An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss

<p>Abstract</p> <p>Background</p> <p>Newborn weight measurements are used as a key indicator of breastfeeding adequacy. The purpose of this study was to explore non-feeding factors that might be related to newborn weight loss. The relationship between the intravenous fluids women receive during parturition (the act of giving birth, including time in labour or prior to a caesarean section) and their newborn's weight loss during the first 72 hours postpartum was the primary interest.</p> <p>Methods</p> <p>In this observational cohort study, we collected data about maternal oral and IV fluids during labour or before a caesarean section. Participants (n = 109) weighed their newborns every 12 hours for the first three days then daily to Day 14, and they weighed neonatal output (voids and stools) for three days.</p> <p>Results</p> <p>At 60 hours (nadir), mean newborn weight loss was 6.57% (SD 2.51; n = 96, range 1.83-13.06%). When groups, based on maternal fluids, were compared (≤1200 mls [n = 21] versus > 1200 [n = 53]), newborns lost 5.51% versus 6.93% (p = 0.03), respectively. For the first 24 hours, bivariate analyses show positive relationships between a) neonatal output and percentage of newborn weight lost (r(96) = 0.493, p < 0.001); and b) maternal IV fluids (final 2 hours) and neonatal output (r(42) = 0.383, p = 0.012). At 72 hours, there was a positive correlation between grams of weight lost and all maternal fluids (r(75) = 0.309, p = 0.007).</p> <p>Conclusions</p> <p>Timing and amounts of maternal IV fluids appear correlated to neonatal output and newborn weight loss. Neonates appear to experience diuresis and correct their fluid status in the first 24 hours. We recommend a measurement at 24 hours, instead of birth weight, for baseline when assessing weight change. Because practices can differ between maternity settings, we further suggest that clinicians should collect and analyze data from dyads in their care to determine an optimal baseline measurement.</p

Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Relationship between intravenous fluids given to women during parturition and their breastfed newborns' weight loss

Neonatal weight measurements are used as a key indicator of breastfeeding adequacy. The purpose of this study was to explore non-feeding factors that might be related to newborn weight loss. The relationship between the intravenous (IV) fluids women receive during parturition (the act of giving birth including time in labour or prior to a cesarean section) and their newborn's weight loss during the first 72 hours postpartum was the primary interest. Three hypotheses guided the thesis. Specifically, the hypotheses stated that in the first 72 hours postpartum, there is a positive association between: (a) the amount of IV fluid given to a woman during parturition and the amount of weight her infant loses; (b) the amount of IV fluid given to a woman during parturition and the amount her infant eliminates; and (c) the amount an infant eliminates and the infant's weight loss. In an effort to clarify patterns of weight loss, a systematic review was completed to determine reference weight loss, and the results are reported in this thesis. Additionally, the issue of who should consent for neonates in lactation and breastfeeding research studies was raised during the ethics review, and the results of an examination of the underpinning principles for such consent are presented in this thesis. A prospective observational cohort study was conducted to explore associations between maternal fluids during parturition, neonatal output, and newborn weight loss. During labour or before a cesarean section, maternal IV and oral fluids were recorded. Participants weighed their newborns every 12 hours for 72 hours, then weight was measured daily from Day 4 to Day 14. Parents weighed all output (i.e. diapers) in the first 72 hours. Results of the systematic review show that the 7% maximum allowable weight loss recommended in four clinical practice guidelines appears to be based on mean weight loss and does not account for standard deviation. Although we determined patterns of weight loss, causes of weight loss and implications for morbidity and mortality were not established. Completing the systematic review clarified assumptions about how birth weight is used as the baseline for calculating weight loss and how clinical decisions are based on the percentage of loss from birth weight. The three hypotheses were supported. At 60 hours postpartum (point of maximum weight loss), mean loss was 237.2 grams (SD 98; n = 96, range 70-467 grams) and the percentage lost was 6.57 (SD 2.51; n = 96, range 1.83-13.06%). There was a positive relationship between maternal IV fluids from admission to birth and neonatal weight loss in grams (r(83) = .199, p = .035). Mean neonatal output for the first 24 hours was 83.04 grams (SD 47.81; n = 107, range 0-314 grams). There was a positive relationship between maternal IV fluids given in the final 2 hours before birth and neonatal output at 24 hours (r(17) = .426, p = .044) which explained 18% of the variability in weight loss. On Day 1, there was a positive relationship between output and weight loss (r(96) = .341, P &lt; .0001) which explained 12% of the variability in weight loss. When groups, based on maternal fluids, were compared (&le;1200 mls [n = 21] versus> 1200 [n =53]), newborns lost 5.51% versus 6.93% (p = 0.03). A hierarchical regression analysis indicated gestational age and birth weight were additional predictors of weight loss. It appears neonates experience diuresis in the first 24 hours with a related weight loss. Overall, the results indicate that maternal IV fluids before birth are related to weight loss in the early postpartum period. It appears neonate's experience varying degrees of diuresis, and consequent weight loss, in the first 24 hours is a correction. Clinicians (e.g. nurses, lactation consultants, and physicians working with breastfeeding women) should reconsider using birth weight as baseline when assessing newborn weight loss. These findings support using weight measured at 24 hours postpartum as the baseline for assessing newborn weight loss

Questioning current definitions for breastfeeding research

Abstract Background The aim of this paper is to examine how breastfeeding is defined for research purposes. Discussion Current breastfeeding definitions focus on the amount of breast milk an infant receives and do not encompass how a baby is fed. Our concerns are that key variables are not measured when mothers are pumping or expressing their milk and bottle feeding. It seems the breastfeeding relationship is not considered in the definition. Conclusion While we appreciate the implications of full versus partial breastfeeding in research studies, we also believe the method of infant feeding to be significant. Researchers should develop new definitions.</p