Neonatal Updates

Härkin P, et al. Paracetamol Accelerates Closure of the Ductus Arteriosus after Premature Birth: A Randomized Trial. The Journal of pediatrics. 2016. Despite all the interest in paracetamol (acetaminophen in N America) for ductal closure, most of the published data so far has been observational (“we gave it to 30 babies and some of them didn’t get a ligation” for example). This is a small RCT in preterm babies of less than 32 weeks gestation who received paracetamol or placebo within 24 hours of birth. The medication caused the PDA to constrict, and the average age of closure was much earlier in the babies who got the active drug. Not powered for clinically important outcomes, nevertheless, this trial at least shows that it does really work. It also was without any detected side effects.

Martillotti G, et al. Predicting Perinatal Outcome from Prenatal Ultrasound Characteristics in Pregnancies Complicated by Gastroschisis. Fetal diagnosis and therapy. 2016;39(4):279-86. Gastroschisis seems to have become much more frequent, and sometimes there are serious complications, the fetuses are now followed very closely, and when ultrasound findings change we often have discussions about what the significance of a finding is, and whether the baby should de delivered. This study, from our hospital, shows that the best predictor of a serious post-natal complication was dilatation of the intra-abdominal bowel. Some of these babies died or had major complications, the only thing that predicted that in the antenatal period was dilatation of the bowel that was still in the abdomen. Whether immediately delivering the babies or not would make a difference is, of course, uncertain.

Basta AM, et al. Fetal Stomach Position Predicts Neonatal Outcomes in Isolated Left-Sided Congenital Diaphragmatic Hernia. Fetal diagnosis and therapy. 2016;39(4):248-55. This is easier than calculating lung volume from an MRI and comparing to expected lung volumes. Where is the stomach?

Stomach position was intra-abdominal in 14% (n = 13), anterior left chest in 19% (n = 17), mid-to-posterior left chest in 41% (n = 37), and retrocardiac in 26% (n = 23). Increasingly abnormal stomach position was linearly associated with an increased odds of death (OR 4.8, 95% CI 2.1-10.9), extracorporeal membrane oxygenation (ECMO; OR 5.6, 95% CI 1.9-16.7), nonprimary diaphragmatic repair (OR 2.7, 95% CI 1.4-5.5), prolonged mechanical ventilation (OR 5.9, 95% CI 2.3-15.6), and prolonged respiratory support (OR 4.0, 95% CI 1.6-9.9). All fetuses with intra-abdominal stomach position survived without substantial respiratory morbidity or need for ECMO.

Manley BJ, et al. Extubating Extremely Preterm Infants: Predictors of Success and Outcomes following Failure. The Journal of pediatrics. 2016. Should we try and take the tube out? One third of this group of very preterm babies (under 28 weeks) failed extubation. “Higher GA and lower pre-extubation PCO2 predicted extubation success. Infants in whom extubation failed were more likely to die and have prolonged respiratory support and hospitalization”. All of the other potential predictors of extubation success were not much use.

And I am still not sure how you would do a trial to find out when you should take the tube out. If you do it too soon and the baby fails, they are more likely to do badly, but that doesn’t mean it was the failed attempt that was causative. If you don’t try when the baby could have a chance of success, and they stay intubated, then have you wrecked their lungs? There must be a good way to figure this out, but its late, and I can’t come up with any clever trial designs. Suggestions welcome.

About Keith Barrington

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