N J Shaw

Health care utilisation of infants with chronic lung disease, related to hospitalisation for RSV infection

AIMS To compare the use of health care resources and associated costs between infants with chronic lung disease (CLD) who had or had not an admission with a proven respiratory syncytial virus (RSV) infection. METHODS Review of community care, outpatient attendances, and readmissions in the first two years after birth. Patients: 235 infants (median gestational age 27 weeks) evaluated in four groups: 45 infants with a proven RSV admission (RSV proven); 24 with a probable bronchiolitis admission; 60 with other respiratory admissions; and 106 with non-respiratory or no admissions. RESULTS The RSV proven compared to the other groups required more frequent and longer admissions to general paediatric wards and intensive care units, more outpatient attendances and GP consultations for respiratory related disorders, and had a higher total cost of care. CONCLUSION RSV hospitalisation in patients with CLD is associated with increased health service utilisation and costs in the first two years after birth. Key message Prematurely born CLD infants who are hospitalised with RSV infection have an increased health service utilisation in the first two years after birth

Open randomised controlled trial of inhaled nitric oxide and early dexamethasone in high risk preterm infants

AIM To determine whether treatment with inhaled nitric oxide (NO) and/or dexamethasone reduces the incidence of chronic lung disease (CLD) and/or death in high risk preterm infants. METHODS Infants below 32 weeks of gestation were recruited at 96 hours of age if they were deemed to be at high risk of developing CLD. Infants were randomly assigned to one of four treatment groups using a factorial design: (1) 5–20 parts per million inhaled NO for 72 hours; (2) 0.5–1 mg/kg/day intravenous dexamethasone for 6 days; (3) both drugs together; (4) continued conventional management. RESULTS Forty two infants were randomised: 10 infants received inhaled NO alone; 11 dexamethasone alone; 10 both treatments; and 11 neither treatment. There was no difference in the combined incidence of CLD and/or death before discharge from hospital between either infants treated with inhaled NO and controls (RR 1.05, 95% CI 0.84–1.25), or those treated with dexamethasone and controls (RR 0.95, 95% CI 0.79–1.18). CONCLUSIONS At 96 hours of age, neither treatment with inhaled NO nor dexamethasone prevented CLD or death.

Health care utilisation of prematurely born, preschool children related to hospitalisation for RSV infection

Background: In prematurely born infants with chronic lung disease (CLD), RSV hospitalisation is associated with increased health service utilisation and costs in the first two years after birth. Aims: To determine whether RSV hospitalisation in the first two years was associated with chronic respiratory morbidity during the preschool years in prematurely born children who had had CLD. Methods: Retrospective review of readmissions, outpatient attendances, and community care in years 2–4 and, at age 5 years, assessment of the children’s respiratory status and their health related quality of life. Comparison was made of the results of children who had had at least one hospitalisation in the first two years after birth for RSV infection (RSV group) to those of the rest of the cohort. Participants were 190 of an original cohort of 235 infants with CLD and a median gestational age 27 (range 22–33) weeks. Results: The 33 children in the RSV group, compared to the rest of the cohort, had a greater duration of hospital stay and more outpatient appointments. The RSV group had required more prescriptions for all treatments and respiratory medications, and more had used an inhaler. The cost of care of the RSV group was higher (median £2630 [€4000, US

Randomised controlled trial of oral vitamin A supplementation in preterm infants to prevent chronic lung disease

4800], range £124–18 091 versus £1360 [€2500, US

Respiratory syncytial virus infection in high risk infants and the potential impact of prophylaxis in a United Kingdom cohort

3000], range £5–18 929) and their health related quality of life was lower. Conclusion: In prematurely born children who had developed CLD, RSV hospitalisation in the first two years was associated with chronic respiratory morbidity and increased cost of care.

Home oxygen status and rehospitalisation and primary care requirements of infants with chronic lung disease

BACKGROUND Intramuscular supplementation with vitamin A in large doses may reduce the incidence of chronic lung disease. AIM To investigate whether oral supplementation with vitamin A would reduce the incidence of chronic lung disease in a group of extremely low birthweight infants. METHODS Infants with birth weight < 1000 g were randomised at birth to receive oral vitamin A supplementation (5000 IU/day) or placebo for 28 days. The primary outcome was oxygen dependency at 28 days of age or death. RESULTS A total of 154 infants were randomised; 77 received vitamin A (median birth weight (interquartile range) 806 (710–890) g), and 77 received placebo (median birth weight (interquartile range) 782 (662–880) g). Plasma vitamin A concentrations in the supplemented group were significantly higher at 24 hours of age but did not differ significantly at birth, 12 hours of age, 7 days, or 28 days of life. There were no significant differences in the proportion of infants who survived, required oxygen at 28 days, required oxygen at 36 weeks postmenstrual age, survived without chronic lung disease at 36 weeks, survived without significant retinopathy, or who survived without significant intraventricular haemorrhage. CONCLUSIONS Oral supplementation with 5000 IU vitamin A in extremely low birthweight infants does not significantly alter the incidence of chronic lung disease. However, this dose may have been inadequate to achieve optimal serum retinol concentrations.

Changes in pulmonary arterial pressure in preterm infants with chronic lung disease.

BACKGROUND Bronchiolitis caused by respiratory syncytial virus (RSV) is an important cause of morbidity in ex-premature infants. In a randomised placebo controlled trial monoclonal antibody prophylaxis showed a 55% reduction in relative risk of hospital admission for these high risk infants, against a background incidence of 10.6 admissions per 100 high risk infants. AIMS To follow a cohort of high risk infants in order to assess hospitalisation rate from RSV and the potential impact of prophylaxis for these patients in a UK local health authority. METHODS A cohort of high risk infants from a local health authority were followed over the 1998/99 and 1999/2000 RSV seasons. The high risk population was defined as infants who, at the beginning of the seasons studied, were: (1) under 6 months old and born prior to 36 weeks gestation with no domiciliary oxygen requirement; or (2) under 24 months of age and discharged home in supplemental oxygen. All admissions with bronchiolitis during the season were identified. RESULTS A total of 370 high risk infants were identified for the 1998/99 season and 286 for the following year. Over the two years there were 68 admissions. Significantly more admissions occurred from group 2 infants. RSV was identified in 27 cases (four admissions per hundred high risk infants). Prophylaxis may have saved up to £195 134 in hospital costs over the two years, but would have cost £1.1 million in drug acquisition costs. CONCLUSIONS Careful consideration of risk factors is needed when selecting infants for RSV prophylaxis.

BTS guidelines for home oxygen in children

Objectives: To determine whether the rehospitalisation and primary care requirements of infants with chronic lung disease (CLD) during the first two years after birth were influenced by a requirement for supplementary oxygen after discharge from the neonatal intensive care unit. Methods: Review of records from both the hospital and general practitioner. Patients: 235 infants, median gestational age 27 (range 22–31) weeks, 88 of whom were receiving supplementary oxygen when discharged home. Results: Overall, the infants required a median of 2 (range 0–20) admissions per patient, 8 (0–41) outpatient attendances, 13 (0–76) contacts with the general practitioner, and 17 (0–169) consultations with other primary healthcare professionals. The home oxygen patients required significantly more and longer admissions (p < 0.01) and more outpatient attendances (p < 0.05). The total cost of care per infant of the home oxygen group was greater (p < 0.001); this reflected higher costs for hospital stay (p < 0.01), total inpatient care (p < 0.01), and primary care drugs (p < 0.01). Conclusion: Despite routine use of antenatal steroids and postnatal surfactant, certain patients with CLD, particularly those who receive home oxygen treatment, show high rates of utilisation of health service resources after discharge from the neonatal care unit.

Detectable IL-8 and IL-10 in bronchoalveolar lavage fluid from preterm infants ventilated for respiratory distress syndrome.

BACKGROUND Pulmonary arterial pressure (PAP) is raised in preterm infants with respiratory distress syndrome who subsequently develop chronic lung disease. The natural history of pulmonary hypertension in infants with chronic lung disease is unknown. OBJECTIVES To investigate changes in PAP, assessed non-invasively using Doppler echocardiography, in infants with chronic lung disease during the 1st year of life. METHODS Serial examinations were performed in infants with chronic lung disease and healthy preterm infants. The Doppler derived acceleration time to right ventricular ejection time ratio (AT/RVET) was calculated from measurements made from the pulmonary artery velocity waveform. RESULTS A total of 248 examinations were performed in 54 infants with chronic lung disease and 44 healthy preterm infants. The median AT/RVET was significantly lower in infants with chronic lung disease than in healthy preterm infants (0.31 v 0.37). AT/RVET significantly correlated with age corrected for prematurity in both infants with chronic lung disease (r = 0.67) and healthy infants (r = 0.55). There was no significant difference between the rate of change in AT/RVET between the two groups. In infants with chronic lung disease, multivariate analysis showed that AT/RVET was significantly independently associated with age and inversely with duration of supplemental oxygen treatment. Median AT/RVET was significantly lower in infants with chronic lung disease until 40–52 weeks of age corrected for prematurity. CONCLUSIONS Although PAP falls with increasing age in both infants with chronic lung disease and healthy preterm infants, it remains persistently raised in infants with chronic lung disease until the end of the 1st year of life.

Randomised controlled trial of patient triggered and conventional fast rate ventilation in neonatal respiratory distress syndrome

> “… as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don’t know we don’t know.” D Rumsfeld, 2002 ### 1.1 Aims and target audience The aims of these guidelines are to present the evidence base for the practice of administering supplemental oxygen to children outside hospital and to make recommendations for best practice. For many aspects high-quality evidence is lacking, and suggestions are made based on clinical experience. It is hoped the guideline will highlight areas where research is needed to further inform clinicians. The target audience is clinicians who prescribe home oxygen for children, principally those in hospital practice. It is also intended for other professionals involved with the whole process, which may include community paediatricians, paediatric neurodisability specialists, nurse specialists, school nurses, occupational therapists and physiotherapists; this is reflected by the multidisciplinary nature of the guideline committee (section 13). ### 1.2 Methodology for generation of the guidelines The initial literature search was carried out by the Centre for Reviews and Dissemination at the University of York. Further searches were then carried out by members of the working group who concentrated on their own topics. Details of the search strategy are given in Appendix 1 available online. Each section of the guideline was researched and drafted by a subgroup of the Paediatric Section of the British Thoracic Society (BTS) Home Oxygen Guideline Development Group (itself a subcommittee of the BTS Standards of Care Committee). Publications were rated according to the SIGN 50 criteria for the calibre of the methodology of the research to give levels of evidence (see box 1). Once all parts were merged into one document, the whole group then met to discuss the first …