RESUMO
OBJECTIVE: To describe the prevalence of and between-center variations in care practices and clinical outcomes of moderate and late preterm infants (MLPIs) admitted to tertiary Canadian neonatal intensive care units (NICUs). STUDY DESIGN: This was a retrospective cohort study including infants born at 320/7 through 366/7 weeks of gestation and admitted to 25 NICUs participating in the Canadian Neonatal Network between 2015 and 2020. Patient characteristics, process measures represented by care practices, and outcome measures represented by clinical in-hospital and discharge outcomes were reported by gestational age weeks. NICUs were compared using indirect standardization after adjustment for patient characteristics. RESULTS: Among 25â669 infants (17% of MLPIs born in Canada during the study period) included, 45% received deferred cord clamping, 7% had admission hypothermia, 47% received noninvasive respiratory support, 11% received mechanical ventilation, 8% received surfactant, 40% received antibiotics in the first 3 days, 4% did not receive feeding in the first 2 days, and 77% had vascular access. Mortality, early-onset sepsis, late-onset sepsis, or necrotizing enterocolitis occurred in <1% of the study cohort. Median (IQR) length of stay was 14 (9-21) days among infants discharged home from the admission hospital and 5 (3-9) days among infants transferred to community hospitals. Among infants discharged home, 33% were discharged on exclusive breastmilk and 75% on any breastmilk. There were significant variations between NICUs in all process and outcome measures. CONCLUSIONS: Care practices and outcomes of MLPIs varied significantly between Canadian NICUs. Standardization of process and outcome quality measures for this population will enable benchmarking and research, facilitating systemwide improvements.
Assuntos
Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Humanos , Canadá , Recém-Nascido , Estudos Retrospectivos , Feminino , Masculino , Centros de Atenção Terciária , Idade Gestacional , Avaliação de Processos e Resultados em Cuidados de Saúde , Doenças do Prematuro/terapia , Doenças do Prematuro/epidemiologiaRESUMO
OBJECTIVE: To evaluate the impact of prophylactic indomethacin on early death (<10 days after birth) or severe neurologic injury and on early death or spontaneous intestinal perforation by completed weeks of gestational age in neonates born <29 weeks of gestation. STUDY DESIGN: This was a multicenter, retrospective cohort study of neonates (n = 12 515) born at 236/7 weeks of gestational age, admitted to neonatal intensive care units participating in the Canadian Neonatal Network who received prophylactic indomethacin started within the first 12 hours after birth. Univariate and multivariate analysis compared the composite outcomes of early death or severe neurologic injury and early death or spontaneous intestinal perforation. RESULTS: Of 12 515 eligible neonates, 1435 (11.5%) were exposed to prophylactic indomethacin; recipients were of lower gestational age and birth weight and had greater severity of illness (Score of Neonatal Acute Physiology with Perinatal Extension) on admission compared with nonrecipients. After we adjusted for confounders, prophylactic indomethacin was associated with reduced odds of early death or severe neurologic injury and early death or spontaneous intestinal perforation in neonates born at 23-24 weeks of gestational age. However, prophylactic indomethacin was associated with increased odds of early mortality or spontaneous intestinal perforation for neonates born at 26-28 weeks of gestational age. CONCLUSIONS: Prophylactic indomethacin use was associated with benefit in neonates born at 23-24 weeks of gestational age, but with harm at 26-28 weeks of gestational age. Given the observation of significantly improved survival, a randomized controlled trial is needed to investigate the effect of prophylactic indomethacin in babies born at 23-25 weeks of gestational age.
Assuntos
Lesões Encefálicas , Perfuração Intestinal , Canadá , Feminino , Idade Gestacional , Humanos , Indometacina , Lactente , Lactente Extremamente Prematuro , Recém-Nascido , Perfuração Intestinal/prevenção & controle , Gravidez , Estudos Retrospectivos , EsteroidesRESUMO
OBJECTIVE: To evaluate the changes in preductal oxygen saturation (SpO2) and heart rate in preterm infants receiving continuous positive airway pressure (CPAP) and/or positive-pressure ventilation (PPV) at birth. STUDY DESIGN: A prospective observational study at birth of infants aged <32 weeks separated into 2 gestational age (GA) groups: 230/7-276/7 weeks (group 1) and 280/7-316/7 weeks (group 2). Infants received delayed cord clamping (DCC) in accordance with institutional protocol. CPAP and/or PPV was applied at the clinical team's discretion. SpO2 and heart rate were recorded every minute for 10 minutes. Preductal SpO2 was targeted according to published nomograms. For heart rate, the goal was to maintain a stable heart rate >100 bpm. RESULTS: The study cohort comprised 96 group 1 infants (mean GA, 26 ± 1 weeks; mean birth weight, 818 ± 208 g) and 173 group 2 infants (mean GA, 30 ± 1 weeks; mean birth weight, 1438 ± 374 g). In general, infants requiring respiratory support reached target values for heart rate and SpO2 more slowly than the published nomograms for spontaneously breathing preterm infants without respiratory support. Infants receiving CPAP reached SpO2 and heart rate targets faster than infants receiving PPV. In group 1, but not group 2 infants, DCC resulted in higher SpO2 and heart rate. CONCLUSION: SpO2 and heart rate do not quickly and reliably reach the values achieved by spontaneously breathing preterm infants not requiring respiratory support.
Assuntos
Frequência Cardíaca/fisiologia , Oxigênio/sangue , Respiração com Pressão Positiva/métodos , Cordão Umbilical/fisiologia , Constrição , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro/fisiologia , Masculino , Oximetria , Estudos Prospectivos , RespiraçãoRESUMO
OBJECTIVES: To examine the amount of exhaled carbon dioxide (ECO2) with different breathing patterns in spontaneously breathing preterm infants after birth. STUDY DESIGN: Preterm infants had a facemask attached to a combined carbon dioxide/flow sensor placed over their mouth and nose to record ECO2 and gas flow. A breath-by-breath analysis of the first 5 minutes of the recording was performed. RESULTS: Thirty spontaneously breathing preterm infants, gestational age (mean ± SD) 30 ± 2 weeks and birth weight 1635 ± 499 g were studied. ECO2 from normal breaths and slow expirations was significantly larger than with other breathing patterns (P < .001). ECO2 per breath also increased with gestational age P < .001. The expiratory hold pattern was the most prevalent breathing pattern both during the first minute of recording and overall. Breathing pattern proportions also varied by gestational age. Finally, ECO2 from the fifth minute of recording was significantly greater than that produced during the first 4 minutes of recording (P ≤ .029). CONCLUSIONS: ECO2 varies with different breathing patterns and increases with gestational age and over time. ECO2 may be an indicator of lung aeration and that postnatal ECO2 monitoring may be useful in preterm infants in the delivery room.
Assuntos
Testes Respiratórios , Dióxido de Carbono/análise , Expiração , Peso ao Nascer , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Monitorização Fisiológica , Estudos Prospectivos , Volume de Ventilação PulmonarRESUMO
OBJECTIVE: To examine the temporal course of lung aeration at birth in preterm infants <33 weeks gestation. STUDY DESIGN: The research team attended deliveries of preterm infants <33 weeks gestation at the Royal Alexandra Hospital. Infants who received only continuous positive airway pressure were eligible for inclusion. A combined carbon dioxide (CO2) and flow-sensor was placed between the mask and the ventilation device. To analyze lung aeration patterns during spontaneous breathing, tidal volume (VT), and exhaled CO2 (ECO2) were recorded for the first 100 breaths. RESULTS: Thirty preterm infants were included with a total of 1512 breaths with mask leak <30%. Mean (SD) gestational age and birth weight was 30 (1) weeks and 1478 (430) g. Initial VT and ECO2 for the first 30 breaths was 5-6 mL/kg and 15-22 mm Hg, respectively. VT and ECO2 increased over the next 20 breaths to 7-8 mL/kg and 25-32 mm Hg, respectively. For the remaining observation period VT decreased to 4-6 mL/kg and ECO2 continued to increase to 35-37 mm Hg. CONCLUSIONS: Preterm infants begin taking deeper breaths approximately 30 breaths after initiating spontaneous breathing to inflate their lungs. Concurrent CO2 removal rises as alveoli are recruited. Lung aeration occurs in 2 phases: initially, large volume breaths with poor alveolar aeration followed by smaller breaths with elimination of CO2 as a consequence of adequate aeration.
Assuntos
Dióxido de Carbono/metabolismo , Recém-Nascido Prematuro/fisiologia , Pulmão/fisiologia , Respiração , Canadá , Pressão Positiva Contínua nas Vias Aéreas , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Pulmão/metabolismo , Masculino , Volume de Ventilação Pulmonar/fisiologiaRESUMO
OBJECTIVE: To describe changes in tidal volume (VT) and their correlation to changes in oxygen saturation and heart rate in spontaneously breathing preterm infants immediately after birth. STUDY DESIGN: In this prospective observational, 2-center study, a flow sensor was attached to the facemask of spontaneously breathing infants born at <37 weeks' gestational age who received continuous positive airway pressure (CPAP) immediately after birth. Respiratory function, heart rate, and oxygen saturation were continuously recorded during spontaneous breathing. RESULTS: Fifty-five infants (mean [SD] gestational age 31 [26-36] weeks and birth weight 1647 [500] g) received mask CPAP in the delivery room. CPAP was started at a median (IQR) 90 (60-118) seconds after birth and was delivered for 720 (300-900) seconds. Median VT ranged between 4.2 and 5.8 mL/kg with the individual VT varied between 0.9 and 19.8 mL/kg. Overall, VT increased over the first few minutes after birth and decreased thereafter. The increase in saturation after birth lagged behind the published normal ranges for spontaneously breathing preterm infants without CPAP. CONCLUSIONS: The 50th percentile for spontaneous VT in preterm infants during mask CPAP ranged from 4.2 to 5.8 mL/kg, with wide individual variation observed in the first minutes after birth. Preterm infants requiring CPAP after birth may take longer to achieve so-called "normal" saturation targets.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Volume de Ventilação Pulmonar/fisiologia , Feminino , Frequência Cardíaca , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Máscaras , Monitorização Fisiológica , Oxigênio/sangue , Oxigênio/uso terapêutico , Estudos Prospectivos , Respiração , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: To examine the association between treatment for patent ductus arteriosus (PDA) and neonatal outcomes in preterm infants, after adjustment for treatment selection bias. STUDY DESIGN: Secondary analyses were conducted using data collected by the Canadian Neonatal Network for neonates born at a gestational age ≤ 32 weeks and admitted to neonatal intensive care units in Canada between 2004 and 2008. Infants who had PDA and survived beyond 72 hours were included in multivariable logistic regression analyses that compared mortality or any severe neonatal morbidity (intraventricular hemorrhage grades ≥ 3, retinopathy of prematurity stages ≥ 3, bronchopulmonary dysplasia, or necrotizing enterocolitis stages ≥ 2) between treatment groups (conservative management, indomethacin only, surgical ligation only, or both indomethacin and ligation). Propensity scores (PS) were estimated for each pair of treatment comparisons, and used in PS-adjusted and PS-matched analyses. RESULTS: Among 3556 eligible infants with a diagnosis of PDA, 577 (16%) were conservatively managed, 2026 (57%) received indomethacin only, 327 (9%) underwent ligation only, and 626 (18%) were treated with both indomethacin and ligation. All multivariable and PS-based analyses detected significantly higher mortality/morbidities for surgically ligated infants, irrespective of prior indomethacin treatment (OR ranged from 1.25-2.35) compared with infants managed conservatively or those who received only indomethacin. No significant differences were detected between infants treated with only indomethacin and those managed conservatively. CONCLUSIONS: Surgical ligation of PDA in preterm neonates was associated with increased neonatal mortality/morbidity in all analyses adjusted for measured confounders that attempt to account for treatment selection bias.
Assuntos
Inibidores de Ciclo-Oxigenase/uso terapêutico , Permeabilidade do Canal Arterial/terapia , Indometacina/uso terapêutico , Displasia Broncopulmonar/epidemiologia , Hemorragia Cerebral/epidemiologia , Comorbidade , Permeabilidade do Canal Arterial/tratamento farmacológico , Permeabilidade do Canal Arterial/epidemiologia , Permeabilidade do Canal Arterial/cirurgia , Enterocolite Necrosante , Humanos , Mortalidade Infantil , Recém-Nascido , Recém-Nascido Prematuro , Ligadura , Razão de Chances , Pontuação de Propensão , Retinopatia da Prematuridade/epidemiologia , Viés de Seleção , Resultado do TratamentoRESUMO
OBJECTIVES: To test whether iron supplementation affects hematologic, biochemical, and developmental status in term breast-fed infants. STUDY DESIGN: Term breast-fed infants (n=77) were randomly selected to receive either 7.5 mg per day of elemental iron as ferrous sulfate or placebo from 1 to 6 months of age. Investigators and families were unaware of group assignment. Complete blood count and ferritin, red cell superoxide dismutase, catalase, plasma ferric reducing antioxidant power, and zinc and copper levels were analyzed at 1, 3.5, 6, and 12 months of age. Bayley mental and psychomotor developmental indexes (MDI and PDI) and visual acuity (with the use of Teller acuity cards) were assessed from 12 to 18 months of age. Analysis performed by analysis of variance and t tests was by intention to treat. RESULTS: Iron supplementation resulted in higher hemoglobin and mean corpuscular volume at 6 months of age and significantly higher visual acuity and PDI at 13 months of age (100+/-12 vs 93+/-9 [+/-SD]). Treatment and placebo groups did not differ in anthropometric indexes, compliance, biochemical status, or demographic characteristics. CONCLUSIONS: Iron supplementation of breast-fed infants appears safe and might have beneficial hematologic and developmental effects for some infants.