Downloaded from http://fn.bmj.com/ on June 19, 2015 - Published by group.bmj.com
PostScript REFERENCES 1
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Reigstad CS, Lundén GO, Felin J, et al. Regulation of serum amyloid A3 (SAA3) in mouse colonic epithelium and adipose tissue by the intestinal microbiota. PLoS ONE 2009;4:e5842. Gardiner GE, O’Flaherty S, Casey PG, et al. Evaluation of colostrum-derived human mammary-associated serum amyloid A3 (M-SAA3) protein and peptide derivatives for the prevention of enteric infection: in vitro and in murine models of intestinal disease. FEMS Immunol Med Microbiol 2009;55:404–13. McDonald TL, Larson MA, Mack DR, et al. Elevated extrahepatic expression and secretion of mammary-associated serum amyloid A 3 (M-SAA3) into colostrum. Vet Immunol Immunopathol 2001;83:203–11. Larson MA, Wei SH, Weber A, et al. Induction of human mammary-associated serum amyloid A3 expression by prolactin or lipopolysaccharide. Biochem Biophys Res Commun 2003;301:1030–7.
Current UK practices in steroid treatment of chronic lung disease Chronic lung disease (CLD) remains an important cause of mortality and morbidity in preterm infants. Lung inflammation, whether of antenatal or postnatal onset, is a major factor in its pathogenesis. Corticosteroids modulate inflammation, improve lung function and reduce ventilator dependency in infants with CLD,1 yet doubts remain about longer-term efficacy and safety. The last two decades have witnessed large oscillations in steroid use to treat CLD, from high-dose protracted treatment courses to virtually zero use, and more recently back towards lower dose regimens. Current trends in the UK are unclear. We therefore conducted a national survey to determine current practices. In the period between August and November 2014, we contacted via email or telephone a consultant neonatologist or senior specialty training registrar/ Advanced Neonatal Nurse Practitioner in each tertiary-level neonatal intensive care unit (NICU). We used a structured questionnaire to ask about steroid use for treating CLD. We obtained data from all 55 NICUs. A total of 37 (67%) responses were from consultant neonatologists and 18 (33%) responses were from senior StRs/senior ANNPs. Within the first postnatal week, no units were using systemic or inhaled steroids for either prophylaxis or treatment of CLD. After the first week, almost all used systemic steroids for treating evolving/established CLD to facilitate extubation of ventilator-dependent babies, and to prevent reintubation: 42 (76%) used the ‘DART (Dexamethasone: A Randomized Arch Dis Child Fetal Neonatal Ed July 2015 Vol 100 No 4
Trial) study’ dexamethasone regimen;2 6 (11%) used the ‘Minidex study’ dexamethasone regimen;3 3 (5.5%) used other ad hoc dexamethasone regimens of variable duration starting at 50–300 mg/kg/ day; three (5.5%) preferred hydrocortisone instead, citing its brain growth sparing effects, and used the Geneva/ Utrecht regimen4 (n=2) or an ad hoc smaller dose/shorter duration course (n=1). One neonatologist (2%) responded that her unit had never used postnatal steroids for CLD treatment in the whole past decade. Of steroid-using units, five reserved treatment until infants were ≥2–3 completed weeks postnatal age and two limited treatment to exceptional infants deemed at very high risk of death. Forty-three (78%) units provided data on annual numbers they treated: a median of eight babies with CLD (range: 0–19) received steroids in 2013. Twelve (22%) units reported that they sometimes used inhaled steroids to facilitate extubation of ventilator-dependent babies with evolving/established CLD. Of these, five reported that their unit’s recent trend was away from using systemic dexamethasone as first-line treatment towards trialling nebulised budesonide delivered via a new-generation vibrating-mesh nebuliser device (Aeroneb Solo, Aerogen, Ireland). Twenty-three units informed that they would be interested to join a trial comparing inhaled versus systemic steroid for treatment of ventilator dependency in babies with evolving CLD if a device that allowed improved inhaled steroid delivery in ventilated babies was available; a further 28 units would consider such a trial. Our national survey shows that postnatal steroids are being widely used to treat evolving and established CLD, but highlights significant variations between NICUs in numbers of babies treated, thresholds for treatment and preferred regimens. The present lack of consensus and uncertainties confirm that research into the best treatments for preterm lung damage is a high priority.5 We advocate further comparative studies of steroid safety and efficacy for CLD treatment. Studies should examine the efficacy and safety of inhaled steroids delivered using modern nebuliser technology and whether they may spare ventilator-dependent babies with CLD the detrimental sideeffects of systemic steroids. Sajeev Job, Paul Clarke Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
Correspondence to Dr Paul Clarke, Neonatal Intensive Care Unit, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK; [email protected] Acknowledgements The authors thank all colleagues who provided their units’ data for this report. Contributors PC: conceived and designed the study. PC and SJ: acquired and analysed the data. SJ and PC: wrote the first and final manuscript drafts, respectively. Both approved the final version. PC is guarantor. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Job S, Clarke P. Arch Dis Child Fetal Neonatal Ed 2015;100:F371. Accepted 10 February 2015 Published Online First 11 March 2015 Arch Dis Child Fetal Neonatal Ed 2015;100:F371. doi:10.1136/archdischild-2014-308060
REFERENCES 1
2
3
4
5
Doyle LW, Ehrenkranz RA, Halliday HL. Late (>7 days) postnatal corticosteroids for chronic lung disease in preterm infants. Cochrane Database Syst Rev 2014;5: CD001145. Doyle LW, Davis PG, Morley CJ, et al. DART Study Investigators. Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial. Pediatrics 2006;117:75–83. Yates HL, Newell SJ. Minidex: very low dose dexamethasone (0.05 mg/kg/day) in chronic lung disease. Arch Dis Child Fetal Neonatal Ed 2011;96: F190–4. Kersbergen KJ, de Vries LS, van Kooij BJ, et al. Hydrocortisone treatment for bronchopulmonary dysplasia and brain volumes in preterm infants. J Pediatr 2013;163:666–71.e1. Duley L, Uhm S, Oliver S, Preterm Birth Priority Setting Partnership Steering Group. Top 15 UK research priorities for preterm birth. Lancet 2014;383:2041–2.
National survey of umbilical venous catheterisation practices in the wake of two deaths Umbilical venous catheter (UVC) insertion is a common invasive procedure. Multiple complications associated with UVCs are described,1 though their relative incidence is unknown. In 2013, 8746 UVCs were inserted in 164 English neonatal intensive care units comprising a total of 37 100 line days (NDAU, unpublished data). In 2014, two deaths related to UVC extravasation were notified to the British Association of Perinatal Medicine (BAPM) and the National Health Service (NHS) National Reporting and Learning System. Both involved parenteral nutrition (PN) infusion via low-lying UVCs, that is, F371
Downloaded from http://fn.bmj.com/ on June 19, 2015 - Published by group.bmj.com
Current UK practices in steroid treatment of chronic lung disease Sajeev Job and Paul Clarke Arch Dis Child Fetal Neonatal Ed 2015 100: F371 originally published online March 11, 2015
doi: 10.1136/archdischild-2014-308060 Updated information and services can be found at: http://fn.bmj.com/content/100/4/F371.1
These include:
References Email alerting service
This article cites 5 articles, 2 of which you can access for free at: http://fn.bmj.com/content/100/4/F371.1#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
PostScript REFERENCES 1
2
3
4
Reigstad CS, Lundén GO, Felin J, et al. Regulation of serum amyloid A3 (SAA3) in mouse colonic epithelium and adipose tissue by the intestinal microbiota. PLoS ONE 2009;4:e5842. Gardiner GE, O’Flaherty S, Casey PG, et al. Evaluation of colostrum-derived human mammary-associated serum amyloid A3 (M-SAA3) protein and peptide derivatives for the prevention of enteric infection: in vitro and in murine models of intestinal disease. FEMS Immunol Med Microbiol 2009;55:404–13. McDonald TL, Larson MA, Mack DR, et al. Elevated extrahepatic expression and secretion of mammary-associated serum amyloid A 3 (M-SAA3) into colostrum. Vet Immunol Immunopathol 2001;83:203–11. Larson MA, Wei SH, Weber A, et al. Induction of human mammary-associated serum amyloid A3 expression by prolactin or lipopolysaccharide. Biochem Biophys Res Commun 2003;301:1030–7.
Current UK practices in steroid treatment of chronic lung disease Chronic lung disease (CLD) remains an important cause of mortality and morbidity in preterm infants. Lung inflammation, whether of antenatal or postnatal onset, is a major factor in its pathogenesis. Corticosteroids modulate inflammation, improve lung function and reduce ventilator dependency in infants with CLD,1 yet doubts remain about longer-term efficacy and safety. The last two decades have witnessed large oscillations in steroid use to treat CLD, from high-dose protracted treatment courses to virtually zero use, and more recently back towards lower dose regimens. Current trends in the UK are unclear. We therefore conducted a national survey to determine current practices. In the period between August and November 2014, we contacted via email or telephone a consultant neonatologist or senior specialty training registrar/ Advanced Neonatal Nurse Practitioner in each tertiary-level neonatal intensive care unit (NICU). We used a structured questionnaire to ask about steroid use for treating CLD. We obtained data from all 55 NICUs. A total of 37 (67%) responses were from consultant neonatologists and 18 (33%) responses were from senior StRs/senior ANNPs. Within the first postnatal week, no units were using systemic or inhaled steroids for either prophylaxis or treatment of CLD. After the first week, almost all used systemic steroids for treating evolving/established CLD to facilitate extubation of ventilator-dependent babies, and to prevent reintubation: 42 (76%) used the ‘DART (Dexamethasone: A Randomized Arch Dis Child Fetal Neonatal Ed July 2015 Vol 100 No 4
Trial) study’ dexamethasone regimen;2 6 (11%) used the ‘Minidex study’ dexamethasone regimen;3 3 (5.5%) used other ad hoc dexamethasone regimens of variable duration starting at 50–300 mg/kg/ day; three (5.5%) preferred hydrocortisone instead, citing its brain growth sparing effects, and used the Geneva/ Utrecht regimen4 (n=2) or an ad hoc smaller dose/shorter duration course (n=1). One neonatologist (2%) responded that her unit had never used postnatal steroids for CLD treatment in the whole past decade. Of steroid-using units, five reserved treatment until infants were ≥2–3 completed weeks postnatal age and two limited treatment to exceptional infants deemed at very high risk of death. Forty-three (78%) units provided data on annual numbers they treated: a median of eight babies with CLD (range: 0–19) received steroids in 2013. Twelve (22%) units reported that they sometimes used inhaled steroids to facilitate extubation of ventilator-dependent babies with evolving/established CLD. Of these, five reported that their unit’s recent trend was away from using systemic dexamethasone as first-line treatment towards trialling nebulised budesonide delivered via a new-generation vibrating-mesh nebuliser device (Aeroneb Solo, Aerogen, Ireland). Twenty-three units informed that they would be interested to join a trial comparing inhaled versus systemic steroid for treatment of ventilator dependency in babies with evolving CLD if a device that allowed improved inhaled steroid delivery in ventilated babies was available; a further 28 units would consider such a trial. Our national survey shows that postnatal steroids are being widely used to treat evolving and established CLD, but highlights significant variations between NICUs in numbers of babies treated, thresholds for treatment and preferred regimens. The present lack of consensus and uncertainties confirm that research into the best treatments for preterm lung damage is a high priority.5 We advocate further comparative studies of steroid safety and efficacy for CLD treatment. Studies should examine the efficacy and safety of inhaled steroids delivered using modern nebuliser technology and whether they may spare ventilator-dependent babies with CLD the detrimental sideeffects of systemic steroids. Sajeev Job, Paul Clarke Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
Correspondence to Dr Paul Clarke, Neonatal Intensive Care Unit, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK; [email protected] Acknowledgements The authors thank all colleagues who provided their units’ data for this report. Contributors PC: conceived and designed the study. PC and SJ: acquired and analysed the data. SJ and PC: wrote the first and final manuscript drafts, respectively. Both approved the final version. PC is guarantor. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Job S, Clarke P. Arch Dis Child Fetal Neonatal Ed 2015;100:F371. Accepted 10 February 2015 Published Online First 11 March 2015 Arch Dis Child Fetal Neonatal Ed 2015;100:F371. doi:10.1136/archdischild-2014-308060
REFERENCES 1
2
3
4
5
Doyle LW, Ehrenkranz RA, Halliday HL. Late (>7 days) postnatal corticosteroids for chronic lung disease in preterm infants. Cochrane Database Syst Rev 2014;5: CD001145. Doyle LW, Davis PG, Morley CJ, et al. DART Study Investigators. Low-dose dexamethasone facilitates extubation among chronically ventilator-dependent infants: a multicenter, international, randomized, controlled trial. Pediatrics 2006;117:75–83. Yates HL, Newell SJ. Minidex: very low dose dexamethasone (0.05 mg/kg/day) in chronic lung disease. Arch Dis Child Fetal Neonatal Ed 2011;96: F190–4. Kersbergen KJ, de Vries LS, van Kooij BJ, et al. Hydrocortisone treatment for bronchopulmonary dysplasia and brain volumes in preterm infants. J Pediatr 2013;163:666–71.e1. Duley L, Uhm S, Oliver S, Preterm Birth Priority Setting Partnership Steering Group. Top 15 UK research priorities for preterm birth. Lancet 2014;383:2041–2.
National survey of umbilical venous catheterisation practices in the wake of two deaths Umbilical venous catheter (UVC) insertion is a common invasive procedure. Multiple complications associated with UVCs are described,1 though their relative incidence is unknown. In 2013, 8746 UVCs were inserted in 164 English neonatal intensive care units comprising a total of 37 100 line days (NDAU, unpublished data). In 2014, two deaths related to UVC extravasation were notified to the British Association of Perinatal Medicine (BAPM) and the National Health Service (NHS) National Reporting and Learning System. Both involved parenteral nutrition (PN) infusion via low-lying UVCs, that is, F371
Downloaded from http://fn.bmj.com/ on June 19, 2015 - Published by group.bmj.com
Current UK practices in steroid treatment of chronic lung disease Sajeev Job and Paul Clarke Arch Dis Child Fetal Neonatal Ed 2015 100: F371 originally published online March 11, 2015
doi: 10.1136/archdischild-2014-308060 Updated information and services can be found at: http://fn.bmj.com/content/100/4/F371.1
These include:
References Email alerting service
This article cites 5 articles, 2 of which you can access for free at: http://fn.bmj.com/content/100/4/F371.1#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
