Faculty Bibliography

BACKGROUND:Bronchopulmonary Dysplasia (BPD) is the most common complication associated with prematurity. Caffeine citrate is a commonly used medication in the neonatal intensive care unit (NICU) for apnea of prematurity (AOP). In the Caffeine Therapy for Apnea of Prematurity study, or CAP trial, infants who received caffeine at 5 mg/kg had reduced rates of BPD compared to the placebo group. Recently, there have been questions regarding the optimal dose of caffeine and if higher doses may have increased benefit on decreasing rates of BPD. OBJECTIVE:The objectives of this study were to determine if infants who received a higher maintenance dose of caffeine have decreased rates of BPD, decreased severity of BPD and improved neurodevelopmental outcomes compared to those who received a lower maintenance dose of caffeine. DESIGN/METHODS/METHODS:This was a retrospective, observational cohort study at a level IV NICU including infants less than 28 weeks gestational age (GA) receiving caffeine. Maternal and infant demographics and clinical data from the infant's hospital course were collected. Infants were assigned to low-dose (n = 62) or high-dose (n = 111) cohorts based on average daily caffeine dose. The low-dose cohort received an average daily dose of ≤6 mg/kg/day, while the high-dose cohort received an average daily dose of >6 mg/kg/day. BPD rates and severity were then evaluated for each subject. Neurodevelopmental follow-up Bayley scores were assessed at 6, 12, 18, and 24-month follow-up visits. Chi-square test, T test, Mann-Whitney U Test, Logistic regression, and Linear regression statistics were completed to evaluate data. RESULTS:Demographics and clinical characteristics were similar between the low and high-dose caffeine groups. The duration of caffeine in each group was similar as well. The percentage of individuals requiring invasive ventilation was similar between the two groups, however, infants in the high-dose group required less intense forms of ventilation and were on invasive ventilation for a shorter time than the low-dose group (Table 1). The rates of BPD were similar in the two groups (79% vs 78%, p = 0.92), however the severity of BPD based on Jensen Criteria was significantly different between the two groups, with lower rates of severe BPD in the high-dose group (p < 0.001) (Tables 2 and 3). Patients in the higher-dose caffeine group had higher Bayley composite scores at 6 months (p < 0.02). No significant differences were noted at later follow-up (Table 3). CONCLUSIONS:The decreased rates of severe BPD in the high-dose group, along with improved Bayley scores at 6-month follow-up suggest the potential benefit of high-dose maintenance caffeine in the extremely premature and extremely low birth weight population. Additional large, prospective studies are required to evaluate the efficacy of high-dose caffeine in preventing BPD and improving long-term outcomes in this most vulnerable population.

OBJECTIVES/OBJECTIVE:To evaluate the safety and efficacy of dexmedetomidine as the primary sedative in neonates. STUDY DESIGN/METHODS:Single center, retrospective study of mechanically ventilated neonates sedated with dexmedetomidine (study group) or opioids/benzodiazepines (control group). Primary outcome was requirement of opioids/benzodiazepines. Secondary outcomes included duration of mechanical ventilation, time to full feeds, bradycardia/hypotension, and unplanned extubation. A subgroup analysis was conducted in premature neonates. RESULTS:There were 148 patients (study group n = 91, control group n = 57) included. Patients who received dexmedetomidine had less cumulative exposure to opioids/benzodiazepines. The median opioid/benzodiazepine requirement was 0 mg/kg/day in the study group compared to the control group with 0.36-0.96 mg/kg/day midazolam equivalents and 1.75-4.1 mg/kg/day morphine equivalents. Unplanned extubations were not different between groups indicating similar efficacy. The study group reached full feeds faster than the control group. CONCLUSION/CONCLUSIONS:Dexmedetomidine as the primary sedative in neonates is safe and efficacious at minimizing opioids and benzodiazepines in both term and premature neonates. CLINICAL TRIAL REGISTRATION/BACKGROUND:N/A.

OBJECTIVE:To compare resting energy expenditure (REE) among premature infants exposed to recorded maternal heartbeat and voice (MHV) vs. ambient noise. STUDY DESIGN/METHODS:A prospective, randomized crossover pilot trial evaluating the effect of MHV on REE using indirect calorimetry in hemodynamically stable premature infants born at 26-34 weeks' gestation. MHV recordings were digitally overlapped, and exposure sequence was randomized. RESULT/RESULTS:Among 34 measurements from seventeen subjects, REE was significantly lower during MHV exposure compared to ambient noise (61.4 ± 10.3 vs. 70.9 ± 10.3 kcal/kg/day, p = 0.0001). Mean heart rate was also significantly lower with MHV (144 ± 13 vs. 150 ± 11 bpm, p = 0.028), with no differences in other vital signs. CONCLUSION/CONCLUSIONS:REE of premature infants decreased during exposure to MHV when compared with ambient noise. MHV may serve as a potential noninvasive therapeutic intervention to improve metabolic efficiency in premature infants, potentially helping with improved growth.

OBJECTIVES/OBJECTIVE:To evaluate ECMO-related morbidity and mortality between Early-term (ET) and Full-term (FT) infants. METHODS:weeks were classified as FT. Primary outcomes were ECMO survival and survival to discharge. Secondary outcomes were complications while on ECMO. Data were analyzed using Mann-Whitney U and Fisher's Exact testing. Logistic regression was performed to assess odds of ECMO survival for factors noted to be significantly different between groups. RESULTS:Of 2,551 infants who met inclusion criteria based on gestational age, we identified 805 (32 %) ET and 1,746 (68 %) FT infants. ET infants had significantly lower ECMO survival (90 vs. 94 %, p<0.01) and survival to discharge (80 vs. 88 %, p<0.01), more neurologic complications on ECMO (15 vs. 12 %, p=0.024), and increased need for hemofiltration (33 vs. 29 %, p=0.033). There were no statistically significant differences between groups in mechanical, hemorrhagic, infectious, metabolic, renal, pulmonary, limb, or cardiovascular complications while on ECMO. Multiple logistic regression showed that ET gestational age, development of neurologic complications on ECMO, and need for hemofiltration are independent negative predictors of ECMO survival. CONCLUSIONS:ET gestational age is an independent risk factor for worse ECMO outcomes and survival in comparison to FT infants, highlighting the vulnerability of this population.

OBJECTIVE:To examine survival and outcomes in neonates who received therapeutic hypothermia (TH) for neonatal encephalopathy (NE) and extracorporeal membrane oxygenation (ECMO) versus ECMO alone. STUDY DESIGN/METHODS:This is a retrospective review of Extracorporeal Life Support Organization (ELSO) Registry data from 2007 to 2017 for neonates undergoing ECMO and TH for NE (TH/ECMO) or ECMO alone. Primary outcomes were ECMO survival and survival to discharge. Secondary outcomes were complications while on ECMO. Statistical analysis was performed using Fisher's Exact and Mann-Whitney U testing. Multivariate regression was performed to identify predictors of ECMO survival. RESULTS:Of 3 672 neonates, 215 (6%) received TH/ECMO, while 3 457 (94%) received ECMO alone. There was no significant difference in ECMO survival (92% vs. 92%, P=0.70) or survival to discharge (87% vs. 85%, P=0.43) between groups. TH/ECMO group had higher hemorrhagic (29% vs. 20%, P<0.01), neurologic (24% vs.12%, P<0.01) , and metabolic (28% vs. 15%, p<0.01) complications. Multivariate regression identified higher gestational age, absence of inotropes during ECMO, and lack of neurologic, pulmonary, or hemorrhagic complications as independent predictors of ECMO survival. CONCLUSION/CONCLUSIONS:Neonates undergoing ECMO and TH for NE had survival rates comparable to those receiving ECMO alone. These findings suggest that ECMO can be considered for neonates with NE undergoing TH who meet criteria for ECMO.

OBJECTIVES/OBJECTIVE:and fractional tissue oxygen extraction (FTOE) in stable preterm infants in the first week of life. METHODS:, splanchnic cerebral oxygen ratio (SCOR), FTOE, and regional intra-subject variability was calculated at each location at five different time intervals: 0-12 h, 12-24 h, 24-48 h, 48-72 h, and one week of life. RESULTS:=0.81). The FTOE increased in all three locations over time. Intra-subject variability was lowest in the cerebral region (1.3 % (±1.9)). CONCLUSIONS:in preterm infants.

OBJECTIVE:To screen for neurodevelopmental delays in a cohort of full-term infants born to mothers with SARS-CoV-2. STUDY DESIGN/METHODS:-3) at 16 to 18 months age. RESULTS:Of 51 subjects, twelve (24%) were below cutoff, and twenty-seven (53%) were either below or close to the cutoff in at least one developmental domain. Communication (29%), fine motor (31%), and problem-solving (24%) were the most affected domains. There were no differences in outcomes between infants born to asymptomatic and mildly symptomatic mothers. CONCLUSION/CONCLUSIONS:We observed increased risk of neurodevelopmental delays during screening of infants born at full-term to mothers with SARS-CoV-2 at 16 to 18 months age. These results highlight the urgent need for follow-up studies of infants born to mothers with SARS-CoV-2.

Introduction Coronavirus disease 2019 (COVID-19) is known to cause cardiac abnormalities in adults. Cardiac abnormalities are well-described in multisystem inflammatory syndrome in children, but effects in children with acute COVID-19 are less understood. In this multicenter study, we assessed the cardiac effects of acute COVID-19 among hospitalized children (<21 years) admitted to three large healthcare systems in New York City. Methods We performed a retrospective observational study. We examined electrocardiograms, echocardiograms, troponin, or B-type natriuretic peptides. Results Of 317 admitted patients, 131 (41%) underwent cardiac testing with 56 (43%) demonstrating cardiac abnormalities. Electrocardiogram abnormalities were the most common (46/117 patients (39%)), including repolarization abnormalities and QT prolongation. Elevated troponin occurred in 14/77 (18%) patients and B-type natriuretic peptide in 8/39 (21%) patients. Ventricular dysfunction was identified in 5/27 (19%) patients with an echocardiogram, all of whom had elevated troponin. Ventricular dysfunction resolved by first outpatient follow-up. Conclusion Electrocardiogram and troponin can assist clinicians in identifying children at risk for cardiac injury in acute COVID-19.