Kamal Ali

Outcome of CDH infants following fetoscopic tracheal occlusion — influence of premature delivery ☆,☆☆

PURPOSE To evaluate the mortality and morbidity of infants with congenital diaphragmatic hernia who had undergone fetal endoscopic tracheal occlusion (FETO) and whether this was influenced by premature birth. METHODS The gestational age at delivery, lung-head ratio (LHR) pre and post FETO, neonatal outcomes, and respiratory, gastro-intestinal, neurological, surgical, and musculoskeletal problems at follow up of consecutive infants who had undergone FETO were determined. Elective reversal of FETO was planned at 34 weeks of gestation. RESULTS The survival rate of the 61 FETO infants was 48%, with 84% delivered prematurely. Thirty-one delivered <35 weeks of gestation. Their survival rate was 18%. Twenty-three of 24 infants who had emergency balloon removal were born <35 weeks of gestation. Survival was related to gestational age at delivery (OR 0.55, 95% CI 0.420, 0.77, p<0.001) and the duration of FETO (OR 0.73, 95% CI 0.59, 0.91, p<0.005). Infants born prior to 35 weeks of gestation compared to those born at ≥ 35 weeks required a longer duration of ventilation (median 45 days versus 12 days, p<0.001), and a greater proportion had surgery for gastro-oesophageal reflux (50% versus 9%, p=0.011). CONCLUSION These results emphasize the need to reduce premature delivery following FETO.

Long-term respiratory outcome of babies born prematurely

Chronic respiratory morbidity is a common adverse outcome of premature birth, particularly in infants who develop bronchopulmonary dysplasia (BPD). Prematurely born infants who had BPD may require supplementary oxygen at home for many months, but few remain oxygen dependent beyond 2 years of age. Readmission to hospital is common, particularly for those who had BPD, but only in the first 2 years after birth. The readmissions are usually for respiratory problems, particularly respiratory syncytial virus lower respiratory infections. Recurrent respiratory symptoms requiring treatment are common, particularly in those who had BPD, even at school age and in adolescence. Affected children have evidence of airways obstruction. Pulmonary function does improve with age, but children with BPD may have ongoing airflow limitation. Computed tomography of the chest gives helpful information at follow up of patients with ongoing respiratory problems who had BPD.

Ventilatory Response to Hypercarbia in Newborns of Smoking and Substance-Misusing Mothers

RATIONALE Infants of mothers who smoked (S) or substance misused (SM) during pregnancy have an increased risk of sudden infant death syndrome (SIDS). OBJECTIVES To test the hypothesis that infants of S and SM mothers compared with infants of non-substance-misusing, nonsmoking mothers (control subjects) would have a reduced ventilatory response to hypercarbia and that any reduction would be greater in the SM infants. METHODS Infants were assessed before maternity/neonatal unit discharge. Maternal and infant urine samples were obtained and tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine, and benzodiazepines. MEASUREMENTS AND MAIN RESULTS Respiratory flow and Vt were measured using a pneumotachograph inserted into a face mask placed over the infants mouth and nose. The ventilatory responses to three levels of inspired carbon dioxide (0 [baseline], 2, and 4% CO2) were assessed. Twenty-three SM, 34 S, and 22 control infants were assessed. The birth weight of the control subjects was higher than the SM and S infants (P = 0.017). At baseline, SM infants had a higher respiratory rate (P = 0.003) and minute volume (P = 0.007) compared with control subjects and S infants. Both the SM and S infants had a lower ventilatory response to 2% (P < 0.001) and 4% (P < 0.001) CO2 than the control subjects. The ventilatory response to CO2 was lower in the SM infants compared with the S infants (P = 0.009). CONCLUSIONS These results are consistent with infants of smoking mothers and substance misuse/smoking mothers having a dampened ventilatory response to hypercarbia, which is particularly marked in the latter group.

Antenatal substance misuse and smoking and newborn hypoxic challenge response

Objectives Infants of smoking (S) and substance misusing (SM) mothers have an increased risk of sudden infant death syndrome. The aim of this study was to test the hypothesis that infants of SM or S mothers compared with infants of non-SM, non-smoking mothers (controls) would have a poorer ventilatory response to hypoxia, which was particularly marked in the SM infants. Design Physiological study. Setting Tertiary perinatal centre. Patients 21 SM; 21 S and 19 control infants. Infants were assessed before maternity/neonatal unit discharge. Interventions Maternal and infant urine samples were tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine and benzodiazepines. Main outcome measures During quiet sleep, the infants were switched from breathing room air to 15% oxygen and changes in minute volume were assessed. Results The SM infants had a greater mean increase (p=0.028, p=0.034, respectively) and a greater magnitude of decline (p<0.001, p=0.018, respectively) in minute volume than the S infants and the controls. The rate of decline in minute volume was greater in the SM infants (p=0.008) and the S infants (p=0.011) compared with the controls. Conclusions Antenatal substance misuse and smoking affect the infants ventilatory response to a hypoxic challenge.

Gastro-Oesophageal Reflux and Apnoea: Is There a Temporal Relationship?

Background: Gastro-oesophageal reflux (GOR) and apnoea are common in infants; whether there is a causal relationship is controversial. Objectives: To determine whether there was a temporal relationship between GOR and apnoea, in particular, the frequency of obstructive apnoeas and if the frequency of GOR episodes correlated with apnoea frequency when maturity at testing was taken into account. Methods: Polysomnography and pH/multichannel intraluminal impedance (MII) studies were performed. Apnoeas were classified as central, obstructive, or mixed. MII events were classified as acidic (pH <4) or weakly acidic (4 < pH < 7). Apnoea frequency in the 5-min period after a reflux event was compared to that in the 5-min period preceding the event and that in a 5-min reflux-free period (control period). Results: Forty infants (median gestational age 29 [range 24-42] weeks) were assessed at a post-conceptional age of 37 (30-54) weeks. Obstructive (n = 580), central (n = 900), and mixed (n = 452) apnoeas were identified; 381 acid reflux events were detected by MII and 153 by the pH probe only. Apnoeas were not more frequent following GOR than during control periods. Both the frequency of apnoeas (p = 0.002) and GOR episodes (p = 0.01) were inversely related to post-conceptional age at testing, but were not significantly correlated with each other when controlled for post-conceptional age. Conclusions: These results suggest that GOR does not cause apnoea.

Congenital Diaphragmatic Hernia: 10-Year Evaluation of Survival, Extracorporeal Membrane Oxygenation, and Foetoscopic Endotracheal Occlusion in Four High-Volume Centres

Background: Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly with significant mortality. Objectives: The aim of this study was to determine if there were trends in survival over the last decade and to compare patient populations, treatment options, and survival rates between 4 high-volume centres, and hence determine which factors were associated with survival. Methods: In 4 high-volume CDH centres from the CDH EURO Consortium, data from all CDH patients born between 2004 and 2013 were analysed. The predictive value of variables known at birth and the influence of centre-specific treatments (extracorporeal membrane oxygenation, ECMO, and foetoscopic endotracheal occlusion, FETO) on survival were evaluated in multivariable logistic regression analyses. Results: Nine hundred and seventy-five patients were included in the analysis, of whom 274 (28.1%) died. ECMO was performed in 259 patients, of whom 81 (31.3%) died. One hundred and forty-five patients (14.9%) underwent FETO, and from those 76 patients (52.4%) survived. Survival differed significantly between years (p = 0.006) and between the 4 centres (p < 0.001). In the multivariable logistic regression analysis, lung-to-head ratio, gestational age at birth, ECMO, centre of birth, and year of birth were significantly associated with survival, whereas FETO was not. Conclusions: The patient populations were different between centres, which influenced outcomes. There was a significant variability in survival over time and between centres, which should be taken into consideration in the planning of future trials.

Antenatal smoking and substance-misuse, infant and newborn response to hypoxia.

To determine at the peak age for sudden infant death syndrome (SIDS) the ventilatory response to hypoxia of infants whose mothers substance misused in pregnancy (SM infants), or smoked during pregnancy (S mothers) and controls whose mothers neither substance misused or smoked. In addition, we compared the ventilatory response to hypoxia during the neonatal period and peak age of SIDS.

Mortality following congenital diaphragmatic hernia repair: the role of anesthesia.

Mortality following surgical repair of congenital diaphragmatic hernia (CDH) remains high. The volume and type of perioperative intravenous fluid administered, baro‐trauma, oxygen toxicity, and the duration of anesthesia are thought to affect outcome in surgical populations.

Mortality and short-term morbidity in infants with exomphalos

Infants with exomphalos major have a high mortality and morbidity. The aims of this study were to identify predictors of survival regardless of the size of the exomphalos, and to analyze morbidity in infants with exomphalos minor.

The effect of caffeine on the ventilatory response to hypercarbia in preterm infants

BackgroundWe tested the hypotheses that caffeine therapy would increase the ventilatory response to hypercarbia in infants above the effect of maturation and those with a weaker ventilatory response to hypercarbia would be more likely to subsequently develop apnea that required treatment.MethodsInfants born at less than 34 weeks of gestation underwent a steady-state hypercarbic challenge using 0, 2, and 4% carbon dioxide soon after birth that was repeated at weekly intervals. The results of the initial study were compared between infants who did or did not subsequently develop apnea requiring treatment with caffeine.ResultsTwenty-six infants born at a median gestation of 32 (range 31–33) weeks were assessed. Caffeine administration was associated with an increase in CO2 sensitivity, and the mean increase was 15.3 (95% CI: 1–30) ml/kg/min/% CO2. Fourteen infants subsequently developed apnea treated with caffeine. After controlling for gestational age and birth weight, they had significantly lower carbon dioxide sensitivity at their initial study compared with those who did not require treatment.ConclusionCaffeine administration was associated with an increase in the ventilatory response to hypercarbia. An initial weaker ventilatory response to hypercarbia was associated with the subsequent development of apnea requiring treatment with caffeine.