Objectives To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates. Study design This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network’s Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks’ gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation. Results Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/bronchopulmonary dysplasia (OR 3.27). Conclusions Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities. Trial registration ClinicalTrials.gov: NCT00233324.

Objective To characterize actual achieved patterns of oxygenation in appropriate (AGA) versus small (SGA) for gestational age infants randomized to a lower (85–89%) versus higher (91–95%) oxygen saturation target in the Surfactant, Positive Pressure and Oxygen Trial (SUPPORT). To determine the association between achieved oxygen saturation levels and survival in AGA and SGA infants enrolled in SUPPORT. Study design Median oxygen saturation and intermittent hypoxemia events (<80%, 20sec–5min) were documented in 1054 infants of 24–27 6/7wks gestation while receiving supplemental oxygen during the first three days of life. Results Lower target SGA infants had the lowest oxygen saturation and highest incidence of IH during the first three days of life. The lowest quartile of oxygen saturation (≤92%) during the first three days of life was associated with lower 90 day survival for both AGA and SGA infants. An increased incidence of IH events during the first three days of life was associated with lower 90 day survival only in SGA infants. Conclusion Lower achieved oxygen saturation during the first three days of life was associated with lower 90 day survival in extremely preterm infants. SGA infants had enhanced vulnerability to lower oxygen saturation targets as evidenced by lower achieved oxygen saturation and an association between increased IH events and lower survival.

Objective To assess the association between prophylactic indomethacin and bronchopulmonary dysplasia (BPD) in a recent, large cohort of extremely preterm infants. Study design Retrospective cohort study using prospectively collected data for infants with gestational ages < 29 weeks or birth weights of 401–1000g born between 2008 and 2012 at participating hospitals of the National Institute of Child Health and Human Development Neonatal Research Network. Infants treated with indomethacin in the first 24 hours of life were compared with those who were not. Study outcomes were BPD, defined as use of supplemental oxygen at 36 weeks postmenstrual age among survivors to that time point, death, and the composite of death or BPD. Pre-specified subgroup analyses were performed. Results Prophylactic indomethacin use varied by hospital. Treatment of a patent ductus arteriosus (PDA) after the first day of life was less common among 2,587 infants who received prophylactic indomethacin compared with 5,244 who did not (21.0% vs. 36.1%, p<0.001). After adjustment for potential confounders, use of prophylactic indomethacin was not associated with higher or lower odds of BPD (OR 0.89, 95% CI 0.72–1.10), death (OR 0.80, 95% CI 0.64–1.01), or death or BPD (OR 0.87, 95% CI 0.72–1.05). The only evidence of subgroup effects associated with prophylactic indomethacin were lower odds of death among infants with birth weights above the 10th percentile and those who were not treated for a PDA after the first day of life. Conclusions Prophylactic indomethacin was not associated with either reduced or increased risk for BPD or death.

Background: Anemia is common in premature infants. Due to risks with red blood cell transfusions, many anemic infants are not transfused. The implications of this pathophysiologic status, especially at times of increased metabolic demand (enteral feedings), is not well understood. Near-infrared spectroscopy (NIRS) allows for the noninvasive determination of regional oxygen saturations (rSO₂) in tissues such as the brain and mesentery, giving insight into their oxygen sufficiency. Objective: We tested the hypothesis that during enteral feedings very low birth weight (VLBW) infants with a hematocrit ≤28% will experience a decrease in splanchnic rSO₂ and splanchnic-cerebral oxygenation ratio (SCOR). Methods: This prospective, observational, 2-centered study included VLBW infants receiving full enteral feedings with a hematocrit ≤28%. Cerebral and splanchnic rSO₂ were monitored via NIRS for 24 h. Average values were calculated for periods immediately preceding, during, and after each feeding. SCOR was calculated from these values (rSO₂ splanchnic/rSO₂ cerebral), and data were analyzed using a linear mixed effect model. Results: Fifty neonates with a median gestational age of 28 weeks (range 23-32), a birth weight of 1,118 ± 284 g (mean ± SD), and a hematocrit of 26 ± 2% (mean ± SD) were studied. During feedings, SCOR decreased significantly from baseline (0.72 ± 0.17 to 0.69 ± 0.17, p = 0.043). With feedings, there was a trend of decreased splanchnic rSO₂ (47 ± 11 to 45 ± 10, p = 0.057) and no change in cerebral rSO₂ (66 ± 8 to 66 ± 7, p = 0.597). Conclusions: VLBW infants with a hematocrit ≤28% had a decrease in SCOR and a trend towards decreased splanchnic rSO₂ with enteral feedings.

Objective-To evaluate neurodevelopmental outcomes of preterm infants with need for Child Protective Services (CPS) supervision at hospital discharge compared with those discharged without CPS supervision. Study design-For infants born at <27 weeks of gestation between 2006 and 2013, prospectively collected maternal and neonatal characteristics and 18-to 26-month corrected age follow-up data were analyzed. Bayley-III cognitive and language scores of infants with discharge CPS supervision were compared with infants without CPS supervision using regression analysis while adjusting for potentially confounding variables, including entering CPS after discharge from the hospital. Results-Of the 4517 preterm infants discharged between 2006 and 2013, 255 (5.6%) were discharged with a need for CPS supervision. Mothers of infants with CPS supervision were significantly more likely to be younger, single, and gravida ≥3; to have less than a high school education; and to have a singleton pregnancy and less likely to have received prenatal care or

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ImportanceThe provision of antenatal corticosteroids to pregnant patients at gestational age (GA) 22 6/7 weeks or less remains controversial and lacks support from randomized clinical trials.ObjectiveTo compare rates of survival and survival without major morbidities among infants born at GA 22 0/7 to 23 6/7 weeks after exposure to antenatal steroids at 22 6/7 weeks’ gestation or less vs no exposure to antenatal steroids.Design, Setting, and ParticipantsThis cohort study enrolled infants born at GA 22 0/7 to 23 6/7 weeks between January 1, 2016, and December 31, 2019, at centers in the National Institute of Child Health and Human Development Neonatal Research Network. Infants who did not receive intensive care and infants with antenatal steroid exposure after GA 22 6/7 weeks were excluded.ExposureInfants were classified as having no, partial, or complete exposure to antenatal steroids.Main Outcomes and MeasuresThe primary outcome was survival to discharge. The main secondary outcome was survival without major neonatal morbidity. The associations of differential exposures to antenatal steroids with outcomes were evaluated using logistic regression, adjusting for GA, sex, race, maternal education, small for GA status, mode of delivery, multiple birth, prolonged rupture of membranes, year of birth, and Neonatal Research Network center.ResultsA total of 431 infants (mean [SD] GA, 22.6 [0.5] weeks; 232 [53.8%] boys) were included, with 110 infants (25.5%) receiving no antenatal steroids, 80 infants (18.6%) receiving partial antenatal steroids, and 241 infants (55.9%) receiving complete antenatal steroids. Seventeen infants were exposed to antenatal steroids at GA 21 weeks. Among infants exposed to complete antenatal steroids, 130 (53.9%) survived to discharge, compared with 30 infants (37.5%) with partial antenatal steroid exposure and 239 infants (35.5%) with no antenatal steroids. Infants born after complete antenatal steroid exposure, compared with those without antenatal steroid exposure, were more likely to survive to discharge (adjusted odds ratio [aOR], 1.95 [95% CI, 1.07-3.56]) and to survive without major morbidity (aOR, 2.74 [95% CI, 1.19-6.30]).Conclusions and RelevanceIn this retrospective cohort study, among infants born between GA 22 0/7 and 23 6/7 weeks who received intensive care, exposure to a complete course of antenatal steroids at GA 22 6/7 weeks or less was independently associated with greater odds of survival and survival without major morbidity. These data suggest that the use of antenatal steroids in patients at GA 22 6/7 weeks or less could be beneficial when active treatment is considered.