Amir Kugelman

Late Preterm Infants: Near Term But Still in a Critical Developmental Time Period

Late preterm (LP) infants are defined as those born at 34-0/7 to 36-6/7 weeks’ gestational age. LP infants were previously referred to as near term infants. The change in terminology resulted from the understanding that these infants are not fully mature and that the last 6 weeks of gestation represent a critical period of growth and development of the fetal brain and lungs, and of other systems. There is accumulating evidence of higher risks for health complications in these infants, including serious morbidity and a threefold higher infant mortality rate compared with term infants. This information is of critical importance because of its scientific merits and practical implications. However, it warrants a critical and balanced review, given the apparent overall uncomplicated outcome for the majority of LP infants. Others reviewed the characteristics of LP infants that predispose them to a higher risk of morbidity at the neonatal period. This review focuses on the long-term neurodevelopmental and respiratory outcomes, with the main aim to suggest putative prenatal, neonatal, developmental, and environmental causes for these increased morbidities. It demonstrates parallelism in the trajectories of pulmonary and neurologic development and evolution as a model for fetal and neonatal maturation. These may suggest the critical developmental time period as the common pathway that leads to the outcomes. Disruption in this pathway with potential long-term consequences in both systems may occur if the intrauterine milieu is disturbed. Finally, the review addresses the practical implications on perinatal and neonatal care during infancy and childhood.

A comprehensive approach to the prevention of bronchopulmonary dysplasia

The current bronchopulmonary dysplasia (BPD) is seen in infants born extremely premature, with less severe respiratory distress syndrome (RDS) and who received prenatal steroids—“new BPD”. The pathophysiology of BPD is based on an impairment of lung maturation with prenatal and postnatal multi‐hit insults and genetic susceptibility. This multifactorial pathophysiology of BPD suggests that no single “magic bullet” will prevent it. Thus, to avoid BPD we need to implement a complex and comprehensive strategy.

Effects of placental transfusion in extremely low birthweight infants: meta-analysis of long- and short-term outcomes.

Risks and benefits of increasing placental transfusion in extremely preterm infants (extremely low birthweight [ELBW], <1000 g) are ill defined. We performed a meta‐analysis to compare long‐ and short‐term outcomes of ELBW infants in trials of enhanced placental transfusion regimens.

Delivery Mode and Severe Intraventricular Hemorrhage in Single, Very Low Birth Weight, Vertex Infants

OBJECTIVE: To investigate the association between delivery mode and grade 3–4 intraventricular hemorrhage in singleton, vertex presenting, very low birth weight (VLBW) (1,500 g or less) liveborn infants. METHODS: The Israel National VLBW Infant Database includes perinatal and neonatal data on greater than 99% of all VLBW newborns. A total of 4,658 singleton vertex-presenting infants born at 24–34 weeks were included (1995–2004). Infants with lethal congenital malformations, delivery room deaths, and home deliveries were excluded. Our population-based observational study evaluated the effect of delivery mode and confounding variables on severe intraventricular hemorrhage using univariable and multivariable logistic regression analyses. RESULTS: The rate of severe intraventricular hemorrhage was 10.4%. Cesarean delivery rate was 54.3%. The rate of severe intraventricular hemorrhage was 7.7% for infants delivered by cesarean compared with 13.6% in vaginal delivery (P<.001). However, analysis according to gestational age showed that the rate of severe intraventricular hemorrhage was similar in cesarean and vaginal delivery in all gestational age groups. In the multivariable model, cesarean delivery had no effect on the odds for severe intraventricular hemorrhage (odds ratio [OR] 0.98, 95% confidence interval [CI] 0.77–1.24). Other factors independently associated with severe intraventricular hemorrhage included gestational age (OR 0.71, 95% CI 0.68–0.75 for each week increase), maternal hypertensive disorder (OR 0.43, 95% CI 0.30–0.61), no antenatal steroids (OR 2.70, 95% CI 2.12–3.45), 1-minute Apgar score 0–3 (OR 1.72, 95% CI 1.33–2.21), delivery room resuscitation (OR 2.16, 95% CI 1.65–2.83), and non-Jewish ethnicity (OR 1.28, 95% CI 1.03–1.59). CONCLUSION: In this population-based study, the odds for severe intraventricular hemorrhage were not influenced by mode of delivery in vertex-presenting singleton VLBW infants after controlling for gestational age. LEVEL OF EVIDENCE: II

Preauricular tags and pits in the newborn: the role of hearing tests

The aim of this study was to determine the role of audiometry in a group of newborn infants with preauricular tags or pits. During the 2 years of prospective study, 26 infants were born with preauricular tags or pits (5.7 per 1000 livebirths) and were assessed for hearing impairment by performing behavioural audiometry on day 3 of life and brainstem‐evoked response audiometry at 4 months of age. Five infants had associated congenital anomalies (19%). The behavioural audiometry was abnormal in seven infants (27%). The evoked response audiometry was abnormal in 4/23 (17%) newborn infants with isolated tags or pits, and revealed both conductive and/or sensorineural hearing impairment. The incidence of hearing impairment with isolated preauricular tag/pit was significantly higher (p < 0.001) than the incidence reported in preschool children. We conclude that hearing assessment is recommended in the routine evaluation of the newborn with isolated preauricular tags or pits. This policy may facilitate early diagnosis and treatment of hearing impairment in this population.

Iatrogenesis in Neonatal Intensive Care Units: Observational and Interventional, Prospective, Multicenter Study

OBJECTIVES. The goals were to determine the incidence of iatrogenic events in NICUs and to determine whether awareness of iatrogenic events could influence their occurrence. METHODS. We performed a prospective, observational, interventional, multicenter study including all consecutive infants hospitalized in 4 NICUs. In the first 3 months (observation period), the medical teams were unaware of the study; in the next 3 months (intervention period), they were made aware of daily ongoing monitoring of iatrogenic events by a designated “Iatrogenesis Advocate.” RESULTS. The numbers of infants admitted to the NICUs were comparable during the observation and intervention periods (328 and 369 infants, respectively). There was no difference between the 2 periods with respect to the number of infants of <1500 g, hospitalization days, or mean daily occupancy of the NICUs. Although the prevalence rates of iatrogenic events were comparable in the observation and intervention periods (18.0 and 18.2 infants with iatrogenic events per 100 hospitalized infants, respectively), the incidence rate decreased significantly during the intervention period (3.2 and 2.4 iatrogenic events per 100 hospitalization days of new admissions, respectively). Of all iatrogenic events, 7.9% were classified as life-threatening and 45.1% as harmful. There was no death related to an iatrogenic event. Eighty-three percent of iatrogenic events were considered preventable, of which 26.9% resulted from medical errors in ordering or delivery of medical care. Only 1.6% of all iatrogenic events were intercepted before reaching the infants, and only 47.0% of iatrogenic events were corrected. For younger and smaller infants, the rate of iatrogenic events was higher (57% at gestational ages of 24 to 27 weeks, compared with 3% at term) and the iatrogenic events were more severe and harmful. Increased length of stay was associated independently with more iatrogenic events. CONCLUSIONS. Neonatal medical teams and parents should be aware of the burden of iatrogenesis, which occurs at a significant rate.

Venovenous versus venoarterial extracorporeal membrane oxygenation in congenital diaphragmatic hernia.

BACKGROUND Extracorporeal membrane oxygenation (ECMO) has a significant role as a final rescue modality in severe respiratory failure of the newborn with congenital diaphragmatic hernia (CDH). The objective of this study was to compare the efficiency of venovenous (VV) versus venoarterial (VA) ECMO in newborns with CDH. METHODS A retrospective report of 11 years experience (1990 through 2001) of a single center, comparing VV and VA ECMO is given. VV ECMO was the preferred rescue modality for respiratory failure unresponsive to maximal medical therapy. Only when the placement of a VV ECMO 14F catheter was not possible, VA ECMO was used. Forty-six patients met ECMO criteria; 26 were treated with VV ECMO and 19 with VA ECMO. One patient underwent conversion from VV to VA ECMO. RESULTS Before ECMO, there was no difference between VV and VA ECMO patients in mean oxygenation index (83 v 83), mean airway pressure (18.4 v 18.9 cm H(2)O), ECMO cannulation age (28 v 20 hours), or in the percentage of patients who needed dopamine and dobutamine (100% v 100%). From November 1994, nitric oxide (NO) was available; before ECMO, 11 of 14 (79%) VV ECMO patients received NO versus 9 of 10 (90%) patients in the VA group. VV ECMO patients were larger (3.34 v 2.77 kg; P <.05) and of advanced gestational age (39.0 v 36.9 wk; P <.05) compared with VA ECMO patients. There was no significant difference between VV and VA ECMO patients in survival rate (18 of 26, 69% v 13 of 19, 68%), ECMO duration (152 v 150 hours), time of extubation (32.0 v 33.5 days), age at discharge (73 v 81 days), or incidence of short-term intracranial complications (3.8% v 10.5%) or myocardial stun (3.8% v 15.8%). CONCLUSIONS The authors conclude that VV ECMO is as reliable as VA ECMO in newborns with CDH in severe respiratory failure who need ECMO support and who can accommodate the VV double-lumen catheter. Because of its potential advantages, VV ECMO may be the preferred ECMO method in these infants.

A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS

To compare the requirement for endotracheal ventilation in preterm infants treated with heated, humidified high‐flow nasal cannula (HHHFNC) with those treated with nasal intermittent positive pressure ventilation (NIPPV) for the primary treatment of respiratory distress syndrome (RDS).

The Impact of Rudeness on Medical Team Performance: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Iatrogenesis often results from performance deficiencies among medical team members. Team-targeted rudeness may underlie such performance deficiencies, with individuals exposed to rude behavior being less helpful and cooperative. Our objective was to explore the impact of rudeness on the performance of medical teams. METHODS: Twenty-four NICU teams participated in a training simulation involving a preterm infant whose condition acutely deteriorated due to necrotizing enterocolitis. Participants were informed that a foreign expert on team reflexivity in medicine would observe them. Teams were randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or control (neutral comments). The videotaped simulation sessions were evaluated by 3 independent judges (blinded to team exposure) who used structured questionnaires to assess team performance, information-sharing, and help-seeking. RESULTS: The composite diagnostic and procedural performance scores were lower for members of teams exposed to rudeness than to members of the control teams (2.6 vs 3.2 [P = .005] and 2.8 vs 3.3 [P = .008], respectively). Rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance. A model specifying information-sharing and help-seeking as mediators linking rudeness to team performance explained an even greater portion of the variance in diagnostic and procedural performance (R2 = 52.3 and 42.7, respectively). CONCLUSIONS: Rudeness had adverse consequences on the diagnostic and procedural performance of the NICU team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.

Is Visual Assessment of Jaundice Reliable as a Screening Tool to Detect Significant Neonatal Hyperbilirubinemia

OBJECTIVE To assess the reliability of visual assessment of bilirubin levels (BiliEye) in newborns as a screening tool to detect significant neonatal hyperbilirubinemia. STUDY DESIGN 5 neonatologists and 17 nurses estimated 3,532 BiliEye in 1,129 term and late preterm (> or = 35 weeks) infants before discharge from the nursery, at 62 +/- 24 hours. Total serum bilirubin (TSB) levels were measured concomitantly. RESULTS Mean TSB and BiliEye were 6.7 +/- 2.9 mg/dL (range, 0.4-18.2 mg/dL) and 6.6 +/- 3.2 mg/dL (range, 0.0-17.2 mg/dL), respectively, with good correlation (Pearsons r = 0.752, P < .0001), but other measures of agreement were poor. 61.5% of the 109 babies with TSB levels in high-risk zones were clinically misclassified. The area under curve (AUC) of the receiver-operating characteristics plotted for these high-risk zones was 0.825, but became low for early discharge (< or = 36 hours; AUC = 0.638) and late preterm (35-37 weeks; AUC = 0.613). There was significant interobserver variation (low weighted kappa, 0.363). CONCLUSIONS Although there was good correlation between BiliEye and actual TSB level, visual assessment was unreliable as a screening tool to detect significant neonatal hyperbilirubinemia before discharge. Babies with TSB levels within high-risk zones may be clinically misdiagnosed as low-risk, resulting in inadequate follow-up.