Apnea of prematurity: from cause to treatment

Apnea of prematurity (AOP) is a common problem affecting premature infants, likely secondary to a “physiologic” immaturity of respiratory control that may be exacerbated by neonatal disease. These include altered ventilatory responses to hypoxia, hypercapnia, and altered sleep states, while the roles of gastroesophageal reflux and anemia remain controversial. Standard clinical management of the obstructive subtype of AOP includes prone positioning and continuous positive or nasal intermittent positive pressure ventilation to prevent pharyngeal collapse and alveolar atelectasis, while methylxanthine therapy is a mainstay of treatment of central apnea by stimulating the central nervous system and respiratory muscle function. Other therapies, including kangaroo care, red blood cell transfusions, and CO2 inhalation, require further study. The physiology and pathophysiology behind AOP are discussed, including the laryngeal chemoreflex and sensitivity to inhibitory neurotransmitters, as are the mechanisms by which different therapies may work and the potential long-term neurodevelopmental consequences of AOP and its treatment

A Model Analysis of Arterial Oxygen Desaturation during Apnea in Preterm Infants

Rapid arterial O2 desaturation during apnea in the preterm infant has obvious clinical implications but to date no adequate explanation for why it exists. Understanding the factors influencing the rate of arterial O2 desaturation during apnea () is complicated by the non-linear O2 dissociation curve, falling pulmonary O2 uptake, and by the fact that O2 desaturation is biphasic, exhibiting a rapid phase (stage 1) followed by a slower phase when severe desaturation develops (stage 2). Using a mathematical model incorporating pulmonary uptake dynamics, we found that elevated metabolic O2 consumption accelerates throughout the entire desaturation process. By contrast, the remaining factors have a restricted temporal influence: low pre-apneic alveolar causes an early onset of desaturation, but thereafter has little impact; reduced lung volume, hemoglobin content or cardiac output, accelerates during stage 1, and finally, total blood O2 capacity (blood volume and hemoglobin content) alone determines during stage 2. Preterm infants with elevated metabolic rate, respiratory depression, low lung volume, impaired cardiac reserve, anemia, or hypovolemia, are at risk for rapid and profound apneic hypoxemia. Our insights provide a basic physiological framework that may guide clinical interpretation and design of interventions for preventing sudden apneic hypoxemia

Congenital Diaphragmatic hernia – a review

Congenital Diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity interfering with normal development of the lungs. The defect may range from a small aperture in the posterior muscle rim to complete absence of diaphragm. The pathophysiology of CDH is a combination of lung hypoplasia and immaturity associated with persistent pulmonary hypertension of newborn (PPHN) and cardiac dysfunction. Prenatal assessment of lung to head ratio (LHR) and position of the liver by ultrasound are used to diagnose and predict outcomes. Delivery of infants with CDH is recommended close to term gestation. Immediate management at birth includes bowel decompression, avoidance of mask ventilation and endotracheal tube placement if required. The main focus of management includes gentle ventilation, hemodynamic monitoring and treatment of pulmonary hypertension followed by surgery. Although inhaled nitric oxide is not approved by FDA for the treatment of PPHN induced by CDH, it is commonly used. Extracorporeal membrane oxygenation (ECMO) is typically considered after failure of conventional medical management for infants ≥ 34 weeks’ gestation or with weight >2 kg with CDH and no associated major lethal anomalies. Multiple factors such as prematurity, associated abnormalities, severity of PPHN, type of repair and need for ECMO can affect the survival of an infant with CDH. With advances in the management of CDH, the overall survival has improved and has been reported to be 70-90% in non-ECMO infants and up to 50% in infants who undergo ECMO

Association between Hypothermia in the First Day of Life and Survival in the Preterm Infant

International audienceObjective: Hypothermia is associated with elevated mortality in the preterm infant. The preterm infant's thermoregulatory capacity is limited, and the thermal environment in an incubator is often perturbed by nursing procedures. We evaluated the incidence of a postnatal low body temperature and hypothermia in preterm infants and its association with mortality. Methods: We measured the lowest body temperature during the first 24 h of life (TBody Nadir 24h) and hypothermia (TBody Nadir 24h < 36.0 ° C) in preterm infants (gestational age: 230\textendash 316 weeks) in a neonatal intensive care unit. Prenatal and neonatal characteristics associated with mortality were identified in univariate and multivariable analyses. Results: A total of 102 preterm infants were included, with a mean gestational age at birth of 28.4 ± 2.3 weeks. The incidence of hypothermia during the first 24 h was 53%. A Cox multivariate regression model indicated that TBody Nadir 24h (hazard ratio (HR) [95% confidence interval]: 0.57 [0.36\textendash 0.90]; P = 0.017), gestational age (0.62 [0.50\textendash 0.76]; P < 0.001), and amine use (4.55 [2.01\textendash 10.28]; P = 0.001) were significantly associated with mortality. When considering a threshold for TBody Nadir 24h, a value of 35.0 ° C had the highest HR (3.30 [1.42\textendash 7.68]; P < 0.01). Conclusion: In preterm infants, the incidence of hypothermia during the first 24 h of life was 53%. TBody Nadir 24h had an influence on mortality, independently of other factors (notably birth weight and amine use). Within the framework of a quality improvement strategy, the implementation of a thermoregulation bundle is required to prevent hypothermia and decrease mortality in preterm infants. \textcopyright 2021 French Society of Pediatric

Distal skin vasodilation precedes sleep onset in preterm neonates and children

23rd Congress of the European-Sleep-Research-Society, Bologna, ITALY, SEP 13-16, 2016International audienc

Respiratory Distress Management in Moderate and Late Preterm Infants: The NEOBS Study

International audienceObjective: To investigate the characteristics and management of respiratory failure (RF) in moderate-to-late preterm infants. Methods: NEOBS was a prospective, multicenter, observational study conducted in 46 neonatal intensive care units caring for preterm infants (30 + 0/7 to 36 + 6/7 weeks of gestation [WG]) in France in 2018. The cohort was stratified into two groups: 30\textendash 33 WG (group 1) and 34\textendash 36 WG (group 2). Infants with early neonatal RF were included and the outcomes assessed were maternal, pregnancy, and delivery characteristics and how RF was managed. Results: Of the 560 infants analyzed, 279 were in group 1 and 281 were in group 2. Most pregnancies were singleton (64.1%), and 67.4% of women received prenatal corticosteroids (mostly two doses). Infants were delivered by cesarean section in 59.6% of cases; 91.7% of the infants had an Apgar score ≥q 7 at 5 min. More than 90% of infants were hospitalized post-birth (median duration, 36 and 15 days for groups 1 and 2, respectively). Medical intervention was required for 95.7% and 90.4% of the infants in group 1 and group 2, respectively, and included noninvasive ventilation (continuous positive airway pressure [CPAP]: 88.5% and 82.9%; high-flow nasal cannula: 55.0% and 44.7%, or other) and invasive ventilation (19.7% and 13.2%). The two main diagnoses of RF were respiratory distress syndrome (39.8%) and transient tachypnea of the newborn (57.3%). Surfactant was administered to 22.5% of the infants, using the less invasive surfactant administration (LISA) method for 34.4% of the patients. In the overall population, 8.6% of the infants had respiratory and/or hemodynamic complications. Conclusions: The NEOBS study demonstrated that CPAP was widely used in the delivery room and the LISA method was chosen for 34.4% of the surfactant administrations for the management of RF in moderate-to-late preterm infants. The incidence of RF-related complications was low. \textcopyright 2021 French Society of Pediatric

Was child abuse underdetected during the COVID-19 lockdown?

International audienc

Neonatal and Adult ICU Ventilators to Provide Ventilation in Neonates, Infants, and Children: A Bench Model Study (vol 59, pg 1463, 2014)

International audienc