Prospects for neonatal intensive care

Abstract

In today's Lancet we publish a clinical Series on neonatal intensive care in higher resource settings. The Series, led by Lex Doyle from The Royal Women's Hospital in Melbourne, VIC, Australia, includes new approaches to the old nemesis of bronchopulmonary dysplasia (which still affects up to 50% of infants born before 28 weeks’ gestation), discusses the delicacy of fine-tuning interventions in response to evolving evidence, and explores the frontier of nutritional research by referring to preterm birth as a nutritional emergency. This Series is of wide interest not only because of the extent and rate of progress in neonatal intensive medicine, but also because management of prematurity has profound consequences for the course of cardiovascular, metabolic, neurological, and pulmonary diseases throughout life. Peripartum asphyxia contributes to disability and to the 2·7 million children estimated to die in the neonatal period. Therefore, the first Review, Towards evidence-based resuscitation of the newborn infant, is of particular importance, as many interventions can be generalised. It is a reminder that contemporary attitudes to evidence had their birth in neonatal practice, epitomised by the logo of the Cochrane Collaboration that depicts the pivotal meta-analysis of antenatal corticosteroids to reduce mortality after preterm birth. The message from the evidential underpinnings of neonatal intensive care is clear: adequately powered, generalisable trials that test today's interventions at different stages of gestation in both sexes are essential to inform tomorrow's practice. Especially important is a focus on long-term neurodevelopmental results in addition to short-term neonatal outcomes. The emotional and ethical environment for research in neonatal intensive care units is complex, but not insurmountable. Just as good neonatal care begins before birth, so too should sound research questions, developed with parental input. The recent revision of Would Your Child Benefit from a Clinical Trial?, posted on the US Food and Drug Administration's consumer website, is a welcome example of outreach to expand the culture of much needed research in children of all ages, including those newly born. Towards evidence-based resuscitation of the newborn infantEffective resuscitation of the newborn infant has the potential to save many lives around the world and reduce disabilities in children who survive peripartum asphyxia. In this Series paper, we highlight some of the important advances in the understanding of how best to resuscitate newborn infants, which includes monitoring techniques to guide resuscitative efforts, increasing awareness of the adverse effects of hyperoxia, delayed umbilical cord clamping, the avoidance of routine endotracheal intubation for extremely preterm infants, and therapeutic hypothermia for hypoxic–ischaemic encephalopathy. Full-Text PDF The evolution of modern respiratory care for preterm infantsPreterm birth rates are rising, and many preterm infants have breathing difficulty after birth. Treatments for infants with prolonged breathing difficulty include oxygen therapy, exogenous surfactant, various modes of respiratory support, and postnatal corticosteroids. In this Series paper, we review the history of neonatal respiratory care and its effect on long-term outcomes, and we outline the future direction of the research field. The delivery and monitoring of oxygen therapy remains controversial, despite being in use for more than 50 years. Full-Text PDF Advances in nutrition of the newborn infantNutrition of newborn infants, particularly of those born preterm, has advanced substantially in recent years. Extremely preterm infants have high nutrient demands that are challenging to meet, such that growth faltering is common. Inadequate growth is associated with poor neurodevelopmental outcomes, and although improved early growth is associated with better cognitive outcomes, there might be a trade-off in terms of worse metabolic outcomes, although the contribution of early nutrition to these associations is not established. Full-Text PDF