Antenatal Steroid Use Research Articles

From Liquid to Air: Breathing after Birth

The first breaths after birth are characterized by a rapid transition from liquid- to air-filled lungs. Air is drawn into the lung during inspiration, and some remains at end expiration to establish an end-expiratory gas volume or functional residual capacity (FRC). This is usually marked by a cry, often misinterpreted as a protest from the baby. Some infants, especially those born preterm, require respiratory support during this transitional phase. To do this effectively, we need to understand the normal physiological processes occurring at this time. Sometimes it can be difficult to aerate the lungs of preterm infants with intermittent positive pressure ventilation with pressures recommended in international guidelines, particularly when the infant does not breathe and aeration is completely dependent on the inflation pressures. Studies have shown that intermittent positive pressure ventilation should be performed without high tidal volumes to avoid damaging the lung while establishing the FRC. 1,2 However, since the use of antenatal steroids, more very preterm infants breathe spontaneously at birth, only requiring support from nasal continuous positive airway pressure. Understanding the normal spontaneous breathing pattern after birth is essential for developing safe, efficient ventilatory strategies when breathing is inadequate. Numerous physiological studies immediately after birth of spontaneously breathing infants were published between 1960 and 1986. 3-10 However, little new data are currently available on this topic, reflecting the difficulties of performing these studies. This review will discuss what happens during the first breaths of air with the emphasis on where the liquid goes and the current knowledge about the spontaneous breathing pattern adopted by infants immediately after birth.

Risk factors for gastroesophageal reflux disease in very low birth weight infants with bronchopulmonary dysplasia

To assess risk factors for gastroesophageal reflux disease (GERD) in very low birth weight infants with bronchopulmonary dysplasia. A case-control study was carried out in 23 cases and 23 control subjects with bronchopulmonary dysplasia submitted to 24-hour esophageal pH monitoring between January 2001 and October 2005. Cases and controls were compared for gestational age, birth weight, gender, use of antenatal steroids, duration of assisted ventilation, duration of oxygen therapy, length of gastric tube use, administration of xanthines, postconceptual age, and weight at esophageal pH monitoring. Multiple logistic regression analysis was used to establish the odds ratio (OR) with a 95% confidence interval (95%CI). None of the groups (with and without GERD) showed statistically significant differences in terms of demographic variables and postnatal outcome, use of antenatal and postnatal corticosteroids, or in terms of caffeine use and duration of mechanical ventilation and oxygen therapy. However, feeding intolerance (OR = 6.55; 95%CI 1.05-40.8) and length of gastric tube use (OR = 1.67; 95%CI 1.11-2.51) turned out to be risk factors for GERD. Postconceptual age at the time of pH monitoring (OR = 0.02; 95%CI < 0.001-0.38) was regarded as a protective factor against GERD. The data obtained allow inferring that prolonged gastric tube use and feeding intolerance increase the risk for GERD. On the other hand, older postconceptual age at the time of pH monitoring reduces the risk for GERD in preterm infants with bronchopulmonary dysplasia weighing less than 1,500 g.

Ethics ain't easy: do we need simple rules for complicated ethical decisions?

Recommendations from national bodies regarding extremely preterm infants have focussed almost exclusively on thresholds for intervention based upon estimated gestational age (GA) alone. We reviewed policy statements that address active intervention for newborn infants and compare them with those that are available for older patients. We reviewed research, examining attitudes towards preterm infants, uncertainties in GA assessment and other factors important in determining prognosis at the time of birth. Policy statements regarding active care of very preterm infants treat this population differently from others in morally significant ways--without rationalizing this discrepancy. Extremely preterm infants are devalued in medical and lay opinion compared to older individuals with similar outcomes. Uncertainty in GA estimates often covers a range with vastly differing prognoses. Sex, birth weight, inborn-outborn status and use of antenatal steroids are vitally important in prognosis, but clinical findings in the delivery room are not. Most policy statements fail to account for these factors. Simplistic policies based on GA alone should be avoided. Decision making for extremely preterm infants should recognize that they are each unique and must be individualized, taking into account all relevant prognostic factors and the values and wishes of the families.

The role of antenatal corticosteroids for improving the maturation of choroid plexus capillaries in fetal mice

We investigated whether the use of antenatal corticosteroids could improve the maturation of choroid plexus capillaries in fetal mice. The study was carried out in two groups of preterm mice. The study group consisted of pregnant mice that received dexamethasone at a dose of 4 mg/kg intraperitoneally. This group was further subdivided into four subgroups according to the timing of steroid administration as follows: day 13, day 14, day 15, and day 16 of pregnancy, and each subgroup included 12 premature mice. All animals received a second injection 24 hours after the first injection. The control group was given normal saline. The pregnant mice were operated on to obtain premature mice. The choroid plexus capillaries were assessed for integrity and thickness of their basement membranes by electronmicroscopy. We found that, in the study group, the maturity of the basement membrane of the choroid plexus capillaries was more precise, in that capillaries were better in control animals at term for the following reasons: (a) the basement membrane becomes more intact, (b) thickness of the basement membrane increased, and (c) the protein particles become tighter. Antenatal dexamethasone improved the maturation of the choroid plexus capillaries in fetal mice but also decreased the incidence of periventricular-intraventricular hemorrhage (PIVH). Using two doses of steroids had no influence on birthweight or brainweight of the mice. In conclusion, these findings provide an experimental basis for the use of antenatal steroids for decreasing the incidence of PIVH in premature infants.

Bioethical aspects in the care of extremely preterm infants

The survival rate of extremely preterm infants improved over the last years as a result of a better prenatal and neonatal care mainly due to a greater use of antenatal steroids, appropriate management in the delivery room and in the initial care, surfactant therapy, and better modalities of assisted ventilation. However, this improvement in survival has not been associated with an equal reduction in morbidity. In fact, the frequency of bronchopulmonary displasia, sepsis, poor growth, and neurological disorders in the future may have increased. The purpose of this article is to examine, from a bioethical point of view, different aspects in perinatal care at the threshold of viability.

Expectant management compared with physical examination–indicated cerclage (EM-PEC) in selected women with a dilated cervix at 14 0/7-25 6/7 weeks: results from the EM-PEC international cohort study

The objective of the study was to compare pregnancy outcomes in selected women with a dilated cervix who underwent expectant management or physical examination-indicated cerclage. This was a historical cohort study conducted by the Global Network for Perinatal and Reproductive Health. Women between 14(0/7) and 25(6/7) weeks' gestation with a dilated cervix were identified at 10 centers by ultrasound or digital examination. Primary outcome was time from presentation until delivery (weeks). Secondary outcomes were neonatal survival, birthweight greater than 1500 g and preterm birth less than 28 weeks. Multivariate regression was used to assess the likelihood of neonatal outcomes and control for confounders. Of 225 women, 152 received a physical examination-indicated cerclage, and 73 were managed expectantly without cerclage. Cervical dilation, gestational age at presentation, and antenatal steroid use differed between groups. In the adjusted analyses, cerclage was associated with longer interval from presentation until delivery, improved neonatal survival, birthweight greater than 1500 g and preterm birth less than 28 weeks, compared with expectant management. Similar results were obtained in the analyses limited to women dilated between 2 and 4 cm (n = 122). In this study, the largest cohort reported to date, physical examination-indicated cerclage appears to prolong gestation and improve neonatal survival, compared with expectant management in selected women with cervical dilation between 14(0/7) and 25(6/7) weeks. A randomized, controlled trial should be conducted to determine whether these potential benefits outweigh the risks of cerclage placement in this population.

A randomized controlled trial of synchronized nasal intermittent positive pressure ventilation in RDS

Comparison of outcomes of infants with respiratory distress syndrome (RDS), post-surfactant, extubated to synchronized nasal intermittent positive pressure ventilation (SNIPPV) or continued on conventional ventilation (CV). Prospective post-surfactant randomized controlled trial of primary mode SNIPPV compared with CV in infants (born from July 2000 to March 2005) with birth weights (BW) of 600 to 1250 g. Primary mode SNIPPV was defined as its use in the acute phase of RDS, following the administration of the first dose of surfactant. There were no significant differences in the maternal demographics, antenatal steroid use, mode of delivery, BW, gestational age, gender or Apgar at 5 min between infants continued on CV (n=21) and those extubated to primary mode SNIPPV (n=20). Significantly, more babies in the CV group had the primary outcome of bronchopulmonary dysplasia (BPD)/death, compared to the SNIPPV group (52 versus 20%, P=0.03). There was no difference in the incidence of other common neonatal morbidities. There were no differences in the Mental or Psychomotor Developmental Index scores on follow-up between the two groups. Infants of BW 600 to 1250 g with RDS receiving surfactant with early extubation to SNIPPV had a significantly lower incidence of BPD/death. Primary mode SNIPPV is a feasible method of ventilation in small premature infants.

Effectiveness of Fetal Fibronectin Testing Compared with Digital Cervical Assessment of Women With Preterm Contractions

The purpose of this study is to determine the effectiveness of fetal fibronectin (FFN) compared to assessment of cervical dilation (CD) in clinical management of women with symptomatic preterm labor (PTL). Pregnant women presenting to Thomas Jefferson University Hospital between May 1, 2001 and November 30, 2002 with symptomatic PTL underwent FFN sampling and had a complete clinical evaluation including a pelvic bimanual examination. Inclusion criteria were singleton pregnancy, gestational age (GA) between 24 (0) and 33 (6) weeks, CD < 3 cm, and intact amniotic membranes. FFN samples were sent out and results were available within 4-12 hours. Clinical management including tocolysis, antenatal steroids, and hospitalization was determined based on digital CD assessment and FFN status. A dilated cervix was defined as CD > 1 cm. Ninety-three patients were included. Spontaneous preterm delivery (SPTD) at < 37 weeks occurred in 20 of 93 (21.5%) patients. Medical therapy use was significantly higher in patients with dilated cervix than in those with a closed cervix (all P values < 0.05). Tocolysis and steroid use in FFN-negative patients and FFN-positive patients were not significantly different. Furthermore, tocolytic use was higher in FFN-negative patients than in women with positive FFN (50% versus 42.1%; P = 0.53). Use of antenatal steroids was similar in patients with CD >/= 1 cm and a positive FFN (54.5% versus 47.4%; P = 0.92). Compared with FFN-negative patients, women with closed cervix were less likely to undergo interventions. In symptomatic PTL patients, CD determined clinical management more than FFN status. Overall, the use of FFN was not effective in decreasing "unnecessary" clinical interventions.

Intima–media thickness of the abdominal aorta of neonate with different gestational ages

To determine aortic intima-media thickness (aIMT) values in newborns with different gestational ages and to asses the effect of antenatal steroids on aIMT. Two hundred forty newborns from healthy mothers had their distal abdominal aIMT measured during abdominal sonographic examination. The neonates were divided into 4 groups (60 in each group) according to gestational age: group I (25-28 weeks), group II (29-32 weeks), group III (33-37 weeks), and group IV (38-42 weeks). The interobserver and intersubject intraclass correlation coefficient was 0.93 and 0.94, respectively. Mean aIMT was 0.316 mm, 0.335 mm, 0.348 mm, and 0.385 mm, respectively, in group I, II, III, and IV, increasing significantly with gestational age at birth (p < 0.0001). There was no apparent effect of antenatal steroid use on aIMT. Multivariate regression models for mean aIMT demonstrated a significant association with aortic lumen diameter (p < 0.0001). Abdominal aIMT can be reproducibly measured in neonates and may be a useful tool for epidemiologic studies.

Antenatal dexamethasone and renal vascular resistance in preterm infants

To compare vascular resistance, renal volume and insulin levels in preterm infants with and without antenatal steroids. We studied 61 preterm infants (37 with (group A) and 24 without antecedent of antenatal steroids (group B)). We measured insulin levels at birth in cord blood samples. Ultrasound measurements to evaluate renal arteries resistance index and renal volume were performed during the first 72 h of birth. Preterm infants from group A tended to have lower weight and gestational age than those from group B. Resistance index in renal arteries was lower in preterm infants with steroid therapy compared with group B (right renal artery 0.73 vs. 0.80; P=0.001, and left renal artery 0.75 vs. 0.79; P=0.01, respectively). Renal volume and insulin levels were not different between the groups. In the multiple regression analysis for factors associated with resistance index of renal arteries, only antenatal steroids use was included in the model (R2=0.13; P=0.003 and R2=0.10; P=0.01 for left and right renal arteries, respectively). Antenatal dexamethasone in preterm infants during the first 72 h of birth seems to decrease resistance index in renal arteries without affecting renal volume and insulin levels.

Improved Neurodevelopmental Outcomes for Extremely Low Birth Weight Infants in 2000–2002

Neurodevelopmental impairment of extremely low birth weight infants increased in the 1990s. Modern therapeutic changes may have influenced more recent neonatal outcomes. We sought to compare neonatal therapies and outcomes among all extremely low birth weight infants born in 2000-2002 (period III) to 2 previous periods: 1982-1989 (period I) and 1990-1999 (period II). The population included 496 extremely low birth weight infants born at our perinatal center during period I, 749 during period II, and 233 during period III. Therapies, rates of death, and survival with and without impairment at 20 months' corrected age were compared. Between periods I and II, survival increased from 49% to 68% as did neonatal morbidity. This resulted in increased survival without impairment but also increased survival with impairment. Changes in therapy during period III included an increase in antenatal steroid use and a decrease in postnatal steroid use, although the rate of chronic lung disease did not change. Sepsis decreased, as did severe intraventricular hemorrhage. On follow-up, the rate of cerebral palsy decreased from 13% to 5%, resulting in a decrease in neurodevelopmental impairment from 35% to 23%. As a result, during period III versus II, survival without impairment increased, whereas survival with impairment decreased. Since 2000, neurodevelopmental impairment has decreased among extremely low birth weight infants. A variety of perinatal and neonatal factors were associated with the improved outcomes including increased antenatal steroid use and cesarean section delivery, as well as decreased sepsis, severe cranial ultrasound abnormalities, and postnatal steroid use despite no change in the rate of chronic lung disease.

RISK FACTORS FOR SPONTANEOUS INTESTINAL PERFORATION IN EXTREMELY LOW BIRTH WEIGHT NEONATES.

Purpose of Study Spontaneous intestinal perforations (SIP) in extremely low birth weight (ELBW) neonates are distinctly different from necrotizing enterocolitis (NEC) and appear to be increasing in incidence. The etiology of SIP is not well understood. We performed a retrospective cohort study to identify potential patient characteristics, as well as perinatal and neonatal therapeutic interventions that may increase the risk of SIP. Methods All ELBW ( Summary of Results There were 13 cases of SIP identified and 165 NP controls. The mean gestational age was lower for the SIP group, but this did not reach statistical significance (SIP 25.85 ± 0.56 vs NP 26.18 ± 0.16 weeks, p = .46). Likewise, the mean birth weight was comparable for both groups (SIP 732.5 ± 40.07 g and NP 758.1 ± 11.53 g, p = .46). There was no statistical difference in the use of antenatal maternal steroids (SIP 61.5% vs NP 43.6%, p ≤ .25). There were no significant differences in maternal indomethacin (SIP 7.7% vs NP 9.7%) or magnesium sulfate use (38.5% vs 40%). In contrast, there was a significantly higher incidence of terbutaline use in mothers of SIP infants (30.77% vs 9.09%, p ≤ .025). Use of indomethacin in neonates was higher in the SIP group; however, the difference did not reach statistical significance (SIP 69.23% vs NP 56.36%, p ≤ .24). Hydrocortisone administration in the first 16 days of life was higher in the SIP group versus NP, but this also did not reach statistical significance (15.38% vs 10.9%, p ≤ .24). Conclusions Reached Contrary to previous reports, indomethacin does not appear to increase the risk of SIP. Tertbutaline tocolysis of the mother is associated with increased risk for development of SIP in premature infants. Prospective studies need to be designed to confirm this association. In the meantime, a high index of suspicion for SIP must be maintained in preterm infants exposed to maternal terbutaline.

Latency antibiotics in preterm premature rupture of membranes: Are they still indicated?

THEY STILL INDICATED? EVA PRESSMAN, CARLA KOVACS, University of Rochester, Obstetrics and Gynecology, Rochester, New York OBJECTIVE: Prior studies have indicated that antibiotics for the prolongation of latency in patients with preterm premature rupture of membranes (PPROM) lead to improved neonatal outcomes. These studies were done prior to widespread use of tocolytics, antenatal steroids andGroupB streptococcus (GBS)prophylaxis in patientswithPPROM.The purpose of our study is todeterminewhether the use of latency antibiotics improves outcomes in current obstetrical practice. STUDY DESIGN: We performed a retrospective cohort analysis of subjects with PPROM at 18 to 34 weeks from 2002 to 2006. Use of latency antibiotics for PPROM became common in 2004 at our institution. Data were collected on gestational age (GA) at PPROM and the use of latency antibiotics, tocolytics, GBS prophylaxis, and steroids. Primary outcomes were latency until delivery and NICU length of stay (LOS). Secondary outcomes included chorioamnionitis, neonatal sepsis, necrotizing enterocolitis, respiratory distress syndrome, intraventricular hemorrhage and neonatal death. Continuous data were analyzed with t-tests and categorical data with Chi square. RESULTS: We identified 207 subjects; 69 received latency antibiotics and 138 did not. The groups were similar with respect to GA at PPROM (29.4 vs 30.2 wks) and administration of tocolytics (74% vs 71%), GBS prophylaxis (84% vs 89%) and steroids (81% vs 73%), pO0.05 for all. We found no differences in either latency (15.3 vs 15.7 days, p=0.93) or NICU LOS (26.2 vs 30.6 days, p=0.27), or in any of the secondary outcomes. Post hoc power analysis revealed 93% power to detect a 7 day difference in latency and 81% power to detect a 7 day difference in NICU LOS. CONCLUSION: Unlike prior studies, we did not find prolonged latency or improved neonatal outcome in PPROM subjects who received latency antibiotics. Our population differs from prior study populations in the routine use of antenatal steroids, tocolytics and antibiotics for GBS prophylaxis. Our findings draw into question the need for latency antibiotics in PPROM patients who are receiving these therapies.

Hypernatraemia in preterm infants born at less than 27 weeks gestation

To study the incidence of hypernatraemia (plasma sodium >145 mmol/L), identify predisposing factors to and associated complications of hypernatraemia in preterm infants born less than 27 weeks gestation in the first 5 days of life. Preterm infants less than 27 week gestation over an 18-month period were studied by retrospective analysis of patient records. Data were collected on gestation, birthweight, sex, antenatal steroid use, phototherapy, incubator humidity, time of transfer to incubator, plasma sodium, urea and creatinine. Actual fluid and sodium intake was calculated for the first 5 days of life. Data were collected on chronic lung disease, patent ductus arteriosus, intraventricular haemorrhage, necrotising enterocolitis and death. In this study 46 (69.7%) of 66 infants studied developed hypernatraemia (>145 mmol/L), occurring most frequently between 24 and 48 h of age. The median gestation of hypernatraemic babies was significantly lower. There was no significant difference in median birthweight, or factors associated with increased insensible water loss between the hypernatraemic and the non-hypernatraemic groups. Fluid intake was significantly higher on days 2, 3 and 4 in the hypernatraemic group. There was no difference in sodium intake between the two groups. More hypernatraemic babies compared with controls developed chronic lung disease, patent ductus arteriosus, significant intraventricular haemorrhage, necrotising enterocolitis and died, but was not significant. Hypernatraemia occurs commonly in preterm infants less than 27 weeks gestation and was not associated with significant morbidity. The more immature infants developed hypernatraemia and all cases resolved after increasing fluid intake.

Changes in the Use of Postnatal Steroids for Bronchopulmonary Dysplasia in 3 Large Neonatal Networks

Postnatal corticosteroids were widely used in the 1990s in an attempt to reduce the incidence of bronchopulmonary dysplasia. However, high rates of short-term adverse effects and impaired neurodevelopmental outcomes were seen. In early 2002, a joint statement of the American Academy of Pediatrics and Canadian Paediatric Society called for limitation in the use of postnatal corticosteroids. The impact of this statement is not known. The purpose of this work was to determine the frequency of postnatal corticosteroid use and mortality and morbidities over time, particularly before and after the joint statement. We conducted a retrospective analysis of cohort data within 3 large network registries (the National Institute of Child Health and Development Neonatal Research Network [18 centers], the Vermont Oxford Network [444 centers], and the Canadian Neonatal Network [10 centers]) for the following 3 periods: prestatement (2001), statement (2002), and poststatement (2003) of very low birth-weight infants (501-1500 g). The National Institute of Child Health and Development Neonatal Research Network and the Vermont Oxford Network were also analyzed for longer-term trends from 1990 to 2003. Postnatal corticosteroid use, mortality at discharge, and neonatal morbidities (bronchopulmonary dysplasia at 36 weeks, late-onset infection >72 hours of age, necrotizing enterocolitis treated with surgery, and length of stay) between periods were compared. Mean birth weight (range: 1022-1060 g), postmenstrual age (28 weeks), and gender (51% male) were similar between the networks. Race differed with more black infants in the National Institute of Child Health and Development Neonatal Research Network than the Vermont Oxford Network (38% vs 24%). Antenatal steroid use was similar (range: 61%-75%). Postnatal corticosteroid use rose from 1990 (8%-16%), peaked in 1996-1998 (24%-28%), and began to decline in 1999. Use in 2003 was significantly less than in 2001. Mortality and major morbidities were similar. Postnatal corticosteroid use had decreased significantly in 3 large neonatal networks before the joint statement with further decreases after the statement with no apparent impact on mortality and short-term morbidity. Despite substantial decreases, approximately 8% of very low birth-weight infants continue to be treated with postnatal corticosteroid.

The effects of indomethacin tocolysis on the postnatal response of the ductus arteriosus to indomethacin in extremely low birth weight infants

Antenal indomethacin reportedly decreases the responses of a symptomatic patent ductus arteriosus (sPDA) to postnatal indomethacin treatment. Whether a similar exposure affects the responses to indomethacin prophylaxis is unknown. To evaluate the clinical responsiveness of ductus arteriosus to indomethacin prophylaxis and to the treatment of sPDA in extremely low birth weight (ELBW) infants following indomethacin tocolysis. Retrospective cohort study of 58 ELBW infants whose mothers received indomethacin tocolysis (study) and 58 ELBW infants whose mothers did not (controls), matched by gender, gestational age (GA), birth weight and postnatal sPDA management (prophylaxis or early treatment). Indomethacin was used as a tocolytic at a median dose of 250 mg, for a duration of 2 days, and ending 1 day before delivery. Study and control mothers were comparable in demographics, antenatal steroid use, cesarean delivery, but were different in the incidence of preeclampsia and preterm labor. Study and control infants were similar in birth weight, GA, indomethacin prophylaxis, early sPDA treatment, mortality, necrotizing enterocolitis, severe intraventricular hemorrhage and stage 3-5 retinopathy of prematurity. Seventeen of 43 study and 16 of 43 control infants who received indomethacin prophylaxis developed sPDA and were combined with early treatment sPDA infants (15 to each group). Two of 32 study and two of 31 control infants underwent surgical ligation whereas the remaining were treated with indomethacin. Sixteen of 30 (53%) and 13 of 29 (45%) were successfully treated and did not require ligation. Study infants were divided according to their mothers' indomethacin total dose (28 infants received <or=225 mg and 30 infants received >225 mg). Both subgroups were demographically and clinically comparable and their response to indomethacin prophylaxis and treatment were similar. In ELBW infants, exposure to indomethacin tocolysis does not affect the clinical responsiveness of the ductus arteriosus to prophylaxis or that of the sPDA to indomethacin treatment.

Respiratory Review

Respiratory care of the newborn is a primary focus of nurses in the neonatal intensive care unit because respiratory dysfunction represents a major reason for admission. Important research findings and discoveries, such as antenatal steroid use and exogenous surfactant replacement, have changed the extent, severity, and treatment of respiratory illness in the newborn. Understanding fetal lung development and events surrounding transition of the lung to extrauterine life provides a knowledge base when evaluating respiratory diseases. This article will review fetal lung development, transitional events affecting the lung after delivery, and current pathophysiologic presentation of 3 common respiratory disorders, including transient tachypnea of the newborn, meconium aspiration syndrome, and surfactant deficiency.

Site-specific characteristics of infants developing bronchopulmonary dysplasia

Site-specific variables that contribute to the pathogenesis of bronchopulmonary dysplasia (BPD) can be identified. To evaluate the demographic, nutrition and growth characteristics of infants at risk for developing BPD at two neonatal intensive care units (NICUs: sites A and O). Records of 306 infants of < or = [corrected] 30 weeks gestational age (GA) who survived to at least 36 weeks postmenstrual age were retrospectively reviewed. Data were obtained for maternal and neonatal demographics, weights, total fluids, calories, carbohydrate, protein and fat intake at birth, 7, 14, 21 and 28 days of life. BPD rates were not different at the two sites. No statistical differences were noted in the incidence of maternal chorioamnionitis, pregnancy-induced hypertension or use of antenatal steroids among infants who developed BPD (n = 169) and those who did not (n = 137). White race, birth weight, respiratory distress syndrome requiring surfactant, sepsis and patent ductus arteriosus were significantly associated (all P < or =0.03) with BPD. After controlling for significant confounding variables, infants who developed BPD had significantly (P < 0.001) less weight gain, received less calories and fat in the first postnatal month. In the 26 to 28 weeks GA group, the odds of getting BPD were 5.4 (95%CI: 1.4 to 21.3) times greater for site A than site O (P = 0.017). Our analysis suggests that while some decrease in BPD can be achieved by focusing on ventilation/oxygen use, this approach is unlikely to impact on the youngest infants.

Promoting antenatal steroid use for fetal maturation: Results from the California Perinatal Quality Care Collaborative

The California Perinatal Quality Care Collaborative (CPQCC) was formed to seek perinatal care improvements by creating a confidential multi-institutional database to identify topics for quality improvement (QI). We aimed to evaluate this approach by assessing antenatal steroid administration before preterm (24 to 33 weeks of gestation) delivery. We hypothesized that mean performance would improve and the number of centers performing below the lowest quartile of the baseline year would decrease. In 1998, a statewide QI cycle targeting antenatal steroid use was announced, calling for the evaluation of the 1998 baseline data, dissemination of recommended interventions using member-developed educational materials, and presentations to California neonatologists in 1999-2000. Postintervention data were assessed for the year 2001 and publicly released in 2003. A total of 25 centers voluntarily participated in the intervention. Antenatal steroid administration rate increased from 76% of 1524 infants in 1998 to 86% of 1475 infants in 2001 (P < .001). In 2001, 23 of 25 hospitals exceeded the 1998 lower-quartile cutoff point of 69.3%. Regional collaborations represent an effective strategy for improving the quality of perinatal care.

Catch-up growth and development of very low birth weight infants

Purpose:The aim of this study was to analyze the results and contributing factors of catch-up growth in very low birth weight infants(VLBWI) at the corrected age of 2 years. In addition, we looked for a relationship between the catch-up growth and the development by the bayley scales of infant development II(BSID II). Methods:A retrospective analysis by evaluating medical records was done for the 76 VLBWI whose follow-up was possible up to a corrected age of 2 years, out of the 114 who had been treated in the neonatal intensive care unit during the January of 2000 to December of 2001 at Samsung Cheil Hospital. Based on the Standard Korean Infant's Growth Curve, the catch-up growth group was defined over the 10th percentile of weight at 2 years as the corrected age and the failed catch-up growth group was defined under the 10th percentile. We investigated the clinical factors and courses of each group and compared the scores of the BSID II. Results:The catch-up growth group of the VLBWI was 51 infants and the failed catch-up growth group was 25 infants. In comparison with maternal clinical factors, use of antenatal steroids was significantly higher in the catch-up growth group. In comparisn with clinical factors and courses of VLBWI, two clinical factors were significantly different between the two groups : birth weight and intrauterine growth retardation(IUGR). Numbers of delayed development were increased in the failed catch-up growth group but statistically significant differences could not be observed. Conclusion:The catch-up growth of the VLBWI was affected by the use of antenatal steroids, birth weight and IUGR. No significant differences regarding neurodevelopmental outcome were observed between the catch-up and failed catch-up growth groups.