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OBJECTIVE. The goals were to identify the blood pressures of extremely low gestational age newborns that prompt intervention, to identify other infant characteristics associated with receipt of therapies intended to increase blood pressure, and to assess the interinstitutional variability in the use of these therapies. METHODS. The cohort included 1507 extremely low gestational age newborns born at 23 weeks to 27 6/7 weeks of gestation, at 14 institutions, between March 2002 and August 2004; 1387 survived the first postnatal week. Blood pressures were measured as clinically indicated. Interventions were grouped as any treatment (ie, vasopressor and/or fluid boluses of >10 mL/kg) and vasopressor treatment, and logistic regression analyses were performed. RESULTS. At each gestational age, the lowest mean arterial pressures in treated and untreated infants tended to increase with advancing postnatal age. Infants who received any therapy tended to have lower mean arterial pressures than infants who did not, but uniform thresholds for treatment were not apparent. The proportion of infants receiving any treatment decreased with increasing gestational age from 93% at 23 weeks to 73% at 27 weeks. Treatment nearly always began during the first 24 hours of life. Lower gestational age, lower birth weight, male gender, and higher Score for Neonatal Acute Physiology-II values were associated with any treatment and vasopressor treatment. Institutions varied greatly in their tendency to offer any treatment and vasopressor treatment. Neither the lowest mean arterial pressure on the day of treatment nor other characteristics of the infants accounted for center differences in treatment. CONCLUSIONS. Blood pressure in extremely premature infants not treated for hypotension increased directly with both increasing gestational age and postnatal age. The decision to provide treatment was associated more strongly with the center where care was provided than with infant attributes. Key Words premature infant, blood pressure, hypotension, HYPOTENSION IS ONE of the most common diagnoses assigned to extremely low gestational age newborns (ELGANs), and treatments to increase blood pressure are often used in this population. (1) These [...]

A negative pressure chamber around the infant's body may assist breathing efforts in newborns with breathing difficulties. Researchers randomly assigned 244 newborns to conventional care or care in a specially designed incubator. Among infants receiving negative pressure therapy, 5% fewer patients required intubation, total duration of oxygen therapy among infants surviving to 56 days was 21 days versus 39 days, and the average duration of oxygen use overall was 18 versus 34 days. This resulted in fewer infants experiencing permanent lung injury. However, there was a trend toward more deaths, lung perforations, and abnormal ultrasound brain scans., ABSTRACT. Objective. In uncontrolled clinical trials negative extrathoracic pressure has been shown to be an effective respiratory support. We aimed to assess its role in the context of current neonatal intensive care. Design. A randomized controlled trial, with sequential analysis of matched pairs of infants. Matching was undertaken by stratified randomization from 15 groups divided according to gestational age, oxygen requirement, and whether patients were intubated at 4 hours of age. Setting. Two neonatal intensive care units. Patients. Two hundred forty-four patients (birth weight 1.53 [+ or -] 0.69 kg (mean [+ or -] SD); gestational age 30.4 [+ or -] 3.5 weeks) with respiratory failure. Interventions. Patients were randomized at 4 hours of age to receive either standard neonatal intensive care, or standard care plus continuous negative extrathoracic pressure (CNEP, -4 to -6 cm[H.sub.O]) applied within a purpose-designed neonatal incubator. Outcome Scores. Clinical scores were calculated for each infant at 56 days of age, or death if earlier. Scores included measures for mortality, respiratory outcome, the presence of cerebral ultrasound abnormalities, patent arterial duct, necrotizing enterocolitis, and retinopathy. The treatment given for the higher score for each pair was recorded and the cumulative net number of pairs favoring CNEP plotted in the sequential analysis to provide an ethical early termination strategy. Individual components of the outcome score and other secondary measurements were analyzed on completion of the trial. Results. The sequential analysis reached a decision boundary after 122 out of a possible maximum of 124 pairs were completed. The overall outcome score showed an overall significant benefit for CNEP. Secondary analysis showed that the use of CNEP was associated with an increase in mortality, cranial ultrasound abnormalities, and pneumothoraces, which were not statistically significant. However, 5% fewer patients were intubated (95% confidence interval [CI], 0-10), and the total duration of oxygen therapy among surviving infants at n days was lower (20.5 days, compared with 38.9 in controls; difference 18.4 days, 95% CI 3.8 to 33.0). Among all infants, the mean total duration of oxygen therapy was 18.3 days among CNEP-treated infants compared with 33.6 days among the controls (difference -15.3 days, 95% CI -0.2 to -30.4 This reduction in mean levels is entirely attributable to substantially fewer patients requiring prolonged oxygen therapy, the median duration of treatment being very similar in the two groups. As a result, commensurately fewer surviving infants showed chronic lung disease of prematurity. Conclusions. The use of continuous negative pressure improves the respiratory outcome for neonates with respiratory failure. Pediatrics 1996;98:1154-1160; respiratory distress syndrome, mechanical ventilation, negative pressure., Negative pressure respiratory support was used successfully in neonatal respiratory distress syndrome in the 1960s and 1970s.[1,2] Monin et al[1] compared intermittent positive pressure ventilation (IPPV) and intermittent negative pressure [...]

Many premature babies are still at risk of developing chronic lung disease (CLD) even if they receive artificial lung surfactant. Lung surfactant is a substance in the lungs that is often deficient in premature babies. In a study of 865 very-low-birth-weight babies, 26% had CLD. Risk factors included developing an infection in the hospital, too much dietary fluid, being placed on a ventilator, and a patent ductus arteriosus., Objective. To identify risk factors for chronic lung disease (CLD) in a population-based cohort of very low birth weight infants, born in an era of surfactant usage. We specifically investigated the effects of antenatal steroids, nosocomial infection, patent ductus arteriosus (PDA), fluid management, and ventilator support strategies. Methods. Data were prospectively collected on 1244 infants born in North Carolina in 1994 with birth weights 500 to 1500 g, and treated at 1 of the 13 intensive care nurseries across the state. The outcome of interest was CLD, defined as dependency on supplemental oxygen at 36 weeks' postmenstrual age. Multivariate odds ratios (OR) and 95% confidence intervals (CI) were estimated with logistic regression models. Results. Among 865 survivors to 36 weeks' postmenstrual age, 224 (26%) had CLD. Nosocomial infection (OR: 2.0; 95% CI: 1.4-3.3), fluid intake on day 2 (OR: 1.06 per 10 mL increase; 95% CI: 1.01-1.11), and the need for ventilation at 48 hours of life (OR: 2.2; 95% CI: 1.3-3.7) were associated with an increased risk of CLD. Among infants ventilated at 48 hours, nosocomial infection (OR: 1.64; 95% CI: 1.02-2.62) and PDA (OR: 1.9; 95% CI: 1.2-3.1) were associated with an increased risk. No association was found with antenatal steroid receipt or increased levels of ventilator support. Conclusion. This analysis suggests that with widespread use of surfactant, nosocomial infection, PDA, and water balance persist as risk factors for CLD. Pediatrics 1999;104:1345-1350; chronic lung disease, bronchopulmonary dysplasia, prematurity, low birth weight, patent ductus arteriosus, betamethasone, infection, ventilation, neonatal factors., ABBREVIATIONS. CLD, chronic lung disease; VLBW, very low birth weight; PMA, postmenstrual age; ANS, antenatal steroids; RDS, respiratory distress syndrome; PDA, patent ductus arteriosus; NCPAP, nasal continuous positive airway pressure; [...]

Chronic lung disease (CLD) remains one of the most challenging diseases in neonatal medicine because there have been very few effective therapies for its prevention or treatment. Systemic corticosteroids, once [...]