The latest issue of Seminars in Perinatology has just appeared on line. This is second part of the report of the NICHD, SMFM, ACOG, AAP joint workshop where Annie and I presented. I think these articles are all free access:
The first of my publications is based on my presentation at the workshop, which was all focused on periviable births. It was an attempt to provide an evidence based review of therapies initiated during the 1st 72 hours of life that have been shown to improve outcomes. This was obviously a difficult task, as far as trying to find things that are proven to improve outcomes of infants born before 25 weeks gestation, for example. So I had to give myself some leeway and review issues that have been investigated in the very immature infant. Even there it was rather difficult, even such issues as how much fluids to give are not well studied, but I did my best and tried to be as systematic as possible.
The conclusions are basically :
1. the exact volume of fluids given are unimportant within reasonable ranges, but the quantity of sodium given is important. Sodium restriction improves survival without chronic lung disease. The situation is complicated because there are some trials, such as the trial of Tammela, which were presented as a comparison of different fluid intakes, but the concentration per litre of sodium was constant in Tammela’s study, so it was simultaneously a trial of different sodium intakes.
2. Attempting to not intubate in the delivery room, and institute CPAP is preferable in terms of survival without BPD, when the intubation group has a standard weaning protocol. When CPAP is compared to INSURE, it is not clear that there is a big advantage of CPAP.
3. Prophylactic indomethacin reduces the incidence of severe IVH, and has other benefits (such as less severe pulmonary hemorrhage and reduced PDA ligation). Even though it is not clear if there is overall benefit in long term neurological or developmental outcome, there is no adverse impact on this outcome, so it should be considered especially in those infants at highest risk of severe hemorrhage.
4. Protocolized care is worth further investigation, as in most areas in medicine, protocolization improves outcomes.
For each of the questions I tried to answer as well as a systematic review of the literature, I presented what I think are the most important research questions.
Also in the issue are papers by Jon Tyson, Myra Wyckoff, Theophil Stokes, Richard Ehrenkrantz, Sadath Sayeed, and by Aaron Caughey, the last was a presentation on cost-effectiveness, which I was surprised to find an absolutely fascinating presentation, I hope that comes over in the article.
All in all I think this issue could be a very useful resource.