Doses Of Antenatal Steroids Research Articles

Comparison of Clinical Outcome of Bacterial Colonization between Nasogastric and Orogastric Enteral Feeding Tubes in Neonates in the Neonatal Intensive Care Unit

Introduction: Enteral feeding tubes are commonly utilized in the neonatal intensive care unit (NICU) due to the underdevelopment of coordination between sucking, swallowing, and breathing, or due to various diseases affecting the respiratory, cardiovascular, gastrointestinal, or neurological systems. The aim of the study was to investigate the differences in bacterial colonization patterns in hospitalized infants who received enteral feeding through either nasogastric (NG) or orogastric (OG) feeding tubes. Materials and Methods: This study was a hospital-based cross-sectional investigation that was carried out on infants who were admitted to the NICU. The NICU gathered feeding tubes throughout 4 months, beginning in August 2022 and continuing through December 2022. In addition, informed consent was collected from the participant’s parents or legal guardians for the entire group of people who took part in the research. The fact that the patient participated in this study had no bearing on the level of care that they were given. The research team gave serious consideration to recruiting any of the newborns who were receiving medical attention in the NICU and who had a feeding tube inserted during the time that sample collection was taking place. The infants did not receive any probiotics as a form of treatment in any of the cases. Results: Infants with NG tubes had a significantly higher number of C-sections ( P = 0.04), infants with NG tube were exclusively breastfed ( P = 0.02), and one or more dose of antenatal steroids was administered more in infants with OG tube ( P = 0.04). The most common types of bacteria found in NG and OG tubes were Proteobacteria (with a mean relative abundance of 50% and 60%, respectively), Firmicutes (with a mean relative abundance of 33% and 23%, respectively), and Actinobacteria (9% and 7%, respectively). Conclusion: Oral versus nasal feeding tube insertion was found to have a greater influence on bacterial colonization than any of the other clinical factors that were evaluated.

Antenatal Steroids, Prophylactic Indomethacin, and the Risk of Spontaneous Intestinal Perforation

To estimate if the odds of spontaneous intestinal perforation (SIP) are increased when antenatal steroids (ANS) given close to delivery are combined with indomethacin on day 1 after birth (Indo-D1). A retrospective cohort study using the Neonatal Research Network (NRN) database of inborn infants, gestational age 220-286weeks or birth weight of 401-1000g, born between January 1, 2016 and December 31, 2019, and surviving >12hours. The primary outcome was SIP through 14days. Time of last ANS dose prior to delivery was analyzed as a continuous variable (using 169hours for durations >168hours or no steroid exposure). Associations between ANS, Indo-D1, and SIP were obtained from a multilevel hierarchical generalized linear mixed model after covariate adjustment. This yielded aOR and 95% CI. Of 6851 infants, 243 had SIP (3.5%). ANS exposure occurred in 6393 infants (93.3%) and IndoD1 was given to 1863 infants (27.2%). The time (median, IQR) from last dose of ANS to delivery was 32.5hours (6-81) vs 37.1hours (7-110) for infants with or without SIP, respectively (P=.10). Indo-D1 was given to 51.9 vs 26.3% of infants with SIP vs no SIP, respectively (P<.0001). Adjusted analysis indicated no interaction between time of last ANS dose and Indo-D1 for SIP (P=.7). Indo-D1 but not ANS was associated with increased odds of SIP (aOR: 1.73, 1.21-2.48, P = .003). The odds of SIP were increased after receipt of Indo-D1. Exposure to ANS prior to Indo-D1 was not associated with an increase in SIP.

Timing of antenatal steroid administration for imminent preterm birth: results of a prospective observational study in Germany

PurposeTo evaluate the timing of antenatal steroid administration and associated medical interventions in women with imminent preterm birth.MethodsWe performed a prospective observational study at a single tertiary center in Germany from September 2018 to August 2019. We included pregnant women who received antenatal steroids for imminent preterm birth and evaluated the interval from administration to birth. 120 women with antenatal steroid application were included into our analysis. Descriptive statistics were performed to analyze factors influencing the timing of antenatal steroids and to evaluate additional medical interventions which women with imminent preterm birth experience.ResultsOf the 120 women included into our study, 35.8% gave birth before 34/0 weeks and 64.2% before 37/0 weeks of gestation. Only 25/120 women (20.8%) delivered within the optimal time window of 1–7 days after antenatal steroid application. 5/120 women (4.2%) only received one dose of antenatal steroids before birth and 3/120 (2.5%) gave birth within 8 to 14 days after antenatal steroids. Most women gave birth more than 14 days after steroid application (72.5%, 87/120). Women with preeclampsia (60%), PPROM (31%), and FGR (30%) had the highest rates of delivery within the optimal time window. Women of all timing groups received additional interventions and medications like antibiotics, tocolytics, or anticoagulation.ConclusionOur observational data indicate that most pregnant women do not give birth within 7 days after the administration of antenatal steroids. The timing was best for preterm birth due to preeclampsia, PPROM, and FGR. Especially for women with symptoms of preterm labor and bleeding placenta previa, antenatal steroids should be indicated more restrictively to improve neonatal outcome and reduce untimely and unnecessary interventions.

Self-assessment

You attend the delivery of a baby born by spontaneous onset normal vaginal delivery at 34+3 weeks gestation. The baby is born in good condition but develops increased work of breathing at a few minutes of life. Antenatal scans and serology were unremarkable except for polyhydramnios. There was no prolonged rupture of membranes or maternal temperature and maternal GBS status was negative. The mother was given one dose of antenatal steroids.

Intraventricular haemorrhage in a Ugandan cohort of low birth weight neonates: the IVHU study

BackgroundGlobally, 15 million neonates are born prematurely every year, over half in low income countries (LICs). Premature and low birth weight neonates have a higher risk of intraventricular haemorrhage (IVH). There are minimal data regarding IVH in sub-Saharan Africa. This study aimed to examine the incidence, severity and timing of and modifiable risk factors for IVH amongst low-birth-weight neonates in Uganda.MethodsThis is a prospective cohort study of neonates with birthweights of ≤2000 g admitted to a neonatal unit (NU) in a regional referral hospital in eastern Uganda. Maternal data were collected from interviews and medical records. Neonates had cranial ultrasound (cUS) scans on the day of recruitment and days 3, 7 and 28 after birth. Risk factors were tabulated and are presented alongside odds ratios (ORs) and adjusted odds ratios (aORs) for IVH incidence. Outcomes included incidence, timing and severity of IVH and 28-day survival.ResultsOverall, 120 neonates were recruited. IVH was reported in 34.2% of neonates; 19.2% had low grade (Papile grades 1–2) and 15% had high grade (Papile grades 3–4). Almost all IVH (90.2%) occurred by day 7, including 88.9% of high grade IVH. Of those with known outcomes, 70.4% (81/115) were alive on day 28 and survival was not associated with IVH. We found that vaginal delivery, gestational age (GA) < 32 weeks and resuscitation in the NU increased the odds of IVH. Of the 6 neonates who received 2 doses of antenatal steroids, none had IVH.ConclusionIn this resource limited NU in eastern Uganda, more than a third of neonates born weighing ≤2000 g had an IVH and the majority of these occurred by day 7. We found that vaginal birth, earlier gestation and need for resuscitation after admission to the NU increased the risk of IVH. This study had a high rate of SGA neonates and the risk factors and relationship of these factors with IVH in this setting needs further investigation. The role of antenatal steroids in the prevention of IVH in LICs also needs urgent exploration.

Timing of Antenatal Steroid Administration and Effects on the Newborn Infant: A Retrospective Study.

The timing of antenatal steroids (ANS) on short- and long-term effects on newborn infants was evaluated. This study was conducted at the University of Cincinnati Medical Center Level-III Neonatal Intensive Care Unit by reviewing the medical records of all women with history of ANS exposure from January 2015 to December 2018. We compared outcomes of newborns delivered within the ideal therapeutic window of 24 hours to 7 days (within window [WW]) after administration to those exposed and delivered outside the therapeutic window (outside window primary group [OWP]). Outcomes included anthropometrics, blood sugars, thyroid hormone profile, and neonatal morbidities. A total of 669 patients were identified as having received at least two doses of ANS. Two-thirds of them delivered within the ideal therapeutic window. Significant differences were found in anthroprometrics including lower birth weight, shorter length, and smaller head circumferences in those born within the window compared with those outside the window. Derangements in glucose homeostasis requiring treatment and elevations of thyroid stimulating hormone (TSH) were seen in infants born outside the ideal therapeutic window compared with those born within the therapeutic window. No differences were found in neonatal morbidities including severe intraventricular hemorrhage (sIVH), necrotizing enterocolitis (NEC), need for resuscitation, exogenous surfactant administration, continuous positive airway pressure (CPAP), mechanical ventilation, bronchopulmonary dysplasia (BPD), or periventricular leukomalacia (PVL). After controlling for selected covariates, only birth length was different between the groups. Effects on anthropometrics, glucose homeostasis, and thyroid function support the need to develop new or refine existing risk stratification systems to time the administration of antenatal steroids. Better targeting of women and fetuses may confer the benefits of systemic corticosteroids while mitigating the risks of adverse effects. · The timing of antenatal steroids on short and long-term effects on newborn infants was evaluated.. · Differences were found in anthroprometrics, glucoses, and thyroid function.. · No differences were found in neonatal morbidities..

56: Association of timing from steroid administration to delivery and neonatal outcomes in the late-preterm period

Administration of antenatal steroids for women at risk of late preterm birth reduces neonatal morbidity but results in more frequent neonatal hypoglycemia. The objective was to evaluate if there is an association between time from steroid administration to delivery and neonatal hypoglycemia. Retrospective cohort of all women with singleton pregnancies admitted between 34-36 6/7 weeks’ from 4/2016-4/2017 and received at least one dose of antenatal steroids. The exposure was steroid latency, defined as the time from first dose of betamethasone to delivery, examined categorically as < 48 versus ≥ 48 hours from receipt of first dose of betamethasone. The primary outcomes were neonatal hypoglycemia ≤35 mg/dL in the first day of life, admission to the NICU, and neonatal dextrose administration. Of the 302 women eligible for inclusion, 49 (16.2%) had a steroid latency ≥48 hours. Women who received steroids ≥48 hours before delivery were more likely to have preeclampsia (8.2% vs. 1.2%; p=0.015) and were more likely to undergo cesarean (38.8% vs 24.5%; p=0.039). They received betamethasone at an earlier gestation(35.2 ± 0.8 vs 35.7 ± 0.8; p=0.001) but delivered at a more advanced gestation(36.2 ± 0.9 vs 35.8 ± 0.9; p=0.002) than women with a < 48 hour steroid latency. There was no difference in the frequency of hypoglycemia ≤35 mg/dL (14.3% vs. 19.0%; p=0.437) by steroid latency, which remained non-significant after accounting for potential confounders (aOR 0.40, 95% CI 0.12-1.30). Steroid latency remained non-associated with hypoglycemia when examined as a continuous variable. NICU admission and IV dextrose administration were also not associated with steroid latency (Table). Although administration of antenatal steroids for women at elevated risk of delivery in the late preterm period has been reported to increase the risk for neonatal hypoglycemia, in this cohort, the amount of time from steroid administration to delivery is not associated with a greater likelihood of neonatal hypoglycemia or related neonatal events.

Effect of Two Separated Doses of Antenatal Steroids at 32 Weeks and Five Days before Delivery in Prevention of neonatal respiratory Distress Syndrome

Effect of Two Separated Doses of Antenatal Steroids at 32 Weeks and Five Days before Delivery in Prevention of neonatal respiratory Distress Syndrome

Legal Briefs: An Infant with an Omphalocele Ends Up with Organ Transplants

A 2,226-g female infant with a prenatal diagnosis of an omphalocele was born at 33 3/7 weeks’ gestation to a 43-year-old gravida 4, para 1, aborta 3 woman. The pregnancy was unremarkable except for the known abdominal defect containing a portion of the liver and preterm labor. Before delivery, the woman had received nifedipine for tocolysis, antibiotics as a result of preterm labor, and 1 dose of antenatal steroids. However, labor progressed and the infant was born via cesarean delivery. The infant emerged active and had Apgar scores of 8 and 9 at 1 and 5 minutes, respectively. A loose nuchal cord was noted at delivery. The umbilical cord gases were normal. The physical examination showed a normal-appearing infant with a soft abdomen without distention and an omphalocele. The surgery team determined that a silo was not necessary because the defect was “small,” with only a portion of the liver as the contents in the sac, and a “large abdominal domain.” The neonatology team covered the omphalocele with xeroform and placed a Replogle tube and peripheral intravenous line. Echocardiography and ultrasonography of the head were performed, and no cardiac or brain abnormalities were found. Fifteen hours after birth, the infant was brought to the operating room (OR) for omphalocele excision with reduction and primary closure. During the 3½ hours in the OR, the surgeons noted that the abdominal cavity was actually too small to fit the large anterior lobe of the liver that was within the sac. Because of this complication, the surgical team digitally stretched the abdomen to provide more space to accommodate the entire liver. During the procedure, a small amount of bleeding occurred on the inferior border of the liver segment, which was compressed with gauze. When the bleeding stopped, the anterior lobe of the liver was …

Legal Briefs: Devastating Outcome Following PDA Ligation and Inadequate Anesthesia

A 32-weeks’-gestation male infant was born to a 38-year-old G3P1Ab1 woman whose pregnancy was complicated by severe pregnancy-induced hypertension. A week before delivery, the biophysical profile (BPP) was 10/10. The mother noticed decreased fetal movement, a repeat BPP evaluation was performed, and it was 4/10. Because of this reduction in BPP, the obstetrician decided to perform an emergent cesarean delivery. One dose of antenatal steroids was given before a vigorous 1,600-g infant was delivered. Cord gases were unremarkable. Apgar Scores were 6 and 9 at 1 and 5 minutes, respectively. The baby was intubated at 5 minutes because of respiratory difficulty. He was given one dose of surfactant replacement therapy. The initial mean blood pressure (BP) was 36 mm Hg. Ampicillin and cefotaxime were started. His complete blood count showed a white blood cell count (WBC) of 5.5 × 103/uL with a normal differential, a hematocrit of 39.5% (0.39) for which he was transfused packed red blood cells, and a platelet count of 114 × 103 u/L. The nucleated red blood cell count was 363 per 100 WBC. The neonatologist retained by the defense pointed out that this elevated nucleated red blood cell count suggested brain damage in utero. The plaintiff neonatologist disagreed and said it suggested stress, not damage. The following day, day 1, the baby remained intubated on a low ventilator setting. His creatinine was 1.4 mg/dL. The neonatologist retained by the defense pointed out that this high creatinine at birth suggested brain damage in utero. The neonatologist retained by the plaintiff said it was not possible to determine if it was from the baby or the mother because her creatinine level was not evaluated, but an elevated creatinine does not necessarily imply brain damage in utero, even if it were from the baby. He had …

Maternal Race, Demography, and Health Care Disparities Impact Risk for Intraventricular Hemorrhage in Preterm Neonates

To determine whether risk factors associated with grade 2-4 intraventricular hemorrhage (IVH) differs between infants of African ancestry and white infants. Inborn, appropriate for gestational age infants with birth weight 500-1250 g and exposure to at least 1 dose of antenatal steroids were enrolled in 24 neonatal intensive care units. Cases had grade 2-4 IVH and controls matched for site, race, and birth weight range had 2 normal ultrasounds read centrally. Multivariate logistic regression modeling identified factors associated with IVH across African ancestry and white race. Subjects included 579 African ancestry or white race infants with grade 2-4 IVH and 532 controls. Mothers of African ancestry children were less educated, and white case mothers were more likely to have more than 1 prenatal visit and multiple gestation (P ≤ .01 for all). Increasing gestational age (P = .01), preeclampsia (P < .001), complete antenatal steroid exposure (P = .02), cesarean delivery (P < .001), and white race (P = .01) were associated with decreased risk for IVH. Chorioamnionitis (P = .01), 5-minute Apgar score <3 (P < .004), surfactant use (P < .001), and high-frequency ventilation (P < .001) were associated with increased risk for IVH. Among African ancestry infants, having more than 1 prenatal visit was associated with decreased risk (P = .02). Among white infants, multiple gestation was associated with increased risk (P < .001), and higher maternal education was associated with decreased risk (P < .05). The risk for IVH differs between infants of African ancestry and white infants, possibly attributable to both race and health care disparities.

Neurodevelopmental outcome of extremely premature infants exposed to incomplete, no or complete antenatal steroids

Objective: To compare the neurodevelopmental outcomes at 18–22 months’ corrected age of extremely premature infants exposed to a complete course, an incomplete course or no dose of antenatal steroids (ANS).Methods: Retrospective chart review of extremely premature (<28 weeks gestational age) neonates over a 3-year period. Neurodevelopmental assessment at 18–22 months’ corrected age included a standardized neurologic examination and the Bayley Scales of Infant and Toddler development II or III. Intact survival was defined as survival without cerebral palsy (CP), blindness or deafness and mental developmental index (MDI)/cognitive score ≥85. Neurodevelopmental impairment (NDI) was defined as any of the following: moderate or severe CP, MDI/cognitive score <70, deafness or blindness. Patients were categorized into three groups: (A) no ANS; (B) incomplete course and (C) complete course of ANS.Results: Outcome data were available for 134 (88%) patients of our cohort (n = 153). Severe intraventricular hemorrhage (IVH) was significantly lower and intact survival was higher in the complete ANS group (p < 0.01). On logistic regression, with gestational age, gender, maternal insurance and ANS exposure as covariates, an incomplete (versus complete) course of ANS (p = 0.006) and gestational age were significantly associated with lower intact survival at 18–22 months.Conclusions: A complete course of ANS was associated with an increased likelihood of intact survival at a corrected age of 18–22 months among extremely premature infants, compared with an incomplete course. Follow-up studies should account for the differential benefit of complete versus incomplete course of ANS administration.

Outcomes of extremely low birth weight infants with varying doses and intervals of antenatal steroid exposure

To compare outcomes of extremely low birth weight (ELBW) infants exposed to no antenatal steroids (ANS); incomplete ANS and complete course of ANS at varying intervals prior to delivery. A retrospective review was performed on 169 ELBW infants with ANS exposure at varied dose-intervals. The odds of mortality, intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD) were compared between Group 1, infants born without ANS exposure, Group 2, infants born after one dose of ANS, Group 3, infants born after two doses of ANS given within a week, and Group 4, infants born after two doses of ANS >7 days prior to delivery. Mortality and IVH were significantly lower in Groups 3 (30% and 10%) and 4 (15% and 30%), compared to Groups 1 (56% and 69%) and 2 (56% and 38%). Increasing gestational age and exposure to complete course of ANS were significantly associated with decrease in mortality, BPD/mortality and IVH. Infants who received one dose of ANS had significantly lower incidence of severe IVH compared to infants without ANS exposure. Beneficial impact of ANS on mortality and composite BPD/mortality is evident only after a complete course and persists even with its administration beyond a week from delivery.

Repeat Doses of Antenatal Steroids and Hypothalamic-Pituitary-Adrenal Axis (HPA) Function

Objective This study was undertaken to compare the effects of exposure to repeated courses of antenatal steroids with those of a single course on hypothalamic-pituitary-adrenal axis function. Study Design Women at risk of premature delivery were assessed for entry into a randomized controlled trial of repeated courses of corticosteroids (ACTORDS). If a woman declined the randomized trial then consent was sought for collection of observational data. Baseline bloods for cortisol and adrenocorticotropic hormone levels were collected and in a subset of infants a metyrapone test performed. Results In the 86 studied infants, cortisol and adrenocorticotropic hormone levels did not differ between those exposed to single and repeated courses of antenatal steroids ( P = .53 and P = .15, respectively). Although cortisol levels fell in response to metyrapone ( P = .03) this response was not different between the single and repeated course groups ( P = .46). Conclusion Repeated courses of antenatal steroids do not cause important hypothalamic-pituitary-adrenal axis suppression in the neonate.

Outcome of Neonates Less Than 30 Weeks Gestation With Histologic Chorioamnionitis

Rates of preterm delivery, preterm premature rupture of membranes, and neonatal illness all are reportedly increased when histologic chorioamnionitis is present. There also are strong associations with intrauterine infection and poor neonatal outcomes. The disorder often is not clinically apparent. The investigators examined perinatal outcomes for infants delivered at or before 30 weeks gestation when there was documented histologic chorioamnionitis. Among 392 newborn infants born at or before 30 weeks gestation, seen in the years 1989 through 1999, histologic chorioamnionitis was confirmed in 41% of 342 cases in which complete placental assessment was possible. Affected infants received antepartum antibiotics by either the oral or intravenous route within 24 hours of delivery in addition to 2 doses of antenatal steroids. Compared with infants lacking histologic chorioamnionitis, those affected delivered earlier (26.3 vs 27.5 weeks), had lower birth weights (920 vs 1030 g), and had lower 5-minute Apgar scores. Overall mortality was not affected. Rates of necrotizing enterocolitis and severe intraventricular hemorrhage did not differ in the infants with and those without chorioamnionitis, but respiratory distress syndrome (RDS) was markedly less frequent in affected infants. Histologic chorioamnionitis related strongly to neonatal septicemia and pneumonia. Associated with histologic chorioamnionitis were a temperature above 38°C, a white blood cell count exceeding 15,000 leukocytes/mm 2 , and malodor at the time of delivery. The duration of membrane rupture did not differ. On logistic regression analysis, the chance of dying perinatally was slightly but not significantly increased. The chance of dying in the neonatal period, however, was more than halved in the presence of histologic chorioamnionitis. The investigators conclude that histologic chorioamnionitis correlates with increased risks of preterm delivery and neonatal septicemia. Both RDS and neonatal mortality were reduced in the present study of infants at less than 30 weeks gestation when histologic chorioamnionitis was definitely present.

Interval head growth for infants exposed to multiple doses of antenatal steroids

ANTENATAL STEROIDS JULIE SLOAN, THADDEUS WATERS, SEAN DALY, MARGARET SHERIDAN-PEREIRA, ROBERT GORMAN, ANTHONY SCISCIONE, RONALD WAPNER, Coombe Women’s Hospital, Dublin, Ireland, Ireland, Drexel University, Obstetrics and Gynecology, Philadelphia, Pennsylvania, Coombe Women’s Hospital, Dublin, Ireland, Ireland, Drexel University College of Medicine, Obstetrics and Gynecology, Philadelphia, Pennsylvania OBJECTIVE: Multiple doses of antenatal steroids have been associated with smaller head circumferences at birth. No study has addressed the long-term head growth of children exposed to antenatal steroids. We sought to determine the long-term effect of multiple courses of antenatal corticosteroids on head circumference. STUDY DESIGN: This is a retrospective case-cohort study performed at a tertiary care hospital. Our obstetrical database identified all singleton pregnancies >24 weeks gestation at risk for preterm birth between 1995-99. Data collected included maternal demographic characteristics, neonatal outcomes, number of steroid doses, gestational age at administration of steroids, gestational age at delivery, neonatal anthropometric measurements and serial anthropometric measurements. A full course of steroid therapy was defined as two doses of dexamethasone 12mg over 48 hours. An attending physician determined weekly steroid doses. We compared the neonates of mothers who received dexamethasone to neonates who were not exposed. Number of steroid courses and follow-up head circumferences were evaluated. Mantel-Haenszel test was used where appropriate. RESULTS: A total of 625 pregnancies were eligible for analysis with 469 infants (75.1%) having at least one follow-up exam for head circumference (HC). All 469 infants had a documented head circumference between 30 days of age and 3 years of age. Steroid dosing and HC at!10th percentile is presented in the table. Infants exposed to antenatal steroids were not more likely to have head circumferences below the 10th percentile than those that were unexposed (OR = 0.20 95% CI 0.007-5.4528). CONCLUSION: Infants exposed to multiple courses of antenatal steroids do not appear to have a higher risk of HC !10th percentile on interval evaluation.

124 Hyperkalaemia in The Extremely Low Birth Weight Preterm Infant

Top of pageAbstract Background: The purpose of the study was to investigate factors that affect potassium(K) homeostasis over the first 6 days of life in extremely low birth weight (ELBW) preterm infants. Methods: Clinical and laboratory data was collected retrospectively on infants >23 and < 27 weeks admitted to NICU from January '01 to December '02. Infants were excluded if they had a congenital abnormality or died at < 24 hours. Haemolysed samples were excluded. Correlation of variables was analysed using Mann Whitney, Fisher Exact, one way ANOVA and multiple linear regression. Results: 80 infants were eligible with a median birth weight and gestational age of 722g(IQR 220g) and 25.0 wks(IQR 1.8 wks). 48(60.0%) had at least 1 episode of hyperkalaemia(K 6.5mmmol/L). Lowest mean K levels(4.8mmol/L SD 1.1) occurred on D1 rising to a peak mean (5.9 mmol/L SD 1.3) on D2 of life. Absolute [K] did not correlate with survival. There was a significant increase in [K] levels on D2–D3 in infants who died vs survivors (0.6mmol/L v–1.0mmol/L p= 0.0087). 16 of 45 infants died in the hyperkalaemic group (35.5%).15 of 31died in the normokalaemic group (48.4%). This was not significant. There was no correlation between [K] and [Na] concentration;mean arterial pressure;urine output;gestation;sex or pH. There was a negative correlation between glucose levels and [K] on days 2, 6 (p- values 0.02, 0.007). Mean [K] were significantly higher in infants who were hypoglycaemic (glucose< 2.8). This was noted on D2 of life(6.8mmol/L vs 5.6mmol/L p= 0.003). The mean [K] were significantly lower in infants who had received 2 doses of antenatal steroids(ANS) (n = 41) vs those who received none (n= 21) on D1(5.(1.1) vs 4.6 (0.9) mmol/L p-value= 0.02) and D2(6.5 (1.5) vs 5.(1.1) p= 0.009). There was no significant difference in [K] noted with 1 dose ANS compared with infants who were given no ANS; this was a small group. Conclusion: Hyperkalaemia affects almost¾ of ELBW preterm infants. [K] tend to rise from D1 to peak on D2. A rise on D3 is associated with a poorer chance of survival. The negative correlation between glucose and [K] may be due to lower substrate source of energy and a decrease in NA-K ATP-ase activity. ANS appear to have a protective effect on [K] levels in the first 48 hours of life in pregnancies of < 27 weeks possibly due to steroid induced maturation of Na-K ATP-ase2. 2.Omar S et al Effect of prenatal steroids on potassium balance in extremely low birth weight neonates.Pediatrics 2000;106(3):561–7

The morbidity and survival of very-low-birth-weight infants in Taiwan.

Advances in obstetrical and neonatal care have increased the survival of very-low-birth-weight (VLBW) infants, defined as infants weighing < or = 1,500 g at birth, in many populations. To understand the morbidity and survival of VLBW infants in Taiwan, the records of all VLBW admitted to the 12 hospitals with a level II+ or level III neonatal intensive care unit (NICU), at < 7 days of age, from January 1 to December 31, 1996, were collected prospectively. A total of 613 VLBW infants (292 males and 301 females) met the enrollment criteria: 305 cases from the northern region, 181 cases from the central region, and 127 cases from the southern region of Taiwan. The mean birth weight was 1,133 g (range, 368-1,500); the mean gestational age (GA) was 28.9 weeks (range, 21-38). Among the VLBW infants, 25.8% were small-for-gestational-age, 90.2% were born to mothers with high-risk factor(s) for preterm delivery, 55% were born by cesarean section, and 68.1% required resuscitation at birth. The percentage of prenatal use of steroids was 52.9%, and < 20% received more than one dose of antenatal steroids. Thirty-three percent were born after antenatal maternal transfer, and the neonatal transfer rate was 23%. The most common neonatal complication was apnea of prematurity (66.1%), followed by respiratory distress syndrome (RDS) (60%). Chronic lung disease occurred in 76 cases (16.5%). The overall survival rate of the 613 VLBW infants was 76.2%; for infants weighing < or = 1000 g at birth, it was 49.2%, and for infants weighing 1,001-1,500 g at birth, it was 88.5%. The survival rate for infants with a GA < or = 26 weeks was 35.3%, and for infants with a GA of 27-36 weeks was 87.5%. No infant with a birth weight < or = 600 g or a GA < 23 weeks survived. The most common cause of death was sepsis, followed by extreme prematurity (GA < or = 23 wks) and RDS. Several perinatal and neonatal factors were related to the mortality. Multiple regression analysis of survival showed that GA < or = 26 weeks, birth weight < or = 800 g, delivery room resuscitation and the occurrence of pneumothorax were related to mortality. Therefore, although the survival rate of VLBW infants admitted to level II(+)-III NICUs showed an improvement over the rate for the previous 20 years in Taiwan, perinatal and neonatal care of extremely preterm infants and neonatal resuscitation programs need to be emphasized to improve the outcome of VLBW infants furthermore.

Current controversies surrounding the use of repeated courses of antenatal steroids.

The use of a single dose of antenatal steroids to facilitate fetal lung maturation in the expectant management of threatened preterm birth has significantly improved the mortality and morbidity of premature infants worldwide. In some settings, the evidence for this practice has been extrapolated with self-reports of up to 6 repeated courses during the antepartum period. Concerns about the use of repeated antenatal courses prompted the National Institutes of Health (NIH) to publish a consensus statement (2000) that reaffirmed the safety and efficacy of a single course of antenatal steroids, but emphasized that there are no data to support the safety and efficacy of repeated courses. The statement cautions against the use of multiple courses outside of research protocols. Despite these recommendations, wide variations in clinical practice continue to exist. There are growing concerns about the potential deleterious effects of steroid exposure on the developing human brain. It is plausible, although not proven, that negative neurodevelopmental impact may occur, or be compounded by multiple antenatal or combined antenatal and postnatal steroid exposures. This article provides a review of the evidence to support appropriate steroid use. The physiology and pharmacology of both endogenous and exogenous steroids are outlined to enhance the clinician's understanding of these potent agents. Recommendations for targeted clinical evaluation and short- and long-term follow-up of steroid exposed infants are provided. A clear understanding of the known and potential risks and benefits of single and multiple courses of antenatal steroids is essential to prompt a critical re-examination of the safety and efficacy of repeated steroid exposure in the neonate.

Efficacy of a single dose of antenatal steroid in surfactant-treated babies under 31 weeks' gestation

Objectives: Antenatal steroids in labor improve the outcome in preterm babies. The objective in this retrospective study was to compare the efficacy of one dose of antenatal steroid against the standard course in surfactant-treated babies. Methods: A total of 226 babies treated with prophylactic surfactant and under 31 weeks' gestation were divided into three groups: group 1 (n = 89), no antenatal steroids; group 2 (n = 68), one dose of antenatal steroids 4-24 h before delivery; and group 3 (n = 69), two or more doses of antenatal steroids 24 h to 7 days before delivery. The three groups were compared for early clinical well-being and ultimate clinical outcome. Results: Apgar and Clinical risk index for babies (CRIB) scores in groups 2 and 3 were similar and both were significantly better than in group 1. Group 2 babies had a 23.5% reduction in serious intraventricular hemorrhage (IVH) (p < 0.0001, relative risk (RR) 0.2 (95% CI 0.07-0.54), numbers needed to treat (NNT) 4.6) and a 22.9% reduction in death (p < 0.001, RR 0.28 (95% CI 0.12-0.63), NNT 4.4) and group 3 babies had a 21.1% reduction in IVH (p < 0.001, RR 0.25 (95% CI 0.10-0.62), NNT 4.6) and a 24.2% reduction in death (p < 0.001, RR 0.23 (95% CI 0.10-0.57), NNT 4.2) compared to group 1. For these parameters, there was no significant difference between groups 2 and 3. Conclusions: One dose of antenatal steroids given 4-24 h before delivery was clinically comparable to the recommended schedule of the National Institutes of Health in surfactant-treated preterm infants. Should the findings of this study be confirmed in randomized controlled trials, the dosage regimen could be simplified, steroid administration reduced and the interval from delivery reduced in acute clinical conditions.