Antenatal Steroid Use Research Articles

Prediction of outcome from the chest radiograph appearance on day 7 of very prematurely born infants

Our aim was to determine whether the chest radiograph appearance at 7 days predicted chronic lung disease development (oxygen dependency at 36 weeks post-menstrual age) or death before discharge and if it was a better predictor than readily available clinical data. Two consecutive studies were performed. In both, chest radiographs taken at 7 days for clinical purposes were assessed using a scoring system for the presence of fibrosis/interstitial shadows, cystic elements and hyperinflation and data were collected regarding gestational age, birth weight, use of antenatal steroids and post-natal surfactant and requirement for ventilation at 7 days. Oxygenation indices were calculated in the first study (study A) at 120 h and in the second (study B) at 168 h. In study A, there were 59 infants with a median gestational age of 26 weeks (range 24 to 28 weeks) and in study B, 40 infants with a median gestational age of 27 weeks (range 25-31 weeks). In both studies, infants who developed chronic lung disease had a significantly higher total chest radiograph score, with a higher score for fibrosis/interstitial shadowing than the rest of the cohort. Infants who died before discharge differed significantly from the rest with regard to significantly higher scores for cysts. In both studies, the areas under the receiver operator characteristic curves with regard to prediction of chronic lung disease were higher for the total chest radiograph score compared to those for readily available clinical data. In infants who require a chest radiograph for clinical purposes at 7 days, the chest radiograph appearance can facilitate prediction of outcome of infants born very prematurely.

Treatment and prevention of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is the most common serious, acquired gastrointestinal disorder in the newborn infant. Although many variables are associated with development of NEC, only prematurity has been consistently identified in case-controlled studies. Traditionally, the diving seal reflex has been invoked as the mechanism responsible for ischaemic injury and necrosis. Intestinal ischaemia is likely to be the final common pathway in NEC; however, it is due to the release of vasoconstricting substances, such as platelet activating factor, rather than perinatal asphyxia. Bacteria and/or bacterial toxins are likely to have a key role in the pathogenesis of NEC by fostering production of inflammatory mediators. The role of feeding practices in the pathogenesis of NEC remains controversial. Treatment of infants with NEC generally includes a regimen of bowel rest, gastric decompression, systemic antibiotics and parenteral nutrition. Infants with perforation are generally operated upon; however, there has been recent interest in primary peritoneal drainage as an alternative. Prevention of NEC still remains elusive. Avoidance of preterm birth, use of antenatal steroids and breast-milk feeding are practices that offer the greatest potential benefits. Use of any other strategy should await further trials.

The association between respiratory distress and nonpulmonary morbidity at 34 to 36 weeks' gestation

Objective The study was undertaken to determine whether respiratory distress syndrome (RDS) is associated with an increased risk of nonpulmonary morbidity in neonates born between 34 to 36 weeks' gestation. Study design We performed a matched case-control study of 75 infants with (cases) and 75 without (controls) RDS, delivered between 34 and 36 weeks' gestation. Infants with RDS and no other causes for respiratory failure (anomalies, hydrops, asphyxia) were included. Controls were matched for gestational age at birth, year of care, gender, plurality, and race. Inpatient records were reviewed for the incidence of nonpulmonary morbidities before discharge. McNemar test and conditional logistic regression were used to evaluate differences between cases and controls. Results Our study cohort was 69% male, 48% white, 33% African American, and 19% Hispanic. Cases had longer hospital (11 vs 7days) and neonatal intensive care unit stays (10 vs 7days), and more frequent apnea-bradycardia (30% vs 5%), pneumonia (12% vs 1%), and suspected sepsis diagnoses (27% vs 3%), P ≤ .008 for each. Antibiotic use (96% vs 45%), transfusion (20% vs 0%), phototherapy (57% vs 29%), and hyperalimentation (57% vs 4%) were more common in the RDS group, P ≤ .002 for each. Other major morbidities (intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, bronchopulmonary dysplasia) were uncommon in cases and controls. Similar results were obtained when controlling for mode of delivery and antenatal steroid use. Conclusion RDS at 34 to 36 weeks is associated with increased morbidity and neonatal interventions. In the absence of RDS, major morbidity is uncommon.

Treatment of patent ductus arteriosus

Patent ductus arteriosus (PDA) continues to be one of the most common problems found in premature infants. The incidence is inversely related to gestation, but may be reduced by use of antenatal steroids, lower volume fluid regimen and judicious use of phototherapy. However, there continues to be controversy as to the appropriate indications for treatment, varying from prophylaxis on the basis of gestation to treatment only when a PDA is demonstrably significant. The situation is further complicated by differing diagnostic criteria for ductal patency or significance. Prophylactic treatment is likely to result in up to 64% of babies being treated unnecessarily. Early treatment of significant or symptomatic PDA depends upon accurate diagnosis. PDA closure can then be achieved using medical means, with surgery reserved for patients in whom this fails or in whom there are contra-indications. However, the optimum timing for intervention remains unknown.

Respiratory distress syndrome in VLBW infants: changes in management and outcomes observed by the NICHD neonatal research network

This article examines the impact of major changes in the prevention and management of respiratory distress syndrome on survival and respiratory morbidities in very low birth weight infants by examination of obstetric and neonatal variables from 15 years of National Institute of Child Health and Human Development (NICHD) Neonatal Network data on 14,494 infants of ≤ 30 weeks gestational age and ≤1500 g. Survival and bronchopulmonary dysplasia were plotted by gestational age and year to show changes coincident with the use of antenatal steroids and postnatal surfactant. Recent trends in bronchopulmonary dysplasia were examined with respect to changes in neonatal respiratory management and the incidence of other pulmonary complications. Surfactant use has steadily increased in infants ≤30 weeks gestational age since its widespread availability in 1990. Antenatal steroids were not widely used until after the 1994 National Institutes of Health (NIH) consensus statement. The percentage of infants receiving a full course of antenatal steroids increased after 1994, but appears to plateau after 1998; coincident with a marked decrease in the use of tocolytics. The proportion of infants 29–30 weeks’ gestation requiring no support increased after 1994, with fewer babies needing mechanical ventilation. This trend ended in 1999. Survival of infants ≥24 weeks improved steadily until 1997. The proportion of survivors requiring oxygen at 36 weeks postmenstrual age has increased since 1993–1994 in infants 24–28 weeks, and infants 29–30 weeks since 1998. There has been a steady increase in the diagnosis of PDA across all gestational ages since 1992. Pulmonary hemorrhage has shown an increased trend since 1998 in infants ≤28 weeks. Pneumothorax decreased in infants 25–30 weeks, from 1987 to 1998, with no clear trend beyond 1998. Postnatal steroid use peaked from 1995–1998, with markedly decreased use after 1998 in 24–26 week infants. The most dramatic improvement in survival and respiratory morbidity have occurred coincident with increased surfactant use since its availability in 1990. There were further improvements coincident with increased antenatal steroid use in 1994. These improvements have shown a plateau since 1998 and oxygen use at 36 weeks in survivors appears to be increasing across all gestational ages. These trends need to be examined further and standardized methods for determining oxygen requirement are needed.

Improved Outcomes for Very-Low-Birthweight Infants: Evidence From a New Zealand National Population-Based Data

The survival chances of very-low-birthweight (VLBW) infants, weighing less than 1500 g, continue to improve, and obstetricians today are more willing to intervene in earlier gestations. Nevertheless, debate continues about the propriety of offering neonatal intensive care for very preterm infants, especially those whose viability is in question. This prospective study compared survival and short-term morbidity in VLBW infants born in New Zealand in 1986 and 1998 through 1999. Data were collected from birth until discharge from the hospital or death. In 1986, 413 VLBW infants, representing 0.78% of live births, were admitted for intensive care. In 1998 through 1999 the number increased to 1084 or 0.96% of all live births, a 31% rise. The proportion of infants weighing 1000 to 1499 g at birth increased 20% from the earlier to the later period, whereas infants weighing 500 to 999 g increased 51%. Survival was significantly higher in 1998 through 1999 for all birth-weight groups, and 38% of 13 infants weighing less than 500 g survived in this period. There was a small reduction in overall median birthweight and gestation in the later period. Fewer infants born in 1998 through 1999 had a 5-minute Apgar score less than 7, and more were exposed to antenatal corticosteroids. There was no substantial difference in the risk of hyaline membrane disease, but more infants in the later period who lived 28 days received assisted ventilation (87% vs. 74% in the earlier group). Chronic lung disease was less frequent in the later period than in 1986, especially in infants weighing 1000 to 1499 g at birth. The same was the case for severe retinopathy of prematurity. The incidence of periventricular leukomalacia was probably higher in 1986. Survival of VLBW infants has improved, significantly in recent years even though more extremely low-birthweight infants are being admitted. At the same time, surviving infants have not experienced more short-term morbidity. Improved regionalization of neonatal intensive care is probably part of the reason, along with the wider use of antenatal steroids, treatments such as exogenous surfactant, and improved technology in the neonatal intensive-care unit.

Effects of gestational age and prenatal and perinatal events on the coagulation status in premature infants

Objective: To study prospectively the effects of prematurity and perinatal events on the coagulation status of premature infants. Patients and main outcome measures: Blood samples from premature infants born before...

REVIEW OF CLINICAL EXPERIENCE WITH ATOSIBAN AND THE TRACTOCILE EFFICACY ASSESSMENT SURVEY IN EUROPE (TREASURE) STUDY PROTOCOL

SUMMARYA phase IV multinational, multicentre study has been designed – the Tractocile Efficacy Assessment Survey in Europe (TREASURE). The aim is to assess atosiban in the clinical setting, which is associated with fewer restrictions than in phase III trials. Atosiban is to be compared with ‘usual care’ in women eligible for treatment, and will also be evaluated as deferred or immediate treatment in women who have not yet fulfilled the diagnostic criteria for pre‐term labour. Exploring the use of atosiban beyond the normal indications may allow the identification of additional subpopulations of women who will benefit from early treatment. TREASURE will offer data on new diagnostic tools, investigate respiratory distress syndrome according to severity and record the use of antenatal steroids. It is hoped that additional information concerning the subtle differences in clinical practice will broaden our understanding of how to manage pre‐term labour and offer the chance to revise treatment guidelines. (Int J Clin Pract 2003; 57(2): 121–127)

Effects of phenobarbital and multiple-dose corticosteroids on developmental outcome at age 7 years

Objective To determine the effects of phenobarbital and repeated antenatal steroid use on the primary outcome (intelligence and achievement) and secondary outcomes (behavior and head circumference) at age 7 years. Methods This study was a secondary analysis of a double-blind clinical trial (phenobarbital–vitamin K versus placebo). Intelligence (Wechsler Intelligence Scale for Children, third edition), achievement (Wide Range Achievement Test, third edition), and behavioral (Achenbach Teacher’s Report Form and the Child Behavioral Check List) testing and head circumference measurement were performed on 7-year-old children whose mothers participated in a trial to determine if antenatal phenobarbital and vitamin K prevented severe intracranial hemorrhage. Antenatal steroid therapy in these women was repeated weekly. Results Two hundred ninety-nine of 372 newborns (80%) whose mothers participated in the trial were followed up at age 7 years. Comparing mean (± standard deviation [SD]) Wechsler Intelligence Scale for Children scores in the placebo versus treatment groups, there were no differences ( P > .4) in Full Scale IQ (100.3 ± 14.2 versus 100.6 ± 14.2), Performance IQ (100.3 ± 14.6 versus 101.5 ± 15.6), and Verbal IQ (100.2 ± 14.9 versus 99.6 ± 13.7). Comparing mean (± SD) Wide Range Achievement Test standardized scores in the placebo versus treatment groups, there were no differences ( P > .4) in Reading (97.3 ± 13.9 versus 98.0 ± 14.9), Spelling (95.8 ± 12.7 versus 95.3 ± 13.3), Mathematics (95.9 ± 13.8 versus 94.5 ± 14.5), or head circumference measurements (20.3 ± 0.6 cm versus 20.4 ± 0.6, P > .2). Similarly, there were no differences in the mean Achenbach Teacher’s Report Form and Child Behavioral Check List scores between the placebo and treatment groups. Conclusion Antenatal phenobarbital and repetitive antenatal corticosteroid therapy was not associated with adverse effects on intelligence, achievement, behavior, or head circumference at age 7 years.

Inhaled versus systemic corticosteroids for the treatment of chronic lung disease in ventilated very low birth weight preterm infants.

Chronic lung disease (CLD) remains a serious and common problem among very low birth weight infants despite the use of antenatal steroids and postnatal surfactant therapy to decrease the incidence and severity of respiratory distress syndrome. Corticosteroids have been widely used to treat or prevent CLD due to their anti-inflammatory properties. However, the use of systemic steroids has been associated with serious short and long term adverse effects. Administration of corticosteroids topically through the respiratory tract might result in beneficial effects on the pulmonary system with fewer undesirable systemic side effects. To compare the effectiveness of inhaled versus systemic corticosteroids administered to ventilator dependent preterm neonates with birth weight </= 1500 grams or gestational age </= 32 weeks after two weeks of life for the treatment of evolving CLD. Randomized and quasi-randomized trials were identified by searching the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 - September 2002), EMBASE (1980 - September 2002), CINAHL (1982 - September 2002), reference lists of published trials and abstracts published in Pediatric Research (1990 - April 2002) from the Society for Pediatric Research/Pediatric Academic Societies' Annual Meetings. Randomized or quasi-randomized trials comparing inhaled versus systemic corticosteroid therapy (irrespective of the dose and duration of therapy) starting after the first two weeks of life in ventilator dependent very low birth weight preterm neonates. Data were extracted regarding clinical outcomes including CLD at 28 days or 36 weeks corrected gestational age (CGA), mortality, combined outcome of death or CLD at 28 days or 36 weeks CGA, other pulmonary outcomes and adverse effects. All data were analyzed using RevMan 4.1. When appropriate, meta-analysis was performed using relative risk (RR), risk difference (RD), and weighted mean difference (WMD) along with their 95% confidence intervals (CI). If RD was statistically significant, number needed to treat (NNT) was calculated. Five trials comparing inhaled versus systemic corticosteroids in the treatment of CLD were identified. Two trials were excluded as both included non ventilator dependent patients. One trial is awaiting assessment and clarification of published data. Two trials qualified for inclusion in this review. Halliday et al (Halliday 2001a) randomized infants < 72 hours, while Suchomski et al (Suchomski 2002) randomized at 12-21 days. Although the steroids were commenced after the first 2 weeks of life in both the trials, the outcomes were measured over different time periods, from the age at randomization in each trial, making it inappropriate to combine results. In neither trial was there a statistically significant difference between the groups in the incidence of CLD at 36 weeks CGA amongst all randomized infants. The estimates for the trial by Halliday et al (Halliday 2001a) were RR 1.10 (95% CI 0.82, 1.47), RD 0.03 (95% CI -0.08, 0.15); number of infants (n) = 292 and for the trial by Suchomski et al (Suchomski 2002) RR 0.90 (95% CI 0.79, 1.02), RD -0.10 (95% CI -0.22, 0.02; n = 78 ). There were no statistically significant differences between the groups in either trial for oxygen dependency at 28 days, death by 28 days or 36 weeks, the combined outcome of death or CLD by 28 days or 36 weeks CGA, duration of intubation, duration of oxygen dependence, or adverse effects. Information on the long term neurodevelopmental outcomes was not available. This review found no evidence that inhaled corticosteroids confer net advantages over systemic corticosteroids in the management of ventilator dependent preterm infants. Neither inhaled steroids, nor systemic steroids, can be recommended as standard treatment for ventilated preterm infants. There was no evidence of difference in effectiveness or side-effect profiles for inhaled versus systemic steroids. A better delivery system guaranteeing selective delivery of inhaled steroids to the alveoli might result in beneficial clinical effects without increasing side-effects. To resolve this issue, studies are needed to identify the risk/benefit ratio of different delivery techniques and dosing schedules for the administration of these medications. The long term effects of inhaled steroids, with particular attention to neurodevelopmental outcome, should be addressed in future studies.

Antenatal steroid use is associated with increased gastroesophageal reflux in neonates.

The objective of this study was to analyze if repetitive administration of antenatal steroids (ANS) had an adverse impact on neonatal outcome at hospital discharge in premature infants. We used a retrospective analysis of 306 infants of gestational age (GA) < or = 34 weeks born between January 1997 and June 1999. A detailed review of maternal and neonatal charts was done. Seventy-one percent (216/306) received ANS. While there was no difference in birth weight (1.37 +/- 0.04 versus 1.49 +/- 0.06 kg; p = 0.09), infants receiving ANS were of lesser GA (29.5 +/- 0.2 versus 30.5 +/- 0.4 weeks; p = 0.02). More babies who received ANS had clinical evidence of gastroesophageal reflux (GER) [59/216 (27%) versus 11/90 (12%); p = 0.007]. After correcting for GA, infants receiving ANS were less likely to need surfactant (p = 0.03) and more likely to be diagnosed with clinical GER (p = 0.02). Ninety (29%) infants received no ANS, 47 (15%) received a suboptimal course, 112 (37%) infants received 1 course of ANS, and 57 (19%) infants received > or = 2 courses. There was a significant increase in the incidence of GER with increasing courses of ANS: 0 course 11/90 (12%), suboptimal 12/47 (26%), 1 course 28/112 (25%), 2 or more courses 18/57 (32%); p = 0.006, linear trend. The increased incidence of GER (p = 0.01) still held true among infants who had GER confirmed by a pH-probe study. Use of ANS is associated with a significantly decreased need for surfactant; however, there is an increased incidence of GER.

Historical Perspectives: The Underpinnings of Neonatal/Perinatal Medicine

The second featured article in Historical Perspectives this month was published in 1972 in Pediatrics (1) and emanated from New Zealand. We asked Dr. Liggins to provide perspective on how antepartum corticosteroids were introduced. As he notes, it took many years before this treatment gained acceptance. Dr. Liggins attributes this (in part) to resentment by neonatologists that obstetricians were intruding on their territory. In contrast, our perception is that the delay in acceptance was largely because obstetricians were unwilling to accept something that appeared in the pediatric literature. There was also concern about the long-term outcome in these infants, although follow-up of the original cohort showed no apparent differences. (2) The consensus development conference on the “Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes” was held in early 1994 and published by the National Institutes of Health later that year. (3) This clearly documented advantages to antepartum corticosteroid administration not only with regard to respiratory distress syndrome, but also in reducing intraventricular hemorrhage and overall …

Alternative strategies for the management of respiratory failure in the newborn – clinical realities

Following the introduction of surfactant in the early 1990s and the growing use of antenatal steroids since that time, the number of infants, term and preterm, suffering severe acute respiratory failure has declined. However, such babies do still occur and their management causes much debate and concern not least because of the recognised high risk of adverse outcome in these babies. This article reviews the therapeutic options available when other more routine strategies fail.

Bronchopulmonary dysplasia: an enduring challenge.

1. Yvonne E. Vaucher, MD, MPH* 1. *Clinical Professor of Pediatrics, Division of Neonatology, University of California, San Diego, Calif. After completing this article, readers should be able to: 1. Describe the most common cause of chronic lung disease during infancy. 2. Explain the importance of a history of bronchopulmonary dysplasia throughout childhood. 3. Identify infants at high risk for developing bronchopulmonary dysplasia. 4. List the adverse effects associated with postnatal corticosteroids. Despite clinical advances in antepartum, intrapartum, and neonatal care, bronchopulmonary dysplasia (BPD) continues to challenge infants who have been in neonatal intensive care units and their caretakers. BPD is the most common cause of chronic respiratory disease during infancy and remains a major cause of long-term medical, pulmonary, and neurodevelopmental morbidity, increasing the cost of health care and the utilization of medical and educational resources throughout childhood. BPD is a clinical diagnosis, defined by oxygen dependence for a specific period of time after birth and accompanied by characteristic radiographic findings that correspond to anatomic abnormalities. Thus far, a precise physiologic definition of BPD is lacking. As the clinical presentation has evolved over the past 30 years, so has the definition. As originally described by Northway in the 1960s, the diagnosis of classic BPD was based on progressive radiographic changes in preterm infants who were treated for severe respiratory distress syndrome (RDS) immediately after birth and had prolonged ventilator and oxygen dependence. This form of BPD occurred in larger, relatively mature preterm infants, who required treatment with high-pressure mechanical ventilation and high concentrations of oxygen. Although the acute respiratory disease initially improved in these infants, oxygen requirements increased 7 to 10 days after birth and persisted for at least 28 days. The definition of BPD subsequently was modified by Bancalari to include preterm infants who had less severe RDS that initially required short-term mechanical ventilation, but who also developed persistent respiratory symptoms and an oxygen requirement for at least 28 days after birth …

Factors associated with permanent closure of the ductus arteriosus: a role for prolonged indomethacin therapy.

Factors associated with permanent closure of the ductus arteriosus: a role for prolonged indomethacin therapy.

Risk factors for intraventricular haemorrhage in very low birth weight infants.

In a prospective study at Uludag University Hospital, 120 premature infants with birthweights of 1500 g or less were screened for intraventricular hemorrhage (IVH) using cranial ultrasound. With the purpose of studying the incidence of IVH, the associated risk factors for these neonates were considered. We studied all the very low birth weight infants admitted in our neonatal unit. We examined the following variables as risk factors for IVH: sex, birth weight, gestational age, Apgar score, mechanichal ventilation, hypercapnia, use of antenatal steroids, tocolytic drugs, vaginal versus cesarean section delivery, and inborn versus outborn status, vasopressor infusion (any vasoactive drug such as dopamine, dobutamine, or epinephrine) not associated with resuscitation, and surfactant administration. The incidence of IVH was 15% (18/120), 50% grade I (9/18), 17% grade II (3/18), 11% grade III (2/18), and 22% grade IV (4/18). IVH occurred mainly in the first week of life (78%; 14/18). The significant risk factors for IVH were found to be prematurity, outborn status, low 5 minute Apgar score, vaginal delivery, hypercapnia, mechanical ventilation, hypotension, and use of vasopressors on the day of admission. Significant protective factors against IVH included antenatal steroid therapy, cesarean section, magnesium sulfate tocolysis, increasing gestational age, and increasing birth weight. Our results concur with the notion that a tertiary center is the optimal location for delivery of the high risk neonate. Transportation of infants in utero to a perinatal center specializing in high risk-deliveries results in a decreased incidence of IVH when compared to infants transported postnatally. Aggressive resuscitation, with avoidance of hypercarbia, and rapid restoration of hypovolemia could potentially reduce the incidence of PVH/IVH.

Early versus delayed initiation of continuous distending pressure for respiratory distress syndrome in preterm infants.

The application of a continuous distending pressure (CDP) has been shown to have some benefits in the treatment of pre-term infants with respiratory distress syndrome (RDS). CDP has the potential to reduce lung damage, particularly if applied early before atelectasis has occurred. Early application of CDP may better conserve an infant's own surfactant stores and consequently be more effective than CDP applied later in the course of RDS. In pre-term infants with RDS to determine if early compared with delayed initiation of CDP results in lower mortality and reduced need for intermittent positive pressure ventilation. The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register (Issue 1, 2002), MEDLINE (1966-2001), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language. Trials among pre-term infants with respiratory distress syndrome spontaneously breathing at trial entry, which used random or quasi-random allocation to either early or delayed CDP. Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used, including independent assessment of trial quality and extraction of data by two authors. In six studies on a total of 165 infants, early CDP was associated with a significant reduction in subsequent use of intermittent positive pressure ventilation, typical RR 0.55, RD -0.16, NNT 6, but there was no evidence of effect on overall mortality. There was no evidence of effect on the rates of pneumothorax (five studies) or bronchopulmonary dysplasia (one study). Early CDP resulted in a reduction in duration of oxygen therapy in the single study reporting this outcome. Early application of CDP has a clinical benefit in the treatment of RDS in that it reduces subsequent use of IPPV and thus may be useful in preventing the adverse effects of this treatment. However, many of the trials were done in the 1970s and 1980s and re-evaluation of the strategy of early CDP in the era of antenatal steroid use and early surfactant administration is indicated.

Cost-effectiveness of prophylactic indomethacin in very-low-birth-weight infants.

To perform cost-effectiveness analysis to facilitate the decision-making process surrounding use of indomethacin in preterm infants to lower the incidence of patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH), and death. A MEDLINE literature search from 1966 to July 2000 was performed to identify relevant randomized, controlled trials (RCTs), as well as cohort and retrospective case-control studies. A decision tree was built representing the choice to use or not use indomethacin, and the potential outcome costs. Probabilities of being in each chance node were obtained from this search. Where data probabilities were not clear, a sensitivity analysis was conducted. There was no difference in the expected survival per year; however, there was a significant difference when effectiveness was measured as quality-adjusted life years (QALYs), resulting in 11 and 10 years for the indomethacin and control groups, respectively. The indomethacin treatment cost was $95,157 and that of the control groups was $99,955. The cost effectiveness per life expectancy of being in the indomethacin and control groups was $7142 and $7727, respectively. The sensitivity analysis for PDA closure and prevention of IVH for infants eventually developing PDA versus those without PDA showed no difference. The cost-effectiveness analysis per QALY was $8443 for the indomethacin treatment and $9168 for the control group. The prophylactic use of indomethacin is less costly and more effective within an important range of certainty. However, this analysis does not include several potentially confounding factors, such as antenatal steroid use or indomethacin-induced renal toxicity. Depending on the frequency with which these factors arise, economic projections may be considerably altered against the early use of indomethacin.

Home oxygen status and rehospitalisation and primary care requirements of infants with chronic lung disease

Objectives: To determine whether the rehospitalisation and primary care requirements of infants with chronic lung disease (CLD) during the first two years after birth were influenced by a requirement for...

A comparison of the outcomes of neonates treated with two different natural surfactants

Objective: Our purpose was to determine whether there exists a mortality difference between neonates treated with Infasurf (surfactant A [SA], ONY, Inc, Amherst, NY) and Survanta (surfactant B [SB], Ross Products Division, Abbott Laboratories, Columbus, OH). Methods: We evaluated 114 different neonatal units' records, between January 1, 2000, and December 31, 2000, of neonates ≤36 weeks' estimated gestational age who were admitted for neonatal intensive care and reported to have been treated with SA or SB. We used stepwise logistic regression analysis to determine whether the type of surfactant was associated with increased incidence of neonatal death, severe intraventricular hemorrhage, or necrotizing enterocolitis independent of estimated gestational age, birth weight, sex, method of delivery, use of antenatal steroids, or place of birth. Results: We studied the records of 5169 neonates; 1115 (22%) received SA and 4054 (78%) received SB. The most important variables associated with neonatal death, intraventricular hemorrhage and necrotizing enterocolitis were birth weight and estimated gestational age. Logistic regression showed that the type of surfactant did not significantly influence any of these 3 outcomes. Neither overall mortality (8.3% vs 8.5%) or birth weight-specific mortality was different between the 2 groups. Conclusion: The differences in mortality previously reported are not present in a larger, more contemporary data set. (J Pediatr 2001;139:828–31)