by 75% of the respondents, but other physiological parameters were rarely monitored (ECG 28%; blood pressure 39%; respiratory rate 34%). The level of sedation was not objectively assessed. Adrenaline (72%) and equipment for managing adverse respiratory outcomes (supplemental oxygen 98%; ventilation equipment 92%) were available in most facilities in which sedation was performed. Only one-third of the respondents had undergone training for paediatric procedural sedation, and only 39% of the hospital units compiled statistical data on sedation-related adverse events. The paediatric procedural sedation practices vary across hospitals. National guidelines for patient monitoring and training of personnel could improve treatment quality and patient safety.

School Performance After Pediatric Intensive Care-Association of Mental Well-Being, Chronic Illnesses, and Family Socioeconomic Status.

OBJECTIVES: To describe school performance in pediatric intensive care survivors, as well as the influence of chronic diseases, psychological well-being, and family socioeconomic status on poor school performance. DESIGN: Register-based observational descriptive follow-up study. SETTING: A multicenter national study. PATIENTS: All pediatric patients who were admitted to an ICU in Finland in 2009-2010. Children and adolescents of or beyond school age. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Questionnaires regarding the child's coping in school classes, chronic illnesses, as well as family socioeconomic factors were sent to every child alive 6 years after discharge from intensive care in Finland. Mental well-being was measured with the Strengths and Difficulties Questionnaire. There were 1,109 responders in an ICU group of 3,674 children. Seven-hundred fifty-three of the respondents were of school age or older. Of these, 13% (101/753) demonstrated poor school performance. Children with difficulties in school more often had a need for regular medication (71.3% vs 32.4%; p < 0.001), healthcare visits (91.1% vs 80.6%; p = 0.01), some regular therapy (60.4% vs 13.7%; p < 0.001), chronic illnesses (86.3% vs 48.4%; p < 0.001), or additional ICU admissions (36.5% vs 14.9%; p = 0.003). Schooling difficulties were reported more often in children with abnormal Strengths and Difficulties Questionnaire scores compared to those with normal or borderline scores (24.8% vs 5.4%; p < 0.001). In an adjusted logistic regression model, which included age, number of chronic diseases, and need for therapy, poor school performance was predicted by abnormal Strengths and Difficulties Questionnaire scores, nonacademic parental education, and paternal manual labor status. CONCLUSIONS: Difficulties in school were more frequent when the child had chronic comorbid illnesses, especially neurologic or chromosomal abnormalities, had poor mental health, father was employed in manual labor, or parents were uneducated.

Systematic review and meta-analysis found that intranasal dexmedetomidine was a safe and effective sedative drug during paediatric procedural sedation.

AIM: This systematic review and meta-analysis evaluated the effectiveness of intranasal dexmedetomidine as a sole sedative during paediatric procedural sedation outside the operating room. METHODS: Relevant literature identified by PubMed, Scopus, ClinicalTrials.gov, ScienceDirect and Cochrane Library up to 31 December 2019 was systematically reviewed. Randomised controlled trials that compared intranasal dexmedetomidine with another sedative or placebo during paediatric procedural sedation were included. Trials that studied intranasal dexmedetomidine as a premedication before anaesthesia were excluded. The primary outcome was the success of the planned procedure. RESULTS: We analysed seven randomised controlled trials of 730 patients: four trials with 570 patients compared dexmedetomidine with chloral hydrate and three trials with 160 patients compared dexmedetomidine with midazolam. The incidence of successfully completing the procedure did not differ between dexmedetomidine and chloral hydrate, but dexmedetomidine had a higher success rate than midazolam. The incidence of hypotension, bradycardia or respiratory complications did not differ between the sedatives used. Nausea and vomiting were more common in children treated with chloral hydrate than in those treated with other sedatives. CONCLUSION: Intranasal dexmedetomidine was a safe and effective sedative for minor paediatric procedures.

Effects of repeat prenatal corticosteroids given to women at risk of preterm birth: An individual participant data meta-analysis.

BACKGROUND: Infants born preterm compared with infants born at term are at an increased risk of dying and of serious morbidities in early life, and those who survive have higher rates of neurological impairments. It remains unclear whether exposure to repeat courses of prenatal corticosteroids can reduce these risks. This individual participant data (IPD) meta-analysis (MA) assessed whether repeat prenatal corticosteroid treatment given to women at ongoing risk of preterm birth in order to benefit their infants is modified by participant or treatment factors. METHODS AND FINDINGS: Trials were eligible for inclusion if they randomised women considered at risk of preterm birth who had already received an initial, single course of prenatal corticosteroid seven or more days previously and in which corticosteroids were compared with either placebo or no placebo. The primary outcomes for the infants were serious outcome, use of respiratory support, and birth weight z-scores; for the children, they were death or any neurosensory disability; and for the women, maternal sepsis. Studies were identified using the Cochrane Pregnancy and Childbirth search strategy. Date of last search was 20 January 2015. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. IPD were analysed using a one-stage approach. Eleven trials, conducted between 2002 and 2010, were identified as eligible, with five trials being from the United States, two from Canada, and one each from Australia and New Zealand, Finland, India, and the United Kingdom. All 11 trials were included, with 4,857 women and 5,915 infants contributing data. The mean gestational age at trial entry for the trials was between 27.4 weeks and 30.2 weeks. There was no significant difference in the proportion of infants with a serious outcome (relative risk [RR] 0.92, 95% confidence interval [CI] 0.82 to 1.04, 5,893 infants, 11 trials, p = 0.33 for heterogeneity). There was a reduction in the use of respiratory support in infants exposed to repeat prenatal corticosteroids compared with infants not exposed (RR 0.91, 95% CI 0.85 to 0.97, 5,791 infants, 10 trials, p = 0.64 for heterogeneity). The number needed to treat (NNT) to benefit was 21 (95% CI 14 to 41) women/fetus to prevent one infant from needing respiratory support. Birth weight z-scores were lower in the repeat corticosteroid group (mean difference -0.12, 95%CI -0.18 to -0.06, 5,902 infants, 11 trials, p = 0.80 for heterogeneity). No statistically significant differences were seen for any of the primary outcomes for the child (death or any neurosensory disability) or for the woman (maternal sepsis). The treatment effect varied little by reason the woman was considered to be at risk of preterm birth, the number of fetuses in utero, the gestational age when first trial treatment course was given, or the time prior to birth that the last dose was given. Infants exposed to between 2-5 courses of repeat corticosteroids showed a reduction in both serious outcome and the use of respiratory support compared with infants exposed to only a single repeat course. However, increasing numbers of repeat courses of corticosteroids were associated with larger reductions in birth z-scores for weight, length, and head circumference. Not all trials could provide data for all of the prespecified subgroups, so this limited the power to detect differences because event rates are low for some important maternal, infant, and childhood outcomes. CONCLUSIONS: In this study, we found that repeat prenatal corticosteroids given to women at ongoing risk of preterm birth after an initial course reduced the likelihood of their infant needing respiratory support after birth and led to neonatal benefits. Body size measures at birth were lower in infants exposed to repeat prenatal corticosteroids. Our findings suggest that to provide clinical benefit with the least effect on growth, the number of repeat treatment courses should be limited to a maximum of three and the total dose to between 24 mg and 48 mg.

Effect of Prophylaxis for Early Adrenal Insufficiency Using Low-Dose Hydrocortisone in Very Preterm Infants: An Individual Patient Data Meta-Analysis.

OBJECTIVE: To assess the effect of prophylaxis for early adrenal insufficiency using low-dose hydrocortisone on survival without bronchopulmonary dysplasia (BPD) in very preterm infants using an individual patient data meta-analysis. STUDY DESIGN: All existing randomized controlled trials testing the efficacy of the prophylaxis of early adrenal insufficiency using low-dose hydrocortisone on survival without BPD were considered for inclusion when data were available. The primary outcome was the binary variable survival without BPD at 36 weeks of postmenstrual age. RESULTS: Among 5 eligible studies, 4 randomized controlled trials had individual patient data available (96% of participants identified; n = 982). Early low-dose hydrocortisone treatment for 10-15 days was associated with a significant increase in survival without BPD (OR, 1.45; 95% CI, 1.11-1.90; P = .007; I2 = 0%), as well as with decreases in medical treatment for patent ductus arteriosus (OR, 0.72; 95% CI, 0.56-0.93; P = .01; I2 = 0%) and death before discharge (OR, 0.70; 95% CI, 0.51-0.97; P = .03; I2 = 0%). The therapy was associated with an increased risk of spontaneous gastrointestinal perforation (OR, 2.50; 95% CI, 1.33-4.69; P = .004; I2 = 31.9%) when hydrocortisone was given in association with indomethacin exposure. The incidence of late-onset sepsis was increased in infants exposed to hydrocortisone (OR, 1.34; 95% CI, 1.02-1.75; P = .04; I2 = 0%), but no adverse effects were reported for either death or 2-year neurodevelopmental outcomes as assessed in an aggregate meta-analysis. CONCLUSIONS: This individual patient data meta-analysis showed that early low-dose hydrocortisone therapy is beneficial for survival without BPD in very preterm infants.

Strengths and Difficulties Questionnaire Assessment of Long-Term Psychological Outcome in Children After Intensive Care Admission.

OBJECTIVES: We investigated the long-term psychologic symptoms of patients who survived pediatric intensive care admission. DESIGN: Longitudinal follow-up study. SETTING: Nationwide cohort study based on a national ICU register and a questionnaire survey. PATIENTS: All pediatric patients (0-16 yr old) who were admitted to an ICU in Finland in 2009-2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Six years after ICU admission, all surviving patients were sent the Strengths and Difficulties Questionnaire, and questionnaires regarding chronic diseases and need for medication and therapy. At the end of the follow-up period, there were 3,674 surviving children who had been admitted to an ICU in 2009-2010. Of these children, 1,105 completed the Strengths and Difficulties Questionnaire 6 years after admission. Strengths and Difficulties Questionnaire scores were abnormal for 84 children (7.6%), borderline for 80 (7.2%), and normal for 941 (85.2%). Participants with abnormal scores were younger at admission to the ICU (3.06 vs 4.70 yr; p = 0.02), and more commonly had a chronic disease (79.5% vs 47.4%; p < 0.001), a need for continuous medication (49.4% vs 31.7%; p < 0.001), a need for therapy (58.5% vs 15.9%; p < 0.001), and a need for annual healthcare visits (91.4% vs 85.2%; p = 0.05). Abnormal Strengths and Difficulties Questionnaire scores were associated with higher rates of neurologic (32.1% vs 10.2%), gastrointestinal (7.1% vs 3.9%), psychiatric (3.6% vs 0.5%), and chromosomal disorders (9.5% vs 1.3%), as well as with long-term pain (1.2% vs 0.6%). CONCLUSIONS: Participants with abnormal Strengths and Difficulties Questionnaire scores (poor psychologic outcome) at 6 years after childhood ICU admission more commonly suffered neurologic, chromosomal, or psychiatric diagnoses or long-term pain, and generally required higher levels of healthcare services, therapies, and medication.

Five-Year Survival and Causes of Death in Children After Intensive Care-A National Registry Study.

OBJECTIVES: The aim of the study was to compare long-term mortality and causes of death in children post admission to an ICU with a control population of same age. DESIGN: Longitudinal follow-up study. SETTING: Registry study of a national ICU register and hospital registries. PATIENTS: Children admitted to an ICU in the years 2009 and 2010. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mortality and causes of death following ICU discharge were analyzed retrospectively. The median follow-up period was 4.9 years (25-75th percentiles, 4.4-5.5 yr). The causes of death in survivors 30 days after ICU discharge were compared with a cohort of 1 million children of the general population of same age. In total, 2,792 children were admitted to an ICU during the study period. Of those, 53 (1.9%) died in the ICU and 2,739 were discharged. Thirteen children died within 30 days of discharge, and 68 died between 30 days and the end of follow-up (December 31, 2014). In the control population (n = 1,020,407 children), there were 1,037 deaths (0.10%) from 2009 to 2014. The standardized mortality rate for the children admitted to the ICU during the study period was 53.4 (95% CI, 44.7-63.2). The standardized mortality rate for those children alive 1 year after discharge was 16.7 (12.1-22.6). One-year cumulative mortality was 3.3%. The most common causes of death in subjects alive 30 days post ICU were cancer (35.3%), neurologic (17.6%), and metabolic diseases (11.7%), whereas trauma was the most common cause in the control group (45.3%). CONCLUSIONS: There was an increased risk of death in a cohort of ICU-admitted children even 3 years after discharge. In those who survived 30 days after discharge, medical causes of death were dominant, whereas deaths due to trauma were most common in the control group.

Using high-flow nasal cannulas for infants with bronchiolitis admitted to paediatric wards is safe and feasible.

AIM: Using a high-flow nasal cannula (HFNC) for infant bronchiolitis is increasingly common, but insufficiently studied. In this retrospective study, we examined the outcomes of HFNC and compared infants who did and did not respond to this oxygen delivery method. METHODS: This 2012-2015 study of six Finnish hospitals focused on 88 infants under 12 months who received HFNC: 53 on paediatric wards and 35 in paediatric intensive care units (PICUs). We reviewed patient files for underlying factors, clinical parameters and HFNC treatment. The treatment failed if the patient was transferred to another respiratory support. RESULTS: We found HFNC treatment was successful in 76 (86%) infants, including all 53 on the paediatric wards and 23/35 PICU patients. The responders' heart rates were significantly lower, and their oxygen saturation was significantly higher at 60 minutes after HFNC treatment started and then stayed relatively constant. Their respiratory rate was only significantly lower after 360 minutes. In non-responders, the respiratory rate initially decreased but was higher at 180 and 360 minutes after the start of HFNC. CONCLUSION: We found preliminary evidence that oxygen support needs and heart rate were useful early predictors of HFNC therapy success in infants hospitalised with bronchiolitis, but respiratory rate was not.

Neurally adjusted ventilatory assist (NAVA) in preterm newborn infants with respiratory distress syndrome-a randomized controlled trial.

UNLABELLED: Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator synchrony during invasive ventilation and leads to lower peak inspiratory pressures (PIP) and oxygen requirements. The aim of this trial was to compare NAVA with current standard ventilation in preterm infants in terms of the duration of invasive ventilation. Sixty infants born between 28 + 0 and 36 + 6 weeks of gestation and requiring invasive ventilation due to neonatal respiratory distress syndrome (RDS) were randomized to conventional ventilation or NAVA. The median durations of invasive ventilation were 34.7 h (quartiles 22.8-67.9 h) and 25.8 h (15.6-52.1 h) in the NAVA and control groups, respectively (P = 0.21). Lower PIPs were achieved with NAVA (P = 0.02), and the rapid reduction in PIP after changing the ventilation mode to NAVA made following the predetermined extubation criteria challenging. The other ventilatory and vital parameters did not differ between the groups. Frequent apneas and persistent pulmonary hypertension were conditions that limited the use of NAVA in 17 % of the patients randomized to the NAVA group. Similar cumulative doses of opiates were used in both groups (P = 0.71). CONCLUSIONS: NAVA was a safe and feasible ventilation mode for the majority of preterm infants suffering from RDS, but the traditional extubation criteria were not clinically applicable during NAVA. WHAT IS KNOWN: • NAVA improves patient-ventilator synchrony during invasive ventilation. • Lower airway pressures and oxygen requirements are achieved with NAVA during invasive ventilation in preterm infants by comparison with conventional ventilation. What is new: • Infants suffering from PPHN did not tolerate NAVA in the acute phase of their illness. • The traditional extubation criteria relying on inspiratory pressures and spontaneous breathing efforts were not clinically applicable during NAVA.

Pediatric Intensive Care in PICUs and Adult ICUs: A 2-Year Cohort Study in Finland.

OBJECTIVES: To investigate the association between the type of ICU and mortality for children treated at PICUs and adult ICUs. DESIGN: This was a national multicenter cohort study. Data were collected from electronic critical care data management systems at 3 units and from national intensive care registries at 26 units. SETTING: We assessed the incidence of admissions, length of stay at ICUs, main diagnoses, and mortality for children at ICUs. Units were categorized as PICUs or as adult ICUs located at university hospitals or at non-academic central hospitals. PATIENTS: Children younger than 17 years of age treated at ICUs in Finland. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: There were 4,876 admissions from 2009 to 2010, and 98.9% of patients survived until unit discharge. The mean length of stay was 3.0 ± 7.4 days; 1,395 patients (35%) required mechanical ventilation at PICUs versus 167 (35%) at adult university hospital ICUs versus 79 (19%) at central hospital ICUs (p < 0.001). The odds for mortality in univariate regression analysis were emergency admission (odds ratio, 3.99; 95% CI, 1.82-8.76), cardiovascular (odds ratio, 7.84; 95% CI, 3.49-22.88), gastrointestinal (odds ratio, 5.37; 95% CI, 1.45-19.88), acute infections (odds ratio, 2.83; 95% CI, 1.23-6.48), hematologic/oncologic disease (odds ratio, 10.32; 95% CI, 3.14-33.86), and nonsurgical trauma (odds ratio, 3.53; 95% CI, 1.19-10.41). Treatment at adult ICUs had higher odds of mortality compared with PICUs (university hospital: odds ratio, 3.93; 95% CI, 1.85-8.35 and central hospital: odds ratio, 3.91; 95% CI, 1.69-9.05), adjusted for readmission less than 48 hours after discharge, emergency admission, mechanical ventilation, and diagnostic group. CONCLUSIONS: Pediatric patients treated at PICUs showed lower mortality. Requirement of mechanical ventilation, emergency admission, and readmission less than 48 hours after discharge and cardiovascular, gastrointestinal, acute infections, hematologic/oncologic disease, and nonsurgical trauma were associated with higher risk of mortality.

Randomised trial of early neonatal hydrocortisone demonstrates potential undesired effects on neurodevelopment at preschool age.

AIM: We evaluated the neurodevelopment and growth of five- to seven-year-old children who had participated in a randomised trial of early low-dose hydrocortisone treatment to prevent bronchopulmonary dysplasia. METHODS: The 51 infants in the original study had birthweights of 501-1250 g and gestational ages of 23-30 weeks, required mechanical ventilation during the first 24 hours and received hydrocortisone or a placebo for 10 days. The majority (80%) of the 90% who survived to five- to seven years of age participated in this follow-up study and their growth, neuromotor, cognitive and speech development were evaluated. RESULTS: Some neurodevelopment impairment was observed in 61% of the hydrocortisone group and 39% of the placebo group, ranging from minor neurological dysfunction to severe neurological conditions (p = 0.182). The mean full-scale intelligence quotient (IQ) was 87.8 (15.3) in the hydrocortisone group and 95.7 (15.0) in the placebo group (p = 0.135), and the mean performance IQ was 88.3 (14.5) and 99.1 (14.0) (p = 0.034), respectively. A fifth (22%) of the hydrocortisone group required physiotherapy, but none of the placebo group did (p = 0.034). The age-standardised growth was comparable between both groups. CONCLUSION: Early hydrocortisone treatment may have undesired effects on neurodevelopment at preschool age, and further safety studies are required.

Effect of body position on ventilation distribution in healthy newborn infants: an observational study.

OBJECTIVES: Newborn infants have unique respiratory physiology compared with older children and adults due to their lungs' structural and functional immaturity and highly compliant chest wall. To date, ventilation distribution has seldom been studied in this age group. This study aims to assess the effect of body position on ventilation distribution in spontaneously breathing healthy neonates. DESIGN: Prospective observational study. SETTING: Maternity wards of Oulu University Hospital. PATIENTS: 20 healthy, spontaneously breathing, newborn infants. INTERVENTIONS: Electrical impedance tomography data were recorded with a 32-electrode belt (Sentec AG, Landquart, Switzerland) in six different body positions in random order. Ventilation distribution was retrospectively assessed 10 minutes after each position change. MAIN OUTCOME MEASURES: In each position, regional tidal impedance variation (ΔZ) and ventral-to-dorsal and right-to-left centre of ventilation were measured. RESULTS: The mean global ΔZ was the largest in supine position and it was smaller in prone and lateral positions. Yet, global ΔZ did not differ in supine positions, ventilation distribution was more directed towards the non-dependent lung region in supine tilted position (p<0.001). In prone, a reduction of global ΔZ was observed (p<0.05) corresponding to an amount of 10% of global tidal variation in supine position. In both lateral positions, tidal ventilation was distributed more to the corresponding non-dependent lung region. CONCLUSIONS: Prone or lateral body positioning in healthy spontaneously breathing newborns leads to a redistribution of ventilation to the non-dependent lung regions and at the same time global tidal volume is reduced as compared with supine.

Long-Term Quality of Life After Pediatric Traumatic Brain Injury Treated in the Intensive Care Unit.

BACKGROUND: To examine the long-term health-related quality of life (HRQL) after pediatric traumatic brain injury (TBI) treated in the intensive care unit (ICU). METHODS: This retrospective cohort study was conducted using data from four university hospital ICUs in Finland. Children aged < 18 years with TBI treated in the ICU during 2003 to 2013 were included. Patients alive at the end of 2020 were sent two different HRQL questionnaires 15/16-dimensional (15D/16D) and RAND-36  and questions regarding chronic diseases, socioeconomical status, and the need for health care support. HRQL was defined as poor when the 15D/16D score total score was below the age- and sex-matched mean population score in Finland minus the minimal clinically important difference. RESULTS: A total of 150 of 337 (44%) patients responded (n = 144 15D/16D responses). Median follow-up time was 11 years. Seventy patients (49%) had a poor HRQL according to 15D/16D score. Patients with TBI had significantly poorer 15D scores in every dimension when compared with the matched population mean values. A higher Helsinki CT score, mechanical ventilation, and female sex were associated with poor long-term HRQL according to the 15D/16D. Patients with poor 15D/16D scores also needed significantly more health care services and medications and had more comorbidities than patients with normal scores. A poor 15D/16D score was associated with lower socioeconomic status. CONCLUSIONS: Half of long-term pediatric ICU-treated TBI survivors had poor HRQL 11 years after injury. More severe head computed tomographic findings at admission and female sex associated with poor HRQL.

Current trends in paediatric and neonatal ventilatory care -- a nationwide survey.

AIM: To assess daily practices in paediatric and neonatal ventilatory care in Finland. METHODS: All neonatal and paediatric intensive care units in Finland were sent a questionnaire on ventilatory strategies and were offered a 3-month prospective survey. RESULTS: A total of 96% of units returned the questionnaire, and clinicians agreed on most of the principles of lung-protective ventilation. Seventeen hospitals (94%) joined the prospective survey. On average, 2.3 new ventilation episodes were started daily, and totally 211 episodes were monitored. Pulmonary problems (64%) were the main cause of treatment in neonates and postoperative care (68%) in older children. Synchronized intermittent mandatory ventilation with pressure support was the primary mode in 42% of episodes. Hypocapnia was observed repeatedly in all units. In adult intensive care units, children often received high oxygen fraction, leading to hyperoxia, and they were frequently sedated with propofol, which is not licensed for that purpose. A large proportion of children had only light sedation or no sedation at all. Despite the different strategies and practices, most episodes resulted in a favourable outcome. CONCLUSION: Most of the principles of lung-protective ventilation have been well accepted by clinicians. More attention should be paid to achieving normocapnia and normoxia and to the correct use of sedatives, especially in units that only occasionally provide paediatric ventilation.

Expressive language skills in Finnish two-year-old extremely- and very-low-birth-weight preterm children.

OBJECTIVE: Preterm children with low birth weight are at greater risk of experiencing speech and language difficulties than full-term children. The aim of the current study was to investigate expressive language skills of Finnish-speaking preterm children with low birth weight [extremely-low-birth-weight (ELBW) children: n = 8; very-low-birth-weight (VLBW) children: n = 10] at 2 years of corrected age and to compare their language results with full-term controls (n = 18), using spontaneous speech samples. METHODS: The children were video recorded in semistructured free-play sessions with their mothers. From these video samples, expressive vocabulary size and maximum sentence length (MSL) were analyzed. In addition, the possible effect of children's gender on language measures as well as associations between different language measures were examined. RESULTS: The results showed that there was no statistically significant difference between the preterm and full-term groups in the size of expressive vocabulary. In contrast, the MSL, which measures morphosyntactic skills, was significantly shorter in preterm children. A positive correlation was found between MSL and expressive vocabulary. Children's gender was not associated with language skills measured. CONCLUSION: The findings indicate that Finnish-speaking preterm children, especially ELBW children, experience difficulties in morphosyntactic skills.

Repeated antenatal corticosteroid treatment: a systematic review and meta-analysis.

OBJECTIVE: To systematically review the efficacy and safety of repeated antenatal corticosteroid on neonatal morbidity, growth and later development. DESIGN: MEDLINE, Cochrane database and a bibliography of identified articles were searched for English language studies. Design. Meta-analysis of randomized controlled trials. SAMPLE: Randomized, controlled trials studying the efficacy and safety of repeat antenatal corticosteroid treatment on neonatal morbidity and early childhood development. MAIN OUTCOME MEASURES: Respiratory distress syndrome, intrauterine growth, neurodevelopment. METHODS: Two reviewers independently assessed titles, abstracts and full studies, extracted data and assessed quality. Meta-analyses were performed, calculating risk ratios and weighted differences of means with 95% confidence intervals using a random-effects model. RESULTS: Eight trials were included. Repeated betamethasone treatment decreased the risk of respiratory distress syndrome (relative risk 0.85, 95% confidence interval 0.77-0.93). Trials involving weekly or biweekly repeated betamethasone and those involving a single rescue dose decreased the risk of respiratory distress syndrome. Intrauterine growth was significantly restricted among preterm infants exposed to weekly or biweekly repeated betamethasone. A single rescue course did not affect growth. Four follow-up studies did not reveal any disturbances in neurodevelopment or growth at two years of corrected age. CONCLUSIONS: Repeated corticosteroid treatment decreased the risk of respiratory distress syndrome among preterm infants. Weekly or biweekly repeated betamethasone restricted intrauterine growth, which raises concerns about long-term consequences on neurodevelopment and metabolism. More follow-up studies are needed to confirm the long-term safety of repeated betamethasone.