Reviews

Repeat doses of antenatal betamethasone and risk factors for cardio-metabolic disease at early school age

GLUCOCORTICOIDS The long-term cardiovascular and metabolic outcomes of repeated doses of antenatal glucocorticoids are not known. This randomized controlled trial studied the long-term cardiovascular and metabolic outcomes of school-aged individuals who received multiple doses of glucocorticoids during gestation. The trial revealed no significant difference in cardiometabolic disease between recipients of single-dose or multiple-dose antenatal glucocorticoids. Thus, this trial provides important evidence that multiple antenatal glucocorticoid doses may be safe.

Re-feeding gastric residuals in extremely preterm infants

ENTERAL FEEDING Establishment of enteral feeding is associated with positive outcomes in preterm infants. This randomized controlled trial studied the effectiveness of re-feeding gastric residuals to reduce the time to establish full enteral feeds in extremely preterm neonates. The trial revealed no significant difference in time to full enteral feeds using gastric residual re-feeding; however, the data suggest that re-feeding of gastric residuals may be safe.

Hypertension at late preterm gestation: deliver immediately or watch and wait?

HYPERTENSION Gestational hypertension causes significant maternal and neonatal morbidity, and few evidence-based guidelines exist for delivery in non-severe late preterm gestational hypertension. This randomized controlled trial evaluated the safety of immediate delivery or expectant management in mothers with gestational hypertension at 34-36 weeks of gestation. The investigation suggested that while there was no significant difference in maternal outcome depending on strategy, immediate delivery significantly increases the risk of neonatal respiratory distress syndrome. Thus, pending collection of additional follow-up data, expectant management can be considered an appropriate strategy for non-severe late gestation hypertension.

Longer and deeper cooling for hypoxic ischemic encephalopathy in neonates does not reduce mortality

HIE Hypoxic-Ischemic Encephalopathy is a common cause of disability or death among full term neonates who experienced perinatal asphyxia. This randomized control trial sought to determine the most effective temperature and duration of therapeutic hypothermia. The study found no reduction in mortality with either longer, deeper, or combined lengthened and deeper cooling. Though follow-up data remains to be collected, longer and deeper cooling cannot currently be recommended as therapies for HIE.

Twin birth – planned vaginal delivery still standard of care

TWINS Twin pregnancy accounts for 2-3% births and is associated with a higher risk for adverse perinatal outcome. Thus, this randomized controlled trial sought to determine whether planned cesarean section resulted in improved outcomes compared to planned vaginal delivery in twin pregnancy. The trial revealed no difference in outcomes for either mothers or infants in the planned cesarean section group. Though long-term follow-up studies are necessary, these data do not suggest that planned cesarean section is superior to vaginal delivery in twin pregnancy.

Delivering non-invasive positive pressure to prevent extubation failure in preterm infants: nasal CPAP remains the standard of care

CPAP Lowering extubation failures in very preterm infants remains an important goal. For this purpose and upon extubation, high-flow nasal cannulae (HFNC) and nasal CPAP were compared. Extubation failure occurred in 34% randomized to HFNC, and in 26% randomized to CPAP. Apnea was the most common cause of extubation failure in both groups. These data provide no compelling argument that HFNC should be considered as equivalent to nasal CPAP as the current standard of care to prevent extubation failure.

Sustained lung inflation in extreme preterm infants

SUSTAINED LUNG INFLATION Preventing CPAP failure remains an elusive goal. Providing prophylactic sustained lung inflation (SLI) in the delivery room is one potential intervention that may prevent CPAP failure, and ultimately improve both pulmonary and neurodevelopmental outcomes in the highest-risk infants. Thus, the ability of prophylactic SLI to prevent the need for mechanical ventilation in the first 3 days of life in infants born at 25-28 weeks was evaluated. This trial showed that use of SLI reduced the need for mechanical ventilation in the first 72 hours of life. However, there was a higher, non-statistically significant increased incidence in pneumothorax in the group randomized to receive SLI. These data show that prophylactic SLI can decrease rates of CPAP failure, but larger studies are necessary to demonstrate safety and the effecton long-term outcomes.

Establishing ventilation in the delivery room: T-piece resuscitator versus self-inflating bag

RESUSCITATION There are different devices for neonatal ventilation. Newborn infants ventilated with a facemask at birth were randomized to use of self-inflating bag (SIB) or T-piece. There was no difference between SIB and T-piece in establishing ventilation, as assessed by heart rate. However, T-piece was associated with lower rates of DR-intubations and BPD. The T-piece resuscitator is less injurious to the lung than the SIB. Future studies should define relations between pressures & volumes during neonatal resuscitation, and respiratory outcomes in preterm infants.

Does fluconazole prophylaxis reduce the incidence of death or invasive candida infection in extremely preterm infants?

CANDIDA Invasive candidiasis remains relatively common and is frequently deadly among extremely low birthweight infants. Thus, strategies to prevent invasive disease are needed. For this purpose, the effectiveness of prophylactic fluconazole to prevent invasive candidiasis in infants born at <750 g was evaluated. The combined outcome of death or invasive candidiasis was not different between treatment and control groups. These data provide no compelling argument that prophylactic fluconazole should be used routinely to prevent invasive candidiasis in infants weighing <750 g at birth.

A randomized blinded trial to assess whether near infrared spectroscopy measures of cerebral saturation in infants

NIRS Cerebral oxygenation after extremely preterm birth may be unstable. Extremely preterm infants (<28 wks) were randomized to NIRS for 3-72 hours after birth and an algorithm to stabilize it, or not (NIRS-data blinded). NIRS-monitoring resulted in longer periods of cerebral oxygen saturation on target (55-85%), but did not significantly reduce IVH or mortality. This report found no significant difference in clinical outcomes. Further validation and clinical demonstration must be provided before NIRS-monitors become standard of care.