Publications by authors named "Orlando da Silva"

34 Publications

Impact of Catheter Choice on Procedural Success of Minimally Invasive Surfactant Therapy.

Am J Perinatol 2021 Sep 24. Epub 2021 Sep 24.

Children's Hospital, London Health Science Centre, Department of Pediatrics, Western University, London, Ontario, Canada.

Objective:  Surfactant delivery via a thin endotracheal catheter during spontaneous breathing; a technique called minimally invasive surfactant therapy (MIST) is an alternative to intubation and surfactant administration. Procedural details among different centers vary, with marked differences in the choice of catheter to instill surfactant. Studies report use of feeding catheters, multiaccess suction catheters, vascular catheters, and more recently custom-built catheters for this purpose. The impact of choice of catheter on procedural success and procedural adverse effects has not been reported. Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart Method) versus a flexible multiaccess catheter (MAC).

Study Design:  This was a retrospective review of prospectively collected data at a tertiary care neonatal intensive care unit in Southwestern Ontario. All neonates who received surfactant via MIST between May 1, 2016 and September 30, 2020 were included in the study. Relevant baseline characteristics and data on procedural details (premedication, type of catheter, etc.) were collected. The procedural success, number of attempts, and adverse effects between neonates who received MIST via MAC and 16G Angiocath was compared by using Chi-square test or Fisher's test as appropriate. A -value of less that 0.05 was considered significant.

Results:  A total of 139 neonates received surfactant via MIST method during the study period. Moreover, 93 neonates received the surfactant via MAC, while 46 received it via Angiocath. The baseline demographic characteristics in the two group were similar. A higher proportion of neonates in Angiocath group received Atropine (100 vs. 76%,  = 0.002) and Fentanyl (98 vs. 36%,  < 0.001) than the MAC group.The procedural success was 91% in the Angiocath group and 89% in the MAC group ( > 0.99). Multiple attempts were needed in 24% of neonates in the Angiocath group and 37% in the MAC group ( = 0.158). More episodes of desaturations were noted in the Angiocath group (89%) than the MAC group (69%;  = 0.012). Other rates of common adverse effects were similar between the two groups. On exploratory analysis fentanyl use held significant association with less success, more desaturation, apneic episodes, and need of positive pressure ventilation /intubation.

Conclusion:  The overall procedural success of MIST is similar in both catheter groups. The proportion of neonates requiring multiple attempts was lower with the Angiocath, though difference was not statistically significant. Desaturation episodes were seen more frequently in the Angiocath group, which was related to higher use of procedural sedation in this group.

Key Points: · MIST is emerging as a less invasive method of surfactant delivery that has proven clinical benefits.. · Considerable, procedural variation is reported, particularly regarding choice of catheter.. · Our present study compares the procedural success and adverse effects of MIST using a semirigid vascular catheter (16G Angiocath-Hobart method) versus a flexible MAC.. · High and comparable procedural success was seen in both groups..
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http://dx.doi.org/10.1055/s-0041-1733956DOI Listing
September 2021

Actuarial Survival Based on Gestational Age in Days at Birth for Infants Born at <26 Weeks of Gestation.

J Pediatr 2020 10 28;225:97-102.e3. Epub 2020 May 28.

Department of Pediatrics, Mount Sinai Hospital, Toronto, ON, Canada; Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada; Departments of Pediatrics and Obstetrics and Gynecology and Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.

Objective: To provide comprehensive, contemporary information on the actuarial survival of infants born at 22-25 weeks of gestation in Canada.

Study Design: In a retrospective cohort study, we included data from preterm infants of 22-25 weeks of gestation admitted to neonatal intensive care units participating in the Canadian Neonatal Network between 2010 and 2017. Infants with major congenital anomalies were excluded. We calculated gestational age using in vitro fertilization date, antenatal ultrasound dating, last menstrual period, obstetrical estimate, or neonatal estimate (in that order). Infants were followed until either discharge or death. Each day of gestational age was considered a category except for births at 22 weeks, where the first 4 days were grouped into one category and the last 3 days were grouped into another category. For each day of life, an actuarial survival rate was obtained by calculating how many infants survived to discharge out of those who had survived up to that day.

Results: Of 4335 included infants, 85, 679, 1504, and 2067 were born at 22, 23, 24, and 25 weeks of gestation, respectively. Survival increased from 32% at 22 weeks to 83% at 25 weeks. Graphs of actuarial survival developed for the first 6 weeks after birth in male and female children indicated a steep increase in survival during the first 7-10 days postnatally.

Conclusions: Survival increased steadily with postnatal survival and was dependent on gestational age in days and sex of the child.
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http://dx.doi.org/10.1016/j.jpeds.2020.05.047DOI Listing
October 2020

Epidemiology of thrombosis in Canadian neonatal intensive care units.

J Perinatol 2020 07 8;40(7):1083-1090. Epub 2020 May 8.

Maternal-Infant Care (MiCare) Research Centre, Mount Sinai Hospital, Toronto, ON, Canada.

Objective: To assess the rate, location, risk factors, management, and outcomes of neonatal thrombosis (NT).

Design: A retrospective study investigating infants admitted to NICUs in Canadian Neonatal Network between January 2014 and December 2016 and diagnosed with NT. Each infant with NT was matched with an infant without NT.

Results: Of 39,971 infants, 587 (1.5%) were diagnosed with NT: 440 (75%) venous, 112 (19%) arterial, 29 (5%) both. NT rate was 1.4% in full-term and 1.7% in preterm infants. Venous thrombi occurred most commonly in the portal vein and arterial thrombi in the cerebral artery. Conservative management and low molecular weight heparin were the most common treatment modalities. Hospital stay was longer (p < 0.001) in the NT patients, but mortality was similar.

Conclusions: NT was diagnosed in ~15/1000 NICU admissions and most commonly in the portal vein and cerebral arteries. Management varied based on the type and location of thrombi. Large multicenter trials are needed to address the best management strategies.
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http://dx.doi.org/10.1038/s41372-020-0678-1DOI Listing
July 2020

High-volume surfactant administration using a minimally invasive technique: Experience from a Canadian Neonatal Intensive Care Unit.

Paediatr Child Health 2019 Aug 15;24(5):313-317. Epub 2018 Dec 15.

Children's Hospital, London Health Science Centre, Department of Pediatrics, Western University, London, Ontario.

Background: Surfactant delivery via a thin endotracheal catheter during spontaneous breathing, a technique called minimally invasive surfactant therapy (MIST), is an alternative to intubation and surfactant administration. There is paucity of data regarding the administration of high-volume surfactant using this technique.

Methods: We conducted a retrospective cohort study to review the safety, efficacy, and procedural details pertaining to the delivery of 5 mL/kg of BLES® via MIST approach. In 2016, our centre initiated a practice change allowing the use of MIST as an alternative method of surfactant delivery in infants born at ≥28 weeks and/or with a birth weight ≥ 1,000 g with respiratory distress syndrome. In this study, we identified all neonates who received surfactant via MIST between May 1, 2016 and July 30, 2018 and collected relevant procedural data.

Results: Since this practice change, MIST technique was attempted in 43 neonates with successful instillation of surfactant in 41 (95.3%) of the neonates. Intubation and positive pressure ventilation was avoided in 35 neonates (85.3%). No serious adverse effect was noted.

Conclusions: Our study reports successful use of higher volume surfactant via MIST. This should encourage other similar centres to consider this technique, in order to avoid unnecessary intubation and positive pressure ventilation.
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http://dx.doi.org/10.1093/pch/pxy162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6656944PMC
August 2019

Effects of bovine lipid extract surfactant administration in preterm infants treated for respiratory distress syndrome.

Health Sci Rep 2018 Apr 24;1(4):e34. Epub 2018 Mar 24.

Children's Hospital at London Health Sciences Centre Children's Health Research Institute London Ontario Canada.

Aim: To review the initial effectiveness of bovine lipid extract surfactant (BLES) for the treatment of respiratory distress syndrome in preterm infants.

Methods And Results: A retrospective review of data collected from infants born <37-week gestation with respiratory distress syndrome treated with BLES between February 1, 2015 and March 1, 2016. Data were analyzed to determine the timing of initial dose, the length of time to wean the fraction of inspired oxygen (FiO) concentration to 0.21 following initial dose, and the number of repeated doses given during hospital admission. Infants were subgrouped by gestational age stratum, 23 to 27 weeks (group 1), 28 to 31 weeks (group 2), and 32 to 36 weeks (group 3). Ninety-eight infants received the surfactant during the study period. After applying exclusion criteria, 77 infants were analyzed. Mean (SD) gestational age was 28 (4) weeks, and mean (SD) birth weight was 1250 (602) g. Initial dose of BLES was given at a median (interquartile range) time of 29 (19-43) minutes in group 1, 150 (20-615) minutes in group 2, and 990 (53-2025) minutes in group 3. Median (interquartile range) length of time to wean the FiO concentration to 0.21 was 14 (5-56) minutes, 10 (5-53) minutes, and 10 (5-38) minutes in groups 1, 2, and 3, respectively. Ten infants required repeated doses.

Conclusion: Given the rapid response of BLES in all the groups, careful monitoring of ventilator parameters is paramount to allow for rapid weaning and early extubation to avoid lung injury associated with mechanical ventilation.
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http://dx.doi.org/10.1002/hsr2.34DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6266363PMC
April 2018

Pregnancy gestation at delivery and breast milk production: a secondary analysis from the trial.

Matern Health Neonatol Perinatol 2018 5;4:21. Epub 2018 Nov 5.

6School of Pharmacy (D.K.), University of Waterloo, Kitchener, ON Canada.

Background: Preterm birth alters the normal sequence of lactogenesis. Lactogenesis I may not yet have started when mothers of very preterm infants (≤ 29 weeks gestation) have given birth. Preterm infants are too small or too ill to initiate suckling in the immediate postpartum period thus altering the normal cascade of event for lactogenesis II. With an increasing demand for mother's own milk as a primary source of nutritional support in the care of very small and preterm infants, mothers of these infants are often at risk of expressing inadequate amounts of milk. The use of galactogogues is often considered when mothers of preterm infants are still having challenges in breast milk production. What is not clear in the literature is the role that pregnancy gestation at birth plays in successful response to galactogogues. Our objective for this study was to evaluate the role of pregnancy gestation at birth on a mother's response to the treatment interventions in the trial.

Methods: For this analysis, the study participants are the 90 mothers who participated in the trial and were in the stratified in two gestational age groups, 23-26 weeks and 27-29 weeks at the time of randomization. The primary outcome measures were the proportion of mothers in each of the gestational age groupings who achieved a 50% increase in breast milk volume on day 14 and day 28 of the study treatment period.

Results: On day 14 of the study treatment, there was no significant difference in the proportion of mothers in the 23-26 weeks gestation group (72.9%) compared to those in the 27-29 weeks gestation group (64.2%), OR 1.51 (95% CI 0.60, 3.78;  = 0.38). Similarly, there was no difference in the proportion of mothers between the two gestational age groupings on day 28 of the study treatment, 70.3% compared to 62.3%, OR 1.43 (95% CI 0.58, 3.51;  = 0.43).

Conclusion: This secondary analysis was able to demonstrate that mothers of very preterm infants, < 30 weeks gestation at birth, were able to respond to the study treatment in a similar fashion regardless of gestation at birth. If non-pharmacologic approaches are unsuccessful, then a 14-day treatment of domperidone may be considered to enhance breast milk production, even in the lowest gestational ages at delivery.

Trial Registration: has been registered at www.clinicaltrials.gov (identifier NCT 01512225) on January 10, 2012.
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http://dx.doi.org/10.1186/s40748-018-0089-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6217780PMC
November 2018

Effectiveness of Family Integrated Care in neonatal intensive care units on infant and parent outcomes: a multicentre, multinational, cluster-randomised controlled trial.

Lancet Child Adolesc Health 2018 04 8;2(4):245-254. Epub 2018 Feb 8.

Department of Paediatrics, Sinai Health System, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Department of Obstetrics and Gynaecology, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada.

Background: Despite evidence suggesting that parent involvement was beneficial for infant and parent outcomes, the Family Integrated Care (FICare) programme was one of the first pragmatic approaches to enable parents to become primary caregivers in the neonatal intensive care unit (NICU). We aimed to analyse the effect of FICare on infant and parent outcomes, safety, and resource use.

Methods: In this multicentre, cluster-randomised controlled trial, we stratified 26 tertiary NICUs from Canada, Australia, and New Zealand by country and size, and assigned them, using a computer-generated random allocation sequence, to provide FICare or standard NICU care. Eligible infants were born at 33 weeks' gestation or earlier, and had no or low-level respiratory support; parents gave written informed consent for enrolment. To be eligible, parents in the FICare group had to commit to be present for at least 6 h a day, attend educational sessions, and actively care for their infant. The primary outcome, analysed at the individual level, was infant weight gain at day 21 after enrolment. Secondary outcomes were weight gain velocity, high frequency breastfeeding (≥6 times a day) at hospital discharge, parental stress and anxiety at enrolment and day 21, NICU mortality and major neonatal morbidities, safety, and resource use (including duration of oxygen therapy and hospital stay). This trial is registered with ClinicalTrials.gov, number NCT01852695.

Findings: From Oct 1, 2012, 26 sites were randomly assigned to provide FICare (n=14) or standard care (n=12). One site assigned to FICare discontinued because of poor site enrolment. Parents and infants were enrolled between April 1, 2013, and Aug 31, 2015, with 895 infants being eligible in the FICare group and 891 in the standard care group. At day 21, weight gain was greater in the FICare group than in the standard care group (mean change in Z scores -0·071 [SD 0·42] vs -0·155 [0·42]; p<0·0002). Average daily weight gain was significantly higher in infants receiving FICare than those receiving standard care (mean daily weight gain 26·7 g [SD 9·4] vs 24·8 g [9·5]; p<0·0001). The high-frequency exclusive breastmilk feeding rate at discharge was higher for infants in the FICare group (279 [70%] of 396) than those in the standard care group (394 [63%] of 624; p=0·016). At day 21, parents in the FICare group had lower mean stress scores than did parents in the standard care group (2·3 [SD 0·8] vs 2·5 [0·8]; p<0·00043), and lower mean anxiety scores (70·8 [20·1] vs 74·2 [19·9]; p=0·0045). There were no significant differences between groups in the rates of the secondary outcomes of mortality, major morbidity, duration of oxygen therapy, and duration of hospital stay. Although the safety assessment was not completed, there were no adverse events.

Interpretation: FICare improved infant weight gain, decreased parent stress and anxiety, and increased high-frequency exclusive breastmilk feeding at discharge, which together suggest that FICare is an important advancement in neonatal care. Further research is required to examine if these results translate into better long-term outcomes for families.

Funding: Canadian Institutes of Health Research Partnerships for Health System Improvement, and Ontario Ministry of Health and Long-Term Care.
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http://dx.doi.org/10.1016/S2352-4642(18)30039-7DOI Listing
April 2018

Neonatal outcomes of extremely preterm infants exposed to maternal hypertension and cigarette smoking.

J Perinatol 2018 08 8;38(8):1051-1059. Epub 2018 May 8.

Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.

Objective: To study the outcomes of extremely preterm infants of hypertensive mothers who smoke.

Study Design: This retrospective cohort study included infants born between 2003 and 2012 at <29 weeks' gestation and admitted to neonatal intensive care units participating in the Canadian Neonatal Network. Infants were divided into four mutually exclusive groups. Infants of hypertensive mothers who smoked; infants of hypertensive, non-smoking mothers; infants of normotensive mothers who smoked; and infants of normotensive, non-smoking mothers. Using infants of normotensive, non-smoking mothers as the reference group, neonatal outcomes were compared between the groups. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were calculated using univariate and multivariate regression analysis.

Results: Of the 12,307 eligible infants, 172 had hypertensive mothers who smoked, 1689 had hypertensive non-smoking mothers, 1535 had normotensive mothers who smoked, and 8911 had normotensive non-smoking mothers. Compared to infants of normotensive non-smoking mothers, infants of hypertensive mothers, regardless of smoking status, had higher odds of developing bronchopulmonary dysplasia (AORs of smokers 1.62; 95% CI 1.12-2.35 and of non-smokers 1.43; 95% CI 1.24-1.64). There was no difference in the odds of mortality and retinopathy of prematurity stage ≥3 between the groups. Infants of hypertensive, non-smoking mothers had decreased odds of intraventricular hemorrhage >grade 2 and higher odds of necrotizing enterocolitis. There was decreased odds of hypertension if the mother was a smoker (AOR 0.71; 95% CI 0.59-0.85).

Conclusion: Maternal hypertension is associated with increased rates of bronchopulmonary dysplasia, irrespective of smoking status.
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http://dx.doi.org/10.1038/s41372-018-0111-1DOI Listing
August 2018

Enhancing Human Milk Production With Domperidone in Mothers of Preterm Infants.

J Hum Lact 2017 02 20;33(1):181-187. Epub 2017 Jan 20.

Christoph Fusch; Lajos Kovacs; Annie Janvier; Georges Cauoette; Abhay Lodha; Barbara Bulleid; Doug McMillan; Balpreet Singh

Background: Mothers of preterm infants often are at risk of expressing an inadequate amount of milk for their infants and the use of galactogogues is often considered. Domperidone is a widely used galactogogue with little information available to guide clinicians regarding initiation, timing, and duration of treatment. Research aim: The primary objective of this study was to determine whether administration of domperidone within the first 21 days after delivery would lead to a higher proportion of mothers achieving a 50% increase in the volume of milk at the end of 14 days of treatment compared with mothers receiving placebo.

Methods: Eligible mothers were randomized to one of two treatment arms: Group A-domperidone 10 mg orally three times daily for 28 days; or Group B-placebo 10 mg orally three times daily for 14 days followed by domperidone 10 mg orally three times daily for 14 days.

Results: A total of 90 mothers of infants ≤ 29 weeks gestation were randomized. Mean milk volumes at entry were similar for both groups. More mothers achieved a 50% increase in milk volume after 14 days in Group A (77.8%) compared with Group B (57.8%), odds ratio = 2.56, 95% confidence interval [1.02, 6.25], p = .04.

Conclusion: A greater number of mothers experienced a 50% or more increase in human milk volume, but the absolute increase in milk volume was modest.
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http://dx.doi.org/10.1177/0890334416680176DOI Listing
February 2017

Bronchodilators for the prevention and treatment of chronic lung disease in preterm infants.

Cochrane Database Syst Rev 2016 12 14;12:CD003214. Epub 2016 Dec 14.

Departments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation, University of Toronto, 600 University Avenue, Toronto, ON, Canada, M5G 1X5.

Background: Chronic lung disease (CLD) occurs frequently in preterm infants. Bronchodilators have the potential effect of dilating small airways with muscle hypertrophy. Increased compliance and tidal volume and decreased pulmonary resistance have been documented with the use of bronchodilators in infants with CLD. Therefore, bronchodilators might have a role in the prevention and treatment of CLD.

Objectives: To determine the effect of bronchodilators given as prophylaxis or as treatment for CLD on mortality and other complications of preterm birth in infants at risk for or identified as having CLD.

Search Methods: On 2016 March 7, we used the standard strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (from 1966), Embase (from 1980) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982). We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We applied no language restrictions.

Selection Criteria: Randomised and quasi-randomised controlled trials involving preterm infants were eligible for inclusion. Initiation of bronchodilator therapy for prevention of CLD had to occur within two weeks of birth. Treatment of patients with CLD had to be initiated before discharge from the neonatal unit. The intervention had to include administration of a bronchodilator by nebulisation, by metered dose inhaler (with or without a spacer device) or by intravenous or oral administration versus placebo or no intervention. Eligible studies had to include at least one of the following predefined clinical outcomes: mortality, CLD, number of days on oxygen, number of days on ventilator, patent ductus arteriosus (PDA), pulmonary interstitial emphysema (PIE), pneumothorax, intraventricular haemorrhage (IVH) of any grade, necrotising enterocolitis (NEC), sepsis and adverse effects of bronchodilators.

Data Collection And Analysis: We used the standard method described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Two review authors extracted and assessed all data provided by each study. We reported risk ratio (RR), risk difference (RD) and number needed to treat for an additional beneficial outcome (NNTB) with 95% confidence interval (CI) for dichotomous outcomes and mean difference (MD) for continuous data. We assessed the quality of the evidence by using the GRADE approach.

Main Results: For this update, we identified one new randomised controlled trial investigating effects of bronchodilators in preterm infants. This study, which enrolled 73 infants but reported on 52 infants, examined prevention of CLD with the use of aminophylline. According to GRADE, the quality of the evidence was very low. One previously included study enrolled 173 infants to look at prevention of CLD with the use of salbutamol. According to GRADE, the quality of the evidence was moderate. We found no eligible trial that studied the use of bronchodilator therapy for treatment of individuals with CLD. Prophylaxis with salbutamol led to no statistically significant differences in mortality (RR 1.08, 95% CI 0.50 to 2.31; RD 0.01, 95% CI -0.09 to 0.11) nor in CLD (RR 1.03, 95% CI 0.78 to 1.37; RD 0.02, 95% CI -0.13 to 0.17). Results showed no statistically significant differences in other complications associated with CLD nor in preterm birth. Investigators in this study did not comment on side effects due to salbutamol. Prophylaxis with aminophylline led to a significant reduction in CLD at 28 days of life (RR 0.18, 95% CI 0.04 to 0.74; RD -0.35, 95% CI -0.56 to -0.13; NNTB 3, 95% CI 2 to 8) and no significant difference in mortality (RR 3.0, 95% CI 0.33 to 26.99; RD 0.08, 95% CI -0.07 to 0.22), along with a significantly shorter dependency on supplementary oxygen in the aminophylline group compared with the no treatment group (MD -17.75 days, 95% CI -27.56 to -7.94). Tests for heterogeneity were not applicable for any of the analyses, as each meta-analysis included only one study.

Authors' Conclusions: Data are insufficient for reliable assessment of the use of salbutamol for prevention of CLD. One trial of poor quality reported a reduction in the incidence of CLD and shorter duration of supplementary oxygen with prophylactic aminophylline, but these results must be interpreted with caution. Additional clinical trials are necessary to assess the role of bronchodilator agents in prophylaxis or treatment of CLD. Researchers studying the effects of bronchodilators in preterm infants should include relevant clinical outcomes in addition to pulmonary mechanical outcomes. We identified no trials that studied the use of bronchodilator therapy for treatment of CLD.
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http://dx.doi.org/10.1002/14651858.CD003214.pub3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6463958PMC
December 2016

Online Calculator to Improve Counseling of Short-Term Neonatal Morbidity and Mortality Outcomes at Extremely Low Gestational Age (23-28 Weeks).

Am J Perinatol 2016 07 8;33(9):910-7. Epub 2016 Apr 8.

Department of Obstetrics and Gynecology, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.

Objective Extremely low gestational age (ELGA) infants are at high risk of perinatal and neonatal morbidity and mortality. Accurate and relevant data are essential for developing a health care plan and providing realistic estimates of infants' outcomes. Study Design Retrospective analysis of all infants delivered between 23(0/7) and 28(6/7) weeks' gestation over 11 years at a single center. Using logistic regression analysis, gestational age (GA)-specific mortality and morbidity rates, and the effects of gender, antenatal corticosteroids, multiple gestation, and birth weight (BW) were determined. Results Of the 766 study infants, 644 (84.1%) were admitted to the neonatal intensive care unit, of which 502 (75.8%) survived to discharge. GA, antenatal corticosteroids, and BW were significant predictors of survival (GA: odds ratio [OR] = 1.83, 95% confidence interval [CI] = 1.64-2.04; corticosteroids: OR = 7.62, 95% CI = 5.19-11.18; BW: OR = 1.56, 95% CI = 1.44-1.69). Increasing BW correlated with a decreasing mortality rate. Conclusion This study provides recent outcome data of ELGA infants delivered at a tertiary level center. The results have been translated into an online counseling tool (http://murmuring-brook-6600.herokuapp.com/ELGA.html).
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http://dx.doi.org/10.1055/s-0036-1581131DOI Listing
July 2016

Evaluation of the Family Integrated Care model of neonatal intensive care: a cluster randomized controlled trial in Canada and Australia.

BMC Pediatr 2015 Dec 15;15:210. Epub 2015 Dec 15.

Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada.

Background: Admission to the neonatal intensive care unit (NICU) may disrupt parent-infant interaction with adverse consequences for infants and their families. Several family-centered care programs promote parent-infant interaction in the NICU; however, all of these retain the premise that health-care professionals should provide most of the infant's care. Parents play a mainly supportive role in the NICU and continue to feel anxious and unprepared to care for their infant after discharge. In the Family Integrated Care (FICare) model, parents provide all except the most advanced medical care for their infants with support from the medical team. Our hypothesis is that infants whose families complete the FICare program will have greater weight gain and better clinical and parental outcomes compared with infants provided with standard NICU care.

Methods/design: FICare is being evaluated in a cluster randomized controlled trial among infants born at ≤ 33 weeks' gestation admitted to 19 Canadian, 6 Australian, and 1 New Zealand tertiary-level NICU. Trial enrollment began in April, 2013, with a target sample size of 675 infants in each arm, to be completed by August, 2015. Participating sites were stratified by country, and by NICU size within Canada, for randomization to either the FICare intervention or control arm. In intervention sites, parents are taught how to provide most of their infant's care and supported by nursing staff, veteran parents, a program coordinator, and education sessions. In control sites standard NICU care is provided. The primary outcome is infants' weight gain at 21 days after enrollment, which will be compared between the FICare and control groups using Student's t-test adjusted for site-level clustering, and multi-level hierarchical models accounting for both clustering and potential confounders. Similar analyses will examine secondary outcomes including breastfeeding, clinical outcomes, safety, parental stress and anxiety, and resource use. The trial was designed, is being conducted, and will be reported according to the CONSORT 2010 guidelines for cluster randomized controlled trials.

Discussion: By evaluating the impact of integrating parents into the care of their infant in the NICU, this trial may transform the delivery of neonatal care.

Trial Registration: NCT01852695 , registered December 19, 2012.
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http://dx.doi.org/10.1186/s12887-015-0527-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4681024PMC
December 2015

Adverse Impact of Maternal Cigarette Smoking on Preterm Infants: A Population-Based Cohort Study.

Am J Perinatol 2015 Oct 31;32(12):1105-11. Epub 2015 Mar 31.

Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.

Objective: The aim of the study is to examine the impact of exposure to maternal cigarette smoking on neonatal outcomes of very preterm infants.

Study Design: A retrospective cohort study examined preterm infants (<33 weeks gestational age) admitted to the Canadian Neonatal Network centers between 2003 and 2011. Mortality and major morbidities (bronchopulmonary dysplasia, severe intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy) were compared between infants exposed and unexposed to maternal smoking during pregnancy after adjusting for confounders.

Results: Among 29,051 study infants, 4,053 (14%) were exposed to maternal smoking during pregnancy. Multivariable analysis revealed higher odds of grade 3 or 4 intraventricular hemorrhage or periventricular leukomalacia (adjusted odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.04-1.41) and bronchopulmonary dysplasia (adjusted OR: 1.16, 95% CI: 1.02-1.33) in the smoking group, while mortality, severe retinopathy, and necrotizing enterocolitis were not significantly different.

Conclusion: Maternal smoking during pregnancy is associated with severe neurological injury and bronchopulmonary dysplasia in preterm infants.
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http://dx.doi.org/10.1055/s-0035-1548728DOI Listing
October 2015

Development and implementation of a novel online breastfeeding support resource: the Maternal Virtual Infant Nutrition Support Clinic.

Breastfeed Med 2014 Dec;9(10):520-3

Department of Pediatrics, Schulich School of Medicine and Dentistry, Child Health Research Institute , London Health Sciences Centre, London, Ontario, Canada .

Exclusive breastfeeding is the optimal method of infant feeding for the first 6 months of life for both term and preterm infants. This recommendation is based on indisputable evidence that breastfeeding offers numerous infant and maternal health benefits. Several trials have shown the beneficial effect of peer and/or professional support on the duration of any breastfeeding up to 6 months. Although many well-established programs exist that provide this support in-person or via telephone, the Internet is a relatively new means to deliver breastfeeding help. Yet, mothers have a vast presence online and a clear desire to seek healthcare information on the Internet. The availability and accessibility of interactive communication technologies via the internet provide the opportunity for developing new methods of healthcare delivery. Our project uses information technology to deliver an innovative and cost-effective way to support breastfeeding mothers. Our new online breastfeeding support clinic has the potential to improve access to specialized professional breastfeeding support in combination with interactive peer support. This new online clinic can be readily implemented to all regions in Canada with reliable Internet access, with the potential to significantly impact the health of all Canadian infants and their families.
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http://dx.doi.org/10.1089/bfm.2014.0051DOI Listing
December 2014

Recurrent late-onset group B Streptococcus sepsis in a preterm infant acquired by expressed breastmilk transmission: a case report.

Breastfeed Med 2013 Feb 25;8(1):134-6. Epub 2012 Jun 25.

Children’s Hospital London Health Sciences Centre, Schulich School of Medicine and Dentistry, University of Western Ontario, London,Ontario, Canada.

Group B Streptococcus is a known cause of neonatal sepsis, being more common in the early period by maternal genital tract transmission and less so in the late neonatal period, ascribed to intestinal colonization or horizontal transmission. Although breastmilk transmission of Group B Streptococcus has rarely been reported in the past, most cases are of patients nursed on the mother's breast and less commonly in expressed breastmilk-fed infants. This case describes a preterm infant (born at a gestational age of 24 weeks 6 days) in the neonatal intensive care unit who acquired recurrent late-onset sepsis with Group B Streptococcus with the mother's expressed breastmilk culture growing the same organism that was later matched to the infant's isolate. The mother had presented with features of mastitis only during the second episode of sepsis and was then treated with oral antibiotics. The infant was fed on formula feeds after the second incidence and remained healthy, being discharged on a regular follow-up plan at 39 weeks corrected gestational age.
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http://dx.doi.org/10.1089/bfm.2012.0016DOI Listing
February 2013

Cost-effectiveness analysis of a system-based approach for managing neonatal jaundice and preventing kernicterus in Ontario.

Paediatr Child Health 2012 Jan;17(1):11-6

University of Western Ontario, London, Ontario.

Objective: To evaluate the incremental cost-effectiveness of a system-based approach for the management of neonatal jaundice and the prevention of kernicterus in term and late-preterm (≥35 weeks) infants, compared with the traditional practice based on visual inspection and selected bilirubin testing.

Study Design: Two hypothetical cohorts of 150,000 term and late-preterm neonates were used to compare the costs and outcomes associated with the use of a system-based or traditional practice approach. Data for the evaluation were obtained from the case costing centre at a large teaching hospital in Ontario, supplemented by data from the literature.

Results: The per child cost for the system-based approach cohort was $176, compared with $173 in the traditional practice cohort. The higher cost associated with the system-based cohort reflects increased costs for predischarge screening and treatment and increased postdischarge follow-up visits. These costs are partially offset by reduced costs from fewer emergency room visits, hospital readmissions and kernicterus cases. Compared with the traditional approach, the cost to prevent one kernicterus case using the system-based approach was $570,496, the cost per life year gained was $26,279, and the cost per quality-adjusted life year gained was $65,698.

Conclusion: The cost to prevent one kernicterus case using the system-based approach is much lower than previously reported in the literature.
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http://dx.doi.org/10.1093/pch/17.1.11DOI Listing
January 2012

Bronchodilators for the prevention and treatment of chronic lung disease in preterm infants.

Cochrane Database Syst Rev 2012 Jun 13(6):CD003214. Epub 2012 Jun 13.

Division of Neonatology, Imperial College Healthcare NHSTrust, St.Mary’s Hospital, London,UK.

Background: Chronic lung disease (CLD) occurs frequently in preterm infants. Bronchodilators have the potential effect of dilating small airways with muscle hypertrophy. Increase in compliance and tidal volume and decrease in pulmonary resistance have been documented with use of bronchodilators in studies of pulmonary mechanics in infants with CLD. Therefore, it is possible that bronchodilators might have a role in the prevention and treatment of CLD.

Objectives: To determine the effect of bronchodilators given either prophylactically or as treatment for CLD on mortality and other complications of prematurity in preterm infants at risk for or having CLD.

Search Methods: For this update of the review, searches of The Cochrane Library, Issue 3, 2012; MEDLINE 1966; EMBASE; CINAHL; personal files and reference lists of identified trials were performed in March 2012. In addition Web of Science and abstracts from the Annual meetings of the Pediatric Academic Societies were searched electronically from 2000 to 2012 on PAS Abstracts2view(TM.) No language restrictions were applied.

Selection Criteria: Randomised controlled trials involving preterm infants were eligible for inclusion. Initiation of bronchodilator therapy had to occur within two weeks of birth for prevention of CLD. For treatment of CLD, treatment had to be initiated before discharge from the neonatal unit. The intervention had to include the administration of a bronchodilator either by nebulisation, metered dose inhaler (with or without a spacer device), intravenously or orally versus placebo or no intervention. Eligible studies had to include at least one of the predefined clinical outcomes (mortality, CLD, number of days on oxygen, number of days on ventilator, patent ductus arteriosus (PDA), pulmonary interstitial emphysema (PIE), pneumothorax, any grade of intraventricular haemorrhage (IVH), necrotising enterocolitis (NEC), sepsis and adverse effects of bronchodilators. Adverse effects of bronchodilators included hypokalaemia, tachycardia, cardiac arrhythmias, tremor, hypertension and hyperglycaemia).

Data Collection And Analysis: We used the standard method described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Two investigators extracted and assessed all data for each study. We reported risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI) for dichotomous outcomes and weighted mean difference (WMD) for continuous data.

Main Results: In this update we identified four randomised controlled trials investigating the effects of bronchodilators in preterm infants. None of these studies fulfilled our inclusion criterion that clinical outcomes should be reported. One eligible study was previously found dealing with prevention of CLD; this study used salbutamol and enrolled 173 infants. No eligible studies were found dealing with treatment of CLD. Prophylaxis with salbutamol did not show a statistically significant difference in mortality (RR 1.08; 95% CI 0.50 to 2.31; RD 0.01; 95% CI -0.09 to 0.11) or CLD (RR 1.03; 95% CI 0.78 to 1.37; RD 0.02; 95% CI -0.13 to 0.17). No statistically significant differences were seen in other complications associated with CLD or preterm birth. No side effects due to salbutamol were commented on in this study.

Authors' Conclusions: There are insufficient data to reliably assess the use of salbutamol for the prevention of CLD. Further clinical trials are necessary to assess the role of salbutamol or other bronchodilator agents in prophylaxis or treatment of CLD. Researchers studying the effects of bronchodilators in preterm infants should include relevant clinical outcomes in addition to pulmonary mechanical outcomes.
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http://dx.doi.org/10.1002/14651858.CD003214.pub2DOI Listing
June 2012

The changing epidemiology of preterm twins and triplets admitted to neonatal intensive care units in Canada, 2003 to 2008.

Am J Perinatol 2012 Apr 1;29(4):237-44. Epub 2011 Aug 1.

Dalla Lana School of Public Health, University of Toronto, Ontario, Canada.

We describe trends in the rates of admission of preterm twin and triplet infants to neonatal intensive care units (NICUs) across Canada and compare their neonatal outcomes over a 6-year period. Temporal trends of admission rates for 5193 twins and triplets < 33 weeks' gestational age to participating NICUs in the Canadian Neonatal Network between 2003 and 2008 were assessed. Trends in infant outcomes were evaluated using logistic regression. The proportion of twins increased from 26.1 to 28.0 per 100 admissions between 2003 and 2008 (7% increase, p = 0.02). In contrast, the proportion of triplets decreased from 5.0 to 3.3 per 100 admissions (34% reduction, p = 0.04). These trends were significant in mothers ≥ 35 years of age. Neonatal outcomes improved for preterm twins (mortality, p < 0.01; survival without any major morbidity, p < 0.01; severe neurological injury, p = 0.02; and severe retinopathy of prematurity, p = 0.03). Similar improvements were observed for triplets, but the sample size was insufficient to reach statistical significance. The rate of NICU admissions for preterm twins at < 33 weeks' gestation has increased in recent years, whereas for triplets it has gradually declined. Neonatal outcomes of preterm twins improved over the study period.
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http://dx.doi.org/10.1055/s-0031-1285100DOI Listing
April 2012

For the sake of our health.

Contemp Clin Dent 2010 Jul;1(3):134-5

President-elect of the FDI World Dental Federation President of the Portuguese Dental Association, Portugal E-mail:

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http://dx.doi.org/10.4103/0976-237X.72773DOI Listing
July 2010

Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks' gestation.

J Obstet Gynaecol Can 2009 Dec;31(12):1124-30

Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.

Objective: To compare maternal and neonatal outcomes after elective induction of labour and elective Caesarean section with outcomes after spontaneous labour in women with low-risk, full-term pregnancies.

Methods: We extracted birth data from 1996 to 2005 from an obstetrical database. Singleton pregnancies with vertex presentation, anatomically normal, appropriately grown fetuses, and no medical or surgical complications were included. Outcomes after elective induction of labour and elective Caesarean section were compared with the outcomes after spontaneous labour, using chi-square and Student t tests and logistic regression.

Results: A total of 9686 women met the study criteria(3475 nulliparous, 6211 multiparous). The incidence of unplanned Caesarean section was higher in nulliparous women undergoing elective induction than in those with spontaneous labour (P < 0.001). Postpartum complications were more common in nulliparous and multiparous women undergoing elective induction (P < 0.001 and P < 0.01, respectively) and multiparous women undergoing elective Caesarean section, (P < 0.001). Rates of triage in NICU were higher in nulliparous women undergoing elective Caesarean section (P < 0.01), and requirements for neonatal free-flow oxygen administration were higher in nulliparous and multiparous women undergoing elective Caesarean section (P < 0.01 for each). Unplanned Caesarean section was 2.7 times more likely in nulliparous women undergoing elective induction of labour (95% CI 1.74 to 4.28, P < 0.001) and was more common among nulliparous and multiparous women undergoing induction of labour and requiring cervical ripening (P < 0. 001 and P < 0.05, respectively).

Conclusion: Elective induction leads to more unplanned Caesarean sections in nulliparous women and to increased postpartum complications for both nulliparous and multiparous women. Elective Caesarean section has increased maternal and neonatal risks.
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http://dx.doi.org/10.1016/s1701-2163(16)34372-9DOI Listing
December 2009

Life and death decisions in the extremely preterm infant: What happens in a level III perinatal centre?

Paediatr Child Health 2007 Sep;12(7):557-62

Division of Neonatal-Perinatal Medicine, Department of Paediatrics.

Objective: To describe resuscitation decisions and withdrawal of treatment practices in live-born infants at the extremes of prematurity at St Joseph's Health Care (London, Ontario).

Study Design: A retrospective chart review was conducted on all neonatal deaths between 22 weeks, zero days' and 25 weeks, six days' gestational age over an eight-year period. Documentation concerning end-of-life discussions was subjected to thematic review to limit or withhold resuscitation or withdraw treatment.

Results: Three hundred eighteen infants were delivered between 22 weeks, zero days' and 25 weeks, six days' gestational age. Of these, 21% of infants (67 of 318) were stillborn, 38% (121 of 318) were alive on discharge from hospital and 41% (130 of 318) died in the neonatal period. Of the live-born infants who did not survive to discharge, 34% (44 of 130) had no initial attempts at resuscitation. Withdrawal of life-sustaining treatment was the immediate cause of death in 84% of cases (61 of 73) in which the infant survived initial resuscitation. Documented parental rationale for withdrawal of treatment included "preventing pain and suffering", "not wanting (their baby) to die on a ventilator" and "poor quality of life". Families in which the mother identified as Catholic were more likely to withhold resuscitation and to withdraw life-sustaining treatment because death was imminent despite ongoing treatment. Non-Catholic families were more likely to withdraw life-sustaining treatment based on prediction of a poor long-term prognosis.

Conclusions: Decisions not to initiate resuscitation remain fairly common practice at the extremes of prematurity. The majority of deaths in those who survive initial resuscitative measures are secondary to withdrawal of treatment decisions made in the neonatal intensive care unit.
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September 2007

Should prevention of chronic kidney disease start before pregnancy?

Int Urol Nephrol 2008 ;40(2):483-8

Department of Paediatrics, Children's Hospital, London Health Science Centre, University of Western Ontario, 800 Commissioners Road East, London, ON, Canada N6A 5W9

Objective: The objective was to evaluate whether there is a role for the prevention of future chronic kidney disease (CKD) in children by improving maternal health at conception, this review addresses: the risk of childhood obesity in the development of CKD, trends in childhood obesity and body composition in children with renal diseases, trends in pre-pregnancy BMI and its association with neonatal outcome, and the effect of pre-pregnancy body mass index (BMI) on blood pressure and body composition in the offspring.

Increased Bmi And Hypertension As Risk Factors For Ckd: It is now well established that the presence of hypertension increases the risk of CKD. Increased BMI can also increase the risk of the development of CKD indirectly, through an increase in the prevalence of hypertension, and, possibly, through a direct effect independent of hypertension.

Trends In Childhood Obesity In General, And Specifically Among Children With Renal Diseases: An unprecedented epidemic of childhood obesity has been witnessed since the 1970s. An estimated 35% of children in North America are reported to be overweight. Children with CKD have even higher BMIs. TRENDS IN PRE-PREGNANCY BMI AND ITS ASSOCIATION WITH NEONATAL OUTCOME: The average BMI of mothers delivering in a single hospital in London, Ontario, rose from 24.3 kg/m2 in 1995 to 25.1 kg/m2 in 2004, whereas the average age of conception of the first child remained unchanged at 28 years. High pre-pregnancy BMIs increased the proportion of large-for-gestational-age newborns, a high proportion of congenital anomalies including renal abnormalities, and the need for Cesarean sections. EFFECT OF PRE-PREGNANCY BMI ON BLOOD PRESSURE AND BODY COMPOSITION IN THE OFFSPRING: Among 1,915 children (mean age 8.3 +/- 5.2 years), studied at the Children's Hospital, London Health Science Centre, BMI z-score correlated significantly with systolic (Spearman r = 0.214, P < 0.0001), and diastolic blood pressure z-scores (Spearman r = 0.143, P < 0.0001). The pre-pregnancy BMI correlated with both BMI z-score (Spearman r = 0.144, P < 0.0001) and blood pressure z-score (Spearman r = 0.13, P = 0.0005) in the children. The birth weight also correlated significantly with a higher BMI z-score (Spearman r = 0.134, P < 0.0001).

Conclusion: There are increasing trends in childhood obesity and pre-pregnancy maternal BMI. Higher pre-pregnancy BMI increases the risk for increased BMI z-score and blood pressure z-score in children. Since elevated BMI and blood pressure clearly are known risk factors of future CKD, targeting healthier weights prior to conception is likely to reduce the CKD burden in children.
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http://dx.doi.org/10.1007/s11255-007-9328-1DOI Listing
September 2008

Choice of antibiotics in late neonatal sepsis in the extremely low birth weight infant.

Can J Infect Dis 2003 Jan;14(1):28-31

Joseph's Health Care London, Department of Paediatrics, Child Health Research Institute, University of Western Ontario, London, Ontario.

Objective: To review the choice of antibiotics in treating suspected late neonatal sepsis in infants weighing 1000 g or less in a neonatal intensive care unit.

Methods: Retrospective review of medical records.

Results: Ninety-six infants weighing 1000 g or less were admitted to the neonatal intensive care unit during the study period. Sixty-two infants survived beyond four days of life and had at least one sepsis workup done to exclude late neonatal infection. Of the 62 study patients, 42 (68%) were started on ampicillin and netilmicin (A/N) and 20 (32%) were started on vancomycin and ceftizoxime (V/C) as the antibiotics of choice, pending culture results. Of the patients started on A/N, 17 of 42 had a positive blood culture compared with 11 of 20 on V/C (40% versus 55%, P=0.40). The mean (+/-SD) birth weight of infants started on A/N was 793+/-133 g compared with a mean of 728+/-153 g in the group that received V/C (P=0.09). Seven patients died in the A/N group compared with three in the V/C group (16.7% versus 15%, P=0.84). In addition to the sepsis episode studied, before they were discharged from hospital, 21 of 42 (50%) infants in the A/N group had further workups for suspected sepsis, compared with 16 of 20 (80%) (P=0.048) infants initially given V/C.

Conclusions: Ampicillin and netilmicin is a safe antibiotic combination for neonates suspected of late sepsis. This, in turn, may be important in reducing vancomycin overuse and the potential for bacterial resistance to this antimicrobial agent.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2094899PMC
http://dx.doi.org/10.1155/2003/510265DOI Listing
January 2003

Opioids in the parturient with chronic nonmalignant pain: a retrospective review.

J Opioid Manag 2006 Jan-Feb;2(1):31-4

Department of Anesthesia and Perioperative Medicine, University of Western Ontario, St. Joseph Health Care, London, Canada.

The purpose of this research was to determine the neonatal outcomes of women who had been taking medically prescribed opioids throughout their pregnancy. A retrospective case study was done of 15 pregnancies associated with maternal opiate use between January 1, 1999, and September 30, 2002. Two cases were excluded due to coaddiction. Neonatal data were collected including gestational age, head circumference, length, birth weight, Apgar score at one and five minutes, details of resuscitation required, and Neonatal Abstinence Score. There were 13 pregnancies, which resulted in 13 live births; opioids prescribed included oxycodone, codeine, meperidine, fentanyl, dilaudid, morphine, and methadone. There were four babies with one-minute Apgar score = -5, and two babies with five-minute Apgar score = 5. It was concluded that neonatal growth markers in this population were within normal limits as plotted on the standard growth and development record of Gairdner-Pearson. Five out of 13 (38.5 percent) neonates were diagnosed with opioid discontinuation syndrome.
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http://dx.doi.org/10.5055/jom.2006.0005DOI Listing
March 2007

Risk factors for the development of bronchopulmonary dysplasia: a case-control study.

Arch Med Res 2004 Nov-Dec;35(6):549-53

Department of Pediatrics, Division of Neonatology, University of Western Ontario, London, Ontario, Canada.

Background: Advances in neonatal care over the past decades have meant that an increasing number of very premature infants survive today than in years past. One of the main factors contributing to the survival of these infants is development in ventilatory support. However, this has lead to lung injury and an increase in the incidence of bronchopulmonary dysplasia (BDP).

Methods: A case-control study was conducted at the National Institute of Perinatology Neonatal Intensive Care Unit in Mexico City, Mexico to evaluate the risk factors associated with the development of BPD in premature infants requiring ventilatory support within the first days of life for respiratory failure. Twenty two cases and 22 control premature infants admitted to the Neonatal Unit requiring assisted ventilation and that survived for more than 28 days were included. The neonatal and maternal risk factors that were considered for analysis were the following; mode of delivery, antenatal steroids, gestational age, birth weight, Apgar scores, sepsis, patent ductus arteriosus, and ventilation parameters.

Results: Factors associated with the development of BPD were late sepsis (OR 7.29, 95% CI 1.61-35.8, p=0.002), and two or more episodes of sepsis (OR 7.60, 95% CI 1.46-44.6, p=0.004). Other risk factors were low birth weight and younger gestational age at birth.

Conclusions: Similar to what has been reported by other investigators in developed countries, our study showed that neonatal sepsis, low birth weight, and gestational age were associated with BPD in our patients.
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http://dx.doi.org/10.1016/j.arcmed.2004.07.001DOI Listing
August 2005

Umbilical cord pH and base excess values in relation to adverse outcome events for infants delivering at term.

Am J Obstet Gynecol 2004 Dec;191(6):2021-8

Department of Obstetrics and Gynaecology, Paediatrics and Physiology, St. Joseph's Health Care, University of Western Ontario, London, Ontario, Canada.

Objective: This study was undertaken to determine the relationship of umbilical cord pH and base excess (BE) values to adverse neonatal outcomes for a large tertiary hospital population delivering at term. Study design The perinatal/neonatal database of St. Joseph's Health Care, London, Canada, was used to obtain the umbilical cord pH and BE values, incidence of adverse neonatal outcomes, and patient demographics for all term (>/=37 weeks' gestation), singleton, liveborn infants with no major anomalies delivering between November 1995 and March 2002 (n=20,456). Statistical analyses included chi(2) analysis, logistic regression models to develop odds ratios and creation of receiver operating characteristic (ROC) curves with area under curve (AUC) calculations.

Results: Umbilical vein and artery pH and BE values for this tertiary care population averaged 7.33 +/- 0.06 and 7.24 +/- 0.07, and -4.5 +/- 2.4 and -5.6 +/- 3.0 mmol/L, respectively. Apgar less than 7 at 5 minutes, neonatal intensive care unit (NICU) admission, and assisted neonatal ventilation had significant inverse relationships with both umbilical artery and umbilical vein pH and BE (all P < .0001), with marginal increases in the incidences of these outcomes beginning with cord blood values close to the mean, and more substantial increases with cord values less than 1 or 2 SD below the mean, depending on the outcome studied. The ROC AUC for all these relationships were significant (P < .001) ranging from 0.76 to 0.79 when predicting Apgar less than 7 at 5 minutes to 0.68 to 0.70 when predicting NICU admission, and with cutoff cord blood values at which sensitivity and specificity were maximized again close to mean values. For each of these neonatal outcomes, the relation to cord blood values was similar with little difference in the data analysis whether using pH or BE values, and whether from the umbilical artery or vein.

Conclusion: There is a progression of risk in term infants for Apgar less than 7 at 5 minutes, NICU admission, and need for assisted ventilation with worsening acidosis at birth, which begins with cord blood values close to mean values indicating a higher threshold for associated acidemia with these outcomes than is seen for more severe neonatal outcomes.
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http://dx.doi.org/10.1016/j.ajog.2004.04.026DOI Listing
December 2004

Myasthenia gravis and pregnancy: clinical implications and neonatal outcome.

BMC Musculoskelet Disord 2004 Nov 16;5:42. Epub 2004 Nov 16.

Department of Neurology, National Institute of Medical Sciences and Nutrition, Salvador Zubirán, Mexico City, Mexico.

Background: The myasthenia gravis is twice as common in women as in men and frequently affects young women in the second and third decades of life, overlapping with the childbearing years. Generally, during pregnancy in one third of patients the disease exacerbates, whereas in two thirds it remains clinically unchanged. Complete remission can occur in some patients.

Methods: To describe the clinical course, delivery and neonatal outcome of 18 pregnant women with the diagnosis of myasthenia gravis. Retrospective chart review of pregnant patients with myasthenia gravis, followed at the National Institute of Perinatology in Mexico City over an 8-year period. Data was abstracted from the medical records on the clinical course during pregnancy, delivery and neonatal outcome.

Results: From January 1, 1996 to December 31, 2003 18 patients with myasthenia gravis were identified and included in the study. The mean +/- SD maternal age was 27.4 +/- 4.0 years. During pregnancy 2 women (11%) had an improvement in the clinical symptoms of myasthenia gravis, 7 women (39%) had clinical worsening of the condition of 9 other patients (50%) remained clinically unchanged. Nine patients delivered vaginally, 8 delivered by cesarean section and 1 pregnancy ended in fetal loss. Seventeen infants were born at mean +/- SD gestational age of 37.5 +/- 3.0 weeks and a mean birth weight of 2710 +/- 73 g. Only one infant presented with transient neonatal myasthenia gravis. No congenital anomalies were identified in any of the newborns.

Conclusions: The clinical course of myasthenia gravis during pregnancy is variable, with a significant proportion of patients experiencing worsening of the clinical symptoms. However, neonatal transient myasthenia was uncommon in our patient population.
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http://dx.doi.org/10.1186/1471-2474-5-42DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC534111PMC
November 2004
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