RESUMO
OBJECTIVE: To investigate long-term outcomes of infants who survive despite life-and-death discussions with families and a decision to withdraw or withhold life-sustaining interventions (WWLST) in one neonatal intensive care unit. STUDY DESIGN: Medical records for neonatal intensive care unit admissions from 2012 to 2017 were reviewed for presence of WWLST discussions or decisions, as well as the 2-year outcome of all children who survived. WWLST discussions were prospectively recorded in a specific book; follow-up to age 2 years was determined by retrospective chart review. RESULTS: WWLST discussions occurred for 266 of 5251 infants (5%): 151 (57%) were born at term and 115 (43%) were born preterm. Among these discussions, 164 led to a WWLST decision (62%) and 130 were followed by the infant's death (79%). Of the 34 children (21%) surviving to discharge after WWLST decisions, 10 (29%) died before 2 years of age and 11 (32%) required frequent medical follow-up. Major functional limitations were common among survivors, but 8 were classified as functionally normal or with mild-to-moderate functional limitations. CONCLUSIONS: When a WWLST decision was made in our cohort, 21% of the infants survived to discharge. By 2 years of age, the majority of these infants had died or had major functional limitations. This highlights the uncertainty of WWLST decisions during neonatal intensive care and the importance of ensuring that parents are informed of all possibilities. Additional studies including longer-term follow-up and ascertaining the family's views will be important.
Assuntos
Unidades de Terapia Intensiva Neonatal , Terapia Intensiva Neonatal , Recém-Nascido , Lactente , Humanos , Criança , Pré-Escolar , Estudos Retrospectivos , Pais , Morte , Suspensão de TratamentoRESUMO
OBJECTIVES: To explore decisional regret of parents of babies born extremely preterm and analyze neonatal, pediatric, and parental factors associated with regret. STUDY DESIGN: Parents of infants born <29 weeks of gestational age, aged between 18 months and 7 years, attending neonatal follow-up were enrolled. Hospital records were reviewed to examine morbidities and conversations with parents about levels of care. Parents were asked the following question: "Knowing what you know now, is there anything you would have done differently?" Mixed methods were used to analyze responses. RESULTS: In total, 248 parents (98% participation) answered, and 54% reported they did not have regret. Of those who reported regret (n = 113), 3 themes were most frequently invoked: 35% experienced guilt, thinking they were responsible for the preterm birth; 28% experienced regret about self-care decisions; and 20% regretted decisions related to their parental role, generally wishing they knew sooner how to get involved. None reported regret about life-and-death decisions made at birth or in the neonatal intensive care unit. Impairment at follow-up, gestational age, and decisions about levels/reorientation of care were not associated with regret. More mothers reported feeling guilt about the preterm birth (compared with fathers); parents of children with severe lesions on ultrasonography of the head were less likely to report regret. CONCLUSIONS: Approximately one-half of the parents of infants born extremely preterm had regrets regarding their neonatal intensive care unit stay. Causes of regret and guilt should be addressed and minimized.
Assuntos
Lactente Extremamente Prematuro , Nascimento Prematuro , Lactente , Feminino , Recém-Nascido , Humanos , Criança , Pais , Emoções , CulpaRESUMO
OBJECTIVE: To determine the extent that social variables influence cognitive development of very low birth weight (VLBW) infants across the preschool years. STUDY DESIGN: Participants were VLBW (500-1250 g) children enrolled in the Caffeine for Apnea of Prematurity randomized trial between 1999 and 2004. We investigated the relationships between 4 potential social advantages: higher maternal education, higher paternal education, caregiver employment, and 2 biologic parents in the same home--and gain in cognitive scores. Cognitive assessments were performed at the corrected ages of 18 months (Mental Development Index score on the Bayley Scales of Infant Development II) and 5 years (Full Scale IQ on the Wechsler Preschool and Primary Scale of Intelligence III). Cognitive gain was computed by subtracting each individual 18-month Mental Development Index score from the corresponding Full Scale IQ at 5 years. RESULTS: Data were available for 1347 children. Mean (SD) cognitive scores were 90.8 (15.7) at 18 months and 98.9 (14.5) at 5 years. Multivariable regression showed that higher maternal education, higher paternal education, and caregiver employment had independent and additive effects of similar size on cognitive gain (P < .001); the mean cognitive gain between 18 months and 5 years increased by 3.6 points in the presence of each of these advantages. When all 3 were present, cognitive scores improved on average by 10.9 points compared with children without any of these advantages. CONCLUSION: In VLBW children, a count of 3 social advantages strongly predicts gains in cognitive scores across the preschool years.
Assuntos
Peso ao Nascer/fisiologia , Desenvolvimento Infantil/fisiologia , Cognição/fisiologia , Recém-Nascido Prematuro , Recém-Nascido de muito Baixo Peso/fisiologia , Inteligência/fisiologia , Pré-Escolar , Feminino , Seguimentos , Humanos , Lactente , Masculino , Prognóstico , Estudos RetrospectivosRESUMO
OBJECTIVE: To determine whether routine probiotic administration to very preterm infants would reduce the incidence of necrotizing enterocolitis (NEC) without adverse consequences. STUDY DESIGN: Since the end of July 2011, we have administered a probiotic mixture to all admitted infants of <32 weeks' gestation. We give 0.5 g of a mixture of 4 bifidobacteria (Bifidobacterium breve, bifidum, infantis, and longum) and Lactobacillus rhamnosus HA-111 [corrected] (2 × 10(9) colony-forming units) per day, starting with the first feed, until the infant reaches 34 weeks. We compared complications among infants admitted during the first 17 months of routine use with those admitted during the previous 17 months. RESULTS: Two hundred ninety-four infants received probiotics, and 317 infants formed the comparison group. Introduction of probiotics was associated with a reduction in NEC (from 9.8% to 5.4%, P < .02), a nonsignificant decrease in death (9.8% to 6.8%), and a significant reduction in the combined outcome of death or NEC (from 17% to 10.5%, P < .05). After adjustment for gestational age, intrauterine growth restriction, and sex, the improvements remained significant (OR for NEC, 0.51; 95% CI, 0.26-0.98; OR for death or NEC, 0.56; 95% CI, 0.33-0.93). There was no effect of probiotics on health care-associated infection. DISCUSSION: A product that is readily available in North America, that has excellent quality control, and that contains strains similar to those that have been shown effective in randomized controlled trials substantially reduced the frequency of NEC in our neonatal intensive care unit.
Assuntos
Bifidobacterium , Enterocolite Necrosante/prevenção & controle , Doenças do Prematuro/prevenção & controle , Terapia Intensiva Neonatal/métodos , Lacticaseibacillus rhamnosus , Probióticos/uso terapêutico , Estudos de Coortes , Enterocolite Necrosante/epidemiologia , Feminino , Humanos , Incidência , Recém-Nascido , Recém-Nascido Prematuro , Doenças do Prematuro/epidemiologia , Unidades de Terapia Intensiva Neonatal , Masculino , Estudos Prospectivos , Quebeque , Resultado do TratamentoAssuntos
Pressão Sanguínea , Hipotensão/terapia , Doenças do Prematuro/terapia , Feminino , Humanos , MasculinoRESUMO
OBJECTIVES: To determine the proportion of infants admitted to our neonatal intensive care unit (NICU) from multiple gestations resulting from artificial reproductive technology (ART), the complications experienced and interventions required by these infants, and the estimated effect of a mandatory policy of single embryo transfer on admissions and complication rates in our hospital and across Canada. STUDY DESIGN: We conducted a review of a prospectively maintained database and of hospital records and calculated excess complications compared with either universal single embryo transfer or a policy allowing transfer of two embryos in as many as 33% of women. RESULTS: Of our NICU admissions, 17% are infants from multiple gestations after ART, a significant increase in 10 years. In a 2-year period, the excess NICU use that would have been saved by mandatory single embryo transfer included 3082 patient days and 270 patient ventilator days. Extrapolated across Canada, a policy of single embryo transfer would prevent 30 to 40 deaths, 34 to 46 severe intracranial haemorrhages, and 13 to 19 retinal surgeries annually. Savings in NICU resources would be 5424 to 7299 patient-days of assisted ventilation and 35 219 to 42 488 patient-days of NICU care. CONCLUSIONS: A mandatory policy of single embryo transfer would be of substantial benefit to the health of Canadian babies while still benefiting infertile couples.
Assuntos
Transferência Embrionária , Política de Saúde , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Gravidez Múltipla , Adulto , Canadá , Bases de Dados Factuais , Feminino , Fertilização in vitro , Mortalidade Hospitalar , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Hemorragias Intracranianas/epidemiologia , Tempo de Internação/estatística & dados numéricos , Apoio Nutricional/estatística & dados numéricos , Oxigenoterapia/estatística & dados numéricos , Gravidez , Respiração Artificial/estatística & dados numéricos , Retinopatia da Prematuridade/epidemiologia , Retinopatia da Prematuridade/cirurgia , Trigêmeos , GêmeosRESUMO
Persistent pulmonary hypertension of the newborn may occur with perinatal asphyxia, either because of direct effects of hypoxia/ischemia on pulmonary arterial function or indirectly because both are associated with meconium aspiration syndrome or perinatal sepsis/pneumonia. Therapies for persistent pulmonary hypertension of the newborn have the potential to affect cerebral function and cerebral perfusion in infants with hypoxic ischemic encephalopathy. Our literature review concludes that hyperventilation should be avoided, bicarbonate therapy is unproven, and hypoxia and hyperoxia should both be avoided. Nitric oxide improves pulmonary artery pressure and systemic perfusion. The effects of inotropic agents on cerebral perfusion or outcomes are uncertain.