NO means NO!

NO means NO!

How to treat the PDA for the best outcome The options for many years for the treatment of the PDA in very low birth weight infants have been surgical ...

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How to treat the PDA for the best outcome The options for many years for the treatment of the PDA in very low birth weight infants have been surgical ligation or indomethacin therapy. For some clinicians, the surgical option is preferable to the possible toxicities associated with indomethacin. Other clinicians do not have good access to PDA ligation or prefer the simplicity of indomethacin therapy. The recent availability of ibuprofen for ductal closure has not changed that equation. The TIPP trial demonstrated that there were not large differences in neurodevelopmental outcomes for infants receiving indomethacin relative to placebo. Depending on how they interpret the results, clinicians use the TIPP trial to justify or avoid the prophylactic use of indomethacin. The results of the new analysis of the TIPP trial by Kabra et al further complicate clinical decisions. Infants who received PDA ligation had less favorable neurodevelopmental outcomes, and BPD and ROP were more common after PDA ligation. These associations are consistent with other reports that anesthesia and surgery in the newborn period are associated with adverse long-term outcomes. The more we know about options to close the PDA, the less secure we are in how to best select the intervention. —Alan H. Jobe, MD, PhD page 229

Death or Neursensory Impairment (%)

100

80

60

40

20

P = 0.37 (Linear Trend)

0

1

2A

March 2007

2

3 4 PDA Ligation Week

≥5

NO means NO! Inhaled nitric oxide reduces the need for ECMO in term and near term infants with severe respiratory failure. Therefore, it seems reasonable to suppose that starting nitric oxide before severe respiratory failure develops might make a greater impact which might translate into improved long term outcome. In this issue of The Journal, Konduri et al report the results of a randomized trial comparing the early and late outcomes in two groups of infants: one that had nitric oxide initiated when moderate to severe hypoxic respiratory failure developed (OI⬎25) and one that had it initiated at an earlier threshold (OI⬎15 and ⬍25). Even though early nitric oxide decreased the progression of respiratory failure, it did not alter the incidence of ECMO or mortality. Nor did it alter the incidence of long term (18 month) morbidities. Early nitric oxide had no significant negative impact on long term outcome, although there were some disturbing trends in Bayley PDI and conductive hearing loss. Different approaches will need to be developed to decrease the significant risk of neurodevelopmental and hearing abnormalities in these high risk infants. —Ronald I. Clyman, MD page 235

Increased pneumothorax with elective C-section The rate of elective C-section is increasing in the United States and is very high in some other countries. Although a repeat C-section after a previous C-section is the most common indication for an elective C-section, the number of C-section deliveries for no apparent medical reason or at parental request is increasing. The number of C-sections prior to 39 completed weeks of pregnancy also is increasing. The rationale for some of these operative deliveries is to minimize risk for the fetus by avoiding labor. Zanardo et al report that the risk of a symptomatic pneumothorax requiring medical intervention increased to 2.9 per 1000 for elective C-section relative to rates of 1.5 per 1000 for emergency Cesarean section and 0.4 per 1000 for vaginal delivery. Pneumothorax was much more frequent for elective C-sections done prior to 38 weeks gestation. These results are not surprising as others have documented increased respiratory distress and problems with neonatal adaptation after elective C-section. Although infrequent, these adverse outcomes need to be balanced against the risks of labor and a vaginal delivery. —Alan H. Jobe, MD, PhD page 252

The Journal of Pediatrics