Efecto neuroprotector del sulfato de magnesio en prematuros. Análisis tras instaurar su protocolo de administración antenatal en un hospital terciario / Neuroprotective effect of magnesium sulfate in premature infants: Analysis after establishing an antenatal administration protocol in a tertiary care hospital

Introducción: En 2016 se desarrolló en nuestro centro un protocolo de administración antenatal de sulfato de magnesio en gestantes con riesgo de parto pretérmino inminente como método para disminuir el riesgo de parálisis cerebral (PC). Material y métodos: Se realizó un estudio observacional y retrospectivo en un hospital de nivel IIIC con objetivo principal de comparar la incidencia de PC previa y posteriormente a la puesta en marcha de este protocolo. Con respecto a los objetivos secundarios, a destacar la incidencia de déficit cognitivo, enterocolitis necrosante y mortalidad en ambos grupos. Los pacientes incluidos fueron recién nacidos prematuros por debajo de 32 semanas de edad gestacional nacidos en los años 2011-2012 (previo a la instauración del protocolo) y 2016-2018 (posteriormente a la instauración del protocolo, cuyas madres habían recibido sulfato de magnesio como neuroprotector). Las características clínicas y epidemiológicas de ambos grupos fueron comparables entre sí. Resultados: Se recogieron datos de un total de 523 pacientes, 263 y 260 de cada grupo. Con respecto al objetivo principal, no se encontraron diferencias estadísticamente significativas. Se objetivó, en el grupo de pacientes nacidos entre 2016-2018 y con edad gestacional entre 26+0 y 27+6 semanas, cuyas madres recibieron sulfato de magnesio, una reducción estadísticamente significativa de la mortalidad y del riesgo de enterocolitis necrosante grave. Conclusiones: En nuestro trabajo, el sulfato de magnesio administrado a madres en riesgo de parto prematuro, no disminuyó el riesgo de desarrollar PC. (AU)

Introduction: In 2016, a protocol was developed in our hospital for the antenatal administration of magnesium sulfate in pregnant women at risk of imminent preterm birth as a method to reduce the risk of cerebral palsy (CP). Material and methods: We conducted a retrospective observational study in a level IIIC hospital with the primary objective of comparing the incidence of CP before and after the implementation of this protocol. Among the secondary outcomes, we ought to highlight the incidence of cognitive deficits and necrotizing enterocolitis and the mortality in both groups. The sample consisted of preterm newborns delivered before 32 weeks of gestation in 2011-2012 (prior to the implementation of the protocol) and in 2016-2018 (after the implementation of the protocol, whose mothers had received magnesium sulfate for neuroprotection). The clinical and epidemiological characteristics of both groups were comparable. Results: We collected data for a total of 523 patients, 263 and 260 in each group. As regards the primary outcome, we did not find statistically significant differences between groups. We observed a statistically significant reduction in mortality and the risk of severe necrotizing enterocolitis in the group of patients born in the 2016-2018 period and between 26+0 and 27+6 weeks of gestation, whose mothers had received magnesium sulfate. Conclusions: In our study, the administration of magnesium sulfate to mothers at risk of preterm birth did not decrease the risk of developing CP. (AU)

Neuroprotective effect of magnesium sulfate in premature infants. Analysis after establishing an antenatal administration protocol in a tertiary care hospital.

INTRODUCTION: In 2016, a protocol was developed in our hospital for the antenatal administration of magnesium sulfate in pregnant women at risk of imminent preterm birth as a method to reduce the risk of cerebral palsy (CP). MATERIAL AND METHODS: We conducted a retrospective observational study in a level IIIC hospital with the primary objective of comparing the incidence of CP before and after the implementation of this protocol. Among the secondary outcomes, we ought to highlight the incidence of cognitive deficits and necrotizing enterocolitis and the mortality in both groups. The sample consisted of preterm newborns delivered before 32 weeks of gestation in 2011-2012 (prior to the implementation of the protocol) and in 2016-2018 (after the implementation of the protocol, whose mothers had received magnesium sulfate for neuroprotection). The clinical and epidemiological characteristics of both groups were comparable. RESULTS: We collected data for a total of 523 patients, 263 and 260 in each group. As regards the primary outcome, we did not find statistically significant differences between groups. We observed a statistically significant reduction in mortality and the risk of severe necrotizing enterocolitis in the group of patients born in the 2016-2018 period and between 26+0 and 27+6 weeks of gestation, whose mothers had received magnesium sulfate. CONCLUSIONS: In our study, the administration of magnesium sulfate to mothers at risk of preterm birth did not decrease the risk of developing CP.

Training, experience and need of booster courses in neonatal cardiopulmonary resuscitation. Survey to pediatricians.

INTRODUCTION: The resuscitation of the newborn in the delivery room requires high capacities and occurs frequently in an unexpected way. Many professionals trained in pediatrics as pediatric residents will work posteriorly in pediatric units with delivery rooms and will perform neonatal resuscitation only occasionally. Skills acquired in practice or resuscitation courses deteriorate over time. MATERIAL AND METHODS: Descriptive observational study through a survey to pediatricians trained in neonatology at a tertiary hospital in Madrid, and who completed their residency period between 2009 and 2016. Questions about their training in resuscitation and their usual work in the delivery room. RESULTS: Out of 179 surveys sent, 140 pediatricians (78,2%) answered it. 73.6% took a training course in neonatal resuscitation during the residency. There was a progressive increase in the number of residents who did the course during the study period. 74.3% have worked after residency in assistance at birth. 40.7% have taken a refresher course in neonatal resuscitation. CONCLUSIONS: Training in neonatal resuscitation has increased and been consolidated during the training process for pediatric residents. A high percentage of pediatricians work after residency in pediatric units with delivery rooms, less than half of these professionals having been recycled in neonatal resuscitation. Recycling and periodic training seem interesting options to improve the performance of these professionals in the delivery room.

Formación, experiencia y necesidad de reciclaje en reanimación neonatal. Encuesta a pediatras / Training, experience and need of booster courses in neonatal cardiopulmonary resuscitation. Survey to pediatricians

Introducción: La reanimación del recién nacido en sala de partos requiere altas capacidades y se produce con frecuencia de manera inesperada. Muchos profesionales formados en pediatría mediante el método de residencia trabajarán a posteriori en unidades pediátricas con paritorio y realizarán reanimación neonatal solo de forma ocasional. Las competencias adquiridas en la práctica o los cursos de reanimación se deterioran con el tiempo. Material y métodos: Estudio descriptivo observacional a través de una encuesta a pediatras formados en Neonatología de un hospital terciario de Madrid y que finalizaron su residencia entre los años 2009 y 2016. Preguntas acerca de su formación en reanimación y su trabajo habitual en paritorio. Resultados: Ciento cuarenta pediatras contestaron la encuesta de 179 encuestas enviadas (78,2%). El 73,6% realizó un curso de formación en reanimación neonatal durante la residencia, objetivándose un incremento progresivo en el número de residentes que lo realizaron durante el período de estudio. El 74,3% ha trabajado tras la residencia en la asistencia al nacimiento. El 40,7% ha realizado algún curso de reciclaje en reanimación neonatal. Conclusiones: Ha aumentado y se ha consolidado la formación en reanimación neonatal durante el proceso de formación de residentes de Pediatría. Un alto porcentaje de pediatras trabajan tras la residencia en Unidades Pediátricas con paritorio, habiéndose reciclado menos de la mitad de esos profesionales en reanimación neonatal. El reciclaje y el entrenamiento periódico parecen opciones interesantes para mejorar la actuación de estos profesionales en sala de partos.(AU)

Introduction: the resuscitation of the newborn in the delivery room requires high capacities and occurs frequently in an unexpected way. Many professionals trained in pediatrics as pediatric residents will work posteriorly in pediatric units with delivery rooms and will perform neonatal resuscitation only occasionally. Skills acquired in practice or resuscitation courses deteriorate over time. Material and methods: descriptive observational study through a survey to pediatricians trained in neonatology at a tertiary hospital in Madrid, and who completed their residency period between 2009 and 2016. Questions about their training in resuscitation and their usual work in the delivery room. Results: Out of 179 surveys sent 140 pediatricians (78,2%) answered it. 73.6% took a training course in neonatal resuscitation during the residency. There was a progressive increase in the number of residents who did the course during the study period. 74.3% have worked after residency in assistance at birth. 40.7% have taken a refresher course in neonatal resuscitation. Conclusions: training in neonatal resuscitation has increased and been consolidated during the training process for pediatric residents. A high percentage of pediatricians work after the residency in pediatric units with delivery rooms, less than half of these professionals having been recycled in neonatal resuscitation. Recycling and periodic training seem interesting options to improve the performance of these professionals in the delivery room. (AU)

Antenatal corticosteroids and the influence of sex on morbidity and mortality of preterm infants.

OBJECTIVE: To study the associated effect of a complete course of antenatal corticosteroids (ACSs) on mortality and morbidity rates among preterm infants in our population. STUDY DESIGN: Observational prospective study of infants born at less than 32 weeks' gestation and admitted to our Neonatal Care Unit between January 2012 and December 2018. We analyzed mortality at discharge and respiratory and neurological morbidity, both during hospitalization and at 24 months' postmenstrual age. RESULTS: The study included a total of 710 patients with a median gestational age of 28.5 weeks (IQR 26.4-30.5) and mean weight of 1.090 g (IQR 800-1.391). Of which, 62.4% received a complete course of antenatal steroids. Given the differences observed in the baseline characteristics of patients who either did or did not receive a full course of antenatal steroids, a propensity score covariate adjustment was performed for all estimations. The effect of ACS therapy differs depending on sex with a positive effect on acute respiratory morbidity and mortality in male patients of less than 29 weeks' gestation. In female infants, there is no significant beneficial association between ACS therapy and mortality or any of the morbidities studied. CONCLUSION: In our population of preterm infants, treatment with antenatal steroids is associated with a different effect depending on sex. Antenatal steroids therapy associated with a positive effect in male patients with a gestational age of less than 29 weeks.

Three-year perinatal outcomes of less invasive beractant administration in preterm infants with respiratory distress syndrome.

Objective: To assess the impact of beractant treatment using the less invasive surfactant administration (LISA) technique on perinatal outcomes in a prospective cohort of preterm infants with respiratory distress syndrome (RDS).Design: Single-center prospective study conducted in a Department of Neonatology of a tertiary care university-affiliated hospital in Madrid, Spain.Methods: Preterm infants born at <31 + 6 weeks' gestation attended in the neonatal intensive care unit (NICU) between 2012 and 2016. The main outcome was the need of invasive mechanical ventilation during the first 3 days of life. Beractant (100 mg; 4 mL/kg) was administered using the intubation-surfactant-extubation (INSURE) method during 2012 and 2013, and using the LISA procedure between 2014 and 2016.Results: The study population included 512 infants, 232 in the first period and 280 in the second period. Mechanical ventilation exposure during hospitalization showed a significant reduction in the second study period, with an adjusted OR of 0.61, 95% CI 0.39-0.96. Also, an increase of free-bronchopulmonary dysplasia (BPD) survival was found (adjusted OR 2.14, 95% CI 1.29-3.55). These significant differences in perinatal outcomes were observed only in the group of infants of 26 + 0 to 28 + 6 gestational weeks. The success rate of the first dose of beractant using LISA regarding no need of intubation during the first 3 days of life was 54% increasing to 69% in the group of 26 + 0-28 + 6 weeks of gestation. The success rate regarding free-BPD survival was 63.5% in the whole series of LISA treated patients and 72.4% in the group of 26 + 0-28 + 6 weeks. Oxygen reduction after surfactant administration (OR 39.6, 95% CI 6.1-255.8, p < .001) was predictor of LISA success, whereas LISA failure was an independent factor for air leak (OR 18.92, 95% CI 1.31-272.32, p = .031) and Death or BPD outcome (OR 19.3, 95% IC 2.5-147.4, p = .004). Gestational age was inversely associated with the need of intubation after LISA (OR 0.53, 95% CI 0.32-0.87, p = .013).Conclusions: Beractant administration by LISA technique effective reduced the need of intubation during the first 3 days of life and was associated with an increase in survival-free BPD in the group of infants born at 26 + 0 and 28 + 6 weeks' gestation.

[Training, experience and need of booster courses in neonatal cardiopulmonary resuscitation. Survey to pediatricians]. / Formación, experiencia y necesidad de reciclaje en reanimación neonatal. Encuesta a pediatras.

INTRODUCTION: the resuscitation of the newborn in the delivery room requires high capacities and occurs frequently in an unexpected way. Many professionals trained in pediatrics as pediatric residents will work posteriorly in pediatric units with delivery rooms and will perform neonatal resuscitation only occasionally. Skills acquired in practice or resuscitation courses deteriorate over time. MATERIAL AND METHODS: descriptive observational study through a survey to pediatricians trained in neonatology at a tertiary hospital in Madrid, and who completed their residency period between 2009 and 2016. Questions about their training in resuscitation and their usual work in the delivery room. RESULTS: Out of 179 surveys sent 140 pediatricians (78,2%) answered it. 73.6% took a training course in neonatal resuscitation during the residency. There was a progressive increase in the number of residents who did the course during the study period. 74.3% have worked after residency in assistance at birth. 40.7% have taken a refresher course in neonatal resuscitation. CONCLUSIONS: training in neonatal resuscitation has increased and been consolidated during the training process for pediatric residents. A high percentage of pediatricians work after the residency in pediatric units with delivery rooms, less than half of these professionals having been recycled in neonatal resuscitation. Recycling and periodic training seem interesting options to improve the performance of these professionals in the delivery room.

New Strategies of Pulmonary Protection of Preterm Infants in the Delivery Room with the Respiratory Function Monitoring.

OBJECTIVE: To investigate if the use of a visible respiratory function monitor (RFM) to use lower tidal volumes (Vts) during positive pressure ventilation (PPV) in the delivery room (DR) reduces the need of surfactant administration and invasive mechanical ventilation during the first 72 hours after birth of preterm infants <32 weeks' gestational age (GA). STUDY DESIGN: Infants <32 weeks' GA (n = 106) requiring noninvasive PPV were monitored with a RFM at birth and randomized to visible (n = 54) or masked (n = 52) display on RFM. Pulmonary data were recorded during the first 10 minutes after birth. Secondary analysis stratified patients by GA (<28, 28-29+6, or ≥30 weeks). RESULTS: Median expiratory Vts during inflations were greater in the masked group (7 mL/kg) than in the visible group (5.8 mL/kg; p = 0.001) same as peak inflation pressure (PIP) administered (21.5 vs. 19.7 cmH2O; p < 0.001). Consequently, minute volumes were greater in the masked group (256 vs. 214 mL/kg/min; p < 0.001), with no differences in respiratory rate. These differences were higher in those <30 weeks' GA. There was no difference in the need of surfactant administration or intubation during the first 72 hours of age. CONCLUSION: Using a RFM in the DR prevents the use of large Vt and PIP during respiratory support inflations, mostly in the more immature newborn infants, but with no other short-term benefits.

Factores de riesgo asociados a mortalidad fetal intraparto en recién nacidos pretérmino / Risks factors associated with intra-partum foetal mortality in pre-term infants

INTRODUCCIÓN: El parto prematuro es una de las principales causas de mortalidad perinatal y fetal. Sin embargo, los factores de riesgo perinatales asociados a mortalidad fetal intraparto en partos pretérmino no han sido bien analizados. OBJETIVO: Analizar la mortalidad fetal y los factores de riesgo perinatales asociados a mortalidad fetal intraparto en gestaciones de menos de 32 semanas. MATERIAL Y MÉTODOS: Se incluyeron en el análisis todos los partos pretérmino entre las semanas 22 y 31 + 6 días, nacidos en un hospital terciario durante un periodo de 7 años (2008-2014). Se realizó análisis de regresión logística para identificar factores de riesgo perinatales asociados a mortalidad fetal intraparto (excluidos malformaciones y cromosomopatías severas). RESULTADOS: En este período el 63,1% (106/168) de la mortalidad fetal (≥ 22 semanas) se produjo en gestaciones menores de 32 semanas. Ochocientos ochenta y dos nacimientos entre las semanas 22 y 31+6 días fueron incluidos en el análisis. La mortalidad fetal fue del 11,3% (100/882). La mortalidad fetal intraparto fue del 2,6% (23/882), afectando en el 78,2% de los casos (18/23) a gestantes hospitalizadas. Encontramos que las técnicas de reproducción asistida, la ecografía fetal patológica, la no administración de corticoides antenatales, la menor edad gestacional y el bajo peso para la edad gestacional fueron factores de riesgo independientes asociados a mortalidad fetal intraparto. CONCLUSIÓN: La mortalidad fetal intraparto afectó a un porcentaje importante de nacimientos entre las semanas 22 y 31 + 6 días. El análisis de la mortalidad fetal intraparto y los factores de riesgo asociados a esta resulta de gran interés clínico y epidemiológico para optimizar el cuidado perinatal y aumentar la supervivencia del recién nacido pretérmino

INTRODUCTION: Pre-term delivery is one of the leading causes of foetal and perinatal mortality. However, perinatal risk factors associated with intra-partum foetal death in preterm deliveries have not been well studied. OBJECTIVE: To analyse foetal mortality and perinatal risk factors associated with intra-partum foetal mortality in pregnancies of less than 32 weeks gestational age. MATERIAL AND METHODS: The study included all preterm deliveries between 22 and 31 +1 weeks gestational age (WGA), born in a tertiary-referral hospital, over a period of 7 years (2008-2014). A logistic regression model was used to identify perinatal risk factors associated with intra-partum foetal mortality (foetal malformations and chromosomal abnormalities were excluded). RESULTS: During the study period, the overall foetal mortality was 63.1% (106/168) (≥ 22 weeks of gestation) occurred in pregnancies of less than 32 WGA. A total of 882 deliveries between 22 and 31 + 6 weeks of gestation were included for analysis. The rate of foetal mortality was 11.3% (100/882). The rate of intra-partum foetal death was 2.6% (23/882), with 78.2% (18/23) of these cases occurring in hospitalised pregnancies. It was found that Assisted Reproductive Techniques, abnormal foetal ultrasound, no administration of antenatal steroids, lower gestational age, and small for gestational age, were independent risk factors associated with intra-partum foetal mortality. CONCLUSION: This study showed that there is a significant percentage intra-partum foetal mortality in infants between 22 and 31+6 WGA. The analysis of intrapartum mortality and risk factors associated with this mortality is of clinical and epidemiological interest to optimise perinatal care and improve survival of preterm infants

[Risks factors associated with intra-partum foetal mortality in pre-term infants]. / Factores de riesgo asociados a mortalidad fetal intraparto en recién nacidos pretérmino.

INTRODUCTION: Pre-term delivery is one of the leading causes of foetal and perinatal mortality. However, perinatal risk factors associated with intra-partum foetal death in preterm deliveries have not been well studied. OBJECTIVE: To analyse foetal mortality and perinatal risk factors associated with intra-partum foetal mortality in pregnancies of less than 32 weeks gestational age. MATERIAL AND METHODS: The study included all preterm deliveries between 22 and 31 +1 weeks gestational age (WGA), born in a tertiary-referral hospital, over a period of 7 years (2008-2014). A logistic regression model was used to identify perinatal risk factors associated with intra-partum foetal mortality (foetal malformations and chromosomal abnormalities were excluded). RESULTS: During the study period, the overall foetal mortality was 63.1% (106/168) (≥22 weeks of gestation) occurred in pregnancies of less than 32 WGA. A total of 882 deliveries between 22 and 31+6 weeks of gestation were included for analysis. The rate of foetal mortality was 11.3% (100/882). The rate of intra-partum foetal death was 2.6% (23/882), with 78.2% (18/23) of these cases occurring in hospitalised pregnancies. It was found that Assisted Reproductive Techniques, abnormal foetal ultrasound, no administration of antenatal steroids, lower gestational age, and small for gestational age, were independent risk factors associated with intra-partum foetal mortality. CONCLUSION: This study showed that there is a significant percentage intra-partum foetal mortality in infants between 22 and 31+6 WGA. The analysis of intrapartum mortality and risk factors associated with this mortality is of clinical and epidemiological interest to optimise perinatal care and improve survival of preterm infants.

Less invasive beractant administration in preterm infants: a pilot study.

OBJECTIVES: The aims of this study were to assess the efficacy and feasibility of a new, less invasive surfactant administration technique for beractant replacement using a specifically designed cannula in preterm infants born at <32 weeks of gestation and to compare short- and long-term outcomes between this approach and standard treatment, consisting of intubation, administration of surfactant and early extubation to nasal continuous positive airway pressure. METHOD: This was a single-center, prospective, open-label, non-randomized, controlled pilot study with an experimental cohort of 30 patients treated with less invasive surfactant administration and a retrospective control group comprising the 30 patients most recently treated with the standard approach. Beractant (4 ml/kg) was administered as an exogenous surfactant in both groups if patients on nasal continuous positive airway pressure during the first three days of life were in need of more than 30% FiO2. Clinicaltrials.gov: NCT02611284. RESULTS: In the group with less invasive surfactant administration, beractant was successfully administered in all patients. Thirteen patients (43.3%) in the group with less invasive surfactant administration required invasive mechanical ventilation for more than 1 hour during the first 3 days of life, compared with 22 (73%) in the control group (p<0.036). The rate of requiring invasive mechanical ventilation for more than 48 hours was similar between the infants in the two groups (46% vs. 40%, respectively). There were no differences in other outcomes. CONCLUSION: The administration of beractant (4 ml/kg) using a less invasive surfactant administration technique with a specifically designed cannula for administration is feasible. Moreover, early invasive mechanical ventilation exposure is significantly reduced by this method compared with the strategy involving intubation, surfactant administration and early extubation.

Less invasive beractant administration in preterm infants: a pilot study

OBJECTIVES: The aims of this study were to assess the efficacy and feasibility of a new, less invasive surfactant administration technique for beractant replacement using a specifically designed cannula in preterm infants born at <32 weeks of gestation and to compare short- and long-term outcomes between this approach and standard treatment, consisting of intubation, administration of surfactant and early extubation to nasal continuous positive airway pressure. METHOD: This was a single-center, prospective, open-label, non-randomized, controlled pilot study with an experimental cohort of 30 patients treated with less invasive surfactant administration and a retrospective control group comprising the 30 patients most recently treated with the standard approach. Beractant (4 ml/kg) was administered as an exogenous surfactant in both groups if patients on nasal continuous positive airway pressure during the first three days of life were in need of more than 30% FiO2. Clinicaltrials.gov: NCT02611284. RESULTS: In the group with less invasive surfactant administration, beractant was successfully administered in all patients. Thirteen patients (43.3%) in the group with less invasive surfactant administration required invasive mechanical ventilation for more than 1 hour during the first 3 days of life, compared with 22 (73%) in the control group (p<0.036). The rate of requiring invasive mechanical ventilation for more than 48 hours was similar between the infants in the two groups (46% vs. 40%, respectively). There were no differences in other outcomes. CONCLUSION: The administration of beractant (4 ml/kg) using a less invasive surfactant administration technique with a specifically designed cannula for administration is feasible. Moreover, early invasive mechanical ventilation exposure is significantly reduced by this method compared with the strategy involving intubation, surfactant administration and early extubation.

Survival estimations at the limit of viability.

OBJECTIVE: The purpose of this study was to assess the variability in neonatal survival to discharge from the neonatal unit by using different inclusion criteria. METHODS: An observational and descriptive study was performed between January 2008 and December 2013 which included infants born between 22 weeks and 31 weeks and 6 d of gestation. The rate of survival was calculated using three different inclusion criteria: the total number of preterm births, the number of all preterm live births, and the number of preterm newborns admitted to the neonatal unit. RESULTS: A total of 783 patients met the inclusion criteria. The survival rate for births between 22 and 31 weeks and 6 d of gestation was 72.8% of total births, 82.3% of live births, and 84.0% of all admissions to the neonatal unit. Therefore, we found a significant difference in survival rates according to whether or not foetal mortality (11.6%) and mortality in the delivery room (2.0%) were included. This variation increased with decreasing gestational age: 17,2%, 25%, and 38,4% at 23 weeks gestation. CONCLUSIONS: Late foetal mortality and the mortality in the delivery room affect the survival rates of preterm infants significantly, especially the most immature newborns.