The Bronchopulmonary Dysplasia score: A predictive model for bronchopulmonary dysplasia or death in high-risk preterm infants.

AIM: Progressive respiratory deterioration in infants at high risk of bronchopulmonary dysplasia (BPD) is associated with patent ductus arteriosus (PDA) exposure. This study aimed to design an early predictive model for BPD or death in preterm infants using early echocardiographic markers and clinical data. METHODS: Infants born with gestational age (GA) ≤ 29 weeks and/or birth weight (BW) < 1500 g at Cork University Maternity Hospital, Ireland were retrospectively evaluated. Those with echocardiography performed between 36 h and 7 days of life were eligible for inclusion. Exclusion criteria were pulmonary hypertension and major congenital anomalies. The primary outcome was a composite of BPD and death before discharge. RESULTS: The study included 99 infants. A predictive model for the primary outcome was developed, which included three variables (BW, Respiratory Severity Score and flow pattern across the PDA), and yielding an area under the curve of 0.98 (95% CI 0.96-1.00, p < 0.001). Higher scores were predictive of the primary outcome. A cut-off of -1.0 had positive and negative predictive values of 89% and 98%, and sensitivity and specificity of 98% and 88%, respectively. CONCLUSION: Our prediction model is an accessible bedside tool that predicts BPD or death in premature infants.

Temporal evolution of electrographic seizures in newborn infants with hypoxic-ischaemic encephalopathy requiring therapeutic hypothermia: a secondary analysis of the ANSeR studies.

BACKGROUND: Despite extensive research on neonatal hypoxic-ischaemic encephalopathy, detailed information about electrographic seizures during active cooling and rewarming of therapeutic hypothermia is sparse. We aimed to describe temporal evolution of seizures and determine whether there is a correlation of seizure evolution with 2-year outcome. METHODS: This secondary analysis included newborn infants recruited from eight European tertiary neonatal intensive care units for two multicentre studies (a randomised controlled trial [NCT02431780] and an observational study [NCT02160171]). Infants were born at 36+0 weeks of gestation with moderate or severe hypoxic-ischaemic encephalopathy and underwent therapeutic hypothermia with prolonged conventional video-electroencephalography (EEG) monitoring for 10 h or longer from the start of rewarming. Seizure burden characteristics were calculated based on electrographic seizures annotations: hourly seizure burden (minutes of seizures within an hour) and total seizure burden (minutes of seizures within the entire recording). We categorised infants into those with electrographic seizures during active cooling only, those with electrographic seizures during cooling and rewarming, and those without seizures. Neurodevelopmental outcomes were determined using the Bayley's Scales of Infant and Toddler Development, Third Edition (BSID-III), the Griffiths Mental Development Scales (GMDS), or neurological assessment. An abnormal outcome was defined as death or neurodisability at 2 years. Neurodisability was defined as a composite score of 85 or less on any subscales for BSID-III, a total score of 87 or less for GMDS, or a diagnosis of cerebral palsy (dyskinetic cerebral palsy, spastic quadriplegia, or mixed motor impairment) or epilepsy. FINDINGS: Of 263 infants recruited between Jan 1, 2011, and Feb 7, 2017, we included 129 infants: 65 had electrographic seizures (43 during active cooling only and 22 during and after active cooling) and 64 had no seizures. Compared with infants with seizures during active cooling only, those with seizures during and after active cooling had a longer seizure period (median 12 h [IQR 3-28] vs 68 h [35-86], p<0·0001), more seizures (median 12 [IQR 5-36] vs 94 [24-134], p<0·0001), and higher total seizure burden (median 69 min [IQR 22-104] vs 167 min [54-275], p=0·0033). Hourly seizure burden peaked at about 20-24 h in both groups, and infants with seizures during and after active cooling had a secondary peak at 85 h of age. When combined, worse EEG background (major abnormalities and inactive background) at 12 h and 24 h were associated with the seizure group: compared with infants with a better EEG background (normal, mild, or moderate abnormalities), infants with a worse EEG background were more likely to have seizures after cooling at 12 h (13 [54%] of 24 vs four [14%] of 28; odds ratio 7·09 [95% CI 1·88-26·77], p=0·0039) and 24 h (14 [56%] of 25 vs seven [18%] of 38; 5·64 [1·81-17·60], p=0·0029). There was a significant relationship between EEG grade at 12 h (four categories) and seizure group (p=0·020). High total seizure burden was associated with increased odds of an abnormal outcome at 2 years of age (odds ratio 1·007 [95% CI 1·000-1·014], p=0·046), with a medium negative correlation between total seizure burden and BSID-III cognitive score (rS=-0·477, p=0·014, n=26). INTERPRETATION: Overall, half of infants with hypoxic-ischaemic encephalopathy had electrographic seizures and a third of those infants had seizures beyond active cooling, with worse outcomes. These results raise the importance of prolonged EEG monitoring of newborn infants with hypoxic-ischaemic encephalopathy not only during active cooling but throughout the rewarming phase and even longer when seizures are detected. FUNDING: Wellcome Trust, Science Foundation Ireland, and the Irish Health Research Board.

Impact of cord clamping on haemodynamic transition in term newborn infants.

OBJECTIVE: To assess the haemodynamic consequences of cord clamping (CC) in healthy term infants. DESIGN: Cohort study. SETTING: Tertiary maternity hospital. PATIENTS: 46 full-term vigorous infants born by caesarean section. INTERVENTIONS: Echocardiography was performed before CC, immediately after CC and at 5 min after birth. MAIN OUTCOME MEASURES: Pulsed wave Doppler-derived cardiac output and the pulmonary artery acceleration time indexed to the right ventricle ejection time were obtained. As markers of loading fluctuations, the myocardial performance indexes and the velocities of the tricuspid and mitral valve annuli were determined with tissue Doppler imaging. Heart rate was derived from Doppler imaging throughout the assessments. RESULTS: Left ventricular output increased throughout the first minutes after birth (mean (SD) 222.4 (32.5) mL/kg/min before CC vs 239.7 (33.6) mL/kg/min at 5 min, p=0.01), while right ventricular output decreased (306.5 (48.2) mL/kg/min before vs 272.8 (55.5) mL/kg/min immediately after CC, p=0.001). The loading conditions of both ventricles were transiently impaired by CC, recovering at 5 min. Heart rate progressively decreased after birth, following a linear trend temporarily increased by CC. The variation in left ventricular output across the CC was directly correlated to the fluctuation of left ventricular preload over the same period (p=0.03). CONCLUSIONS: This study illustrates the cardiovascular consequences of CC in term vigorous infants and offers insight into the haemodynamic transition from fetal to neonatal circulation in spontaneously breathing newborns. Strategies that aim to enhance left ventricular preload before CC may prevent complications of perinatal cardiovascular imbalance.

Neurodevelopmental outcome of low-risk moderate to late preterm infants at 18 months.

Background: Of the 15 million preterm births that occur worldwide each year, approximately 80% occur between 32 and 36 + 6 weeks gestational age (GA) and are defined as moderate to late preterm (MLP) infants. This percentage substantiates a need for a better understanding of the neurodevelopmental outcome of this group. Aim: To describe neurodevelopmental outcome at 18 months in a cohort of healthy low-risk MLP infants admitted to the neonatal unit at birth and to compare the neurodevelopmental outcome to that of a healthy term-born infant group. Study design and method: This single-centre observational study compared the neurodevelopmental outcome of healthy MLP infants to a group of healthy term control (TC) infants recruited during the same period using the Griffith's III assessment at 18 months. Results: Seventy-five MLP infants and 92 TC infants were included. MLP infants scored significantly lower in the subscales: Eye-hand coordination (C), Personal, Social and Emotional Development (D), Gross Motor Development (E) and General Developmental (GD) (p < 0.001 for each) and Foundations of Learning (A), (p = 0.004) in comparison to the TC infant group with Cohen's d effect sizes ranging from 0.460 to 0.665. There was no statistically significant difference in mean scores achieved in subscale B: Language and Communication between groups (p = 0.107). Conclusion: MLP infants are at risk of suboptimal neurodevelopmental outcomes. Greater surveillance of the neurodevelopmental trajectory of this group of at-risk preterm infants is required.

Effectiveness of a proficiency-based progression e-learning approach to training in communication in the context of clinically deteriorating patients: a multi-arm randomised controlled trial.

OBJECTIVE: To determine the effectiveness of proficiency-based progression (PBP) e-learning in training in communication concerning clinically deteriorating patients. DESIGN: Single-centre multi-arm randomised double-blind controlled trial with three parallel arms. RANDOMISATION, SETTING AND PARTICIPANTS: A computer-generated program randomised and allocated 120 final year medical students in an Irish University into three trial groups. INTERVENTION: Each group completed the standard Identification, Situation, Background, Assessment, Recommendation communication e-learning; group 1 Heath Service Executive course group (HSE) performed this alone; group 2 (PBP) performed additional e-learning using PBP scenarios with expert-determined proficiency benchmarks composed of weighted marking schemes of steps, errors and critical errors cut-offs; group 3 (S) (self-directed, no PBP) performed additional e-learning with identical scenarios to (PBP) without PBP. MAIN OUTCOME MEASURES: Primary analysis was based on 114 students, comparing ability to reach expert-determined predefined proficiency benchmark in standardised low-fidelity simulation assessment, before and after completion of each group's e-learning requirements. Performance was recorded and scored by two independent blinded assessors. RESULTS: Post-intervention, proficiency in each group in the low-fidelity simulation environment improved with statistically significant difference in proficiency between groups (p<0.001). Proficiency was highest in (PBP) (81.1%, 30/37). Post hoc pairwise comparisons revealed statistically significant differences between (PBP) and self-directed (S) (p<0.001) and (HSE) (p<0.001). No statistically significant difference existed between (S) and (HSE) (p=0.479). Changes in proficiency from pre-intervention to post-intervention were significantly different between the three groups (p=0.001). Post-intervention, an extra 67.6% (25/37) in (PBP) achieved proficiency in the low-fidelity simulation. Post hoc pairwise comparisons revealed statistically significant differences between (PBP) and both (S) (p=0.020) and (HSE) (p<0.001). No statistically significant difference was found between (S) and (HSE) (p=0.156). CONCLUSIONS: PBP e-learning is a more effective way to train in communication concerning clinically deteriorating patients than standard e-learning or e-learning without PBP. TRIAL REGISTRATION NUMBER: NCT02937597.

Early emollient bathing is associated with subsequent atopic dermatitis in an unselected birth cohort study.

BACKGROUND: Skin barrier dysfunction is a key component of the pathogenesis of atopic dermatitis (AD). Recent research on barrier optimization to prevent AD has shown mixed results. The aim of this study was to assess the relationship between emollient bathing at 2 months and the trajectory of AD in the first 2 years of life in a large unselected observational birth cohort study. METHODS: The Babies After SCOPE: Evaluating the Longitudinal Impact Using Neurological and Nutritional Endpoints Birth Cohort study enrolled 2183 infants. Variables extracted from the database related to early skincare, skin barrier function, parental history of atopy, and AD outcomes. Statistical analysis was performed to adjust for potential confounding variables. RESULTS: One thousand five hundred five children had data on AD status available at 6, 12, and 24 months. Prevalence of AD was 18.6% at 6 months, 15.2% at 12 months, and 16.5% at 24 months. Adjusted for potential confounding variables, the odds of AD at any point were higher among infants who had emollient baths at 2 months (OR (95% CI): 2.41 (1.56 to 3.72), p < .001). Following multivariable analysis, the odds of AD were higher among infants who had both emollient baths and frequent emollient application at 2 months, compared with infants who had neither (OR (95% CI) at 6 months 1.74 (1.18-2.58), p = .038), (OR (95% CI) at 12 months 2.59 (1.69-3.94), p < .001), (OR (95% CI) at 24 months 1.87 (1.21-2.90), p = .009). CONCLUSION: Early emollient bathing was associated with greater development of AD by 2 years of age in this population-based birth cohort study.

Neonatal outcomes following introduction of routine probiotic supplementation to very preterm infants.

AIM: To evaluate the combined outcome of death and/or severe grade necrotising enterocolitis (NEC) in very preterm infants admitted to Cork University Maternity Hospital, Ireland, before and after introduction of routine supplementation with Bifidobacterium bifidum and Lactobacillus acidophilus probiotics (Infloran®). METHODS: A retrospective study of infants <32 weeks gestation and < 1500 g surviving beyond 72 h of life was performed. Two 6-year epochs; pre-probiotics (Epoch 1: 2008-2013) and with probiotics (Epoch 2: 2015-2020), were evaluated. The primary outcome was defined as death after 72 h or NEC Bell stage 2a or greater. RESULTS: Seven-hundred-and-forty-four infants were included (Epoch 1: 391, Epoch 2: 353). The primary outcome occurred in 67 infants (Epoch 1: 37, Epoch 2: 30, p = 0.646). After adjustment, the difference was significant (OR [95% CI]: 0.53 [0.29 to 0.97], p = 0.038). Differences between epochs did not depend on gestational age group (<28 weeks; ≥28 weeks). CONCLUSION: There was an associated reduction of the composite outcome of severe grade NEC and/or death, after adjustment for confounding variables, with introduction of routine administration of a B. bifidum and L. acidophilus probiotic at our institution.

Reference centiles for infant sleep parameters from 4 to 16 weeks of age: findings from an Irish cohort.

OBJECTIVES: To establish unconditional reference centiles for sleep parameters in infants 4-16 weeks of age. DESIGN AND SETTING: Secondary data analysis of sleep parameters recorded at 4-16 weeks of age in a longitudinal randomised controlled trial (RCT) (BabySMART). PATIENTS: Healthy term infants assigned to the non-intervention arm of the RCT. MAIN OUTCOME MEASURES: Infants' sleep duration was recorded by parents/guardians daily, from week 2-16 of age using a sleep diary. Reference centiles for total, daytime, night-time and longest sleep episode duration were estimated using multilevel modelling. RESULTS: One hundred and six infants, mean (SD) gestational age of 39.9 (1.2) weeks and mean (SD) birth weight of 3.6 (0.5) kg had sleep recorded contributing 1264 measurements for each sleep parameter. Between 4 and 16 weeks of age total sleep duration in a 24-hour period, night-time sleep duration in a 12-hour period and infant's longest sleep episode duration increased, while daytime sleep duration in a 12-hour period decreased. CONCLUSIONS: Reference centiles up to 4 months of age in infants highlight the gradual decrease in daytime sleep and large increases in night-time sleep, which occur in tandem with increasing lengths of sleep episodes. These reference centiles provide useful sleep values for infant sleep trajectory occurring in early life and may be helpful for parents and clinicians. TRIAL REGISTRATION NUMBER: NCT03381027.

Parent-led massage and sleep EEG for term-born infants: A randomized controlled parallel-group study.

AIM: To examine the impact of parent-led massage on the sleep electroencephalogram (EEG) features of typically developing term-born infants at 4 months. METHOD: Infants recruited at birth were randomized to intervention (routine parent-led massage) and control groups. Infants had a daytime sleep EEG at 4 months and were assessed using the Griffiths Scales of Child Development, Third Edition at 4 and 18 months. Comparative analysis between groups and subgroup analysis between regularly massaged and never-massaged infants were performed. Groups were compared for sleep stage, sleep spindles, quantitative EEG (primary analysis), and Griffiths using the Mann-Whitney U test. RESULTS: In total, 179 out of 182 infants (intervention: 83 out of 84; control: 96 out of 98) had a normal sleep EEG. Median (interquartile range) sleep duration was 49.8 minutes (39.1-71.4) (n = 156). A complete first sleep cycle was seen in 67 out of 83 (81%) and 72 out of 96 (75%) in the intervention and control groups respectively. Groups did not differ in sleep stage durations, latencies to sleep and to rapid eye movement sleep. Sleep spindle spectral power was greater in the intervention group in main and subgroup analyses. The intervention group showed greater EEG magnitudes, and lower interhemispherical coherence on subgroup analyses. Griffiths assessments at 4 months (n = 179) and 18 months (n = 173) showed no group differences in the main and subgroup analyses. INTERPRETATION: Routine massage is associated with distinct functional brain changes at 4 months. WHAT THIS PAPER ADDS: Routine massage of infants is associated with differences in sleep electroencephalogram biomarkers at 4 months. Massaged infants had higher sleep spindle spectral power, greater sleep EEG magnitudes, and lower interhemispherical coherence. No differences between groups were observed in total nap duration or first cycle macrostructure.

Validation of a touchscreen assessment tool to screen for cognitive delay at 24 months.

AIM: To validate a touchscreen assessment as a screening tool for mild cognitive delay in typically developing children aged 24 months. METHOD: Secondary analysis of data was completed from an observational birth cohort study (The Cork Nutrition & Microbiome Maternal-Infant Cohort Study [COMBINE]), with children born between 2015 and 2017. Outcome data were collected at 24 months of age, at the INFANT Research Centre, Ireland. Outcomes were the Bayley Scales of Infant and Toddler Development, Third Edition cognitive composite score and a language-free, touchscreen-based cognitive measure (Babyscreen). RESULTS: A total of 101 children (47 females, 54 males) aged 24 months (mean = 24.25, SD = 0.22) were included. Cognitive composite scores correlated with the total number of Babyscreen tasks completed, with moderate concurrent validity (r = 0.358, p < 0.001). Children with cognitive composite scores lower than 90 (1 SD below the mean, defined as mild cognitive delay) had lower mean Babyscreen scores than those with cognitive scores equal to or greater than 90 (8.50 [SD = 4.89] vs 12.61 [SD = 3.68], p = 0.001). The area under the receiver operating characteristic curve for the prediction of a cognitive composite score less than 90 was 0.75 (95% confidence interval = 0.59-0.91; p = 0.006). Babyscreen scores less than 7 were equivalent to less than the 10th centile and identified children with mild cognitive delay with 50% sensitivity and 93% specificity. INTERPRETATION: Our 15-minute, language-free touchscreen tool could reasonably identify mild cognitive delay among typically developing children.

Sleep state organisation of moderate to late preterm infants in the neonatal unit.

BACKGROUND: Sleep supports neurodevelopment and sleep architecture reflects brain maturation. This prospective observational study describes the nocturnal sleep architecture of healthy moderate to late preterm (MLP) infants in the neonatal unit at 36 weeks post menstrual age (PMA). METHODS: MLP infants, in the neonatal unit of a tertiary hospital in Ireland from 2017 to 2018, had overnight continuous electroencephalography (cEEG) with video for a minimum 12 h at 36 weeks PMA. The total sleep time (TST) including periods of active sleep (AS), quiet sleep (QS), indeterminate sleep (IS), wakefulness and feeding were identified, annotated and quantified. RESULTS: A total of 98 infants had cEEG with video monitoring suitable for analysis. The median (IQR) of TST in the 12 h period was 7.09 h (IQR 6.61-7.76 h), 4.58 h (3.69-5.09 h) in AS, 2.02 h (1.76-2.36 h) in QS and 0.65 h (0.48-0.89 h) in IS. The total duration of AS was significantly lower in infants born at lower GA (p = 0.007) whilst the duration of individual QS periods was significantly higher (p = 0.001). CONCLUSION: Overnight cEEG with video at 36 weeks PMA showed that sleep state architecture is dependent on birth GA. Infants with a lower birth GA have less AS and more QS that may have implications for later neurodevelopment. IMPACT: EEG provides objective information about the sleep organisation of the moderate to late preterm (MLP) infant. Quantitative changes in sleep states occur with each week of advancing gestational age (GA). Active sleep (AS) is the dominant sleep state that was significantly lower in infants born at lower GA. MLP infants who were exclusively fed orally had a shorter total sleep time and less AS compared to infants who were fed via nasogastric tube.

Machine learning for the early prediction of infants with electrographic seizures in neonatal hypoxic-ischemic encephalopathy.

OBJECTIVE: To assess if early clinical and electroencephalography (EEG) features predict later seizure development in infants with hypoxic-ischemic encephalopathy (HIE). METHODS: Clinical and EEG parameters <12 h of birth from infants with HIE across eight European Neonatal Units were used to develop seizure-prediction models. Clinical parameters included intrapartum complications, fetal distress, gestational age, delivery mode, gender, birth weight, Apgar scores, assisted ventilation, cord pH, and blood gases. The earliest EEG hour provided a qualitative analysis (discontinuity, amplitude, asymmetry/asynchrony, sleep-wake cycle [SWC]) and a quantitative analysis (power, discontinuity, spectral distribution, inter-hemispheric connectivity) from full montage and two-channel amplitude-integrated EEG (aEEG). Subgroup analysis, only including infants without anti-seizure medication (ASM) prior to EEG was also performed. Machine-learning (ML) models (random forest and gradient boosting algorithms) were developed to predict infants who would later develop seizures and assessed using Matthews correlation coefficient (MCC) and area under the receiver-operating characteristic curve (AUC). RESULTS: The study included 162 infants with HIE (53 had seizures). Low Apgar, need for ventilation, high lactate, low base excess, absent SWC, low EEG power, and increased EEG discontinuity were associated with seizures. The following predictive models were developed: clinical (MCC 0.368, AUC 0.681), qualitative EEG (MCC 0.467, AUC 0.729), quantitative EEG (MCC 0.473, AUC 0.730), clinical and qualitative EEG (MCC 0.470, AUC 0.721), and clinical and quantitative EEG (MCC 0.513, AUC 0.746). The clinical and qualitative-EEG model significantly outperformed the clinical model alone (MCC 0.470 vs 0.368, p-value .037). The clinical and quantitative-EEG model significantly outperformed the clinical model (MCC 0.513 vs 0.368, p-value .012). The clinical and quantitative-EEG model for infants without ASM (n = 131) had MCC 0.588, AUC 0.832. Performance for quantitative aEEG (n = 159) was MCC 0.381, AUC 0.696 and clinical and quantitative aEEG was MCC 0.384, AUC 0.720. SIGNIFICANCE: Early EEG background analysis combined with readily available clinical data helped predict infants who were at highest risk of seizures, hours before they occur. Automated quantitative-EEG analysis was as good as expert analysis for predicting seizures, supporting the use of automated assessment tools for early evaluation of HIE.

Non-invasive continuous cardiac output monitoring in infants with hypoxic ischaemic encephalopathy.

OBJECTIVE: To describe early, continuous, non-invasive measures of cardiac output (CO) and evolution over time in infants with hypoxic-ischaemic encephalopathy (HIE). STUDY DESIGN: Prospective observational study of 44 infants with HIE (23 mild, 17 moderate, 4 severe) and 17 term controls. Infants with HIE had non-invasive CO monitoring (NICOM) continuously in the neonatal unit. Term controls had NICOM recorded at 6 and 24 h. A mixed-modelling approach was used to assess change in CO over time by group. RESULTS: Infants with moderate HIE have significantly lower CO than the mild group at all timepoints (10.7 mls/kg/min lower, 95% CI:1.0,20.4, p = 0.03) which increases over time, driven by a gradual increase in stroke volume (SV). CO increased further during rewarming predominantly due to an increase in HR. CONCLUSION: TH has a significant impact on HR but SV appears largely unaffected. NICOM may provide a non-invasive, continuous, low-cost alternative to monitoring CO in infants with HIE however further research is warranted.

Parental atopy and risk of atopic dermatitis in the first two years of life in the BASELINE birth cohort study.

BACKGROUND: Atopic dermatitis (AD) has a strong genetic basis. The objective of this study was to assess the association between parental atopy and AD development by 2 years. METHODS: A secondary data analysis of the BASELINE Birth Cohort study was performed (n = 2183). Parental atopy was self-reported at 2 months. Infants were examined for AD by trained health care professionals at 6, 12, and 24 months. Variables extracted from the database related to skin barrier function, early skincare, parental atopy, and AD. Statistical analysis adjusted for potential confounding variables. RESULTS: Complete data on AD status were available for 1505 children at 6, 12, and 24 months. Prevalence of AD was 18.6% at 6 months, 15.2% at 12 months, and 16.5% at 24 months. Adjusted odds ratios (95% CIs) following multivariable analysis were 1.57 (1.09-2.25) at 6 months and 1.66 (1.12-2.46) at 12 months for maternal AD; 1.90 (1.28-2.83) at 6 months and 1.85 (1.20-2.85) at 24 months for paternal AD; 1.76 (1.21-2.56) at 6 months and 1.75 (1.16-2.63) at 12 months for maternal asthma; and 1.70 (1.19-2.45) at 6 months, 1.86 (1.26-2.76) at 12 months, and 1.99 (1.34-2.97) at 24 months for paternal asthma. Parental rhinitis was only associated with AD with maternal rhinitis at 24 months (aOR (95% CI): 1.79 (1.15-2.80)). CONCLUSION: Parental AD and asthma were associated with increased risk of objectively diagnosed AD in offspring in this contemporary cohort.

Agreement of Cardiac Output Estimates between Electrical Cardiometry and Transthoracic Echocardiography in Very Preterm Infants.

INTRODUCTION: The aim was to evaluate the agreement between cardiac output estimates obtained by electrical cardiometry (EC) and transthoracic echocardiography (TTE) in very preterm infants. METHODS: This is a single-center prospective observational study in infants born<32 weeks gestational age within 48 h of birth. Continuous EC was recorded and simultaneous TTE obtained on day 1 and day 2 of life. Blinded TTE measurements were performed within a 10 s timeframe using beat-to-beat EC data. The primary outcome was %error of left ventricular (LV) output in milliliters per kilogram per minute (cardiac index (CI)) obtained by TTE compared to LV-CI from EC. Secondary outcome parameters were bias, %bias, limits of agreement and include measures of right ventricular (RV) output and LV systolic time intervals. RESULTS: Analysis was performed for 34 infants (median (IQR) gestational age 29 + 0 (24 + 5 to 30 + 6) weeks + days, birthweight 960 (748 to 1,490) grams) including 44 pairwise LV output measurements on 24 participants (22 on day 1 and day 2). The %error was 54% for LV-CI (EC: 214 (38) mL/kg/min vs. TTE: 163 (47) mL/kg/min). The %error was 78% for RV-CI (EC: 213 (37) mL/kg/min vs. TTE: 241 (77) mL/kg/min). While only LV-CI values affected LV-CI bias, signal quality, heart rate, and RV-CI values affected RV-CI bias. CONCLUSION: EC is not interchangeable with TTE to estimate indices of LV or RV output in very preterm infants within the first 48 h postnatally. EC may not measure LV output distinctly in very preterm infants with intra- and extracardiac shunts.

Evolution of early cerebral NIRS in hypoxic ischaemic encephalopathy.

AIM: To describe early cerebral oxygenation (cSO2 ) and fractional tissue oxygen extraction (FTOE) values and their evolution over the first days of life in infants with all grades of hypoxic-ischaemic encephalopathy (HIE) and to determine whether cSO2 and FTOE measured early (6 and 12 h) can predict short-term outcome. METHODS: Prospective, observational study of cerebral near-infrared spectroscopy (NIRS) in infants >36 weeks' gestation with HIE. Ten one-hour epochs of cSO2 and FTOE were extracted for each infant over the first 84 h. Infants with moderate and severe HIE received therapeutic hypothermia (TH). Abnormal outcome was defined as abnormal magnetic resonance imaging (MRI) and/or death. RESULTS: Fifty-eight infants were included (28 mild, 24 moderate, 6 severe). Median gestational age was 39.9 weeks (IQR 38.1-40.7) and birthweight was 3.35 kgs (IQR 2.97-3.71). cSO2 increased and FTOE decreased over the first 24 h in all grades of HIE. Compared to the moderate group, infants with mild HIE had significantly higher cSO2 at 6 h (p = 0.003), 9 h (p = 0.009) and 12 h (p = 0.032) and lower FTOE at 6 h (p = 0.016) and 9 h (0.029). cSO2 and FTOE at 6 and 12 h did not predict abnormal outcome. CONCLUSION: Infants with mild HIE have higher cSO2 and lower FTOE than those with moderate or severe HIE in the first 12 h of life. cSO2 increased in all grades of HIE over the first 24 h regardless of TH status.

Neonatal Seizure Management: Is the Timing of Treatment Critical?

OBJECTIVE: To assess the impact of the time to treatment of the first electrographic seizure on subsequent seizure burden and describe overall seizure management in a large neonatal cohort. STUDY DESIGN: Newborns (36-44 weeks of gestation) requiring electroencephalographic (EEG) monitoring recruited to 2 multicenter European studies were included. Infants who received antiseizure medication exclusively after electrographic seizure onset were grouped based on the time to treatment of the first seizure: antiseizure medication within 1 hour, between 1 and 2 hours, and after 2 hours. Outcomes measured were seizure burden, maximum seizure burden, status epilepticus, number of seizures, and antiseizure medication dose over the first 24 hours after seizure onset. RESULTS: Out of 472 newborns recruited, 154 (32.6%) had confirmed electrographic seizures. Sixty-nine infants received antiseizure medication exclusively after the onset of electrographic seizure, including 21 infants within 1 hour of seizure onset, 15 between 1 and 2 hours after seizure onset, and 33 at >2 hours after seizure onset. Significantly lower seizure burden and fewer seizures were noted in the infants treated with antiseizure medication within 1 hour of seizure onset (P = .029 and .035, respectively). Overall, 258 of 472 infants (54.7%) received antiseizure medication during the study period, of whom 40 without electrographic seizures received treatment exclusively during EEG monitoring and 11 with electrographic seizures received no treatment. CONCLUSIONS: Treatment of neonatal seizures may be time-critical, but more research is needed to confirm this. Improvements in neonatal seizure diagnosis and treatment are also needed.