Neonatal Updates

Hallenberger A, Poets CF, Horn W, Seyfang A, Urschitz MS: Closed-loop automatic oxygen control (clac) in preterm infants: A randomized controlled trial. Pediatrics 2014. This is a report of a small multicenter study of the use of a system built into a specific ventilator to control oxygen administration based on pulse oximeter signals. The authors were from 4 NICUs, which all interestingly had different saturation target ranges, the lower limits were 80, 83, 84 and 90% saturation (which is interesting in view of the criticisms of the oxygen targeting trials!) in a crossover design they examined how much time the infants were in there target range when using the closed-loop system compared to standard practice, 24 hours in each mode. The infants spent more time in the desired range with the system than without, and, unlike the other published trial using a different system, and different target ranges, this study showed less time below the target range with the system. The bedside nurses had to do fewer manual adjustments of the FiO2 as a result, which is a valuable goal in itself.

Joy R, Krishnamurthy S, Bethou A, Rajappa M, Ananthanarayanan PH, Bhat BV: Early versus late enteral prophylactic iron supplementation in preterm very low birth weight infants: A randomised controlled trial. Archives of disease in childhood Fetal and neonatal edition 2013. 104 VLBW babies were randomized to receive their iron starting at 2 weeks, or starting at 6 weeks. By 12 weeks of age the Hemoglobin was 1 gram/dl higher, ferritin was much higher, and there were no adverse effects seen, specifically no increase in NEC or sepsis, retinopathy or PVL, although clearly there is very little power for these outcomes. This is a well done trial, addressing an important clinical issue, although too small to be certain about safety. One criticism of this trial is that there is no evidence that the authors performed a systematic review prior to starting the trial, and they do not really address what this trial adds the totality of the evidence for the very low birth weight infant regarding early versus late supplementation. I am agreement with Iain Chalmers, who has written about this extensively (Clarke M, Hopewell S, Chalmers I: Clinical trials should begin and end with systematic reviews of relevant evidence: 12 years and waiting. The Lancet 2010, 376(9734):20-21.)  It should be an absolute requirement prior to starting a trial to find the totality of the evidence that exists, and when reporting to update the systematic review with the new evidence. Maybe there is only one previous relevant trial, and that could be stated, in this particular example, there are at least 3. Adding together all of the safety data could be really worthwhile, and would have made this report more helpful for practice.

Binenbaum G: Algorithms for the prediction of retinopathy of prematurity based on postnatal weight gain. Clinics in Perinatology 2013, 40(2):261-270. The latest issue of Clinics in Perinatology is all about Retinopathy, with some excellent reviews. This specific article is a resumé of the information about the importance of postnatal weight gain, adn about some models that have been constructed to predict RoP and determine which babies should be screened. The overall conclusion is that they look promising but we don’t yet have enough data to not screen babies who have low risk scores. The other conclusion should be that early postnatal nutrition is hyper-important, and making efforts to optimize the quantity and the quality of that nutrition will save eyes! With the advice from many sources to avoid saturations below 90% we will likely see more retinopathy, which will make every other effort that we can make to reduce risks even more important.

About Keith Barrington

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