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1.
J Perinatol ; 40(5): 695-703, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32203174

RESUMO

OBJECTIVE: To compare the prognostic accuracy of six neonatal illness severity scores (CRIB, CRIB II, SNAP, SNAP II, SNAP-PE, and SNAP-PE II), birthweight (BW), and gestational age (GA) for predicting pre-discharge mortality among very low birth weight (VLBW) infants (<1500 g) and very preterm infants (<32 weeks' gestational age). STUDY DESIGN: PubMed, EMBASE, and Scopus were the data sources searched for studies published before January 2019. Data were extracted, pooled, and analyzed using random-effects models and reported as AUC with 95% confidence intervals (CI). RESULTS: Of 1659 screened studies, 24 met inclusion criteria. CRIB was the most discriminate for predicting pre-discharge mortality [AUC 0.88 (0.86-0.90)]. GA was the least discriminate [AUC 0.76 (0.72-0.80)]. CONCLUSIONS: Although the original CRIB score was the most accurate predictor of pre-discharge mortality, significant heterogeneity between studies lowers confidence in this pooled estimate. A more precise illness severity score to predict pre-discharge mortality is still needed.

2.
Pediatrics ; 144(3)2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31409691

RESUMO

BACKGROUND: Approximately 10% of US newborns require a NICU. We evaluated whether the NICU acoustic environment affects neonatal sleep and whether exposure to the mother's voice can modulate that impact. METHODS: In a level IV NICU with single-infant rooms, 47 neonates underwent 12-hour polysomnography. Their mothers were recorded reading children's books. Continuous maternal voice playback was randomized to either the first or second 6 hours of the polysomnogram. Regression models were used to examine sleep-wake stages, entropy, EEG power, and the probability of awakening in response to ambient noise during and without voice playback. RESULTS: After epochs with elevated noise, the probability was higher with (versus without) maternal voice exposure of neonates staying asleep (P = .009). However, the 20 neonates born at ≥35 weeks' gestation, in contrast to those born at 33 to 34 weeks, showed an age-related increase in percent time awake (R 2 = 0.52; P < .001), a decrease in overall sleep (R 2 = 0.52; P < .001), a reduction in rapid eye movement sleep bouts per hour (R 2 = 0.35; P = .003), and an increase in sleep-wake entropy (R 2 = 0.52; P < .001) all confined solely to the 6 hours of maternal voice exposure. These associations remained significant (P = .02 to P < .001) after adjustment for neurologic examination scores and ambient noise. CONCLUSIONS: Hospitalized newborns born at ≥35 weeks' gestation but not at 33 to 34 weeks' gestation show increasing wakefulness in response to their mother's voice. However, exposure to the mother's voice during sleep may also help protect newborns from awakening after bursts of loud hospital noise.


Assuntos
Recém-Nascido/psicologia , Recém-Nascido Prematuro/psicologia , Unidades de Terapia Intensiva Neonatal , Mães , Sono , Voz , Feminino , Idade Gestacional , Humanos , Masculino , Ruído , Polissonografia , Vigília
3.
Pediatr Res ; 86(4): 444-451, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31100754

RESUMO

BACKGROUND: Inflammation contributes to neonatal hypoxic-ischemic brain injury pathogenesis. We evaluated the neuroprotective efficacy of azithromycin, a safe, widely available antibiotic with anti-inflammatory properties, in a neonatal rodent hypoxic-ischemic brain injury model. METHODS: Seven-day-old rats underwent right carotid artery ligation followed by 90-min 8% oxygen exposure; this procedure elicits quantifiable left forepaw functional impairment and right cerebral hemisphere damage. Sensorimotor function (vibrissae-stimulated forepaw placing, grip strength) and brain damage were compared in azithromycin- and saline-treated littermates 2-4 weeks later. Multiple treatment protocols were evaluated (variables included doses ranging from 15 to 45 mg/kg; treatment onset 15 min to 4 h post-hypoxia, and comparison of 1 vs. 3 injections). RESULTS: All azithromycin doses improved function and reduced brain damage; efficacy was dose dependent, and declined with increasing treatment delay. Three azithromycin injections, administered over 48 h, improved performance on both function measures and reduced brain damage more than a single dose. CONCLUSION: In this neonatal rodent model, azithromycin improved functional and neuropathology outcomes. If supported by confirmatory studies in complementary neonatal brain injury models, azithromycin could be an attractive candidate drug for repurposing and evaluation for neonatal neuroprotection in clinical trials.

4.
Pediatr Pulmonol ; 54(5): 557-562, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30688037

RESUMO

OBJECTIVE: Among older infants and children, sleep-disordered breathing (SDB) has negative neurocognitive consequences. We evaluated the frequency and potential impact of SDB among newborns who require intensive care. STUDY DESIGN: Term and near-term newborns at risk for seizures underwent 12-h attended polysomnography in the neonatal intensive care unit (NICU). Bayley Scales of Infant Development, third edition (Bayley-III) were administered at 18-22 months. RESULT: The 48 newborns (EGA 39.3 ± 1.6) had a median pediatric apnea-hypopnea index (AHI) of 10.1 (3.3-18.5) and most events were central (vs obstructive). Maternal and prenatal factors were not associated with AHI. Moreover, neonatal PSG results were not associated with Bayley-III scores (P > 0.05). CONCLUSION: SDB is common among term and near-term newborns at risk for seizures. Follow-up at ages when more nuanced testing can be performed may be necessary to establish whether neonatal SDB is associated with long-term neurodevelopmental disability.


Assuntos
Apneia do Sono Tipo Central/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Masculino , Polissonografia , Estudos Prospectivos , Risco , Convulsões/epidemiologia , Síndromes da Apneia do Sono/epidemiologia , Síndromes da Apneia do Sono/fisiopatologia , Apneia do Sono Tipo Central/fisiopatologia , Apneia Obstrutiva do Sono/fisiopatologia , Nascimento a Termo
5.
J Pediatr ; 204: 96-102.e4, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30337189

RESUMO

OBJECTIVE: To assess whether length of hospital stay is decreased among moderately preterm infants weaned from incubator to crib at a lower vs higher weight. STUDY DESIGN: This trial was conducted in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants with gestational ages 29-33 weeks, birthweight <1600 g, and in an incubator were randomly assigned to a weaning weight of 1600 or 1800 g. Within 60 to 100 g of weaning weight, the incubator temperature was decreased by 1.0°C to 1.5°C every 24 hours until 28.0°C. The infants were weaned to the crib following stable temperature at 36.5°C to 37.4°C for 8 to 12 hours. Clothing and bedcoverings were standardized. The primary outcome was length of hospital stay from birth to discharge; secondary outcomes included length of stay and growth velocity from weaning to discharge. Adverse events were monitored. RESULTS: Of 1565 infants screened, 885 were eligible, and 366 enrolled-187 to the 1600-g and 179 to the 1800-g group. Maternal and neonatal characteristics did not differ among weight groups. Length of hospital stay was a median of 43 days in the lower and 41 days in the higher weight group (P = .12). Growth velocity from completion of weaning to discharge was higher in the lower weight group, 13.7 g/kg/day vs 12.8 g/kg/day (P = .005). Groups did not differ in adverse events. CONCLUSIONS: Among moderately preterm neonates, weaning from incubator to crib at a lower weight did not decrease length of stay, but was safe and was accompanied by higher weight gain after weaning. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02160002.


Assuntos
Incubadoras para Lactentes/estatística & dados numéricos , Equipamentos para Lactente/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Peso Corporal , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro/fisiologia , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Masculino
6.
ASAIO J ; 65(7): 690-697, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30585874

RESUMO

An artificial placenta (AP) utilizing extracorporeal life support (ECLS) could protect premature lungs from injury and promote continued development. Preterm lambs at estimated gestational age (EGA) 114-128 days (term = 145) were delivered by Caesarian section and managed in one of three groups: AP, mechanical ventilation (MV), or tissue control (TC). Artificial placenta lambs (114 days EGA, n = 3; 121 days, n = 5) underwent venovenous (VV)-ECLS with jugular drainage and umbilical vein reinfusion for 7 days, with a fluid-filled, occluded airway. Mechanical ventilation lambs (121 days, n = 5; 128 days, n = 5) underwent conventional MV until failure or maximum 48 hours. Tissue control lambs (114 days, n = 3; 121 days, n = 5; 128 days, n = 5) were sacrificed at delivery. At the conclusion of each experiment, lungs were procured and sectioned. Hematoxylin and eosin (H&E) slides were scored 0-4 in seven injury categories, which were summed for a total injury score. Slides were also immunostained for platelet-derived growth factor receptor (PDGFR)-α and α-actin; lung development was quantified by the area fraction of double-positive tips of secondary alveolar septa. Support duration of AP lambs was 163 ± 9 (mean ± SD) hours, 4 ± 3 for early MV lambs, and 40 ± 6 for late MV lambs. Total injury scores at 121 days were 1.7 ± 2.1 for AP vs. 5.5 ± 1.6 for MV (p = 0.02). Using immunofluorescence, double-positive tip area fraction at 121 days was 0.017 ± 0.011 in AP lungs compared with 0.003 ± 0.003 in MV lungs (p < 0.001) and 0.009 ± 0.005 in TC lungs. At 128 days, double-positive tip area fraction was 0.012 ± 0.007 in AP lungs compared with 0.004 ± 0.004 in MV lungs (p < 0.001) and 0.016 ± 0.009 in TC lungs. The AP is protective against lung injury and promotes lung development compared with mechanical ventilation in premature lambs.

7.
J Pediatr Surg ; 53(10): 1896-1903, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29960740

RESUMO

PURPOSE: An artificial placenta (AP) utilizing extracorporeal life support (ECLS) could avoid the harm of mechanical ventilation (MV) while allowing the lungs to develop. METHODS: AP lambs (n = 5) were delivered at 118 days gestational age (GA; term = 145 days) and placed on venovenous ECLS (VV-ECLS) with jugular drainage and umbilical vein reinfusion. Lungs remained fluid-filled. After 10 days, lambs were ventilated. MV control lambs were delivered at 118 ("early MV"; n = 5) or 128 days ("late MV"; n = 5), and ventilated. Compliance and oxygenation index (OI) were calculated. After sacrifice, lungs were procured and H&E-stained slides scored for lung injury. Slides were also immunostained for PDGFR-α and α-actin; alveolar development was quantified by the area fraction of alveolar septal tips staining double-positive for both markers. RESULTS: Compliance of AP lambs was 2.79 ±â€¯0.81 Cdyn compared to 0.83 ±â€¯0.19 and 3.04 ±â€¯0.99 for early and late MV, respectively. OI in AP lambs was lower than early MV lambs (6.20 ±â€¯2.10 vs. 36.8 ±â€¯16.8) and lung injury lower as well (1.8 ±â€¯1.6 vs. 6.0 ±â€¯1.2). Double-positive area fractions were higher in AP lambs (0.012 ±â€¯0.003) than early (0.003 ±â€¯0.0005) and late (0.004 ±â€¯0.002) MV controls. CONCLUSIONS: Lung development continues and lungs are protected from injury during AP support relative to mechanical ventilation. LEVEL OF EVIDENCE: n/a (basic/translational science).


Assuntos
Órgãos Artificiais , Oxigenação por Membrana Extracorpórea , Pulmão/crescimento & desenvolvimento , Nascimento Prematuro/terapia , Animais , Animais Recém-Nascidos , Modelos Animais de Doenças , Feminino , Idade Gestacional , Pulmão/fisiologia , Placenta/fisiologia , Gravidez , Ovinos
8.
J Pediatr ; 195: 59-65.e3, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29398046

RESUMO

OBJECTIVE: To determine the outcome of preterm infants whose cystic periventricular leukomalacia "disappeared" on serial screening cranial imaging studies. STUDY DESIGN: Infants ≤26 weeks of gestation born between 2002 and 2012 who had cranial imaging studies at least twice, the most abnormal study at <28 days of age and another closest to 36 weeks, were reviewed. The outcome of late death (after 36 weeks postmenstrual age) or neurodevelopmental impairment (NDI) in surviving infants at 18-26 months corrected age was compared between the infants with no cystic periventricular leukomalacia on both studies and cystic periventricular leukomalacia that disappeared (cystic periventricular leukomalacia at <28 days but not at 36 weeks), persisted (cystic periventricular leukomalacia on both studies), or appeared late (cystic periventricular leukomalacia only at 36 weeks). Predictors of NDI were evaluated by logistic regression. RESULTS: Of 7063 eligible infants, 433 (6.1%) had cystic periventricular leukomalacia. Among the 433 infants with cystic periventricular leukomalacia, cystic periventricular leukomalacia disappeared in 76 (18%), persisted in 87 (20%), and 270 (62%) had late cystic periventricular leukomalacia. Loss to follow-up ranged between 3% and 13%. Death or NDI was more common in infants with disappeared cystic periventricular leukomalacia compared with those with no cystic periventricular leukomalacia (38 of 72 [53%] vs 1776 of 6376 [28%]; OR [95% CI] 2.8 [1.8-4.6]). Disappeared, persistent, and late cystic periventricular leukomalacia were all also independently associated with NDI (OR 1.17, 1.21, and 1.16, respectively). CONCLUSIONS: Infants with "disappeared" cystic periventricular leukomalacia are at increased risk of adverse outcome similar to infants with persistent or late cystic periventricular leukomalacia.


Assuntos
Encéfalo/diagnóstico por imagem , Leucomalácia Periventricular/diagnóstico por imagem , Triagem Neonatal/métodos , Estudos de Casos e Controles , Deficiências do Desenvolvimento/epidemiologia , Feminino , Idade Gestacional , Humanos , Lactente , Lactente Extremamente Prematuro , Recém-Nascido , Leucomalácia Periventricular/mortalidade , Modelos Logísticos , Masculino , Estudos Prospectivos , Fatores de Risco , Ultrassonografia
9.
J Pediatr ; 194: 244-247.e1, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29221695

RESUMO

In a matched cohort study, we report that the apnea-hypopnea index is significantly higher in neonates with myelomeningocele (34 ± 22) compared with age-matched controls (19 ± 11; P = .021). Assessment of newborns with myelomeningocele for sleep-disordered breathing may facilitate early treatment; the impact on long-term neurodevelopment is unknown.


Assuntos
Meningomielocele/complicações , Síndromes da Apneia do Sono/etiologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Recém-Nascido , Masculino , Polissonografia/métodos , Síndromes da Apneia do Sono/epidemiologia
10.
ASAIO J ; 64(4): 552-556, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28937410

RESUMO

An artificial placenta (AP) using venovenous extracorporeal life support (VV-ECLS) could represent a paradigm shift in the treatment of extremely premature infants. However, AP support could potentially alter cerebral oxygen delivery. We assessed cerebral perfusion in fetal lambs on AP support using near-infrared spectroscopy (NIRS) and carotid arterial flow (CAF). Fourteen premature lambs at estimated gestational age (EGA) 130 days (term = 145) underwent cannulation of the right jugular vein and umbilical vein with initiation of VV-ECLS. An ultrasonic flow probe was placed around the right carotid artery (CA), and a NIRS sensor was placed on the scalp. Lambs were not ventilated. CAF, percentage of regional oxygen saturation (rSO2) as measured by NIRS, hemodynamic data, and blood gases were collected at baseline (native placental support) and regularly during AP support. Fetal lambs were maintained on AP support for a mean of 55 ± 27 hours. Baseline rSO2 on native placental support was 40% ± 3%, compared with a mean rSO2 during AP support of 50% ± 11% (p = 0.027). Baseline CAF was 27.4 ± 5.4 ml/kg/min compared with an average CAF of 23.7 ± 7.7 ml/kg/min during AP support. Cerebral fractional tissue oxygen extraction (FTOE) correlated negatively with CAF (r = -0.382; p < 0.001) and mean arterial pressure (r = -0.425; p < 0.001). FTOE weakly correlated with systemic O2 saturation (r = 0.091; p = 0.017). Cerebral oxygenation and blood flow in premature lambs are maintained during support with an AP. Cerebral O2 extraction is inversely related to carotid flow and is weakly correlated with systemic O2 saturation.


Assuntos
Órgãos Artificiais , Circulação Cerebrovascular/fisiologia , Placenta , Animais , Feminino , Feto , Humanos , Masculino , Gravidez , Carneiro Doméstico
11.
Sleep ; 40(11)2017 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-28958087

RESUMO

Objectives: The neurological examination of critically ill neonates is largely limited to reflexive behavior. The exam often ignores sleep-wake physiology that may reflect brain integrity and influence long-term outcomes. We assessed whether polysomnography and concurrent cerebral near-infrared spectroscopy (NIRS) might improve prediction of 18-month neurodevelopmental outcomes. Methods: Term newborns with suspected seizures underwent standardized neurologic examinations to generate Thompson scores and had 12-hour bedside polysomnography with concurrent cerebral NIRS. For each infant, the distribution of sleep-wake stages and electroencephalogram delta power were computed. NIRS-derived fractional tissue oxygen extraction (FTOE) was calculated across sleep-wake stages. At age 18-22 months, surviving participants were evaluated with Bayley Scales of Infant Development (Bayley-III), 3rd edition. Results: Twenty-nine participants completed Bayley-III. Increased newborn time in quiet sleep predicted worse 18-month cognitive and motor scores (robust regression models, adjusted r2 = 0.22, p = .007, and 0.27, .004, respectively). Decreased 0.5-2 Hz electroencephalograph (EEG) power during quiet sleep predicted worse 18-month language and motor scores (adjusted r2 = 0.25, p = .0005, and 0.33, .001, respectively). Predictive values remained significant after adjustment for neonatal Thompson scores or exposure to phenobarbital. Similarly, an attenuated difference in FTOE, between neonatal wakefulness and quiet sleep, predicted worse 18-month cognitive, language, and motor scores in adjusted analyses (each p < .05). Conclusions: These prospective, longitudinal data suggest that inefficient neonatal sleep-as quantified by increased time in quiet sleep, lower electroencephalogram delta power during that stage, and muted differences in FTOE between quiet sleep and wakefulness-may improve prediction of adverse long-term outcomes for newborns with neurological dysfunction.


Assuntos
Sono/fisiologia , Vigília/fisiologia , Encéfalo/fisiologia , Desenvolvimento Infantil , Estado Terminal/psicologia , Eletroencefalografia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Oxigênio/metabolismo , Polissonografia , Estudos Prospectivos , Convulsões/congênito , Convulsões/diagnóstico , Convulsões/fisiopatologia , Fases do Sono/fisiologia , Espectroscopia de Luz Próxima ao Infravermelho , Fatores de Tempo
12.
JAMA ; 318(1): 57-67, 2017 Jul 04.
Artigo em Inglês | MEDLINE | ID: mdl-28672318

RESUMO

Importance: Hypothermia for 72 hours at 33.5°C for neonatal hypoxic-ischemic encephalopathy reduces death or disability, but rates continue to be high. Objective: To determine if cooling for 120 hours or to a temperature of 32.0°C reduces death or disability at age 18 months in infants with hypoxic-ischemic encephalopathy. Design, Setting, and Participants: Randomized 2 × 2 factorial clinical trial in neonates (≥36 weeks' gestation) with hypoxic-ischemic encephalopathy at 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network between October 2010 and January 2016. Interventions: A total of 364 neonates were randomly assigned to 4 hypothermia groups: 33.5°C for 72 hours (n = 95), 32.0°C for 72 hours (n = 90), 33.5°C for 120 hours (n = 96), or 32.0°C for 120 hours (n = 83). Main Outcomes and Measures: The primary outcome was death or moderate or severe disability at 18 to 22 months of age adjusted for center and level of encephalopathy. Severe disability included any of Bayley Scales of Infant Development III cognitive score less than 70, Gross Motor Function Classification System (GMFCS) level of 3 to 5, or blindness or hearing loss despite amplification. Moderate disability was defined as a cognitive score of 70 to 84 and either GMFCS level 2, active seizures, or hearing with amplification. Results: The trial was stopped for safety and futility in November 2013 after 364 of the planned 726 infants were enrolled. Among 347 infants (95%) with primary outcome data (mean age at follow-up, 20.7 [SD, 3.5] months; 42% female), death or disability occurred in 56 of 176 (31.8%) cooled for 72 hours and 54 of 171 (31.6%) cooled for 120 hours (adjusted risk ratio, 0.92 [95% CI, 0.68-1.25]; adjusted absolute risk difference, -1.0% [95% CI, -10.2% to 8.1%]) and in 59 of 185 (31.9%) cooled to 33.5°C and 51 of 162 (31.5%) cooled to 32.0°C (adjusted risk ratio, 0.92 [95% CI, 0.68-1.26]; adjusted absolute risk difference, -3.1% [95% CI, -12.3% to 6.1%]). A significant interaction between longer and deeper cooling was observed (P = .048), with primary outcome rates of 29.3% at 33.5°C for 72 hours, 34.5% at 32.0°C for 72 hours, 34.4% at 33.5°C for 120 hours, and 28.2% at 32.0°C for 120 hours. Conclusions and Relevance: Among term neonates with moderate or severe hypoxic-ischemic encephalopathy, cooling for longer than 72 hours, cooling to lower than 33.5°C, or both did not reduce death or moderate or severe disability at 18 months of age. However, the trial may be underpowered, and an interaction was found between longer and deeper cooling. These results support the current regimen of cooling for 72 hours at 33.5°C. Trial Registration: clinicaltrials.gov Identifier: NCT01192776.


Assuntos
Hipotermia Induzida , Hipóxia-Isquemia Encefálica/terapia , Transtornos do Neurodesenvolvimento/prevenção & controle , Teorema de Bayes , Feminino , Humanos , Hipotermia Induzida/mortalidade , Hipóxia-Isquemia Encefálica/complicações , Hipóxia-Isquemia Encefálica/mortalidade , Lactente , Recém-Nascido , Masculino , Transtornos do Neurodesenvolvimento/epidemiologia , Transtornos do Neurodesenvolvimento/etiologia , Fatores de Tempo , Falha de Tratamento
13.
Pediatrics ; 139(1)2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27974588

RESUMO

OBJECTIVES: To determine the current practice patterns of retinopathy of prematurity (ROP) screening and treatment and the attitudes toward new screening and treatment modalities in level III and level IV NICUs, as reported by medical directors. METHODS: Surveys were mailed to the medical directors of 847 level III NICUs identified in the 2011 American Academy of Pediatrics directory in April 2015. In September 2015, responses were compared with American Academy of Pediatrics guidelines and previous reports. Within-sample comparisons were made by level, setting, size, and academic status. RESULTS: Respondents indicated that ROP screening is most often performed in their NICUs by pediatric and/or retina specialists (90%); retinal imaging devices are infrequently used (21%). Treatment is performed by pediatric (39%) and/or retina (57%) specialists in the NICU, usually under conscious sedation (60%). The most common treatment modality was laser photocoagulation (85%), followed by anti-vascular endothelial growth factor injection (20%). Some NICUs do not provide treatment services (28%), often due to a lack of ophthalmologists (78%). Respondents showed slightly more agreement (35%) than disagreement (25%) that a retinal imaging device could replace indirect ophthalmoscopy (40% were neutral). More respondents agreed than disagreed (30% vs 15%) that telemedicine for ROP screening is safe, but most were neutral (55%). CONCLUSIONS: Screening and treatment of ROP are not implemented uniformly in NICUs across the United States. Concerns regarding an insufficient ROP workforce are validated.


Assuntos
Unidades de Terapia Intensiva Neonatal , Triagem Neonatal/tendências , Retinopatia da Prematuridade/diagnóstico , Retinopatia da Prematuridade/terapia , Atitude do Pessoal de Saúde , Fidelidade a Diretrizes/tendências , Pesquisas sobre Serviços de Saúde/estatística & dados numéricos , Humanos , Recém-Nascido , Injeções Intraoculares , Comunicação Interdisciplinar , Colaboração Intersetorial , Terapia a Laser/estatística & dados numéricos , Retinoscopia , Estados Unidos , Fator A de Crescimento do Endotélio Vascular/efeitos adversos
14.
Pediatr Res ; 81(1-2): 202-209, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27673420

RESUMO

Acute postasphyxial encephalopathy around the time of birth remains a major cause of death and disability. The possibility that hypothermia may be able to prevent or lessen asphyxial brain injury is a "dream revisited". In this review, a historical perspective is provided from the first reported use of therapeutic hypothermia for brain injuries in antiquity, to the present day. The first uncontrolled trials of cooling for resuscitation were reported more than 50 y ago. The seminal insight that led to the modern revival of studies of neuroprotection was that after profound asphyxia, many brain cells show initial recovery from the insult during a short "latent" phase, typically lasting ~6 h, only to die hours to days later during a "secondary" deterioration phase characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this conceptual framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild induced hypothermia significantly improves intact survival and neurodevelopmental outcomes to midchildhood.


Assuntos
Asfixia Neonatal/história , Asfixia Neonatal/terapia , Hipotermia Induzida/história , Hipotermia Induzida/métodos , Animais , Asfixia/complicações , Lesões Encefálicas , História do Século XX , História Antiga , Humanos , Hipóxia-Isquemia Encefálica/terapia , Recém-Nascido , Neuroproteção , Ensaios Clínicos Controlados Aleatórios como Assunto , Convulsões/complicações
15.
Pediatr Pulmonol ; 52(1): 84-90, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27362468

RESUMO

STUDY OBJECTIVES: Sleep disruption is increasingly recognized in hospitalized patients. Impaired sleep is associated with measureable alterations in neurodevelopment. The neonatal intensive care unit (NICU) environment has the potential to affect sleep quality and quantity. We aimed: (i) to determine the frequency and duration of hands-on care, and its impact on sleep, for NICU patients; and (ii) to assess the incidence of respiratory events associated with handling for a cohort of sick neonates. METHODS: Term and near-term neonates admitted to the NICU and at risk for cerebral dysfunction due to severity of illness or clinical suspicion for seizures underwent attended, bedside polysomnography. Continuous polysomnogram segments were analyzed and data on handling, infant behavioral state, and associated respiratory events were recorded. RESULTS: Video and polysomnography data were evaluated for 25 infants (gestational age 39.4 ± 1.6 weeks). The maximum duration between handling episodes for each infant was 50.9 ± 26.2 min, with a median of 2.3 min between contacts. Handling occurred across all behavioral states (active sleep 29.5%; quiet sleep 23.1%; awake 29.9%; indeterminate 17.4%; P = 0.99). Arousals or awakenings occurred in 57% of contacts with a sleeping infant. Hypopnea, apnea, and oxygen desaturation occurred with 16%, 8%, and 19.5% of contacts, respectively. Hypopnea was most likely to occur following contact with infants in active sleep (28%; P < 0.001). CONCLUSIONS: Infants in the NICU experience frequent hands-on care, associated with disturbances of sleep and respiration. The potential health and developmental impact of these disturbances merits study, as strategies to monitor sleep and minimize sleep-disordered breathing might then improve NICU outcomes. Pediatr Pulmonol. 2017;52:84-90 © 2016 Wiley Periodicals, Inc.


Assuntos
Unidades de Terapia Intensiva Neonatal , Polissonografia , Respiração , Síndromes da Apneia do Sono/terapia , Sono/fisiologia , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Masculino , Síndromes da Apneia do Sono/fisiopatologia
16.
J Cereb Blood Flow Metab ; 37(1): 307-318, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-26738750

RESUMO

The typical US diet has >30% calories from fat; yet, typical laboratory diets contain 17% calories from fat. This disparity could confound the clinical relevance of findings in cerebral ischemia models. We compared outcomes after neonatal brain injury in offspring of rat dams fed standard low-fat chow (17% fat calories) or a higher fat diet (34% fat calories) from day 7 of pregnancy. On postnatal day 7, hypoxic-ischemic injury was induced by right carotid ligation, followed by 60, 75 or 90 min 8% oxygen exposure. Sensorimotor function, brain damage, and serum and brain fatty acid content were compared 1 to 4 weeks later. All lesioned animals developed left forepaw placing deficits; scores were worse in the high-fat groups (p < 0.0001, ANOVA). Similarly, reductions in left forepaw grip strength were more pronounced in the high-fat groups. Severity of right hemisphere damage increased with hypoxia-ischemia duration but did not differ between diet groups. Serum and brain docosahexaenoic acid fatty acid fractions were lower in high-fat progeny (p < 0.05, ANOVA). We speculate that the high-fat diet disrupted docosahexaenoic acid-dependent recovery mechanisms. These findings have significant implications both for refinement of neonatal brain injury models and for understanding the impact of maternal diet on neonatal neuroplasticity.


Assuntos
Lesões Encefálicas/etiologia , Dieta Hiperlipídica , Hipóxia-Isquemia Encefálica/etiologia , Mães , Animais , Animais Recém-Nascidos , Modelos Animais de Doenças , Ácidos Graxos/análise , Feminino , Plasticidade Neuronal , Ratos , Córtex Sensório-Motor/fisiologia
17.
J Pediatr Surg ; 51(7): 1091-5, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26655216

RESUMO

PURPOSE: This study sought to evaluate prenatal markers' ability to predict severe congenital diaphragmatic hernia(CDH) and assess this subgroup's morbidity and mortality. METHODS: A retrospective review was performed between 2006 and 2014. Prenatal criteria for severe CDH included: liver herniation, lung-to-head ratio (LHR) <1 on prenatal ultrasound and/or observed-to-expected LHR (o/eLHR) <25%, and/or observed-to-expected total lung volume (o/eTLV) <25% on fetal MRI. Postnatal characteristics included: mortality, ECMO utilization, patch closure, persistent suprasystemic pulmonary hypertension (PHtn), O2 requirement at discharge, and few ventilator-free days in the first 60. Statistics performed used unpaired t-test, p<0.05 significant. RESULTS: Overall, 47.5%(29/61) of patients with prenatally diagnosed, isolated CDH met severe criteria. Mean LHR: 1.04±0.35, o/eLHR: 31±10% and o/eTLV: 20±7%. Distribution was 72% LCDH, 24% R-CDH. Overall survival: 38%. ECMO requirement: 92%. Patch rate: 91%. Mean ventilator-free days in 60: 7.1±14. Supplemental oxygen at discharge was required in 27%. In this prenatally diagnosed severe cohort, 58%(15/26) had persistent PHtn post-ECMO requiring inhaled nitric oxide±epoprostenol. Comparing patients with and without PHtn: mean ECMO duration 18±10 days versus 9±7 days (p=0.01) and survival 20% versus 72% (p=0.006). CONCLUSION: A combination of prenatal markers accurately identified severe CDH patients. Outcomes of this group remain poor and persistent PHtn contributes significantly to mortality.


Assuntos
Doenças Fetais/diagnóstico , Cabeça/diagnóstico por imagem , Hérnias Diafragmáticas Congênitas/diagnóstico , Pulmão/diagnóstico por imagem , Oxigenação por Membrana Extracorpórea , Feminino , Doenças Fetais/patologia , Cabeça/embriologia , Cabeça/patologia , Hérnia/congênito , Hérnia/diagnóstico , Hérnias Diafragmáticas Congênitas/mortalidade , Hérnias Diafragmáticas Congênitas/terapia , Humanos , Hipertensão Pulmonar/diagnóstico , Recém-Nascido , Hepatopatias/congênito , Hepatopatias/diagnóstico , Pulmão/embriologia , Pulmão/patologia , Medidas de Volume Pulmonar , Imagem por Ressonância Magnética , Masculino , Valor Preditivo dos Testes , Estudos Retrospectivos , Índice de Gravidade de Doença , Taxa de Sobrevida , Ultrassonografia Pré-Natal
18.
Pediatr Res ; 78(1): 91-6, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25812123

RESUMO

BACKGROUND: Near-infrared spectroscopy (NIRS) measures oxygen metabolism and is increasingly used for monitoring critically ill neonates. The implications of NIRS-recorded data in this population are poorly understood. We evaluated NIRS monitoring for neonates with seizures. METHODS: In neonates monitored with video-electroencephalography, NIRS-measured cerebral regional oxygen saturation (rSO2) and systemic O2 saturation were recorded every 5 s. Mean rSO2 was extracted for 1-h blocks before, during, and after phenobarbital doses. For each electrographic seizure, mean rSO2 was extracted for a period of three times the duration of the seizure before and after the ictal pattern, as well as during the seizure. Linear mixed models were developed to assess the impact of phenobarbital administration and of seizures on rSO2 and fractional tissue oxygen extraction. RESULTS: For 20 neonates (estimated gestational age: 39.6 ± 1.5 wk), 61 phenobarbital doses and 40 seizures were analyzed. Cerebral rSO2 rose (P = 0.005), and fractional tissue oxygen extraction declined (P = 0.018) with increasing phenobarbital doses. rSO2 declined during seizures, compared with baseline and postictal phases (baseline 81.2 vs. ictal 77.7 vs. postictal 79.4; P = 0.004). Fractional tissue oxygen extraction was highest during seizures (P = 0.002). CONCLUSIONS: Cerebral oxygen metabolism decreases after phenobarbital administration and increases during seizures. These small, but clear, changes in cerebral oxygen metabolism merit assessment for potential clinical impact.


Assuntos
Anticonvulsivantes/uso terapêutico , Encéfalo/metabolismo , Oxigênio/metabolismo , Fenobarbital/uso terapêutico , Convulsões/tratamento farmacológico , Anticonvulsivantes/efeitos adversos , Eletroencefalografia , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido , Modelos Lineares , Masculino , Monitorização Fisiológica/métodos , Oximetria , Fenobarbital/efeitos adversos , Espectroscopia de Luz Próxima ao Infravermelho
19.
J Child Neurol ; 30(11): 1526-31, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25724376

RESUMO

Amplitude-integrated EEG (aEEG) is a commonly used predictor of outcome after hypoxic ischemic encephalopathy. Cerebral and systemic near-infrared spectroscopy and acute kidney injury might also have prognostic value. The authors monitored neonates with aEEG, cerebral and systemic near-infrared spectroscopy during therapeutic hypothermia, assigned an acute kidney injury stage, and measured neurodevelopmental outcome. For 18 infants, cerebral near-infrared spectroscopy variables did not differentiate between those with favorable (n = 13) versus adverse (death or moderate-severe disability; n = 5) 18-month outcomes. However, systemic rSO2 variability was higher during hours 48-72 of cooling among those with favorable outcomes (.02 < P < .03). Mean aEEG amplitude during hours 24 to 48 of cooling was higher among those with good outcomes (.027 < P < .032). The aEEG lower margin was also higher during hours 12 to 48 for those with good outcomes (.014 < P < .035). Acute kidney injury did not predict outcome (P > .05). aEEG is a useful prognostic tool for outcomes after neonatal hypoxic ischemic encephalopathy, but the role of near-infrared spectroscopy in the hypothermia-treated population remains uncertain.


Assuntos
Encéfalo/fisiopatologia , Eletroencefalografia , Hipotermia Induzida , Hipóxia-Isquemia Encefálica/diagnóstico , Hipóxia-Isquemia Encefálica/terapia , Espectroscopia de Luz Próxima ao Infravermelho , Eletroencefalografia/métodos , Feminino , Seguimentos , Humanos , Hipotermia Induzida/métodos , Hipóxia-Isquemia Encefálica/fisiopatologia , Recém-Nascido , Masculino , Projetos Piloto , Prognóstico , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Fatores de Tempo , Resultado do Tratamento
20.
Am J Perinatol ; 32(10): 973-9, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25730135

RESUMO

OBJECTIVE: The aim of this study is to determine whether the cystic periventricular leukomalacia (cPVL) detection rate differs between imaging studies performed at different time points. DESIGN: We retrospectively reviewed the prospectively collected data of 31,708 infants from the NICHD Neonatal Research Network. Inclusion criteria were infants < 1,000 g birth weight or < 29 weeks' gestational age who had cranial imaging performed using both early criterion (cranial ultrasound [CUS] < 28 days chronological age) and late criterion (CUS, magnetic resonance imaging, or computed tomography closest to 36 weeks postmenstrual age [PMA]). We compared the frequency of cPVL diagnosed by early and late criteria. RESULTS: About 664 (5.2%) of the 12,739 infants who met inclusion criteria had cPVL using either early or late criteria; 569 using the late criterion, 250 using the early criterion, and 155 patients at both times. About 95 (14.3%) of 664 cPVL cases seen on early imaging were no longer visible on repeat screening closest to 36 weeks PMA. Such disappearance of cPVL was more common in infants < 26 weeks' gestation versus infants of 26 to 28 weeks' gestation (18.5 vs. 11.5%; p = 0.013). CONCLUSIONS: Cranial imaging at both < 28 days chronological age and closest to 36 weeks PMA improves cPVL detection, especially for more premature infants.


Assuntos
Encéfalo/patologia , Leucomalácia Periventricular/diagnóstico , Encéfalo/diagnóstico por imagem , Ecoencefalografia , Humanos , Recém-Nascido de Peso Extremamente Baixo ao Nascer , Lactente Extremamente Prematuro , Recém-Nascido , Recém-Nascido Prematuro , Imagem por Ressonância Magnética , Triagem Neonatal , Estudos Retrospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X
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