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The purpose of this study is to evaluate the association of Electrical Cardiometry (EC)-derived cardiac output indexed to weight (CO) and its changes during the first 48 h in relation to adverse short-term outcome in very preterm infants. In this prospective observational study of preterm infants < 32 weeks gestational age (GA), the combined adverse outcome was defined as mortality or abnormal cranial ultrasound (any grade intracranial hemorrhage (ICH) or periventricular leukomalacia) within the first 2 weeks postnatally. Logistic regression models were used to investigate the association between median CO and outcome and mixed-effects models for the time trajectory of CO. In the absence of device-specific thresholds for low or high CO, no thresholds were used in our analysis. Fifty-three infants (median (IQR) GA 29.0 (25.4–30.6) weeks, birthweight 1020 (745–1505) g) were included in the analysis. Median CO was 241 (197–275) mL/kg/min for the adverse outcome and 198 (175–227) mL/kg/min for normal outcome (odds ratio (OR) (95% confidence interval (95% CI)), 1.01 (1.00 to 1.03); p = 0.028). After adjustment for GA, the difference was not significant (adjusted OR (95% CI), 1.01 (0.99 to 1.02); p = 0.373). CO trajectory did not differ by outcome (p = 0.352). A post hoc analysis revealed an association between CO time trajectory and ICH ≥ grade 2. Conclusions: EC-derived CO estimates within 48 h postnatally were not independently associated with brain injury (any grade) or mortality in the first 14 days of life. CO time trajectory was found to be associated with ICH ≥ grade 2. What is Known: • Bioreactance-derived cardiac output indexed to bodyweight (CO) in the transitional period has been associated with adverse short-term outcome in preterm infants. What is New: • Electrical Cardiometry (EC)-derived CO measurements in very preterm infants during the transitional period are not independently associated with adverse outcome (death or ultrasound detected brain damage) within 2 weeks postnatally. • In the first 48 h EC-derived CO increases over time and is higher in extremely preterm infants compared to very preterm and differs from previously reported bioreactance-derived CO values. [ABSTRACT FROM AUTHOR]

Prematurity is the leading cause of neonatal morbidity and mortality worldwide. Premature infants often require extended hospital stays, with increased risk of developing infection compared with term infants. A picture is emerging of wide-ranging deleterious consequences resulting from innate immune system activation in the newborn infant. Those who survive infection have been exposed to a stimulus that can impose long-lasting alterations into later life. In this review, we discuss sepsis-driven alterations in integrated neuroendocrine and metabolic pathways and highlight current knowledge gaps in respect of neonatal sepsis. We review established biomarkers for sepsis and extend the discussion to examine emerging findings from human and animal models of neonatal sepsis that propose novel biomarkers for early identification of sepsis. Future research in this area is required to establish a greater understanding of the distinct neonatal signature of early and late-stage infection, to improve diagnosis, curtail inappropriate antibiotic use, and promote precision medicine through a biomarker-guided empirical and adjunctive treatment approach for neonatal sepsis. There is an unmet clinical need to decrease sepsis-induced morbidity in neonates, to limit and prevent adverse consequences in later life and decrease mortality. [ABSTRACT FROM AUTHOR]

Objective. Adaptation to the extra-uterine environment presents many challenges for infants born less than 28 weeks of gestation. Quantitative analysis of readily available physiological signals at the cotside could provide valuable information during this critical time. We aim to assess the time-varying coupling between heart rate (HR) and perfusion index (PI) over the first 24 h after birth and relate this coupling to gestational age (GA), inotropic therapy, and short-term clinical outcome. Approach. We develop new nonstationary measures of coupling to summarise both frequency- and direction-dependent coupling. These measures employ a coherence measure capable of measuring time-varying Granger casuality using a short-time information partial-directed coherence function. Measures are correlated with GA, inotropic therapy (yes/no), and outcome (adverse/normal). Main results. In a cohort of 99 extremely preterm infants (<28 weeks of gestation), we find weak but significant coupling in both the HR → PI and PI → HR directions (P < 0.05). HR → PI coupling increases with maturation (correlation r = 0.26; P = 0.011). PI → HR coupling increases with inotrope administration (r = 0.27; P = 0.007). And nonstationary features of PI → HR coupling are associated with adverse outcome (r = 0.27; P = 0.009). Significance. Nonstationary features are necessary to distinguish different coupling types for complex biomedical systems. Time-varying directional coupling between PI and HR provides objective and independent biomarkers of adverse outcome in extremely preterm infants. [ABSTRACT FROM AUTHOR]

Objective:Recent evidence suggests that high cortisol concentrations are associated with increased morbidity and mortality in very low birth weight (VLBW) infants. Neonatal illness severity and mortality risk scores are reliable in predicting morbidity and mortality. The objectives were (i) to assess the correlation between serum cortisol levels and clinical assessment of multi-organ dysfunction/illness severity scores (CRIB II, SNAPPE-II and neonatal multiple organ dysfunction score (NEOMOD)) in first 24 h in VLBW infants and (ii) to assess the relationship between surrogates of end organ blood flow and serum cortisol levels.Study Design:A prospective observational cohort study. Neonates with birth weight <1500 g were eligible for enrollment. Echocardiography evaluation of superior vena cava (SVC) flow was carried out in the first 24 h life. Cortisol levels were measured simultaneously and appropriate clinical scores were calculated.Result:A total of 54 VLBW neonates were enrolled following parental consent. Two patients were excluded because of congenital malformations. In 14 babies the cortisol value was not simultaneously obtained. The mean birth weight was 1.08 kg, mean gestational age was 27.8 weeks. There was a significant correlation between cortisol and NEOMOD score (P=0.006). There was no correlation between cortisol and CRIB II score (P=0.34), SVC flow (P=0.49) and mean arterial blood pressure respectively (P=0.35).Conclusion:There was no correlation between SVC flow and cortisol values or between cortisol and mean blood pressure values. There was a significant correlation between cortisol levels and neonatal organ dysfunction score evaluated suggesting that stressed VLBW infants do mount a cortisol response. [ABSTRACT FROM AUTHOR]

Objective To assess the efficacy of oral sucrose combined with swaddling and non-nutritive suck (NNS) as a method for reducing pain associated with retinopathy of prematurity (ROP) screening. Design Randomised placebo controlled study. Setting Tertiary level neonatal intensive care unit. Sample 40 infants undergoing primary eye examination for ROP screening. Intervention The control group were swaddled, and received 0.2 ml of sterile water given by mouth using a syringe and a soother. The intervention group were swaddled, and received 0.2 ml of sucrose 24% given by mouth using a syringe and a soother. Results 40 infants were included in the study. There was no difference in mean gestational age at birth, mean birth weight or corrected gestational age at first examination between both groups. The sucrose group had a significantly lower median Neonatal Pain, Agitation and Sedation Scale (N-PASS) score during ROP screening, initially following insertion of the speculum (6.5 vs 5, p=0.02) and subsequently during scleral indentation (9.5 vs 7.5, p=0.03). Fewer infants experienced episodes of desaturations or bradycardia in the intervention group (1 vs 4, p=0.18). Conclusion ROP screening is a necessary but recognised painful procedure. Sucrose combined with NNS and swaddling reduced the behavioural and physiological pain responses. However, pain scores remained consistently high and appropriate pain relief for ROP screening remains a challenge. [ABSTRACT FROM AUTHOR]

Background: Advances in neonatal care continue to lower the limit of viability. Decision making in this grey zone remains a challenging process. Objective: To explore the opinions of healthcare providers on resuscitation and outcome in the less than 28-week preterm newborn. Design/Methods: An anonymous postal questionnaire was sent to health care providers working in maternity units in the Republic of Ireland. Questions related to neonatal management of the extreme preterm infant, and estimated survival and long-term outcome. Results: The response rate was 55% (74% obstetricians and 70% neonatologists). Less than 1% would advocate resuscitation at 22 weeks, 10% of health care providers advocate resuscitation at 23 weeks gestation, 80% of all health care providers would resuscitate at 24 weeks gestation. 20% of all health care providers would advocate cessation of resuscitation efforts on 22–25 weeks gestation at 5 min of age. 65% of Neonatologists and 54% trainees in Paediatrics would cease resuscitation at 10 min of age. Obstetricians were more pessimistic about survival and long term outcome in newborns delivered between 23 and 27 weeks when compared with neonatologists. This difference was also observed in trainees in paediatrics and obstetrics. Conclusion: Neonatologists, trainees in paediatrics and neonatal nurses are generally more optimistic about outcome than their counterparts in obstetrical care and this is reflected in a greater willingness to provide resuscitation efforts at the limits of viability. [ABSTRACT FROM AUTHOR]

Background: Superior vena cava (SVC) flow assesses blood flow from the upper body, and may provide a reliable assessment of systemic blood flow. Aim: (i) To assess the relationship between SVC flow in first 24 h and adverse outcome in very low birthweight (VLBW) infants (ii) To assess correlation between SVC flow and left and right ventricular outputs and anterior cerebral artery (ACA) velocity measurements. Methods: A prospective, observational cohort study. Neonates with birthweight <1500 g were eligible and those with congenital heart disease (excluding patent ductus arteriosus) or major congenital malformations were excluded. Echocardiographic evaluation of SVC flow, right and left ventricular outputs and ductal patency was done in the first 24 h of life. Capillary refill time, blood pressure and urine output were also measured simultaneously. The primary outcome was intraventricular haemorrhage (IVH) grade ⩾ II and/or early neonatal death (<7 days). Results: 40 VLBW neonates were enrolled following parental consent. Two were excluded. 8 babies (21%) had low flow states. There was no difference between the cohorts in median birth weight (1.14 kg vs 1.17 kg; p = 0.76), gestational age (26.5 vs 28.0 weeks, respectively; p = 0.12) or hours of life at examination (18.5 h vs 21 h, respectively; p = 0.36). The incidence of primary outcome (lVH ⩾ grade II and/or early neonatal death) was 50% and 6.7%, respectively (p = 0.01). There was no correlation between SVC flow and right ventricular outputs and ACA velocity and blood pressure measurements. Conclusions: 21% of our VLBW infants had low SVC flow in the first 24 h, and this was associated with early neonatal death and/or severe IVH. [ABSTRACT FROM AUTHOR]

Methods:We performed systematic reviews of the literature in order to determine which preterm infants may benefit from treatment with interventions to elevate blood pressure (BP), and which interventions improve clinically important outcomes.Results:Our review was not able to define a threshold BP that was significantly predictive of a poor outcome, nor whether any interventions for hypotensive infants improved outcomes, nor which interventions were more likely to be beneficial.Conclusions:There is a distinct lack of prospective research of this issue, which prevents good clinical care. It is possible that a simple BP threshold that indicates the need for therapy does not exist, and other factors, such as the clinical status or systemic blood flow measurements, may be much more informative. Such a paradigm shift will also require careful prospective study.A very large proportion of extremely preterm infants receive treatments for hypotension. There are, however, marked variations in indications for treatment, and in the interventions used, between neonatal intensive care units and between neonatologists.Journal of Perinatology (2007) 27, 469–478; doi:10.1038/sj.jp.7211774 [ABSTRACT FROM AUTHOR]

BACKGROUND The use of cerebral oximetry monitoring in the care of extremely preterm infants is increasing. However, evidence that its use improves clinical outcomes is lacking. METHODS In this randomized, phase 3 trial conducted at 70 sites in 17 countries, we as-signed extremely preterm infants (gestational age, <28 weeks), within 6 hours after birth, to receive treatment guided by cerebral oximetry monitoring for the first 72 hours after birth or to receive usual care. The primary outcome was a composite of death or severe brain injury on cerebral ultrasonography at 36 weeks' postmenstrual age. Serious adverse events that were assessed were death, severe brain injury, bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and late-onset sepsis. RESULTS A total of 1601 infants underwent randomization and 1579 (98.6%) were evaluated for the primary outcome. At 36 weeks' postmenstrual age, death or severe brain injury had occurred in 272 of 772 infants (35.2%) in the cerebral oximetry group, as compared with 274 of 807 infants (34.0%) in the usual-care group (relative risk with cerebral oximetry, 1.03; 95% confidence interval, 0.90 to 1.18; P=0.64). The incidence of serious adverse events did not differ between the two groups. CONCLUSIONS In extremely preterm infants, treatment guided by cerebral oximetry monitoring for the first 72 hours after birth was not associated with a lower incidence of death or severe brain injury at 36 weeks' postmenstrual age than usual care. (Funded by the Elsass Foundation and others; SafeBoosC-III ClinicalTrials.gov number, NCT03770741.) [ABSTRACT FROM AUTHOR]