Publications by authors named "Hans Ulrich Bucher"

87 Publications

Effect of Early Recombinant Human Erythropoietin on Neurodevelopmental Outcomes at Age 5 Years-Reply.

JAMA 2021 04;325(14):1471-1472

Department of Neonatology, University Hospital Zurich, Zurich, Switzerland.

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http://dx.doi.org/10.1001/jama.2021.0836DOI Listing
April 2021

Swiss neonatal caregivers express diverging views on parental involvement in shared decision-making for extremely premature infants.

Acta Paediatr 2021 Mar 3. Epub 2021 Mar 3.

Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Aim: Due to scarce available national data, this study assessed current attitudes of neonatal caregivers regarding decisions on life-sustaining interventions, and their views on parents' aptitude to express their infant's best interest in shared decision-making.

Methods: Self-administered web-based quantitative empirical survey. All 552 experienced neonatal physicians and nurses from all Swiss NICUs were eligible.

Results: There was a high degree of agreement between physicians and nurses (response rates 79% and 70%, respectively) that the ability for social interactions was a minimal criterion for an acceptable quality of life. A majority stated that the parents' interests are as important as the child's best interest in shared decision-making. Only a minority considered the parents as the best judges of what is their child's best interest. Significant differences in attitudes and values emerged between neonatal physicians and nurses. The language area was very strongly associated with the attitudes of neonatal caregivers.

Conclusion: Despite clear legal requirements and societal expectations for shared decision-making, survey respondents demonstrated a gap between their expressed commitment to shared decision-making and their view on parental aptitude to formulate their infant's best interest. National guidelines need to address these barriers to shared decision-making to promote a more uniform nationwide practice.
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http://dx.doi.org/10.1111/apa.15828DOI Listing
March 2021

Creative Music Therapy with Premature Infants and Their Parents: A Mixed-Method Pilot Study on Parents' Anxiety, Stress and Depressive Symptoms and Parent-Infant Attachment.

Int J Environ Res Public Health 2020 12 31;18(1). Epub 2020 Dec 31.

Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, 8091 Zurich, Switzerland.

Premature birth is stressful for infants and parents and can adversely affect the parent-infant dyad. This mixed-methods pilot study evaluates whether creative music therapy (CMT) can alleviate anxiety, stress, and depressive symptoms in parents and support the bonding process with their infant. Sixteen parent couples were included. Ten couples were randomly allocated to the music therapy group (MTG) and six to the control group (CG). All couples completed psychological questionnaires measuring anxiety and depressive symptoms as well as an implicit measure of parent-infant attachment at two weeks postpartum (T1), at approximate neonatal intensive care unit (NICU) hospitalization halftime (T2), and two weeks after the infant had been discharged (T3). At T1 and T2, the parents additionally completed a questionnaire assessing the degree of stress they experienced at the NICU. Qualitative data were collected through a semi-structured, problem-centered interview with MTG parents at T3. The results of the quantitative analyses revealed reductions in anxiety levels from T1 to T2 ( = 0.002) as well as decreases in depressive symptoms from T2 to T3 ( = 0.022). No such changes were apparent in the CG. In fact, parental stress increased from T1 to T2 ( = 0.016). Significant increases in attachment across time were also observed within the MTG, but not in the CG. The qualitative inquiry confirmed that CMT can support the parent-infant relationship. Being in musical interaction evoked feelings of joy and relaxation in the parents and encouraged them to interact more profoundly with their infant. The results call for a more extensive powered follow-up study to further investigate CMT's potential for parental well-being and parent-infant bonding.
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http://dx.doi.org/10.3390/ijerph18010265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7795112PMC
December 2020

Overlapping borders: limit of viability and late terminations of pregnancy - a retrospective multicentre observational study.

Swiss Med Wkly 2020 Jan 7;150:w20186. Epub 2020 Feb 7.

NEO FOR NAMIBIA, Lucerne, Switzerland.

Aims Of The Study: Based on an incidental observation made in the context of the Swiss National Science Foundation (SNSF) Project 67 “End-of-life decision-making in extremely low birth weight infants in Switzerland”, this retrospective multicentre observational study aimed to analyse circumstances of delivery room deaths after late termination of pregnancy (LTOP) in Switzerland over a 3-year period.

Methods: All delivery room deaths (including live and stillbirths) following LTOP among infants with a gestational age between 22 0/7 and 27 6/7 weeks at the nine Swiss level III perinatal centres between 1 July 2012 and 30 June 2015 were analysed. Indications for LTOP were classified as either (a) maternal emergencies or (b) fetal anomalies severe enough to cause significant maternal psychological distress. Whenever possible, specific diagnoses were recorded. Spontaneous intrapartum death and fetal death caused by injection of a cardioplegic drug were distinguished for stillborn infants.

Results: A total of 465 delivery room deaths among extremely low gestational age newborns (ELGANs) were identified over the 3-year study period of the SNSF project. Of these, 195 (42%) occurred in the context of LTOP. Central nervous system malformations, chromosomal anomalies, severe congenital heart disease, multiple malformations and maternal emergencies accounted for 70% of all LTOPs. LTOPs resulted in live births in 76 (39%) cases. No correlation between gestational age and rate of live births was observed. Fetal death caused by injection of a cardioplegic drug was documented in only three cases. All infants born alive after LTOP died in the delivery room without resuscitation attempts. The use of drugs for palliative care in these patients was either rare or, alternatively, incompletely documented.

Conclusion: LTOPs contribute significantly to mortality rates among ELGANs and should therefore be included in perinatal registries. Uniform reporting of LTOPs should be established. Infants born alive after LTOP are entitled to comprehensive palliative care like any other infant born under different circumstances. Development of national guidelines for LTOPs (including the role of fetal death caused by injection of a cardioplegic drug and palliative birth as an alternative to induced abortion) would be highly desirable to guarantee acceptable standards of care.
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http://dx.doi.org/10.4414/smw.2020.20186DOI Listing
January 2020

Correction to: Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses.

BMC Pediatr 2020 Jan 31;20(1):47. Epub 2020 Jan 31.

Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland.

After publication of our article [1] it was brought to our attention that we did not have permission to reproduce the questionnaire in Additional File 1.
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http://dx.doi.org/10.1186/s12887-019-1890-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993516PMC
January 2020

Creative music therapy to promote brain function and brain structure in preterm infants: A randomized controlled pilot study.

Neuroimage Clin 2020 13;25:102171. Epub 2020 Jan 13.

Department of Neonatology and Pediatric Intensive Care, Children's University Hospital of Zurich, Steinwiesstrasse 75, 8032 Zürich, Switzerland; Children's Research Center, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zürich, Switzerland.

Cognitive and neurobehavioral problems are among the most severe adverse outcomes in very preterm infants. Such neurodevelopmental impairments may be mitigated through nonpharmacological interventions such as creative music therapy (CMT), an interactive, resource- and needs-oriented approach that provides individual social contact and musical stimulation. The aim was to test the feasibility of a study investigating the role of CMT and to measure the short- and medium-term effects of CMT on structural and functional brain connectivity with MRI. In this randomized, controlled clinical pilot feasibility trial, 82 infants were randomized to either CMT or standard care. A specially trained music therapist provided CMT via infant-directed humming and singing in lullaby style. To test the short-term effects of CMT on brain structure and function, diffusion tensor imaging data and resting-state functional imaging data were acquired. Clinical feasibility was achieved despite moderate parental refusal mainly in the control group after randomization. 40 infants remained as final cohort for the MRI analysis. Structural brain connectivity appears to be moderately affected by CMT, structural connectomic analysis revealed increased integration in the posterior cingulate cortex only. Lagged resting-state MRI analysis showed lower thalamocortical processing delay, stronger functional networks, and higher functional integration in predominantly left prefrontal, supplementary motor, and inferior temporal brain regions in infants treated with CMT. This trial provides unique evidence that CMT has beneficial effects on functional brain activity and connectivity in networks underlying higher-order cognitive, socio-emotional, and motor functions in preterm infants. Our results indicate the potential of CMT to improve long-term neurodevelopmental outcomes in children born very preterm.
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http://dx.doi.org/10.1016/j.nicl.2020.102171DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6974781PMC
January 2021

Treatment of opioid withdrawal in neonates with morphine, phenobarbital, or chlorpromazine: a randomized double-blind trial.

Eur J Pediatr 2020 Jan 6;179(1):141-149. Epub 2019 Nov 6.

Department of Neonatology, University Hospital Zurich, CH - 8091, Zurich, Switzerland.

Three suitable compounds (morphine, chlorpromazine, and phenobarbital) to treat neonatal abstinence syndrome were compared in a prospective multicenter, double-blind trial. Neonates exposed to opioids in utero were randomly allocated to one of three treatment groups. When a predefined threshold of a modified Finnegan score was reached, treatment started and increased stepwise until symptoms were controlled. If symptoms could not be controlled with the predefined maximal dose of a single drug, a second drug was added. Among 143 infants recruited, 120 needed pharmacological treatment. Median length of treatment for morphine was 22 days (95% CI 18 to 33), for chlorpromazine 25 days (95% CI 21 to 34), and for phenobarbital 32 days (95% CI 27 to 38) (p = ns). In the morphine group, only 3% of infants (1/33) needed a second drug; in the chlorpromazine group, this proportion was 56% (24/43), and in the phenobarbital group 30% (13/44).Conclusion: None of the drugs tested for treating neonatal abstinence syndrome resulted in a significantly shorter treatment length than the others. As morphine alone was able to control symptoms in almost all infants, it may be preferred to the two other drugs but should still be tested against more potent opioids such as buprenorphine.Trial registration: At ClinicalTrials.gov NCT02810782 (registered retrospectively).What is Known:• Neonates exposed to opiates in utero and presenting with withdrawal symptoms should first be treated by non-pharmacological supportive measures.• In those who fail, drugs have to be given, but there is controversy which drug is best.What is New:• Among three candidates, morphine, chlorpromazine and phenobarbital, none resulted in significantly shorter treatment time.• As morphine alone was able to control symptoms in almost all infants, it may be preferred to the two other drugs.
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http://dx.doi.org/10.1007/s00431-019-03486-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6942588PMC
January 2020

Correction to: decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses.

BMC Pediatr 2018 07 9;18(1):226. Epub 2018 Jul 9.

Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland.

After publication of the original article [1], the corresponding author noticed the given names and family names of the members included in the Swiss Neonatal End-of-Life Study Group were incorrectly reverted.
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http://dx.doi.org/10.1186/s12887-018-1204-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038305PMC
July 2018

In vivo precision assessment of a near-infrared spectroscopy-based tissue oximeter (OxyPrem v1.3) in neonates considering systemic hemodynamic fluctuations.

J Biomed Opt 2018 06;23(6):1-10

University of Zurich, University Hospital Zurich, Biomedical Optics Research Laboratory, Department, Switzerland.

The aim was to determine the precision of a noninvasive near-infrared spectroscopy (NIRS)-based tissue oximeter (OxyPrem v1.3). Using a linear mixed-effects model, we quantified the variability for cerebral tissue oxygenation (StO2) measurements in 35 preterm neonates to be 2.64%, a value that meets the often-articulated clinicians' demand for a precise tissue oxygenation measurement. We showed that the variability of StO2 values measured was dominated by spontaneous systemic hemodynamic fluctuations during the measurement, meaning that precision of the instrument was actually even better. Based on simultaneous and continuous measurements of peripheral arterial oxygenation and cerebral StO2 with a second sensor, we were able to determine and quantify the physiological instability precisely. We presented different methods and analyses aiming at reducing this systematic physiological error of in vivo precision assessments. Using these methods, we estimated the precision of the OxyPrem tissue oximeter to be   ≤  1.85  %  . With our study, we deliver relevant information to establish highly precise cerebral oxygenation measurements with NIRS-based oximetry, facilitating the further development toward a substantially improved diagnosis and treatment of patients with respect to brain oxygenation.
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http://dx.doi.org/10.1117/1.JBO.23.6.067003DOI Listing
June 2018

Variability of Very Low Birth Weight Infant Outcome and Practice in Swiss and US Neonatal Units.

Pediatrics 2018 05 13;141(5). Epub 2018 Apr 13.

Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

Objectives: Outcomes of very preterm infants vary considerably between health care facilities. Our objective was to compare outcome and practices between the Swiss Neonatal Network (SNN) and US members of the Vermont Oxford Network (US-VON).

Methods: Retrospective observational study including all live-born infants with a birth weight between 501 and 1500 g as registered by SNN and US-VON between 2012 and 2014. We performed multivariable and propensity score-matched analyses of neonatal outcome by adjusting for case-mix, race, prenatal care, and unit-level factors, and compared indirectly standardized practices.

Results: A total of 123 689 infants were born alive in 696 US-VON units and 2209 infants were born alive in 13 SNN units. Adjusted risk ratios (aRRs) for the composite "death or major morbidity" (aRR: 0.56, 95% confidence interval: 0.51-0.62) and all other outcomes were either comparable or lower in SNN except for mortality, for which aRR was higher (aRR: 1.28, 95% confidence interval: 1.09-1.50). Propensity score matching and restricting the analysis to infants for which we expect no survival bias, because both networks routinely initiate intensive care at birth, revealed comparable aRR. Variations in observed practices between SNN and US-VON were large.

Conclusions: The SNN units had a significantly lower risk ratio for death or major morbidity. Despite higher mortality, this difference is independent of survival bias. The higher delivery room mortality reflects the SNN practice to favor primary nonintervention for infants born <24 completed gestational weeks. We propose further research into which practice differences have the strongest beneficial impact.
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http://dx.doi.org/10.1542/peds.2017-3436DOI Listing
May 2018

Decision-making at the limit of viability: differing perceptions and opinions between neonatal physicians and nurses.

BMC Pediatr 2018 02 22;18(1):81. Epub 2018 Feb 22.

Department of Neonatology, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zürich, Switzerland.

Background: In the last 20 years, the chances for intact survival for extremely preterm infants have increased in high income countries. Decisions about withholding or withdrawing intensive care remain a major challenge in infants born at the limits of viability. Shared decision-making regarding these fragile infants between health care professionals and parents has become the preferred model today. However, there is an ongoing ethical debate on how decisions regarding life-sustaining treatment should be reached and who should have the final word when health care professionals and parents do not agree. We designed a survey among neonatologists and neonatal nurses to analyze practices, difficulties and parental involvement in end-of-life decisions for extremely preterm infants.

Methods: All 552 physicians and nurses with at least 12 months work experience in level III neonatal intensive care units (NICU) in Switzerland were invited to participate in an online survey with 50 questions. Differences between neonatologists and NICU nurses and between language regions were explored.

Results: Ninety six of 121 (79%) physicians and 302 of 431(70%) nurses completed the online questionnaire. The following difficulties with end-of-life decision-making were reported more frequently by nurses than physicians: insufficient time for decision-making, legal constraints and lack of consistent unit policies. Nurses also mentioned a lack of solidarity in our society and shortage of services for disabled more often than physicians. In the context of limiting intensive care in selected circumstances, nurses considered withholding tube feedings and respiratory support less acceptable than physicians. Nurses were more reluctant to give parents full authority to decide on the course of action for their infant. In contrast to professional category (nurse or physician), language region, professional experience and religion had little influence if any on the answers given.

Conclusions: Physicians and nurses differ in many aspects of how and by whom end-of-life decisions should be made in extremely preterm infants. The divergencies between nurses and physicians may be due to differences in ethics education, varying focus in patient care and direct exposure to the patients. Acknowledging these differences is important to avoid potential conflicts within the neonatal team but also with parents in the process of end-of-life decision-making in preterm infants born at the limits of viability.
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http://dx.doi.org/10.1186/s12887-018-1040-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5822553PMC
February 2018

Patterns of paediatric end-of-life care: a chart review across different care settings in Switzerland.

BMC Pediatr 2018 02 16;18(1):67. Epub 2018 Feb 16.

Department of Pediatrics, Inselspital Bern University Hospital, Bern, Switzerland.

Background: Paediatric end-of-life care is challenging and requires a high level of professional expertise. It is important that healthcare teams have a thorough understanding of paediatric subspecialties and related knowledge of disease-specific aspects of paediatric end-of-life care. The aim of this study was to comprehensively describe, explore and compare current practices in paediatric end-of-life care in four distinct diagnostic groups across healthcare settings including all relevant levels of healthcare providers in Switzerland.

Methods: In this nationwide retrospective chart review study, data from paediatric patients who died in the years 2011 or 2012 due to a cardiac, neurological or oncological condition, or during the neonatal period were collected in 13 hospitals, two long-term institutions and 10 community-based healthcare service providers throughout Switzerland.

Results: Ninety-three (62%) of the 149 reviewed patients died in intensive care units, 78 (84%) of them following withdrawal of life-sustaining treatment. Reliance on invasive medical interventions was prevalent, and the use of medication was high, with a median count of 12 different drugs during the last week of life. Patients experienced an average number of 6.42 symptoms. The prevalence of various types of symptoms differed significantly among the four diagnostic groups. Overall, our study patients stayed in the hospital for a median of six days during their last four weeks of life. Seventy-two patients (48%) stayed at home for at least one day and only half of those received community-based healthcare.

Conclusions: The study provides a wide-ranging overview of current end-of-life care practices in a real-life setting of different healthcare providers. The inclusion of patients with all major diagnoses leading to disease- and prematurity-related childhood deaths, as well as comparisons across the diagnostic groups, provides additional insight and understanding for healthcare professionals. The provision of specialised palliative and end-of-life care services in Switzerland, including the capacity of community healthcare services, need to be expanded to meet the specific needs of seriously ill children and their families.
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http://dx.doi.org/10.1186/s12887-018-1021-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5816353PMC
February 2018

Creative music therapy to promote brain structure, function, and neurobehavioral outcomes in preterm infants: a randomized controlled pilot trial protocol.

Pilot Feasibility Stud 2017 26;3:36. Epub 2017 Sep 26.

Department of Pediatric Intensive Care and Neonatology, University Children's Hospital, 8032 Zurich, Switzerland.

Background: Preterm birth is associated with increased risk of neurological impairment and deficits in cognition, motor function, and behavioral problems. Limited studies indicate that multi-sensory experiences support brain development in preterm infants. Music appears to promote neurobiological processes and neuronal learning in the human brain. Creative music therapy (CMT) is an individualized, interactive therapeutic approach based on the theory and methods of Nordoff and Robbins. CMT may promote brain development in preterm infants via concurrent interaction and meaningful auditory stimulation. We hypothesize that preterm infants who receive creative music therapy during neonatal intensive care admission will have developmental benefits short- and long-term brain function.

Methods/design: A prospective, randomized controlled single-center pilot trial involving 60 clinically stable preterm infants under 32 weeks of gestational age is conducted in preparation for a multi-center trial. Thirty infants each are randomized to either standard neonatal intensive care or standard care with CMT. Music therapy intervention is approximately 20 min in duration three times per week. A trained music therapist sings for the infants in lullaby style, individually entrained and adjusted to the infant's rhythm and affect. Primary objectives of this study are feasibility of protocol implementation and investigating the potential mechanism of efficacy for this new intervention. To examine the effect of this new intervention, non-invasive, quantitative magnetic resonance imaging (MRI) methods at corrected age and standardized neurodevelopmental assessments using the Bayley Scales of Infant and Toddler Development third edition at a corrected age of 24 months and Kaufman Assessment Battery for Children at 5 years will be performed. All assessments will be performed and analyzed by blinded experts.

Discussion: To our knowledge, this is the first randomized controlled clinical trial to systematically examine possible effects of creative music therapy on short- and long-term brain development in preterm infants. This project lies at the interface of music therapy, neuroscience, and medical imaging. New insights into the potential role and impact of music on brain function and development may be elucidated. If such a low-cost, low-risk intervention is demonstrated in a future multi-center trial to be effective in supporting brain development in preterm neonates, findings could have broad clinical implications for this vulnerable patient population.

Trial Registration: ClinicalTrials.gov, NCT02434224.
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http://dx.doi.org/10.1186/s40814-017-0180-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613472PMC
September 2017

Sources of distress for physicians and nurses working in Swiss neonatal intensive care units.

Swiss Med Wkly 2017 3;147:w14477. Epub 2017 Aug 3.

Department of Neonatology, Perinatal Centre, University Hospital Zurich, University of Zurich, Switzerland.

Background: Medical personnel working in intensive care often face difficult ethical dilemmas. These may represent important sources of distress and may lead to a diminished self-perceived quality of care and eventually to burnout.

Aims Of The Study: The aim of this study was to identify work-related sources of distress and to assess symptoms of burnout among physicians and nurses working in Swiss neonatal intensive care units (NICUs).

Methods: In summer 2015, we conducted an anonymous online survey comprising 140 questions about difficult ethical decisions concerning extremely preterm infants. Of these 140 questions, 12 questions related to sources of distress and 10 to burnout. All physicians and nurses (n = 552) working in the nine NICUs in Switzerland were invited to participate.

Results: The response rate was 72% (398). The aspects of work most commonly identified as sources of distress were: lack of regular staff meetings, lack of time for routine discussion of difficult cases, lack of psychological support for the NICU staff and families, and missing transmission of important information within the caregiver team. Differences between physicians' and nurses' perceptions became apparent: for example, nurses were more dissatisfied with the quality of the decision-making process. Different perceptions were also noted between staff in the German- and French- speaking parts of Switzerland: for example, respondents from the French part rated lack of regular staff meetings as being more problematic. On the other hand, personnel in the French part were more satisfied with their accomplishments in the job. On average, low levels of burnout symptoms were revealed, and only 6% of respondents answered that the work-related burden often affected their private life.

Conclusions: Perceived sources of distress in Swiss NICUs were similar to those in ICU studies. Despite rare symptoms of burnout, communication measures such as regular staff meetings and psychological support to prevent distress were clearly requested.
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http://dx.doi.org/10.4414/smw.2017.14477DOI Listing
June 2018

Placebo by Proxy in Neonatal Randomized Controlled Trials: Does It Matter?

Children (Basel) 2017 05 30;4(6). Epub 2017 May 30.

Department of Neonatology, University Hospital Zürich, 8091 Zürich, Switzerland.

Placebo effects emerging from the expectations of relatives, also known as placebo by proxy, have seldom been explored. The aim of this study was to investigate whether in a randomized controlled trial (RCT) there is a clinically relevant difference in long-term outcome between very preterm infants whose parents assume that verum (PAV) had been administered and very preterm infants whose parents assume that placebo (PAP) had been administered. The difference between the PAV and PAP infants with respect to the primary outcome-IQ at 5 years of age-was considered clinically irrelevant if the confidence interval (CI) for the mean difference resided within our pre-specified ±5-point equivalence margins. When adjusted for the effects of verum/placebo, socioeconomic status (SES), head circumference and sepsis, the CI was [-3.04, 5.67] points in favor of the PAV group. Consequently, our study did not show equivalence between the PAV and PAP groups, with respect to the pre-specified margins of equivalence. Therefore, our findings suggest that there is a small, but clinically irrelevant degree to which a preterm infant's response to therapy is affected by its parents' expectations, however, additional large-scale studies are needed to confirm this conjecture.
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http://dx.doi.org/10.3390/children4060043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5483618PMC
May 2017

Comparison of three different methods for risk adjustment in neonatal medicine.

BMC Pediatr 2017 04 17;17(1):106. Epub 2017 Apr 17.

Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

Background: Quality improvement in health care requires identification of areas in need of improvement by comparing processes and patient outcomes within and between health care providers. It is critical to adjust for different case-mix and outcome risks of patient populations but it is currently unclear which approach has higher validity and how limitations need to be dealt with. Our aim was to compare 3 approaches towards risk adjustment for 7 different major quality indicators in neonatal intensive care (21 models).

Methods: We compared an indirect standardization, logistic regression and multilevel approach. Parameters for risk adjustment were chosen according to literature and the condition that they may not depend on processes performed by treating clinics. Predictive validity was tested using the mean Brier Score and by comparing area under curve (AUC) using high quality population based data separated into training and validation sets. Changes in attributional validity were analysed by comparing the effect of the models on the observed-to-expected ratios of the clinics in standardized mortality/morbidity ratio charts.

Results: Risk adjustment based on indirect standardization revealed inferior c-statistics but superior Brier scores for 3 of 7 outcomes. Logistic regression and multilevel modelling were equivalent to one another. C-statistics revealed that predictive validity was high for 8 and acceptable for 11 of the 21 models. Yet, the effect of all forms of risk adjustment on any clinic's comparison with the standard was small, even though there was clear risk heterogeneity between clinics.

Conclusions: All three approaches to risk adjustment revealed comparable results. The limited effect of risk adjustment on clinic comparisons indicates a small case-mix influence on observed outcomes, but also a limited ability to isolate quality improvement potential based on risk-adjustment models. Rather than relying on methodological approaches, we instead recommend that clinics build small collaboratives and compare their indicators both in risk-adjusted and unadjusted form together. This allows qualitatively investigating and discussing the residual risk-differences within networks. The predictive validity should be quantified and reported and stratification into risk groups should be more widely used to correct for confounding.
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http://dx.doi.org/10.1186/s12887-017-0861-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5392992PMC
April 2017

Exploring societal solidarity in the context of extreme prematurity.

Swiss Med Wkly 2017 7;147:w14418. Epub 2017 Mar 7.

Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland.

Question: Extreme prematurity can result in long-term disabilities. Its impact on society is often not taken into account and deemed controversial. Our study examined attitudes of the Swiss population regarding extreme prematurity and people's perspectives regarding the question of solidarity with disabled people.

Methods: We conducted a nationwide representative anonymous telephone survey with 1210 Swiss residents aged 18 years or older. We asked how people estimate their own personal solidarity, the solidarity of their social environment and the solidarity across the country with disabled persons. Spearman's correlation calculations were used to assess if a correlation exists between solidarity and setting financial limits to intensive care and between solidarity and withholding neonatal intensive care.

Results: According to 36.0% of the respondents intensive medical care should not be withheld from extremely preterm infants, even if their chances for an acceptable quality of life were poor. For 28.8%, intensive care should be withheld from these infants, and 26.9% held an intermediate position depending on the situation. A total of 31.5% were against setting a financial limit to treatment of extremely preterm newborns with an uncertain future quality of life, 34.2% were in favour and 26.9% were deliberating. A majority (88.8%) considered their solidarity toward disabled people as substantial; the solidarity of their personal environment and of the society at large was estimated as high by 79.1% and 48.6%, respectively.

Conclusions: The Swiss population expressed a high level of solidarity which may alleviate some pressure on parents and health care providers in the decision-making process in neonatal intensive care units. In addition, there was no relationship between solidarity and people's willingness to pay for the care or withholding treatment of extremely preterm babies.
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http://dx.doi.org/10.4414/smw.2017.14418DOI Listing
October 2017

Fidgety movements in infants born very preterm: predictive value for cerebral palsy in a clinical multicentre setting.

Dev Med Child Neurol 2017 Jun 19;59(6):618-624. Epub 2017 Jan 19.

Division of Neonatalology, University Hospital Zurich, Zurich, Switzerland.

Aim: This study assessed predictive values of fidgety movement assessment (FMA) in a large sample of infants born very preterm for developmental abnormalities, in particular for cerebral palsy (CP) at 2 years in an everyday clinical setting.

Method: This is a multicentre study of infants born preterm with gestational age lower than 32.0 weeks. FMA was performed at 3 months corrected age; neurodevelopment (Bayley Scales of Infant Development, 2nd edition) and neurological abnormalities were assessed at 2 years. Predictive values of FMA for the development of CP were calculated and combined with abnormalities at cerebral ultrasound.

Results: Five hundred and thirty-five infants (gestational age 28.2wks [standard deviation 1.3wks]) were included. Eighty-one percent showed normal fidgety movements and 19% atypical (82 absent, 21 abnormal) fidgety movements. Absent fidgety movements predicted CP at 2 years with an odds ratio (OR) of 8.9 (95% confidence interval [CI] 4.1-17.0), a combination of atypical fidgety movements and major brain lesion on cerebral ultrasound predicted it with an OR of 17.8 (95% CI 5.2-61.6). Mean mental developmental index of infants with absent fidgety movements was significantly lower (p=0.012) than with normal fidgety movements.

Interpretation: Detection of infants at risk for later CP through FMA was good, but less robust when performed in a routine clinical setting; prediction improved when combined with neonatal cerebral ultrasound.
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http://dx.doi.org/10.1111/dmcn.13386DOI Listing
June 2017

Population based report on health related quality of life in adolescents born very preterm.

Early Hum Dev 2017 01 6;104:7-12. Epub 2016 Dec 6.

Department of Neonatology, Zurich University Hospital, Frauenklinikstrasse 10, 8091 Zurich, Switzerland.

Background: As the survival rate of preterm infants constantly improves, knowledge on the impact of prematurity on long-term health-related quality of life (HRQoL) is important for clinical and parental guidance. We aimed to assess HRQoL in a national cohort of young adolescents born very preterm, and to identify predictors for poorer HRQoL.

Patients And Methods: All surviving Swiss live-born children below 30weeks of gestation during the year 2000 (290 subjects) were contacted at age 12years, together with their parents (262 families). HRQoL of the study children was assessed using both the Kidscreen-27 (KS-27) self- and parent forms. Neonatal data of the cohort were prospectively collected.

Results: Among the contacted families, 176 returned the complete set of questionnaires for 194 adolescents (67%): 100 (51%) females, mean (range) gestational age was 27.8 (24.1-29.9) weeks, birth weight 1025 (420-1730) grams, mean age at assessment 12.0 (11.0-13.0) years. Included children had similar neonatal and socio-demographic characteristics as non-responders. Average self- and parent-reported HRQoL of former preterms was similar to Swiss KS-27 norms. According to the multivariable models (r=0.2), surgical closure of patent ductus arteriosus, attention deficit/hyperactivity disorder, severe neurodevelopment impairment were negatively associated with both self- and parent-reported HRQoL.

Conclusions: HRQoL in this population-based cohort of adolescents born very preterm is good. Surgical closure of patent ductus arteriosus, attention deficit/hyperactivity disorder, severe neurodevelopment impairment were identified as predictors of poorer HRQoL using multivariable models, explaining however only a low proportion of variance in HRQoL.
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http://dx.doi.org/10.1016/j.earlhumdev.2016.11.002DOI Listing
January 2017

Attitudes towards decisions about extremely premature infants differed between Swiss linguistic regions in population-based study.

Acta Paediatr 2017 Mar 22;106(3):423-429. Epub 2016 Dec 22.

Department of Neonatology, Perinatal Centre, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Aim: Studies have provided insights into the different attitudes and values of healthcare professionals and parents towards extreme prematurity. This study explored societal attitudes and values in Switzerland with regard to this patient group.

Methods: A nationwide trilingual telephone survey was conducted in the French-, German- and Italian-speaking regions of Switzerland to explore the general population's attitudes and values with regard to extreme prematurity. Swiss residents of 18 years or older were recruited from the official telephone registry using quota sampling and a logistic regression model assessed the influence of socio-demographic factors on end-of-life decision-making.

Results: Of the 5112 people contacted, 1210 (23.7%) participated. Of these 5% were the parents of a premature infant and 26% knew parents with a premature infant. Most participants (77.8%) highlighted their strong preference for shared decision-making, and 64.6% said that if there was dissent then the parents should have the final word. Overall, our logistic regression model showed that regional differences were the most significant factors influencing decision-making.

Conclusion: The majority of the Swiss population clearly favoured shared decision-making. The context of sociocultural demographics, especially the linguistic region in which the decision-making took place, strongly influenced attitudes towards extreme prematurity and decision-making.
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http://dx.doi.org/10.1111/apa.13680DOI Listing
March 2017

Effect of Early Prophylactic High-Dose Recombinant Human Erythropoietin in Very Preterm Infants on Neurodevelopmental Outcome at 2 Years: A Randomized Clinical Trial.

JAMA 2016 May;315(19):2079-85

Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Importance: Very preterm infants are at risk of developing encephalopathy of prematurity and long-term neurodevelopmental delay. Erythropoietin treatment is neuroprotective in animal experimental and human clinical studies.

Objective: To determine whether prophylactic early high-dose recombinant human erythropoietin (rhEPO) in preterm infants improves neurodevelopmental outcome at 2 years' corrected age.

Design, Setting, And Participants: Preterm infants born between 26 weeks 0 days' and 31 weeks 6 days' gestation were enrolled in a randomized, double-blind, placebo-controlled, multicenter trial in Switzerland between 2005 and 2012. Neurodevelopmental assessments at age 2 years were completed in 2014.

Interventions: Participants were randomly assigned to receive either rhEPO (3000 IU/kg) or placebo (isotonic saline, 0.9%) intravenously within 3 hours, at 12 to 18 hours, and at 36 to 42 hours after birth.

Main Outcomes And Measures: Primary outcome was cognitive development assessed with the Mental Development Index (MDI; norm, 100 [SD, 15]; higher values indicate better function) of the Bayley Scales of Infant Development, second edition (BSID-II) at 2 years corrected age. The minimal clinically important difference between groups was 5 points (0.3 SD). Secondary outcomes were motor development (assessed with the Psychomotor Development Index), cerebral palsy, hearing or visual impairment, and anthropometric growth parameters.

Results: Among 448 preterm infants randomized (mean gestational age, 29.0 [range, 26.0-30.9] weeks; 264 [59%] female; mean birth weight, 1210 [range, 490-2290] g), 228 were randomized to rhEPO and 220 to placebo. Neurodevelopmental outcome data were available for 365 (81%) at a mean age of 23.6 months. In an intention-to-treat analysis, mean MDI was not statistically significantly different between the rhEPO group (93.5 [SD, 16.0] [95% CI, 91.2 to 95.8]) and the placebo group (94.5 [SD, 17.8] [95% CI, 90.8 to 98.5]) (difference, -1.0 [95% CI, -4.5 to 2.5]; P = .56). No differences were found between groups in the secondary outcomes.

Conclusions And Relevance: Among very preterm infants who received prophylactic early high-dose rhEPO for neuroprotection, compared with infants who received placebo, there were no statistically significant differences in neurodevelopmental outcomes at 2 years. Follow-up for cognitive and physical problems that may not become evident until later in life is required.

Trial Registration: clinicaltrials.gov Identifier: NCT00413946.
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http://dx.doi.org/10.1001/jama.2016.5504DOI Listing
May 2016

Short courses of dual-strain probiotics appear to be effective in reducing necrotising enterocolitis.

Acta Paediatr 2016 Mar 23;105(3):255-9. Epub 2015 Dec 23.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Aim: Prophylactic probiotics to reduce necrotising enterocolitis (NEC) are mostly given for at least 28 days or until discharge. We describe the effects of a shorter duration dosing strategy.

Methods: Retrospective cohort study of neonates (birthweight 400-1500 g) in three neonatal intensive care units in Switzerland and Germany that embarked on probiotic prophylaxis given for 10 or 14 days, employing a fixed combination (Lactobacillus acidophilus plus Bifidobacterium infantis, each 10(9) CFU/day) licensed as a drug in Switzerland. Probiotics were initiated upon discontinuation of antibiotics, or on day 1-3 in infants without antibiotics. Repeat probiotic courses were given whenever antibiotics had been instituted and were discontinued.

Results: Birthweight and gestational age were similar in the two 24-month pre- and postimplementation cohorts. NEC rates fell from 33 of 633 (5.2%) to 8 of 591 infants alive at three days (1.4%; risk ratio (RR) 0.26, 95% confidence interval (CI) 0.12-0.55). The drop in NEC was significant both for infants of 400-999 g (6.4% to 2.5%) and 1000-1500 g birthweight (4.4% to 0.6%). Mortality was 5.1% (32/633) without, as opposed to 3.5% (21/591) with probiotics, respectively (RR 0.69, 95% CI 0.41-1.19).

Conclusion: Short courses of a dual-strain probiotics appear to be effective in reducing NEC.
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http://dx.doi.org/10.1111/apa.13280DOI Listing
March 2016

Erythropoietin for the Repair of Cerebral Injury in Very Preterm Infants (EpoRepair).

Neonatology 2015 8;108(3):198-204. Epub 2015 Aug 8.

Division of Neonatology, University of Basel Children's Hospital (UKBB), Basel, Germany.

Background: Preterm infants suffering from intraventricular hemorrhage (IVH) are at increased risk for neurodevelopmental impairment. Observational data suggest that recombinant human erythropoietin (rEPO) improves long-term cognitive outcome in infants with IVH. Recent studies revealed a beneficial effect of early high-dose rEPO on white matter development in preterm infants determined by magnetic resonance imaging (MRI).

Objectives: To summarize the current evidence and to delineate the study protocol of the EpoRepair trial (Erythropoietin for the Repair of Cerebral Injury in Very Preterm Infants).

Methods: The study involves a review of the literature and the design of a double-blind, placebo-controlled, multicenter trial of repetitive high-dose rEPO administration, enrolling 120 very preterm infants with moderate-to-severe IVH diagnosed by cranial ultrasound in the first days of life, qualitative and quantitative MRI at term-equivalent age and long-term neurodevelopmental follow-up until 5 years of age.

Results And Conclusions: The hypothesis generated by observational data that rEPO may improve long-term cognitive outcomes of preterm infants suffering from IVH are to be confirmed or refuted by the randomized controlled trial, EpoRepair.
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http://dx.doi.org/10.1159/000437248DOI Listing
June 2016

Safety of Early High-Dose Recombinant Erythropoietin for Neuroprotection in Very Preterm Infants.

J Pediatr 2015 Jul 8;167(1):52-7.e1-3. Epub 2015 Apr 8.

Division of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland.

Objective: To investigate the safety and short term outcome of high dose recombinant human erythropoietin (rhEpo) given shortly after birth and subsequently over the first 2 days for neuroprotection to very preterm infants.

Study Design: Randomized, double masked phase II trial. Preterm infants (gestational age 26 0/7-31 6/7 weeks) were given rhEpo (nt = 229; 3000 U/kg body weight) or NaCl 0.9% (nc = 214) intravenously at 3, 12-18, and 36-42 hours after birth.

Results: There were no relevant differences between the groups for short-term outcomes such as mortality, retinopathy of prematurity, intraventricular hemorrhage, sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia. At day 7-10, we found significantly higher hematocrit values, reticulocyte, and white blood cell counts, and a lower platelet count in the rhEpo group.

Conclusions: Early high-dose rhEpo administration to very premature infants is safe and causes no excess in mortality or major adverse events.

Trial Registration: ClinicalTrials.gov: NCT00413946.
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http://dx.doi.org/10.1016/j.jpeds.2015.02.052DOI Listing
July 2015

Very preterm infants show earlier emergence of 24-hour sleep-wake rhythms compared to term infants.

Early Hum Dev 2015 Jan 27;91(1):37-42. Epub 2014 Nov 27.

Child Development Center, Department of Pediatrics, University Children's Hospital Zürich, CH-8032 Zürich, Switzerland; Children's Research Center (CRC), University Children's Hospital Zürich, CH-8032 Zürich, Switzerland. Electronic address:

Background: Previous studies show contradictory results about the emergence of 24-h rhythms and the influence of external time cues on sleep-wake behavior in preterm compared to term infants.

Aims: To examine whether very preterm infants (<32 weeks of gestational age) differ in their emergence of the 24-h sleep-wake rhythm at 5, 11 and 25 weeks corrected age compared to term infants and whether cycled light conditions during neonatal intermediate care affects postnatal 24-h sleep-wake rhythms in preterm infants.

Study Design: Prospective cohort study with nested interventional trial.

Subjects: 34 preterm and 14 control term infants were studied. During neonatal hospitalization, preterm infants were randomly assigned to cycled light [7 am-7 pm lights on, 7 pm-7 am lights off, n=17] or dim light condition [lights off whenever the child is asleep, n=17].

Outcome Measures: Sleep and activity behavior recorded by parental diary and actigraphy at 5, 11 and 25 weeks corrected age.

Results: Sleep at nighttime and the longest consolidated sleep period between 12 pm-6 am was longer (mixed model analysis, factor group: p=0.02, resp. p=0.01) and activity at nighttime was lower (p=0.005) at all ages in preterm compared to term infants. Cycled light exposed preterm infants showed the longest nighttime sleep duration. Dim light exposed preterm infants were the least active.

Conclusions: Preterm infants show an earlier emergence of the 24-h sleep-wake rhythm compared to term infants. Thus, the length of exposure to external time cues such as light may be important for the maturation of infant sleep-wake rhythms. Trial registry number: This trial has been registered at www.clinicaltrials.gov (identifier NCT01513226).
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http://dx.doi.org/10.1016/j.earlhumdev.2014.11.002DOI Listing
January 2015

Association between early administration of high-dose erythropoietin in preterm infants and brain MRI abnormality at term-equivalent age.

JAMA 2014 Aug;312(8):817-24

Division of Development and Growth, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland.

Importance: Premature infants are at risk of developing encephalopathy of prematurity, which is associated with long-term neurodevelopmental delay. Erythropoietin was shown to be neuroprotective in experimental and retrospective clinical studies.

Objective: To determine if there is an association between early high-dose recombinant human erythropoietin treatment in preterm infants and biomarkers of encephalopathy of prematurity on magnetic resonance imaging (MRI) at term-equivalent age.

Design, Setting, And Participants: A total of 495 infants were included in a randomized, double-blind, placebo-controlled study conducted in Switzerland between 2005 and 2012. In a nonrandomized subset of 165 infants (n=77 erythropoietin; n=88 placebo), brain abnormalities were evaluated on MRI acquired at term-equivalent age.

Interventions: Participants were randomly assigned to receive recombinant human erythropoietin (3000 IU/kg; n=256) or placebo (n=239) intravenously before 3 hours, at 12 to 18 hours, and at 36 to 42 hours after birth.

Main Outcomes And Measures: The primary outcome of the trial, neurodevelopment at 24 months, has not yet been assessed. The secondary outcome, white matter disease of the preterm infant, was semiquantitatively assessed from MRI at term-equivalent age based on an established scoring method. The resulting white matter injury and gray matter injury scores were categorized as normal or abnormal according to thresholds established in the literature by correlation with neurodevelopmental outcome.

Results: At term-equivalent age, compared with untreated controls, fewer infants treated with recombinant human erythropoietin had abnormal scores for white matter injury (22% [17/77] vs 36% [32/88]; adjusted risk ratio [RR], 0.58; 95% CI, 0.35-0.96), white matter signal intensity (3% [2/77] vs 11% [10/88]; adjusted RR, 0.20; 95% CI, 0.05-0.90), periventricular white matter loss (18% [14/77] vs 33% [29/88]; adjusted RR, 0.53; 95% CI, 0.30-0.92), and gray matter injury (7% [5/77] vs 19% [17/88]; adjusted RR, 0.34; 95% CI, 0.13-0.89).

Conclusions And Relevance: In an analysis of secondary outcomes of a randomized clinical trial of preterm infants, high-dose erythropoietin treatment within 42 hours after birth was associated with a reduced risk of brain injury on MRI. These findings require assessment in a randomized trial designed primarily to assess this outcome as well as investigation of the association with neurodevelopmental outcomes.

Trial Registration: clinicaltrials.gov Identifier: NCT00413946.
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http://dx.doi.org/10.1001/jama.2014.9645DOI Listing
August 2014

Randomized controlled trials in very preterm infants: does inclusion in the study result in any long-term benefit?

Neonatology 2014 20;106(2):114-9. Epub 2014 Jun 20.

Division of Neonatology, University Hospital Zurich, Zurich, Switzerland.

Background: Since the introduction of randomized controlled trials (RCT) in clinical research, there has been discussion of whether enrolled patients have worse or better outcomes than comparable non-participants.

Objective: To investigate whether very preterm infants randomized to a placebo group in an RCT have equivalent neurodevelopmental outcomes to infants who were eligible but not randomized (eligible NR).

Methods: In the course of an RCT investigating the neuroprotective effect of early high-dose erythropoietin on the neurodevelopment of very preterm infants, the outcome data of 72 infants randomized to placebo were retrospectively compared with those of 108 eligible NR infants. Our primary outcome measures were the mental (MDI) and psychomotor (PDI) developmental indices of the Bayley Scales of Infant Development II at 24 months of corrected age. The outcomes of the two groups were considered equivalent if the confidence intervals (CIs) of their mean differences fitted within our ±5-point margin of equivalence.

Results: Except for a higher socioeconomic status of the trial participants, both groups were balanced for most perinatal variables. The mean difference (90% CI) between the eligible NR and the placebo group was -2.1 (-6.1 and 1.9) points for the MDI and -0.8 (-4.2 and 2.5) points for the PDI. After adjusting for the socioeconomic status, maternal age and child age at follow-up, the mean difference for the MDI was -0.5 (-4.3 and 3.4) points.

Conclusions: Our results indicate that the participation of very preterm infants in an RCT is associated with equivalent long-term outcomes compared to non-participating infants.
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http://dx.doi.org/10.1159/000362784DOI Listing
May 2015

Impact of perinatal factors on continuous early monitoring of brain electrocortical activity in very preterm newborns by amplitude-integrated EEG.

Pediatr Res 2014 Jun 7;75(6):774-80. Epub 2014 Mar 7.

Child Development Centre, Zurich University Children's Hospital, Zurich, Switzerland.

Background: Amplitude-integrated electroencephalogram (aEEG) is increasingly used for neuromonitoring in preterms. We aimed to quantify the effects of gestational age (GA), postnatal age (PNA), and other perinatal factors on the development of aEEG early after birth in very preterm newborns with normal cerebral ultrasounds.

Methods: Continuous aEEG was prospectively performed in 96 newborns (mean GA: 29.5 (range: 24.4-31.9) wk, birth weight 1,260 (580-2,120) g) during the first 96 h of life. aEEG tracings were qualitatively (maturity scores) and quantitatively (amplitudes) evaluated using preestablished criteria.

Results: A significant increase in all aEEG measures was observed between day 1 and day 4 and for increasing GA (P < 0.001). The effect of PNA on aEEG development was 6.4- to 11.3-fold higher than that of GA. In multivariate regression, GA and PNA were associated with increased qualitative and quantitative aEEG measures, whereas small-for-GA status was independently associated with increased maximum aEEG amplitude (P = 0.003). Morphine administration negatively affected all aEEG measures (P < .05), and caffeine administration negatively affected qualitative aEEG measures (P = 0.02).

Conclusion: During the first few days after birth, aEEG activity in very preterm infants significantly develops and is strongly subjected to the effect of PNA. Perinatal factors may alter the early aEEG tracing and interfere with its interpretation.
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http://dx.doi.org/10.1038/pr.2014.32DOI Listing
June 2014

Changes in cerebral oxygenation during early postnatal adaptation in newborns delivered by vacuum extraction measured by near-infrared spectroscopy.

BMC Pediatr 2014 Jan 27;14:21. Epub 2014 Jan 27.

Division of Neonatology, Department Obstetrics & Gynecology, University Hospital Zurich, Frauenklinikstrasse 10, Zurich CH-8091, Switzerland.

Background: Newborns delivered by vacuum extraction quite often show clinical signs of a hemodynamic compromise, which is difficult to assess in terms of severity. The conventional means to measure the hemodynamic status are not sensitive enough to appreciate the severity of general, and more specifically of cerebral circulatory imbalance. The aim was to study cerebral tissue oxygenation during postnatal adaptation in these infants using near-infrared spectroscopy.

Methods: The tissue hemoglobin index (THI), tissue oxygenation index (TOI), arterial oxygen saturation (pre-ductal SaO₂) and heart rate (HR) were recorded immediately after birth, and again after 12-24 hours of life in 15 newborns delivered by vacuum extraction due to fetal distress. A comparison with 19 healthy newborns delivered by elective cesarean section was performed.

Results: Newborns delivered by vacuum extraction had significantly higher THI 10 to 15 minutes after birth. TOI and HR were significantly higher in the first 5 min and SaO₂ in the first 10 minutes but then did not differ from those after cesarean section.

Conclusion: Infants delivered by vacuum extraction following fetal distress show transient deviations in cerebral oxygenation and perfusion after birth which were not detectable after 24 hours.
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http://dx.doi.org/10.1186/1471-2431-14-21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3913969PMC
January 2014