Malcolm R. Battin

Oxygen Saturation and Outcomes in Preterm Infants

BACKGROUNDnThe clinically appropriate range for oxygen saturation in preterm infants is unknown. Previous studies have shown that infants had reduced rates of retinopathy of prematurity when lower targets of oxygen saturation were used.nnnMETHODSnIn three international randomized, controlled trials, we evaluated the effects of targeting an oxygen saturation of 85 to 89%, as compared with a range of 91 to 95%, on disability-free survival at 2 years in infants born before 28 weeks gestation. Halfway through the trials, the oximeter-calibration algorithm was revised. Recruitment was stopped early when an interim analysis showed an increased rate of death at 36 weeks in the group with a lower oxygen saturation. We analyzed pooled data from patients and now report hospital-discharge outcomes.nnnRESULTSnA total of 2448 infants were recruited. Among the 1187 infants whose treatment used the revised oximeter-calibration algorithm, the rate of death was significantly higher in the lower-target group than in the higher-target group (23.1% vs. 15.9%; relative risk in the lower-target group, 1.45; 95% confidence interval [CI], 1.15 to 1.84; P=0.002). There was heterogeneity for mortality between the original algorithm and the revised algorithm (P=0.006) but not for other outcomes. In all 2448 infants, those in the lower-target group for oxygen saturation had a reduced rate of retinopathy of prematurity (10.6% vs. 13.5%; relative risk, 0.79; 95% CI, 0.63 to 1.00; P=0.045) and an increased rate of necrotizing enterocolitis (10.4% vs. 8.0%; relative risk, 1.31; 95% CI, 1.02 to 1.68; P=0.04). There were no significant between-group differences in rates of other outcomes or adverse events.nnnCONCLUSIONSnTargeting an oxygen saturation below 90% with the use of current oximeters in extremely preterm infants was associated with an increased risk of death. (Funded by the Australian National Health and Medical Research Council and others; BOOST II Current Controlled Trials number, ISRCTN00842661, and Australian New Zealand Clinical Trials Registry numbers, ACTRN12605000055606 and ACTRN12605000253606.).

Continuous glucose monitoring in newborn babies at risk of hypoglycemia

OBJECTIVEnTo determine the usefulness of continuous glucose monitoring in babies at risk of neonatal hypoglycemia.nnnSTUDY DESIGNnBabies >/=32 weeks old who were at risk of hypoglycemia and admitted to newborn intensive care received routine treatment, including intermittent blood glucose measurement using the glucose oxidase method, and blinded continuous interstitial glucose monitoring.nnnRESULTSnContinuous glucose monitoring was well tolerated in 102 infants. There was good agreement between blood and interstitial glucose concentrations (mean difference, 0.0 mmol/L; 95% CI, -1.1-1.1). Low glucose concentrations (<2.6 mmol/L) were detected in 32 babies (32%) with blood sampling and in 45 babies (44%) with continuous monitoring. There were 265 episodes of low interstitial glucose concentrations, 215 (81%) of which were not detected with blood glucose measurement. One hundred seven episodes in 34 babies lasted >30 minutes, 78 (73%) of which were not detected with blood glucose measurement.nnnCONCLUSIONnContinuous interstitial glucose monitoring detects many more episodes of low glucose concentrations than blood glucose measurement. The physiological significance of these previously undetected episodes is unknown.

Does Head Cooling With Mild Systemic Hypothermia Affect Requirement for Blood Pressure Support

OBJECTIVE. Our goal was to evaluate whether head cooling with mild systemic hypothermia for neonatal encephalopathy is associated with greater requirement for volume or inotrope support. PATIENTS AND METHODS. We studied term infants (≥36 weeks) with moderate-to-severe neonatal encephalopathy plus abnormal amplitude integrated electroencephalography, randomly assigned to head cooling for 72 hours starting within 6 hours of birth, with the rectal temperature maintained at 34.5°C ± 0.5°C (n = 112), or conventional care (n = 118). DESIGN. This was a multicenter randomized, controlled study (the CoolCap trial). The primary outcome was the time relationship between mean arterial blood pressure and subsequent administration of inotropes or volume administration. RESULTS. Pooled data from 0 to 76 hours after randomization revealed no difference in mean arterial blood pressure between groups and significantly lower mean heart rate during cooling. The use of inotropes or volume was related to preceding mean arterial blood pressure and not to treatment group in the first 24 hours. In contrast, from 24 to 76 hours, there was no effect of mean arterial blood pressure, but there was an overall reduction in pressure support over time and significantly more frequent pressure support in the cooled group than in controls. CONCLUSIONS. Mild systemic hypothermia did not affect arterial blood pressure or initial treatment with inotropes or volume in infants with moderate-to-severe encephalopathy but was associated with an apparent change in physician behavior, with slower withdrawal of therapy in cooled infants.

Escherichia coli: a growing problem in early onset neonatal sepsis

Aims: To review the demographic characteristics, antecedents and outcome for early neonatal Escherichia coli sepsis. Secondary aims were to identify antenatal antibiotic use and to review the antimicrobial susceptibility.

Admissions to neonatal intensive care unit following pregnancies complicated by gestational or type 2 diabetes

Background:u2002 When gestational diabetes mellitus (GDM) is diagnosed in a population with a high prevalence of unrecognised type 2 diabetes mellitus (type 2 DM), the rate of neonatal morbidity is not clear. There is also a paucity of data reporting neonatal outcome in women with recognised type 2 DM.

A survey of the management of neonatal hypoglycaemia within the Australian and New Zealand Neonatal Network.

Background:u2003 Neonatal hypoglycaemia is a common problem linked to both brain damage and death. There is controversy regarding both the definition of and best treatment for neonatal hypoglycaemia.

Antenatal antecedents of moderate or severe neonatal encephalopathy in term infants – a regional review

Background: Regional audits of term infants with neonatal encephalopathy (NE) provide an opportunity to examine issues related to causation and quality of care.

Chest radiographs after removal of chest drains in neonates - clinical benefit or common practice?

Background: Chest drain insertion is a common procedure in neonatal care. Routine radiography after removal of chest drains increases radiation exposure, handling and cost, but there are few data proving clinical benefit. Objectives: To review current practice and determine the yield of routinely obtained chest radiographs (CXR). Methods: A retrospective chart review of all infants undergoing removal of chest tubes in a single tertiary neonatal unit in New Zealand between January 1998 and July 2004 was performed. Results: In total, 119 infants were identified, from the database, to have a chest drainage performed. In 19 cases, the procedure was needle aspiration or the drain was removed outside of our unit, hence these were excluded. The remaining 100 patients with 110 episodes of chest drain removal after 174 chest tube insertions were analysed. In asymptomatic infants, routine radiography showed some reaccumulation of air in nine of 35 cases of pneumothorax or of fluid in two of the five cases of pleural effusion, but chest tube reinsertion was not required. In the 12 clinically symptomatic infants, chest tubes were reinserted in five cases (four reaccumulations of pneumothorax and one pleural effusion), and one infant had symptomatic right upper lobe collapse. In the remaining infants, there were no abnormalities on CXR accounting for deterioration. Conclusions: Given the low yield for routine radiography after chest drain removal, we suggest that close observation is likely to detect clinically relevant recurrence of pneumothorax.

Twin–twin transfusion syndrome, coarctation of the aorta and hypoplastic aortic arch: A case series report

Aim:u2003 The twin–twin transfusion syndrome (TTTS) complicates 10–30% of monochorionic pregnancies. The incidence of pulmonary stenosis and endocardial fibroelastosis is especially high in the recipient twin. We report a novel finding of four cases of coarctation of the aorta and hypoplastic aortic arch in the donor to raise awareness of cardiac lesions in twins affected by TTTS.

Sclerema Neonatorum Following Hypothermia

McMaster et al . described an infant who developed hepatitis as a complication of Rotavirus gastroenteritis. 1 I believe that the labelling of this case as one of Reye syndrome is inappropriate and unsubstantiated. Reye syndrome is believed to be a mitochondrial hepatopathy where predisposed individuals, thought to have some underlying undiagnosed metabolic defect, are exposed to the combination of aspirin and viral infection. 2 The three criteria used by the Centers of Disease Control to make the diagnosis include (i) the presence of an acute non-inflammatory encephalopathy; (ii) significant hepatopathy; and (iii) no other reasonable alternative explanation. 3