Weekly Updates #24

Stutchfield PR, Whitaker R, Gliddon AE, Hobson L, Kotecha S, Doull IJM: Behavioural, educational and respiratory outcomes of antenatal betamethasone for term caesarean section (ASTECS trial). Archives of Disease in Childhood – Fetal and Neonatal Edition 2013. Caesarean delivery, even at term, leads to more respiratory problems than vaginal delivery. This is particularly the case when slightly early, at 37 and 38 weeks gestation. Transient tachypnea of the newborn, hyaline membrane disease and pulmonary hypertension are all more frequent. The ASTECS trial published in 2005 showed in a multicenter RCT that respiratory morbidity was reduced by 50% when antenatal betamethasone was given for 48 hours before elective caesarean delivery at term. There were 1000 mothers in the original trial, unfortunately they were only able to collect childhood follow up data on 407 of the babies. But they found no evidence of any adverse effect of the steroids. I think the better solution is not to do elective caesareans before 39 weeks. But if for some reason you have to, then it looks like betamethasone might be worth discussing with the mother.

Ohlsson A, Jacobs SE: NIDCAP: A Systematic Review and Meta-analyses of Randomized Controlled Trials. Pediatrics 2013. There are several varieties of “developmental care” the original, NIDCAP, has been the most studied, but as noted in the discussion of this systematic review includes many untested features, and is “resource-consuming, labor intensive and expensive”. This systematic review was unable to find reliable evidence that long term neuro-developmental outcomes are improved, or short term medical outcomes. Hospital stay is shorter, by an estimated 6 days in overall. There are not a large number of babies studied, in the 2 largest trials, which were of good quality, there are a total of only about 200 infants. I think that a greater sensitivity to the preterm infants behavior and trying to disturb them less, recognizing signs of stress, are good things to do. The overall NIDCAP program though has not been shown to have clinically important benefits.

El-Khuffash AF, Jain A, McNamara PJ: Ligation of the Patent Ductus Arteriosus in Preterm Infants: Understanding the Physiology. The Journal of pediatrics 2013(0) Very well written review article about the effects of PDA ligation in the preterm infant. I do have some issues with the suggested algorithm at the end, which proposes using drugs that are not known to have any beneficial effects in the preterm infant (such as milrinone, which is stated to be a vasodilator that improves contractility, there is no evidence that it increases contractility in the preterm infant, it may well not do so). I think the hemodynamic complications that he describes are ripe for investigation. The algorithm he described could well be prospectively studied.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
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