Sleep‐disordered breathing is common among term and near term infants in the NICU

ObjectiveAmong older infants and children, sleep‐disordered breathing (SDB) has negative neurocognitive consequences. We evaluated the frequency and potential impact of SDB among newborns who require intensive care.Study DesignTerm and near‐term newborns at risk for seizures underwent 12‐h attended polysomnography in the neonatal intensive care unit (NICU). Bayley Scales of Infant Development, third edition (Bayley‐III) were administered at 18‐22 months.ResultThe 48 newborns (EGA 39.3 ± 1.6) had a median pediatric apnea‐hypopnea index (AHI) of 10.1 (3.3‐18.5) and most events were central (vs obstructive). Maternal and prenatal factors were not associated with AHI. Moreover, neonatal PSG results were not associated with Bayley‐III scores (P > 0.05).ConclusionSDB is common among term and near‐term newborns at risk for seizures. Follow‐up at ages when more nuanced testing can be performed may be necessary to establish whether neonatal SDB is associated with long‐term neurodevelopmental disability.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/149248/1/ppul24266.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/149248/2/ppul24266_am.pd

Impact of hands‐on care on infant sleep in the neonatal intensive care unit

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135460/1/ppul23513_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135460/2/ppul23513.pd

Weaning of Moderately Preterm Infants from the Incubator to the Crib: A Randomized Clinical Trial

OBJECTIVE: To assess whether length of hospital stay is decreased among moderately preterm infants weaned from incubator to crib at a lower vs higher weight. STUDY DESIGN: This trial was conducted in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants with gestational ages 29-33 weeks, birthweight <1600 g, and in an incubator were randomly assigned to a weaning weight of 1600 or 1800 g. Within 60 to 100 g of weaning weight, the incubator temperature was decreased by 1.0°C to 1.5°C every 24 hours until 28.0°C. The infants were weaned to the crib following stable temperature at 36.5°C to 37.4°C for 8 to 12 hours. Clothing and bedcoverings were standardized. The primary outcome was length of hospital stay from birth to discharge; secondary outcomes included length of stay and growth velocity from weaning to discharge. Adverse events were monitored. RESULTS: Of 1565 infants screened, 885 were eligible, and 366 enrolled-187 to the 1600-g and 179 to the 1800-g group. Maternal and neonatal characteristics did not differ among weight groups. Length of hospital stay was a median of 43 days in the lower and 41 days in the higher weight group (P = .12). Growth velocity from completion of weaning to discharge was higher in the lower weight group, 13.7 g/kg/day vs 12.8 g/kg/day (P = .005). Groups did not differ in adverse events. CONCLUSIONS: Among moderately preterm neonates, weaning from incubator to crib at a lower weight did not decrease length of stay, but was safe and was accompanied by higher weight gain after weaning

Effect of Depth and Duration of Cooling on Death or Disability at Age 18 Months Among Neonates With Hypoxic-Ischemic Encephalopathy: A Randomized Clinical Trial

Importance Hypothermia for 72 hours at 33.5°C for neonatal hypoxic-ischemic encephalopathy reduces death or disability, but rates continue to be high. Objective To determine if cooling for 120 hours or to a temperature of 32.0°C reduces death or disability at age 18 months in infants with hypoxic-ischemic encephalopathy. Design, Setting, and Participants Randomized 2 × 2 factorial clinical trial in neonates (≥36 weeks’ gestation) with hypoxic-ischemic encephalopathy at 18 US centers in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network between October 2010 and January 2016. Interventions A total of 364 neonates were randomly assigned to 4 hypothermia groups: 33.5°C for 72 hours (n = 95), 32.0°C for 72 hours (n = 90), 33.5°C for 120 hours (n = 96), or 32.0°C for 120 hours (n = 83). Main Outcomes and Measures The primary outcome was death or moderate or severe disability at 18 to 22 months of age adjusted for center and level of encephalopathy. Severe disability included any of Bayley Scales of Infant Development III cognitive score less than 70, Gross Motor Function Classification System (GMFCS) level of 3 to 5, or blindness or hearing loss despite amplification. Moderate disability was defined as a cognitive score of 70 to 84 and either GMFCS level 2, active seizures, or hearing with amplification. Results The trial was stopped for safety and futility in November 2013 after 364 of the planned 726 infants were enrolled. Among 347 infants (95%) with primary outcome data (mean age at follow-up, 20.7 [SD, 3.5] months; 42% female), death or disability occurred in 56 of 176 (31.8%) cooled for 72 hours and 54 of 171 (31.6%) cooled for 120 hours (adjusted risk ratio, 0.92 [95% CI, 0.68-1.25]; adjusted absolute risk difference, −1.0% [95% CI, −10.2% to 8.1%]) and in 59 of 185 (31.9%) cooled to 33.5°C and 51 of 162 (31.5%) cooled to 32.0°C (adjusted risk ratio, 0.92 [95% CI, 0.68-1.26]; adjusted absolute risk difference, −3.1% [95% CI, −12.3% to 6.1%]). A significant interaction between longer and deeper cooling was observed (P = .048), with primary outcome rates of 29.3% at 33.5°C for 72 hours, 34.5% at 32.0°C for 72 hours, 34.4% at 33.5°C for 120 hours, and 28.2% at 32.0°C for 120 hours. Conclusions and Relevance Among term neonates with moderate or severe hypoxic-ischemic encephalopathy, cooling for longer than 72 hours, cooling to lower than 33.5°C, or both did not reduce death or moderate or severe disability at 18 months of age. However, the trial may be underpowered, and an interaction was found between longer and deeper cooling. These results support the current regimen of cooling for 72 hours at 33.5°C

Therapeutic hypothermia translates from ancient history in to practice

Acute postasphyxial encephalopathy around the time of birth remains a major cause of death and disability. The possibility that hypothermia may be able to prevent or lessen asphyxial brain injury is a “dream revisited”. In this review, a historical perspective is provided from the first reported use of therapeutic hypothermia for brain injuries in antiquity, to the present day. The first uncontrolled trials of cooling for resuscitation were reported more than 50 y ago. The seminal insight that led to the modern revival of studies of neuroprotection was that after profound asphyxia, many brain cells show initial recovery from the insult during a short “latent” phase, typically lasting ~6 h, only to die hours to days later during a “secondary” deterioration phase characterized by seizures, cytotoxic edema, and progressive failure of cerebral oxidative metabolism. Studies designed around this conceptual framework showed that mild hypothermia initiated as early as possible before the onset of secondary deterioration, and continued for a sufficient duration to allow the secondary deterioration to resolve, is associated with potent, long-lasting neuroprotection. There is now compelling evidence from randomized controlled trials that mild induced hypothermia significantly improves intact survival and neurodevelopmental outcomes to midchildhood

Recommendations for the design of therapeutic trials for neonatal seizures

Although seizures have a higher incidence in neonates than any other age group and are associated with significant mortality and neurodevelopmental disability, treatment is largely guided by physician preference and tradition, due to a lack of data from welldesigned clinical trials. There is increasing interest in conducting trials of novel drugs to treat neonatal seizures, but the unique characteristics of this disorder and patient population require special consideration with regard to trial design. The Critical Path Institute formed a global working group of experts and key stakeholders from academia, the pharmaceutical industry, regulatory agencies, neonatal nurse associations, and patient advocacy groups to develop consensus recommendations for design of clinical trials to treat neonatal seizures. The broad expertise and perspectives of this group were invaluable in developing recommendations addressing: (1) use of neonate-specific adaptive trial designs, (2) inclusion/exclusion criteria, (3) stratification and randomization, (4) statistical analysis, (5) safety monitoring, and (6) definitions of important outcomes. The guidelines are based on available literature and expert consensus, pharmacokinetic analyses, ethical considerations, and parental concerns. These recommendations will ultimately facilitate development of a Master Protocol and design of efficient and successful drug trials to improve the treatment and outcome for this highly vulnerable population

Between Critique and Accommodation: Reflections on an EAP course for Masters of Architecture Students

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/88148/1/swales-between_critique.pd

Quantitative sleep stage analysis as a window to neonatal neurologic function

Objective: To test the hypothesis that neonatal sleep physiology reflects cerebral dysfunction, we compared neurologic examination scores to the proportions of recorded sleep/wake states, sleep depth, and sleep fragmentation in critically ill neonates. Methods: Newborn infants (≥35 weeks gestation) who required intensive care and were at risk for seizures were monitored with 8- to 12-hour polysomnograms (PSGs). For each infant, the distribution of sleep-wake states, entropy of the sequence of state transitions, and delta power from the EEG portion of the PSG were quantified. Standardized neurologic examination (Thompson) scores were calculated. Results: Twenty-eight infants participated (mean gestational age 39.0 ± 1.6 weeks). An increased fraction of quiet sleep correlated with worse neurologic examination scores (Spearman rho = 0.54, p = 0.003), but the proportion of active sleep did not (p \u3e 0.1). Higher state entropy corresponded to better examination scores (rho = −0.43, p = 0.023). Decreased delta power during quiet sleep, but not the power at other frequencies, was also associated with worse examination scores (rho = −0.48, p = 0.009). These findings retained significance after adjustment for gestational age or postmenstrual age at the time of the PSG. Sleep stage transition probabilities were also related to examination scores. Conclusions: Among critically ill neonates at risk for CNS dysfunction, several features of recorded sleep—including analyses of sleep stages, depth, and fragmentation—showed associations with neurologic examination scores. Quantitative PSG analyses may add useful objective information to the traditional neurologic assessment of critically ill neonates

Maternal Voice and Infant Sleep in the Neonatal Intensive Care Unit.

BACKGROUND: Approximately 10% of US newborns require a NICU. We evaluated whether the NICU acoustic environment affects neonatal sleep and whether exposure to the mother\u27s voice can modulate that impact. METHODS: In a level IV NICU with single-infant rooms, 47 neonates underwent 12-hour polysomnography. Their mothers were recorded reading children\u27s books. Continuous maternal voice playback was randomized to either the first or second 6 hours of the polysomnogram. Regression models were used to examine sleep-wake stages, entropy, EEG power, and the probability of awakening in response to ambient noise during and without voice playback. RESULTS: After epochs with elevated noise, the probability was higher with (versus without) maternal voice exposure of neonates staying asleep ( CONCLUSIONS: Hospitalized newborns born at ≥35 weeks\u27 gestation but not at 33 to 34 weeks\u27 gestation show increasing wakefulness in response to their mother\u27s voice. However, exposure to the mother\u27s voice during sleep may also help protect newborns from awakening after bursts of loud hospital noise