Treatment for Premature Infants May Have Long-Term Benefits on Cognition

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Treating premature infants with erythropoietin or darbepoetin may improve their neurodevelopmental outcomes at 18-22 months of age. Image: JAMA, ©AMA

Treatment of premature infants with red blood cell–stimulating agents such as erythropoietin or darbepoetin in the early weeks of life may have long-term benefits on cognitive outcomes and brain development, according to a study released today in Pediatrics.

Erythropoietin and darbepoetin, which help stimulate the bone marrow to produce more red blood cells, are used in both children and adults to treat certain types of chronic anemia (low red blood cell counts). However, early studies in both animals and humans have suggested that these agents also may act on nerve cells in the brain and have positive effects on brain development and cognition. Such effects could be particularly helpful for premature infants, in whom incomplete brain development often results in future complications, such as cerebral palsy or developmental delay.

Researchers from the University of New Mexico in Albuquerque randomly assigned more than 100 premature, very low-birth-weight infants (500 to 1250 grams at birth) to receive injections of erythropoietin, darbepoetin, or placebo from birth to what would have been 35 weeks gestation. When the infants were evaluated for cognitive outcomes at age 18 to 22 months (by individuals who didn’t know whether the infants received one of the drugs or placebo), scores on cognitive testing were significantly higher among infants in both the erythropoietin and darbepoetin groups compared with the placebo group.

The authors found no difference in weight, head circumference, hearing impairment, or visual impairment among the 3 groups. However, 5 of the 24 children in the placebo group had a diagnosis of cerebral palsy vs none of the 56 children in the erythropoietin or darbepoetin groups.

The study did not include enough patients to determine if there was a difference between erythropoietin and darbepoetin. Previous studies looking at erythropoietin and cognitive outcomes have had mixed results, but this is the first randomized trial involving darbepoetin, which the authors suggest may be more advantageous because darbepoetin treatment only requires a once-weekly injection compared with erythropoietin, which requires 3 injections per week.

Study Suggests Treatment Strategy for Respiratory Distress Syndrome in Very Preterm Infants

New research suggests a slight advantage to using nasal continuous positive airway pressure over mechanical ventilation by intubation in treating very preterm infants for respiratory distress syndrome. (Image: herjua/iStockphoto.com)

New research suggests a slight advantage to using nasal continuous positive airway pressure over mechanical ventilation by intubation in treating very preterm infants for respiratory distress syndrome. (Image: herjua/iStockphoto.com)

A study published Thursday in BMJ provides some guidance to neonatologists treating lung issues in very preterm infants.

Nearly all infants born before 28 weeks of pregnancy develop respiratory distress syndrome resulting from the lungs’ structural immaturity and their inability to make enough surfactant, a substance that coats the inside of the lungs, keeping air sacs open and allowing oxygen and carbon dioxide exchange. Left untreated, respiratory distress syndrome can lead to brain and other organ damage and even death. Most infants who show signs of the syndrome are quickly moved to a neonatal intensive care unit for around-the-clock care, which includes surfactant replacement therapy and breathing support through mechanical ventilation.

But breathing support—either by intubation or from a nasal continuous positive airway pressure (CPAP) machine—makes these infants susceptible to bronchopulmonary dysplasia, a chronic lung disorder characterized by inflammation and scarring in the lungs. This increases the risk for frequent hospital readmissions in the first 2 years after birth and even into adolescence for persistent respiratory symptoms and lung function abnormalities.

The BMJ study, by researchers from Austria and Canada, found nasal CPAP to be slightly better than intubation for reducing the risk of bronchopulmonary dysplasia. The authors concluded that 1 additional infant could survive to 36 weeks without bronchopulmonary dysplasia for every 25 babies treated with nasal CPAP rather than being intubated. They based this conclusion on a meta-analysis of 4 randomized controlled trials involving 2782 preterm infants needing respiratory support.

The authors offered some caveats to their findings, noting that surfactant administration varied among the trials and that the infants ranged in gestational age from 24 to 29 weeks at enrollment, which left out those born even earlier, who are a high-risk group with high mortality. The authors said that future trials should investigate different levels of nasal CPAP and different strategies and thresholds for administering surfactant.

Author Insights: Do-Not-Resuscitate Orders May Influence Overall Care for Pediatric Patients

 Amy Sanderson, MD, a pediatric intensivist at Boston Children’s Hospital, and her colleagues found that having a do-not-resuscitate order for a pediatric patient may in some cases lead to more compassionate care or change the patient’s overall care in some way. Image: Boston Children’s Hospital


Amy Sanderson, MD, a pediatric intensivist at Boston Children’s Hospital, and her colleagues found that having a do-not-resuscitate order for a pediatric patient may in some cases lead to more compassionate care or change the patient’s overall care in some way. Image: Boston Children’s Hospital

Do-not-resuscitate (DNR) orders for a pediatric patient with a serious illness may influence that child’s overall care, for better or worse, according to results of a survey published today in JAMA Pediatrics.

Discussions that lead up to a DNR order can help patients or their proxies become better informed about the options for care in the event of a cardiac arrest. Such orders give physicians crucial information about the preferred course of action, but there is some evidence that having a DNR for an adult patient may also influence the care the patient receives outside of the circumstances of a cardiac arrest.

To investigate whether this holds true for pediatric patients, a team of researchers from Boston recently conducted a survey of pediatric nurses and physicians to gather more information about possible effects of a DNR on pediatric care.

The investigators surveyed 107 physicians and 159 nurses at Boston Children’s Hospital and the Dana-Farber Children’s Hospital Cancer Center. They found that 66.7% of the respondents believe the DNR only limits care in the case of a cardiac arrest, while 33.1% believed a DNR suggested limitations for other nonresuscitation-related treatments. Two-thirds of the surveyed clinicians said that DNR orders have broader effects on patient care. Of those who believe patient care changes more globally after a DNR, 11.2% said such changes only occur when a cardiac arrest has happened; 36.7% said there is an increased emphasis on patient comfort; and 52.1% reported changes in nonresuscitation-related care, such as reduced testing or withdrawal of treatments.

Lead author Amy Sanderson, MD, a pediatric intensivist at Boston Children’s Hospital, discussed the findings with news@JAMA.

news@JAMA: Some patients may worry about having a DNR for fear that physicians will “give up.” Does your study give us a sense of whether those fears are justified?

Dr Sanderson: We did ask clinicians whether they thought that having a DNR meant giving up on a patient, and the vast majority of physicians thought that was not the case at all.

news@JAMA: In what ways did clinicians report that having a DNR changes patient care?

Dr Sanderson: The majority of clinicians thought it changed patient care if a cardiopulmonary arrest happens, and that is what a DNR is intended to do. Some other physicians thought having a DNR leads to an increase in attention to patient comfort.

news@JAMA: When do you think is the optimal timing for these discussions?

Dr Sanderson: It’s a hard question to answer; it’s probably different for every patient. Physicians in the survey thought that, on the whole, it happens a little later than is ideal.

news@JAMA: You found that parent-related factors were often cited for delaying the discussion of a DNR or other care preferences. What were these factors?

Dr Sanderson: The top 3 barriers mentioned were unrealistic parent expectations of the patient’s condition or prognosis, a lack of parent readiness to discuss a DNR, and a difference between parents’ and clinicians’ understanding of the prognosis.

news@JAMA: How do you think communication and care surrounding DNR can be improved?

Dr Sanderson: When discussing a DNR, it should happen in the context of a discussion about the overall goals of care for the patient. When DNRs are discussed in isolation, there may be inappropriate assumptions by clinicians about what the parent or patient would like.

New Approach May Prevent Some Unnecessary Emergency CT Scans in Children

Seven clinical criteria reported in a new study can help emergency physicians rule out which children with abdominal injuries do not need a diagnostic computed tomography scan. (Image: JAMA, ©AMA)

Seven clinical criteria reported in a new study can help emergency physicians rule out which children with abdominal injuries do not need a diagnostic computed tomography scan. (Image: JAMA, ©AMA)


A new study shows how emergency department physicians can avoid needless diagnostic computed tomography (CT) scanning of children with abdominal injuries. Researchers who developed a decision support tool say their findings could prevent many vulnerable children from being unnecessarily exposed to medical radiation.

Between 5 million and 9 million CT scans are performed on US children annually, according to the National Cancer Institute. The scans can save lives, but with annual growth in the number of CT scans estimated at 10%, they’re now the top contributor to medical radiation exposure in the United States.

Published online today in the Annals of Emergency Medicine, the study describes 7 clinical criteria that accurately predicted which children arriving in emergency departments with blunt torso trauma didn’t have injuries severe enough to require a diagnostic CT scan. Continue reading

Inducing Hypothermia Provides Long-term Survival Benefits for Infants Born With Oxygen Deficiencies

Inducing hypothermia in infants experiencing deficient oxygen during delivery improves their chances of surviving into early childhood. (Image: Martin Wimmer/iStockphoto.com )

Cooling the body temperature of infants born with oxygen deficiencies improves their chances of surviving into early childhood compared with such children treated with usual care. The finding, by researchers affiliated with the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network, appears today in the New England Journal of Medicine.

Oxygen deprivation during the birth process, called hypoxic-ischemic encephalopathy (HIE), occurs because of complications during delivery. The condition is fairly rare, affecting about 1 of every 1000 births. In severe cases, death rates can reach 50%, and newborns who survive often sustain brain damage that can result in cerebral palsy, cognitive impairment, or hearing or vision loss. In an earlier study of 208 infants diagnosed with HIE within 6 hours of birth, the researchers found that inducing hypothermia and reducing an infant’s temperature to as low as 91.4°F for 72 hours improved survival at 18 to 22 months of age while maintaining an equivalent risk for disability, compared with those treated with usual care. Continue reading

Author Insights: Caffeine Boosts Preemies’ Short-term Neurological Development, Long-term Motor Skills

Barbara Schmidt, MD, MSc, of the department of neonatology at the Hospital of the University of Pennsylvania in Philadelphia, and her colleagues found that neurodevelopmental gains seen in premature infants treated with caffeine attenuate over time as both treated and untreated children make developmental strides. (Image: EBNEO/Francesco Cardona)

Premature infants treated with caffeine, which is often used to aid breathing in those born very early, appear to get a boost in their cognitive abilities at age 18 months. Although results of a new study published in JAMA today suggest that these effects may not persist at age 5 years, an encouraging aspect of the findings is that both treated and untreated individuals make big strides in neurodevelopment during this time period, suggesting an innate resiliency.

Barbara Schmidt, MD, MSc, of the department of neonatology at the Hospital of the University of Pennsylvania in Philadelphia, and her colleagues analyzed 5-year follow-up data on 1640 children who were enrolled in the Caffeine for Apnea of Prematurity trial. The children had birth weights between 500 and 1250 g. They found no difference between treated and untreated children at 5 years in death or disability, the main outcome examined in the study. In fact, they found that both groups showed a lower incidence of cognitive impairment at 5 years. The treated group did have better coordination and visual perception than the untreated group. Continue reading

Author Insights: Very Preterm Infants May Benefit From Corticosteroid Therapy

Waldemar A. Carlo, MD, from the University of Alabama at Birmingham, and colleagues found an association between corticosteroid therapy in mothers and improved outcomes in infants born as young as 23 weeks of gestation. (Image: Steven Wood, University of Alabama at Birmingham)

Giving mothers injections of corticosteroids within a week of giving birth reduces a substantial risk that infants born at 23 to 25 weeks of gestation will die or experience neurodevelopmental impairment, new research has found.

Although mothers experiencing preterm labor at less than 35 weeks of gestation are currently given corticosteroid therapy to improve infant lung maturity, decrease neonatal problems, and reduce infant death, there has been a lack of data to establish whether such therapy improves outcomes for preterm infants born at weeks 22 to 25 of gestation. Now, research findings appearing today in JAMA indicate that corticosteroid therapy is associated with a reduction in death or neurodevelopmental impairment for infants born at weeks 23 to 25, but not at week 22, of gestation.

The study involved 4924 very preterm infants delivered at 25 weeks or less who were born in 1993 through 2009 and followed up for 18 to 22 months. Although the therapy improved outcomes, the researchers also noted the treatment offers only limited protection, reducing the percentage of preterm infants who died or lived with neurodevelopmental impairment at 18 to 22 months from 81.5% among those whose mothers were not treated to 64.2% among infants whose mothers received therapy. Continue reading