Neonatology

Clinical Research Pathway

Therapeutic Drift in the Neonatal Intensive Care Unit: Practice Without Evidence

Chair(s)

• JO

  Ju Lee Oei, MBBS FRACP MD

  Professor
  Newborn Care
  Royal Hospital for Women
  Randwick, New South Wales, Australia
• 

  Richard Martin, MD

  Professor
  Pediatrics/Reproductive Biology/Physiology & Biophysics
  Case Western
  Cleveland, Ohio, United States

No area of medicine has had as much success as newborn care. Fifty years ago, more than 75% of preterm infants died soon after birth. Those that survived were left with serious complications. Now, more than 75% of preterm infants survive, including those at the limits of viability. Such astounding achievements would not have been possible without research and the rapid implementation of research findings into clinical practice. Indeed, neonatal care is now one of the most active and cost-effective fields of research in medicine.

However, therapeutic drift has crept into many areas of our practice. Based on incomplete or little substantive evidence, our current treatment of sick infants and their mothers may actually do more harm than good and there are multiple areas where equipoise has been lost, which obstructs future research and evaluation of these missing pieces of information.

In this session, we look at some of the most important practices in neonatology that are now almost universally accepted despite little evidence of benefit or harm. Collectively, the topics discussed in this session have the potential to affect every single birth in the world (>130 million each year), including ~15 million of the sickest infants affected by prematurity and hypoxia, the two single most important causes of infant mortality and disability in the world.

Specifically, our speakers will address:

Antenatal steroids: used to promote lung maturation, steroids are now given to even early term infants and sometimes, in repeated doses with questionable benefit and possible harm to neurodevelopment.

Delayed Cord Clamping (DCC) is routinely used in extremely preterm infants to promote cardiovascular stabilization thereby aiming to reduce brain injury and mortality. DCC is routinely practiced in more mature infants as well as healthy term infants with potential adverse sequelae including hyperviscosity and jaundice.

Oxygen for newborn resuscitation. Studies on hypoxic full-term infants demonstrated significantly decreased mortality when the infants were resuscitated with air compared to pure oxygen. Over the years, clinicians have moved towards using lower oxygen strategies based on these studies and others which demonstrated oxidative stress and injury with high oxygen administration. Whether lower oxygen strategies are sufficient to prevent hypoxia, especially in preterm infants with lung immaturity is uncertain.

Apnoea affects almost every premature infant. It can be successfully treated with respiratory support and caffeine. However, there remains significant variability in the timing of discontinuation of caffeine, and convalescent preterm infants continue to have episodes of intermittent hypoxemia beyond the postmenstrual age when most clinicians stop caffeine therapy. Apnoea and intermittent hypoxemia is associated with poor neurodevelopmental outcomes but conversely, monitoring and prolonging supports like caffeine and oxygen supplementation beyond what the infant requires can do more harm than good, as well as being extremely costly.

Therapeutic hypothermia (TH) at 33.5◦C for 72 hours is the only proven therapy that reduces the risk of death or disability in infants with moderate or severe encephalopathy . Today, there is an increased use of TH in infants with mild encephalopathy, following cardiac arrest and other indications that do not reflect evidence from robust randomised controlled studies.

Presentations:

• 9:00 AM - 9:20 AM US CT

  Before birth: Can antenatal steroids do more harm than good?
  

  Presenter: Augusto F. Schmidt, MD, PhD – University of Miami
• 9:20 AM - 9:40 AM US CT

  At birth: Delayed cord clamping: one size fits all?
  

  Presenter: Georg Schmolzer, MD,PhD – University of Alberta
• 9:40 AM - 10:00 AM US CT

  After birth: Air for newborn resuscitation: when is a little not enough.
  

  Presenter: Ola Saugstad, MD, PhD – University of Oslo
• 10:00 AM - 10:20 AM US CT

  In the NICU: Enough already: when can we stop caffeine and preterm cardiorespiratory monitoring.
  

  Presenter: Eric Eichenwald, MD – Children's Hospital of Philadelphia
• 10:20 AM - 10:40 AM US CT

  Not only in an NICU: Therapeutic Hypothermia---Beyond Evidenced Based Medicine.
  

  Presenter: Seetha Shankaran, MD – Wayne State University
• 10:40 AM - 11:30 AM US CT

  Break
  

  Presenter: Belinda Thomas
• 11:30 AM - 12:00 PM US CT

  Click for Live Q&A: Therapeutic Drift in the Neonatal Intensive Care Unit: Practice Without Evidence
  

  Presenter: Belinda Thomas