Neonatal Updates #34

Hartling L, et al. Benefits and Harms of Treating Gestational Diabetes Mellitus: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2013 (open access). A very comprehensive review, as is usual from this source, I can’t pretend to have read it all in detail, but the conclusions are: Treating GDM reduces macrosomia (which in turn leads to less shoulder dystocia), but not neonatal hypoglycemia, there is no real evidence of harm.

Ishii N, Kono Y, Yonemoto N, Kusuda S, Fujimura M, for the Neonatal Research Network J. Outcomes of Infants Born at 22 and 23 Weeks’ Gestation. Pediatrics. 2013. 36% of the infants born alive at 22 to 22 weeks 6 days survived to 3 years of age, and 63% of those born at 23 weeks. The rates of severe CP and moderate to severe developmental delay at 3 years were high among the 22 and 23 week infants. The survival rates are very impressive, we need to find ways to reduce impairments.  They also present outcomes for more mature infants up to 25 weeks, and some summary data about in-hospital complications. The rates of BPD are incredibly low, only 30% at 23 weeks, severe intracranial hemorrhage was common at 22 and 23 weeks, over 20%, and a very high proportion had RoP requiring therapy, 30% right up to 25 weeks. This suggests some ways to reduce impairments, I don’t know if they use prophylactic indomethacin, but that intervention reduces severe hemorrhage, and PDA ligation without adverse effects, in a population with such a high risk of severe bleeds, that would be worth considering. Secondary analysis of the TIPP data showed in one high risk group (boys) that developmental outcomes were better with indomethacin treatment. Overall, it is true there was no effect on developmental delay, but the incidence of severe bleeds in the controls was much lower than this, 13%.

Corvaglia L, Aceti A, Mariani E, Legnani E, Ferlini M, Raffaeli G, et al. Lack of efficacy of a starch-thickened preterm formula on gastro-oesophageal reflux in preterm infants: a pilot study. The journal of maternal-fetal & neonatal medicine. 2012;25(12):2735-8. A cross-over study of a new formula with amylopectin. There were fewer reflux episodes, but no difference in total acid exposure of the lower esophagus, and no effect on non-acid reflux. One could ask ‘why bother?’  They start the article stating 

Gastro-oesophageal reflux (GOR) is commonly diagnosed in preterm infants in neonatal intensive care units (NICUs); it is known to cause morbidity, prolong hospital stay and is associated with some relevant complications, such as aspiration of gastric content and oesophagitis.

I beg to differ. GOR is commonly diagnosed, yes: ‘known to cause morbidity’, little or no evidence. The authors state that they enrolled infants with ‘symptomatic’ reflux; the list of symptoms they give  ‘frequent regurgitations, post-prandial desaturations, chewing, hiccupping and back arching’ are not statistically more frequent in infants with more frequent GOR on esophageal impedance/pH monitoring than in infants with less frequent reflux.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
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2 Responses to Neonatal Updates #34

  1. Ola Didrik Saugstad says:

    This is a moving as well as a disturbing story. I am scared and deeply concerned by the attitudes regarding these parents and their child. Tomorrow morning I will share this blog with all the doctors at the Paediatric Department at Oslo University Hospital, Rikshospitalet. This is important especially because this happened in Norway. Siri Fuglem Berg and her husband have a lot of sympathy in Norway where their story has been told in newspapers. Still it seems we have a job to do before all children are accepted in our society.
    Ola Didrik Saugstad
    Professor of Paediatrics
    Oslo University Hospital
    University of Oslo, Norway

    • Thank you,
      I have no idea which hospitals these events occurred in, but I must say, the experiences of this family are similar to those of many others from around the world. Many Canadian families have had similar experiences, but also many families have met supportive physicians (and other caregivers), who have listened to them, helped them and encouraged them, and found ways to improve the short (and sometimes not-so-short) lives of these little ones. Those positive experiences are also heard from families around the world. I think attitudes are changing, anything we can do to increase the appreciation of the value of all children will make our societies kinder and more humane.

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