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Biomedical subjects

V Flenady

Publications and source records attributed to V Flenady.

17 recordsLinked to original sources
PubMed2006

Immunostimulants for preventing respiratory tract infection in children.

BACKGROUND: Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs. OBJECTIVES: To determine the efficacy and safety of IS in preventing ARTIs in children. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005); MEDLINE (January 1966 to January 2006); and EMBASE (January 1990 to January 2006); PASCAL (up to January 2006); SciSearch (up to January 2006); and IPA (up to January 2006) for reports of trials. Investigators in the field were also contacted. Ongoing studies were searched in the trial registration web site, metaRegister of Controlled Trials. SELECTION CRITERIA: All comparative trials which enrolled patients less than 18 years of age were included. The intervention of interest was the use of an IS medication administered by any method for preventing ARTIs. Clinical trials using random or quasi-random allocation and comparing IS medication or medications to placebo were included. DATA COLLECTION AND ANALYSIS: The outcome on ARTIs was analyzed both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. Meta-analysis was undertaken using a random-effects model and results were presented as weighted mean differences (WMD) with 95% confidence intervals (CI). The trials search, quality assessment and data extraction were undertaken independently by two authors. A funnel plot suggested there may be publication bias in the trials identified. MAIN RESULTS: Thirty-four placebo controlled trials (3877 participants) provided data in a form suitable for inclusion in the meta-analysis. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (WMD -1.27; 95% CI -1.58 to -0.97) and the difference in ARTIs rates (WMD -39.68%; 95% CI -47.27% to -32.09%). The trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups AUTHORS' CONCLUSIONS: This review showed that IS reduces the incidence of ARTIs in children, by 40% on average. However, due to significant heterogeneity and the poor quality of the trials this positive result should be interpreted with caution. The safety profile of IS appears to be good. Further high-quality trials are needed and we encourage national health authorities to conduct large, multicenter, double-blind, placebo-controlled trials on the role of IS in the prevention of ARTIs.

Adjuvants, Immunologic↗
PubMed2006

Prenatal administration of progesterone for preventing preterm birth.

BACKGROUND: Preterm birth is the major complication of pregnancy associated with perinatal mortality and morbidity and occurs in up to 6% to 10% of all births. Administration of progesterone for the prevention of preterm labour has been advocated. OBJECTIVES: To assess the benefits and harms of progesterone administration during pregnancy in the prevention of preterm birth. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Specialised Register of Controlled Trials (March 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2004), MEDLINE (1965 to January 2005), EMBASE (1988 to August 2004), and Current Contents (1997 to August 2004). SELECTION CRITERIA: All published and unpublished randomised controlled trials, in which progesterone was given by any route for preventing preterm birth. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Collaboration and the Cochrane Pregnancy and Childbirth Group were used. Evaluation of methodological quality and trial data extraction were undertaken independently by two authors. Results are presented using relative risk with 95% confidence intervals. MAIN RESULTS: For all women administered progesterone, there was a reduction in the risk of preterm birth less than 37 weeks (six studies, 988 participants, relative risk (RR) 0.65, 95% confidence interval (CI) 0.54 to 0.79) and preterm birth less than 34 weeks (one study, 142 participants, RR 0.15, 95% CI 0.04 to 0.64). Infants born to mothers administered progesterone were less likely to have birthweight less than 2500 grams (four studies, 763 infants, RR 0.63, 95% CI 0.49 to 0.81) or intraventricular haemorrhage (one study, 458 infants, RR 0.25, 95% CI 0.08 to 0.82). There was no difference in perinatal death between women administered progesterone and those administered placebo (five studies, 921 participants, RR 0.66, 95% CI 0.37 to 1.19). There were no other differences reported for maternal or neonatal outcomes. AUTHORS' CONCLUSIONS: Intramuscular progesterone is associated with a reduction in the risk of preterm birth less than 37 weeks' gestation, and infant birthweight less than 2500 grams. However, other important maternal and infant outcomes have been poorly reported to date, with most outcomes reported from a single trial only (Meis 2003). It is unclear if the prolongation of gestation translates into improved maternal and longer-term infant health outcomes. Similarly, information regarding the potential harms of progesterone therapy to prevent preterm birth is limited. Further information is required about the use of vaginal progesterone in the prevention of preterm birth.

17-alpha-Hydroxyprogesterone↗
PubMed2005

Oxytocin receptor antagonists for inhibiting preterm labour.

BACKGROUND: Preterm birth, defined as birth before 37 completed weeks, is the single most important cause of perinatal mortality and morbidity in high-income countries. Oxytocin receptor antagonists have been proposed as effective tocolytic agents for women in preterm labour to postpone the birth, with fewer side-effects than other tocolytic agents. OBJECTIVES: To assess the effects on maternal, fetal and neonatal outcomes of tocolysis with oxytocin receptor antagonists for women with preterm labour compared with placebo or no intervention and compared with any other tocolytic agent. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2004), CENTRAL (The Cochrane Library, Issue 3, 2004), MEDLINE (1965 to June 2004), EMBASE (1988 to June 2004). SELECTION CRITERIA: Randomised trials of oxytocin receptor antagonists for tocolysis in the management of women in labour between 20 and 36 weeks' gestation. DATA COLLECTION AND ANALYSIS: Two authors independently evaluated methodological quality and extracted trial data. We sought additional information from trial authors. MAIN RESULTS: Six trials (1695 women) were included. Compared with placebo, atosiban did not reduce incidence of preterm birth or improve neonatal outcome. In one trial (583 infants), atosiban was associated with an increase in infant deaths at 12 months of age compared with placebo (relative risk (RR) 6.15; 95% confidence intervals (CI) 1.39 to 27.22). However, this trial randomised significantly more women to atosiban before 26 weeks' gestation. Use of atosiban resulted in lower infant birthweight (weighted mean difference -138.31 gm; 95% CI -248.76 to -27.86) and more maternal adverse drug reactions (RR 4.02; 95% CI 2.05 to 7.85, 2 trials, 613 women).Compared with betamimetics, atosiban increased the numbers of infants born under 1500 gm (RR 1.96; 95% CI 1.15 to 3.35, 2 trials, 575 infants). Atosiban was associated with fewer maternal drug reactions requiring treatment cessation (RR 0.04; 95% CI 0.02 to 0.11, number needed to treat 6; 95% CI 5 to 7, 4 trials, 1035 women). AUTHORS' CONCLUSIONS: This review failed to demonstrate the superiority of atosiban over betamimetics or placebo in terms of tocolytic efficacy or infant outcomes. The finding of an increase in infant deaths in one placebo controlled trial warrants caution. A recent Cochrane review suggests that calcium channel blockers (mainly nifedipine) are associated with better neonatal outcome and fewer maternal side-effects than betamimetics. However, a randomised comparison of nifedipine with placebo is not available. Further well-designed randomised controlled trials of tocolytic therapy are needed. Such trials should incorporate a placebo arm.

Albuterol↗
PubMed2005

Cyclo-oxygenase (COX) inhibitors for treating preterm labour.

BACKGROUND: Preterm birth is a major cause of perinatal mortality and morbidity. Cyclo-oxygenase (COX) inhibitors inhibit uterine contractions, are easily administered and have fewer maternal side-effects compared to conventional tocolytics. However, adverse effects have been reported on the fetus and newborn as a result of exposure to COX inhibitors. OBJECTIVES: To assess the effects on maternal, fetal and neonatal outcomes of COX inhibitors administered as a tocolytic agent to women in preterm labour when compared with (i) placebo or no intervention and (ii) other tocolytics. In addition, to compare the effects of non-selective COX inhibitors with COX-2 selective inhibitors. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's trials register (August 2004). We also contacted recognised experts and cross referenced relevant material. SELECTION CRITERIA: All published and unpublished randomised trials in which COX inhibitors were used for tocolysis for women in labour between 20 and 36 completed weeks' gestation. DATA COLLECTION AND ANALYSIS: Three authors independently evaluated methodological quality and extracted data. We sought additional information from trial authors. MAIN RESULTS: This review includes outcome data from 13 trials with a total of 713 women. The non-selective COX inhibitor, indomethacin was used in 10 trials. When compared with placebo, COX inhibition (indomethacin only) resulted in a reduction in birth before 37 weeks' gestation (relative risk (RR) 0.21; one trial, 36 women), an increase in gestational age (weighted mean difference (WMD) 3.53 weeks) and birthweight (WMD 716.34 gm; two trials, 67 women). Compared to any other tocolytic, COX inhibition resulted in a reduction in birth before 37 weeks' gestation (RR 0.53; three trials, 168 women) and a reduction in maternal drug reaction requiring cessation of treatment (RR 0.07; five trials and 355 women). A comparison of non-selective COX inhibitors versus any COX-2 inhibitor (two trials, 54 women) did not demonstrate any differences in maternal or neonatal outcomes. Due to small numbers, all estimates of effect are imprecise and need to be interpreted with caution. Potential adverse effects of COX inhibition on the fetus, newborn or mother could not be adequately assessed due to insufficient data. AUTHORS' CONCLUSIONS: There is insufficient information on which to base decisions about the role of COX inhibition for women in preterm labour. Further well designed trials are needed.

Cyclooxygenase Inhibitors↗
PubMed2005

Routine neonatal postextubation chest physiotherapy: a randomized controlled trial.

OBJECTIVE: To test the effects of a neonatal postextubation programme on the incidence of postextubation collapse and adverse outcomes. METHODS: A randomized controlled trial was carried out at the Mater Mothers' Hospital, Brisbane. Mechanically ventilated infants were randomized into one of two groups, physiotherapy group--which involved a regimen of chest wall percussion and oropharyngeal suctioning and control group - which involved suctioning without the percussion unless indicated. Chest X-rays were taken at 6 h and at 24 h postextubation. The primary outcome measure was postextubation collapse as determined by a paediatric radiologist blinded to the group allocation. RESULTS: One hundred and seventy-seven neonates were enrolled in the trial between 1997 and 1999. After an interim analysis, the trial was stopped early. No statistically significant difference was shown in the rate of postextubation collapse (15 of 87 (17.2%) physiotherapy group and 17 of 86 (19.8%) control group (P = 0.85)). No differences were shown between the groups in the number of apnoeic or bradycardic events, duration of requirement for supplemental oxygen or the need for re-intubation within 24 h postextubation. CONCLUSION: The results of this trial suggest that a routine neonatal postextubation chest physiotherapy programme for all infants is not indicated. There was no evidence that chest physiotherapy is associated with any adverse outcomes.

Data Collection↗
PubMed2004

Intramuscular penicillin for the prevention of early onset group B streptococcal infection in newborn infants.

BACKGROUND: Early-onset group B streptococcal disease (EOGBSD) is the most frequent cause of serious infection in the newborn period. Current strategies used to prevent EOGBSD are focused upon maternal antibiotic prophylaxis to reduce transmission of GBS to the infant. Observational studies have suggested that the administration of intramuscular penicillin to the newborn immediately following delivery may be an effective strategy to reduce the incidence of EOGBSD. OBJECTIVES: To determine if the administration of intramuscular penicillin to newborns at birth is a safe and effective method to prevent morbidity and mortality from EOGBSD. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group was used. This included searches of electronic databases: Oxford Database of Perinatal Trials, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 1, 2004), and MEDLINE (1966 - Dec 2003); and previous reviews including cross references, expert informants and journal hand searching in the English language as well as conference and symposia proceedings published in Pediatric Research. SELECTION CRITERIA: Randomised trials in which intramuscular penicillin was administered as prophylaxis for EOGBSD within four hours of birth.Outcomes considered were EOGBSD, neonatal mortality, late-onset GBSD, neonatal sepsis, and other secondary outcomes such as neurodevelopmental status and length of hospital stay. DATA COLLECTION AND ANALYSIS: The search for and assessment of trials for inclusion, quality assessment and data extraction were undertaken independently by the reviewers. Meta-analysis was not undertaken as data from only one trial is included in this review. Data were analysed using relative risk (RR) with 95% confidence intervals (CI). MAIN RESULTS: One randomised controlled trial was included in this review. In this trial of 1187 infants of birthweight 501 to 2000 grams, there were no significant differences found for the outcomes of EOGBSD (RR 0.73; 95%CI 0.32, 1.62), or neonatal mortality (RR 0.78; 95% CI 0.55, 1.11). No other outcomes were able to be assessed. REVIEWERS' CONCLUSIONS: This review does not support the routine use of intramuscular penicillin to prevent EOGBSD in newborn infants. There is a discrepancy between this finding and the results of a number of larger non-randomised trials. Explanations for this are proposed. There is a need for this intervention to be tested as a component of the existing prevention strategies in widespread use.

Humans↗
PubMed2004

Transfer of preterm infants from incubator to open cot at lower versus higher body weight.

BACKGROUND: The use of incubators in helping to maintain a thermoneutral environment for preterm infants has become routine practice in neonatal nurseries. As one of the key criteria for discharging preterm infants from nurseries is their ability to maintain temperature, the infant will need to make the transition from incubator to open cot at some time before discharge. The timing of this transition is important because when an infant is challenged by cold, the infant attempts to increase its heat production to maintain body temperature. The increase in energy expenditure may affect weight gain. The practice of transferring infants from incubators to open cots usually occurs once a weight of around 1700-1800 g has been reached; however, this practice varies widely between neonatal units. This preferred weight mark appears to be largely based on tradition or the personal experience of clinicians, with little consideration of the infant's weight or gestational age at birth. OBJECTIVES: The main objective was to assess the effects on weight gain and temperature control of a policy of transferring preterm infants from incubator to open cot at lower versus higher body weight. SEARCH STRATEGY: Searches were undertaken of MEDLINE from June 2003 back to 1966, CINAHL from June 2003 back to 1987 and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. SELECTION CRITERIA: Trials in which preterm infants were randomly allocated to a policy of transfer from incubators to open cots at a lower body weight versus at a higher body weight. DATA COLLECTION AND ANALYSIS: Quality assessments and data extraction for included trials were conducted independently by the reviewers. Data for individual trial results were analysed using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, meta-analysis could not be undertaken. MAIN RESULTS: Four studies were identified as potentially eligible for inclusion in this review. Two studies were excluded as random allocation to the exposure was not employed. One study is pending, awaiting additional information from the authors. Therefore, one study involving 60 preterm infants, employing a matched-pairs design, which compared the transfer of infants to open cots at 1700 g versus 1800 g, is included in this review. Only two outcomes could be included from this study; return to incubator and daily weight gain. No statistically significant difference was shown for either return to incubator (RR 2.00, 95% CI 0.40 to 10.11) or daily weight gain [MD 4.00 g/day (95% CI -5.23, 13.23)]. Due to small numbers, effects on clinically important outcomes could not be adequately assessed. REVIEWERS' CONCLUSIONS: There is currently little evidence from randomised trials to inform practice on the preferred weight for transferring preterm infants from incubators to open cots. There is a need for larger randomised controlled trials to address this deficiency.

Body Temperature Regulation↗
PubMed2004

Classification of perinatal deaths: development of the Australian and New Zealand classifications.

Classifications of perinatal deaths have been undertaken for surveillance of causes of death, but also for auditing individual deaths to identify suboptimal care at any level, so that preventive strategies may be implemented. This paper describes the history and development of the paired obstetric and neonatal Perinatal Society of Australia and New Zealand (PSANZ) classifications in the context of other classifications. The PSANZ Perinatal Death Classification is based on obstetric antecedent factors that initiated the sequence of events leading to the death, and was developed largely from the Aberdeen and Whitfield classifications. The PSANZ Neonatal Death Classification is based on fetal and neonatal factors associated with the death. The classifications, accessible on the PSANZ website (http://www.psanz.org), have definitions and guidelines for use, a high level of agreement between classifiers, and are now being used in nearly all Australian states and New Zealand.

Australia↗
PubMed2004

High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial.

OBJECTIVE: To compare two dosing regimens for caffeine citrate in the periextubation period for neonates born at less than 30 weeks gestation in terms of successful extubation and adverse effects. DESIGN: A multicentre, randomised, double blind, clinical trial. SETTING: Four tertiary neonatal units within Australia. PATIENTS: Infants born less than 30 weeks gestation ventilated for more than 48 hours. INTERVENTIONS: Two dosing regimens of caffeine citrate (20 v 5 mg/kg/day) for periextubation management. Treatment started 24 hours before a planned extubation or within six hours of an unplanned extubation. MAIN OUTCOME MEASURE: Failure to extubate within 48 hours of caffeine loading or reintubation and ventilation or doxapram within seven days of caffeine loading. RESULTS: A total of 234 neonates were enrolled. A significant reduction in failure to extubate was shown for the 20 mg/kg/day dosing group (15.0% v 29.8%; relative risk 0.51; 95% confidence interval (CI) 0.31 to 0.85; number needed to treat 7 (95% CI 4 to 24)). A significant difference in duration of mechanical ventilation was shown for infants of less than 28 weeks gestation receiving the high dose of caffeine (mean (SD) days 14.4 (11.1) v 22.1 (17.1); p = 0.01). No difference in adverse effects was detected in terms of mortality, major neonatal morbidity, death, or severe disability or general quotient at 12 months. CONCLUSIONS: This trial shows short term benefits for a 20 mg/kg/day dosing regimen of caffeine citrate for neonates born at less than 30 weeks gestation in the periextubation period, without evidence of harm in the first year of life.

Caffeine↗
PubMed2003

Cot-nursing versus incubator care for preterm infants.

BACKGROUND: An optimal thermal environment is desirable for preterm infants. These infants are usually nursed in incubators, but cot-nursing may provide an alternative. Measures to assist the maintenance of body temperature for smaller infants in open cots include extra clothing/bedding, warming up the nursery and heating the cot mattress. Recently a heated water-filled mattress has been developed to maintain the temperature of a cot-nursed preterm infant. While there may be benefits of nursing preterm infants in open cots, there may be potential risks such as nosocomial infection caused by more handling due to easier access. OBJECTIVES: Among preterm infants allocated to cot-nursing vs incubator care in neonatal period, to assess effects on their temperature control and weight gain. SEARCH STRATEGY: The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases: Oxford Database of Perinatal Trials; Cochrane Controlled Trials Register (Cochrane Library Issue 4 2001); MEDLINE (1966-2001); and CINAHL (1982-2001), previous reviews including cross references. SELECTION CRITERIA: All trials using random or quasi-random patient allocation in which infants receiving care in standard newborn cots were compared to infants managed in a conventional air heated incubator. DATA COLLECTION AND ANALYSIS: The authors independently assessed trial quality and extracted data for the primary outcomes of temperature control and weight gain. Meta-analysis was conducted using a fixed effects model. Results are presented as relative risk (RR) for categorical data and mean difference (MD) and weighted mean differences (WMD) for data measured on a continuous scale. MAIN RESULTS: Nine potential studies were identified of which four, involving 173 babies, were included in this review. When compared to incubator care, cot-nursing resulted in a statistically significantly higher mean body temperature (MD 0.30 degrees C; 95% CI 0.10, 0.50, one trial) and a decrease in proportion of infants not breast feeding at hospital discharge (RR 0.52; 95% CI 0.28, 0.94, two trials, 77 infants). No statistically significant difference was shown in weight gain, reported by two trials involving 69 infants. The comparison of cot-nursing using a heated water-filled mattress versus incubator care, which included four trials and a total of 149 infants, produced similar results. Cot-nursing with warming of the nursery resulted in statistically significantly smaller weight gain during week one compared to the incubator group in one trial that involved 49 infants (MD -5.90 g/kg/day; 95% CI -11.13, -0.67) with no significant difference found for weeks two and three. REVIEWER'S CONCLUSIONS: Due to the small numbers of trials included and infants studied, and the resulting imprecision in the measures of effect for all outcomes, the review does not give a clear indication for the role of cot-nursing for preterm infants. Further assessment of the role of cot nursing for preterm infants using randomised controlled trials is necessary.

Beds↗
PubMed2002

Antibiotics for prelabour rupture of membranes at or near term.

BACKGROUND: Prelabour rupture of the membranes at or near term (term PROM) increases the risk of infection for the woman and her baby. The routine use of antibiotics for women at the time of term PROM may reduce this risk. However, due to increasing problems with bacterial resistance and the risk of maternal anaphylaxis with antibiotic use, it is important to assess the evidence addressing risks and benefits in order to ensure judicious use of antibiotics. This review was undertaken to assess the balance of risks and benefits to the mother and infant of antibiotic prophylaxis for prelabour rupture of the membranes at or near term. OBJECTIVES: To assess the effects of antibiotics administered prophylactically to women with prelabour rupture of the membranes at 36 weeks or beyond, on maternal, fetal and neonatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's specialised register of controlled trials (October 2001), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), MEDLINE (1965 to 2001). Other sources included contacting recognised experts and cross referencing relevant material. SELECTION CRITERIA: All randomised trials which compared outcomes for women and infants when antibiotics were administered prophylactically for prelabour rupture of the membranes at or near term, with outcomes for controls (placebo or no treatment). DATA COLLECTION AND ANALYSIS: Assessment of trial quality and data extraction were undertaken independently by the two authors who then compared and resolved differences. Additional data were received from the investigators of included trials. Meta-analysis was undertaken using a fixed effects model and results are presented using relative risk (RR), risk difference (RD) and number needed to treat (NNT) (where appropriate) for categorical data, and mean difference (MD) for variables measured on a continuous scale. All results are presented with 95% confidence intervals (CI). MAIN RESULTS: The results of two trials, involving a total of 838 women, are included in this review. The use of antibiotics resulted in a statistically significant reduction in maternal infectious morbidity (chorioamnionitis or endometritis): RR 0.43 (95% CI 0.23, 0.82), RD -4% (95% CI -7%, -1%), NNT 25 (95% CI 14 -100). No statistically significant differences were shown for outcomes of neonatal morbidity. REVIEWER'S CONCLUSIONS: No clear practice recommendations can be drawn from the results of this review on this clinically important question, related to a paucity of reliable data. Further well designed randomised controlled trials are needed to assess the effects of routine use of maternal antibiotics for women with prelabour rupture of the membranes at or near term.

Antibiotic Prophylaxis↗
PubMed2001

Preoxygenation for tracheal suctioning in intubated, ventilated newborn infants.

BACKGROUND: Endotracheal suctioning for mechanically ventilated infants is routine practice in neonatal intensive care. However, this practice is associated with serious complications including lobar collapse, pneumothorax, bradycardia and hypoxemia. Increasing the inspired oxygen immediately prior to suction (preoxygenation) has been proposed as an intervention to minimise the risk of complications. OBJECTIVES: To compare the effects of preoxygenation with no preoxygenation for endotracheal suctioning on ventilated newborn infants. To conduct sub group analyses by i) different populations of newborn infants; by gestational age <30 weeks, <34 weeks and <37 weeks and by disease; infants with chronic lung disease compared to those without and; ii) by different techniques of endotracheal suctioning; with or without disconnection from the ventilator, increased mechanical ventilation, use of manual ventilation and chest wall vibrations or percussion. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group was used. This included searches of electronic databases; Oxford Database of Perinatal Trials; Cochrane Controlled Trials Register (Cochrane Library Issue 1 2001); MEDLINE (1966 - April 2001); and CINAHL (1982-2001) using MeSH term infant-newborn and text terms oxygen* and suction*, preoxygenation, pre-oxygenation and premature and also previous reviews including cross references, abstracts in conferences and symposia proceedings, expert informants, journal hand searching in the English language. SELECTION CRITERIA: Random or quasi random controlled trials of mechanically ventilated neonates in which endotracheal suctioning with preoxygenation was compared to suctioning without preoxygenation. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used, including independent assessment of trial quality and extraction of data by the authors. Data were analysed using relative risk (RR) for dichotomous outcomes and mean difference (MD) for data measured on a continuous scale with the use of 95% confidence intervals. Meta-analysis was conducted using a fixed effects model. MAIN RESULTS: One cross-over trial involving outcomes for 16 preterm neonates was included in this review. Preoxygenation, prior to an endotracheal suctioning procedure involving two suctions, resulted in a statistically significant reduction in infants with hypoxemia (TcPO2 <40 mmHg) at the end of the first suction (RR 0.18, 95% CI 0.05, 0.69), at the end of the second suction (RR 0.23, 95% CI 0.08, 0.66) and also at 120 seconds after the second suction (RR 0.10, 95% CI 0.01, 0.69). Mean TcPO2 was statistically significantly higher in the preoxygenation group at the end of the first suction (MD 25.00 mmHg, 95%CI 14.20, 35.80), second suction (MD 24.80, 95% CI 14.80, 34.80) and also at 120 seconds after the second suction (MD 29.10, 95% CI 14.96, 43.24). The time taken to return to baseline oxygenation status was shorter than the group not receiving preoxygenation (MD -2.12 minutes, 95% CI -3.82, -0.42). REVIEWER'S CONCLUSIONS: No recommendations for practice can be confidently made from the results of this review. Although preoxygenation was shown to decrease hypoxemia at the time of suctioning, other clinically important short and longer-term outcomes including adverse effects were unable to be assessed. Further studies are needed to adequately assess the effects of this widely practiced procedure.

Humans↗
PubMed2001

Tracheal suctioning without disconnection in intubated ventilated neonates.

BACKGROUND: Assisted mechanical ventilation is the mainstay of management of a variety of conditions affecting the neonate. However there are a number of potential hazards associated with this life saving intervention. New suctioning techniques have been introduced into clinical practice which aim to prevent or reduce these untoward effects. OBJECTIVES: To assess the effects of endotracheal suctioning without disconnection in intubated ventilated neonates. SEARCH STRATEGY: The review has drawn on the search strategy for the Cochrane Neonatal Review Group. A comprehensive search of MEDLINE, Cochrane Library, MEDLINE and CINAHL databases was undertaken by the reviewers. SELECTION CRITERIA: All trials utilizing random or quasi-random patient allocation in which suctioning with or without disconnection from the ventilator is compared in the neonatal population. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Neonatal Group were used. Each author reviewed trials for eligibility and quality and extracted data separately, then compared and resolved differences. Analysis was performed using the fixed effects model and outcomes were reported using relative risk for categorical data and weighted mean difference for outcomes measured on a continuous scale. MAIN RESULTS: Two trials (22 infants) were included in this review. The trials employed a cross-over design in which suctioning with or without disconnection was compared. Suctioning without disconnection resulted in a reduction in episodes of hypoxia (RR 0.30, 95% CI 0.11, 0.80) and a smaller percentage decrease in the TcPO2 (WMD 18.5%, 95% CI 8.11, 28.89). There were also fewer infants who experienced episodes where TcPO2 decreased by > 10% (RR 0.36, 95% CI 0.17, 0.79). Suctioning without disconnection resulted in a smaller percentage decrease in heart rate (WMD 11.53%, 95% CI 3.64, 19.43) and a reduction in the number of infants experiencing a decrease in heart rate by > 10% (RR 0.56, 95% CI 0.32, 0.99). REVIEWER'S CONCLUSIONS: Based upon the results of this review, there is insufficient evidence to decide between endotracheal suctioning with or without disconnection. There is, however, evidence of some benefit from performing suctioning without disconnection for some specific short-term outcomes. Further research should be undertaken to fully assess this practice with particular focus on extremely low birth weight infants and different modes of mechanical ventilation, and to address clinically important outcomes.

Cross-Over Studies↗
PubMed2000

Antibiotics for preterm labour with intact membranes.

BACKGROUND: There may be a link between infection and preterm birth. OBJECTIVES: Since rupture of the membranes is an important factor in the progression of preterm labour, it is important to see if antibiotics are of any benefit prior to membrane rupture. The objective of this review was to assess the effects of antibiotics administered to women in preterm labour with intact membranes, on maternal and neonatal outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and reference lists of articles. We contacted experts in the field. SELECTION CRITERIA: Randomised trials which compared antibiotic treatment with placebo or no treatment for women in preterm labour (between 20 and 36 weeks gestation) with intact membranes. DATA COLLECTION AND ANALYSIS: Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing data. MAIN RESULTS: Meta-analysis of the ten included trials demonstrated a statistically significant prolongation of pregnancy associated with the use of antibiotics (5. 4 days, 95% confidence interval (CI) 0.9- 9.8 days). Antibiotic treatment was also associated with a statistically significant reduction in maternal infection (odds ratio (OR) 0.59, 95% CI 0.36, 0.97) and neonatal necrotising enterocolitis (OR 0.33, 95% CI 0.13, 0.88). No statistically significant effect was detected on the neonatal outcomes of respiratory distress syndrome and neonatal sepsis, although there was a trend towards the latter (OR 0.67, 95% CI 0.42, 1.07). An increase in perinatal mortality was observed in the group receiving antibiotics (OR 3.36, 95% CI 1.21, 9.32). REVIEWER'S CONCLUSIONS: Although a prolongation in time to delivery and a trend towards a reduction in neonatal sepsis was detected, this review fails to demonstrate a clear overall benefit from antibiotic treatment for preterm labour with intact membranes on neonatal outcomes and raises concerns about increased perinatal mortality for those who received antibiotics. This treatment cannot therefore be currently recommended for routine practice. Further research is required to identify a subgroup of women (and their babies) who are more likely to experience benefit from antibiotic treatment for preterm labour prior to membrane rupture, and to identify which antibiotic or combination of antibiotics is most effective. The results of the ongoing ORACLE trial should help resolve some of the uncertainties revealed by this review.

Anti-Bacterial Agents↗
PubMed1997

Population pharmacokinetics of intravenous caffeine in neonates with apnea of prematurity.

OBJECTIVE: The study the population pharmacokinetics of caffeine after intravenous administration to premature infants with apnea. METHODS: A prospective, blinded parallel study in which daily caffeine citrate doses of 30, 15, and 3 mg/kg were administered over 7 days by intermittent intravenous infusion. Arterial blood samples (three to six per patient) were assayed for caffeine content by means of HPLC. Population pharmacokinetic modeling was performed with NONMEM. RESULTS: Clearance (L/hr) = (0.00000399 . current weight [grams]) + (0.000128 . postnatal age [days]). For gestational age > 28 weeks, volume of distribution (L) = (0.000764 . weight [grams] + (0.0468 . postnatal age [days]); for gestational age < or = 28 weeks, volume of distribution (L) = (0.000755 . weight [grams]) + (0.0224. postnatal age [days]). Interpatient variability (coefficient of variation, in percent) was approximately 25% for clearance and approximately 11% for volume of distribution. Intrapatient error (standard deviation) was 3.9 mg/L. There was insignificant bias between observed and model-predicated serum caffeine concentrations in a separate group of 30 infants. CONCLUSIONS: Caffeine was well tolerated at all doses. Clearance was markedly lower and volume of distribution was higher than the values reported previously for term infants and adults. Both parameters were significantly influenced by postnatal age and current body weight, whereas volume of distribution in infants > 28 weeks' gestational age was higher than that in more premature babies. The predictive performance and the clinical application of the derived population models was satisfactorily shown.

Apnea↗