Mohammad A. Attar

Barriers to screening infants for retinopathy of prematurity after discharge or transfer from a neonatal intensive care unit.

OBJECTIVE:To assess neonatal intensive care unit (NICU) practices affecting screening and follow-up for retinopathy of prematurity (ROP).METHODS:Retrospective study of infants at risk for ROP, eligible for back transport, admitted to a regional NICU from January 1, 1999 until May 31, 2002. Patients failed to receive needed follow-up for ROP after discharge or transfer from a NICU, if we could not verify their ROP screening follow-up within 1 month.RESULTS:A total of 74 infants were identified to need follow-up eye care. Infants who did not receive the follow-up care had greater mean gestational age (mean SD; 30.7±2.3 vs 29.6±2.5 weeks, p=0.05) and birth weights (mean SD; 1581±366 vs 1360±508 g, p=0.007), compared to infants who received the recommended care. Infants transported back to the community hospital were significantly more likely to miss follow-up eye care compared to infants discharged from the regional center (relative risk 2.81, 95% confidence interval (CI) (1.09 to 7.20)). Infants not screened for ROP in the NICU had greater risk for missing follow-up care compared to infants who had their first retinal examination in the NICU (relative risk 4.25, 95% CI (1.42 to 12.73)).CONCLUSIONS:Infants transferred back or discharged from the NICU before ROP screening represent a high-risk group for not receiving follow-up eye care.

Pregnant mothers out of the perinatal regionalization's reach

Introduction:Birth of very low birth weight (VLBW) infants outside subspecialty perinatal centers increases risk for death and major morbidities.Objective:The purpose of this study is to evaluate barriers to utilizing a regional perinatal center for the birth of VLBW infants to mothers not living in the immediate vicinity of the center.Methods:We conducted a retrospective cohort study of VLBW infants residing in the catchment area of a community level II, Specialty Neonatal Unit (SN) admitted to a Regional Subspecialty Neonatal Intensive Care Unit (RC) between January 1999 and December 31, 2004. Maternal demographics and prenatal care as well as outcomes were compared by place of birth.Results:Out of 98 VLBW infants admitted to the RC, 49 (50%) were delivered outside the RC (out-born) and 49 (50%) were born at the RC (in-born). There was no statistical difference in insurance coverage, race, gestational age, severity of illness or maternal demographic factors between out-born and in-born infants. Less than adequate prenatal care rather than distance of maternal residence from the RC was associated with birth outside the RC. Adjusting for prenatal care, distance of residence from the RC increased the risk for delivering outside the center in the subset of mothers insured by Medicaid.Conclusions:Mothers of VLBW infants who received less than adequate prenatal care and did not live in the vicinity of a subspecialty center had an increased risk for delivery outside that center compared to those with adequate care. Appropriate place of birth for VLBW infants to low-income mothers may be influenced by the distance of their residence to an RC.

Back Transport of Neonates: Effect on Hospital Length of Stay

INTRODUCTION:In a regionalized perinatal system, recovering neonates may be back transported from a regional Neonatal Intensive Care Unit (NICU) to community hospitals closer to their residence to convalesce prior to hospital discharge.OBJECTIVE:This study evaluates the practice of neonatal back transport for growth and the duration of total hospitalization.METHODS:We conducted a retrospective study comparing length of stay (LOS) for infants back transported from a regional NICU to a level II nursery for convalescent care (BT), with LOS for infants eligible for back transport discharged home from the Regional Center (RC).RESULTS:A total of 221 infants were studied. BT infants (n=104) had lower birth weights (median; 1955 vs 2700 g, p=0.001), more frequently needed mechanical ventilation (84 vs 65%, p=0.002) and parenteral nutrition (71 vs 55%, p=0.013), less frequently were evaluated by subspecialists (20 vs 59% p=0.0001), and had longer total LOS (median; 20 vs 11 days, p<0.0001) compared to infants discharged home from the RC (n=117). However, in the subgroup with birth weights ≤1500 g (very low birth weight (VLBW)), BT (n=25) infants had similar birth weight (median; 1160 vs 1215 g, p=0.9) compared to those discharged home from the RC (n=24) and did not have a statistically different total LOS (median; 50 vs 56 days, p=0.1). Almost all infants who had major surgeries, treatment for retinopathy of prematurity, seizures, or had severe intra-ventricular hemorrhages were discharged home from the RC. The rates of hospital readmissions or emergency room visits acutely after their discharge to home from the RC or the community hospital were similar.CONCLUSIONS:BT Infants differed based on clinical features compared to premature infants discharged from the RC. VLBW infants, back transported for growth, had similar total LOS compared to similar weight infants discharged home from the RC.

Immediate Changes in Lung Compliance Following Natural Surfactant Administration in Premature Infants with Respiratory Distress Syndrome: a Controlled Trial

OBJECTIVE: To compare immediate changes in lung compliance following the administration of two commercially available natural surfactants.METHOD: We conducted a prospective, randomized study of 40 preterm infants with respiratory distress syndrome requiring surfactant. Infants received either Infasurf® or Survanta®. The primary outcome measure was the change in compliance assessed by bedside pulmonary monitoring.RESULTS: There were no significant changes in dynamic lung compliance within or between the two groups 1 hour after surfactant administration. However, infants given Survanta required more doses per patient (4 vs 2, p=0.05) and were more likely to require >2 doses (57 vs 26%, p=0.05). Infants requiring >1 dose of surfactant had a greater change in airway pressure and improved oxygenation just before the second dose when treated with Infasurf.CONCLUSIONS: We found no significant difference in acute changes in lung compliance. However, treatment with Infasurf seems to be more long lasting than Survanta.

The effect of late preterm birth on mortality of infants with major congenital heart defects

Objective:We evaluated the effect of late preterm delivery (34 to 36 weeks) on hospital mortality of infants with congenital heart defects (CHDs).Study Design:Retrospective record review of infants with major CHD born at or after to 34 weeks, cared for in a single tertiary perinatal center between 2002 and 2009. Factors associated with death before discharge from the hospital were ascertained using univariate and multivariate analyses.Result:Of the 753 infants with CHD, 117 were born at late preterm. Using logistic regression analysis, white race (OR; 95% CI) (0.60; 0.39 to 0.95), late preterm delivery (2.70; 1.69 to 4.33), and need for intubation in the delivery room (3.15; 1.92 to 5.17) were independently associated with hospital death.Conclusion:Late preterm birth of infants with major CHDs was independently associated with increased risk of hospital death compared with delivery at more mature gestational ages.

INDUCTION OF ICAM-1 EXPRESSION ON ALVEOLAR EPITHELIAL CELLS DURING LUNG DEVELOPMENT IN RATS AND HUMANS

Intercellular adhesion molecule-1 (ICAM-1) is an adhesion protein involved in immune and inflammatory cell recruitment and activation. In normal, uninflamed adult rat lung, ICAM-1 is expressed at high levels on type I alveolar epithelial cells and is minimally expressed on type II cells. ICAM-1 expression by alveolar epithelial cells in vitro is a function of the state of cellular differentiation, and is regulated by factors influencing cell shape. Based upon this observation, we hypothesized that ICAM-1 expression by fetal lung epithelial cells is developmentally regulated. To investigate this hypothesis, rat and human lung tissues were obtained at time points that represent the canalicular, saccular, and alveolar stages of development. The relative expression of ICAM-1 protein and mRNA were determined in rat lungs from gestational days 18 and 21 (term = 22 days), from day 8 neonatal rats, and from adult rats. ICAM-1 protein was detectable at low level on day 18 and increased progressively during development. Relative expression of ICAM-1 protein was maximal in adult lung. Expression of ICAM-1 mRNA paralleled that of ICAM-1 protein. By immunohistochemical methods in rat and human lung, ICAM-1 was expressed at low level on cuboidal and flattening epithelial cells in the developing alveolar space at the canalicular and saccular stages; however, ICAM-1 expression was increased as epithelial cells spread and flattened during alveolarization. ICAM-1 was predominantly expressed on type I cells rather than type II cells at the alveolar stage in both the rat and human lungs. Thus, relative ICAM-1 expression progressively increased during lung development. ICAM-1 expression is correlated with the increase in surface area as alveolar structures develop and type I cell differentiation takes place. These data indicate that alveolar epithelial cell ICAM-1 expression is developmentally regulated.

Evidence-based management of chylothorax in infants

PURPOSE Management guidelines for infants with chylothorax lack substantial evidence. We sought to identify variables that impact outcomes in these patients in order to develop an evidence-based management algorithm. METHODS We retrospectively reviewed the medical records of all infants diagnosed with chylothorax from June 2005 to December 2014 at our institution. Data collected included demographics, chest tube output (CTO), medical and dietary interventions, surgical procedures, and absolute lymphocyte count (ALC). Outcomes analyzed included death, sepsis, necrotizing enterocolitis (NEC), requiring surgery, and success of therapy, defined as CTO decrease by >50% within 7days. RESULTS Of 178 neonates with chylothorax, initial therapy was high medium chain triglyceride (MCT) feedings in 106 patients, nothing by mouth (NPO), total parenteral nutrition (TPN) in 21, and NPO/TPN plus octreotide in 45. Octreotide use in addition to NPO/TPN revealed no significant differences in any outcome including success (47% vs. 43%, p=0.77). Initial CTO and ALC correlated with needing surgery (p=0.002 and p=0.006, respectively), and with death (p=0.028 and p=0.043, respectively). ALC also correlated with sepsis (p<0.001). CONCLUSIONS Octreotide has no advantage over NPO/TPN alone in infants with chylothorax. CTO and ALC predict requiring surgery. We propose a management guideline based on CTO and ALC without a role for octreotide. TYPE OF STUDY Retrospective case-control study. LEVEL OF EVIDENCE 3.

Late intraventricular hemorrhage in preterm infants

Objective: To determine the likelihood of intraventricular hemorrhage (IVH) occurring after the first three days of life and to develop a predictive model for late IVH in preterm infants. Methods: A retrospective study was conducted on very low birth weight infants with grades IVH II-IV. IVH was considered early if detected by ultrasound within the first three days of life and it was considered late if detected beyond this time. Infants with late IVH had at least one documented negative ultrasound scan on or after day of life three. Data were evaluated for associated risk factors using univariate and logistic regression analyses. Results: One-hundred thirty infants with IVH grades II-IV met the inclusion criteria. Early IVH occurred in 82 (63%) and late IVH occurred in 48 (37%). Infants with late IVH were more commonly exposed to prenatal steroids (OR 4.2, 95% CI 1.5–12.0), cesarean delivery (OR 2.8, 95% CI 1.1–7.0), or had symptomatic PDA requiring medical or surgical therapy prior to IVH detection (OR 12.0, 95% CI 3.8–37.7) compared to infants with early IVH. Conclusions: IVH after day of life three is not rare in VLBW infants. Further exploration of risk factors associated with late IVH compared to infants without IVH through interventional trials is warranted.

The use of high frequency jet ventilation to treat suspected pulmonary hypoplasia

We report two cases of term male infants with suspected pulmonary hypoplasia, who could not be managed successfully with conventional mechanical ventilation. Both responded to rescue support with high frequency jet ventilation (HFJV) using an optimal positive end expiratory pressure strategy. One infant had the oligohydramnios sequence secondary to posterior urethral valves. The second infant was diagnosed prenatally with a severe right-sided congenital diaphragmatic hernia. We summarize the literature on the use of HFJV to support infants with severe pulmonary dysfunction. Unique air flow dynamics of HFJV may enable better gas exchange with less barotrauma, less volutrauma and ventilation at lower mean airway pressure. Our experience and the available literature suggest that HFJV appears to offer a unique advantage over conventional ventilation in such infants.

Do prenatal steroids improve the survival of late preterm infants with complex congenital heart defects

AIM We evaluated the use of prenatal steroids (PNS) and the effect of that practice on hospital mortality of late preterm infants with complex congenital heart defects (CHD). METHODS Retrospective review of records of late preterm infants with complex CHD infants that were cared for in a single tertiary perinatal center between 2002 and 2009. Multivariate logistic regression analysis was performed to determine which of the risk factors commonly associated with death prior to discharge from the hospital predict the outcome (hospital death). RESULTS Of the 106 late preterm infants with complex CHD, 31(29%) died and 15 (14%) received PNS. Endotracheal intubation in the delivery room (42% vs 15%), necrotizing enterocolitis (10% vs 0%) and hypoplastic left heart syndrome (52% vs 25%) were statistically more frequent in non-surviving infants. Non-surviving infants were more frequently treated with PNS (23% vs 11%) but this difference was not statistically significant (p = 0.131). Using logistic regression analysis, delivery room intubation (OR 4.91; 95% CI 1.78 - 13.51) and the hypoplastic left heart syndrome (OR 3.29; 95% CI 1.28 - 8.48), but not prenatal steroids were independently associated with increased risk of hospital death. CONCLUSIONS In a selected population of late preterm infants with complex CHD, prenatal steroid treatment did not independently influence survival.