Dr. Allen Cherer | Neonatal Care & Pediatrics

Dr. Allen Cherer is a neonatal care expert with over 30 years of medical accomplishments to his name.

Tag: Plan

Noting the Extraordinary Success of Hib Vaccination

August is observed as National Immunization Awareness Month and is a time to highlight the extreme importance and value of vaccination for people of all ages. Vaccination serves as one of the best ways to protect infants, children, and adolescents from sixteen potentially harmful, and even deadly, diseases. Although it is common to think of the vaccines against measles, pertussis, and polio, an astonishingly important vaccine since the end of the 20th century has targeted the bacteria, Haemophilus influenzae type b (Hib).

Haemophilus influenzae is a small, pleomorphic, gram negative coccobacillus. Some strains of H. influenzae possess a polysaccharide capsule, and these strains are serotyped into six different types (a-f) based on their biochemically different capsules.

The H. influenzae strains with no capsule are termed nonencapsulated H. influenzae or nontypable H. influenzae (NTHi). H. influenzae type b is the most virulent, with its polysaccharide capsule being the main factor. Antibody to the capsule is the primary contributor to serum bactericidal activity, and increasing levels of antibody are associated with decreasing risk of invasive H. influenzae disease.

H. influenzae type b most commonly causes pneumonia, bacteremia, meningitis, epiglottitis, and cellulitis. Non-type b encapsulated forms present in a similar manner to type b infections, while non typable strains more commonly cause infections of the respiratory tract, such as pneumonia, otitis media, sinusitis, and conjunctivitis.

Generally, the mode of transmission is person to person by inhalation of respiratory tract droplets or by direct contact with respiratory tract secretions. Pharyngeal colonization by H. influenzae is relatively common, especially with nontypable and non-type b capsular strains.
Before effective Hib conjugate vaccines for infants older than 2 months were available in 1990, Haemophilus influenzae type b was the leading cause of invasive bacterial disease among children in the United States.

One in 200 children developed invasive Hib disease by 5 years of age; approximately 60% of these children had meningitis and 3-6% died from the disease. Of the Hib meningitis survivors, many exhibited permanent sequelae ranging from mild hearing loss to mental retardation.

Sadly, I recall as a Pediatric resident admitting to the hospital at least one infant with H. influenzae type b meningitis almost every night when on call.Remarkably, since the introduction of Hib conjugate vaccines in the United States, the incidence of invasive Hib disease has decreased a stunning 99% to fewer than 1 case/100,000 children younger than 5 years of age, and in 2012, only 30 cases of invasive type b disease were reported in children under 5 years old.

Truly, it has been an amazing accomplishment. Nevertheless, the risk for invasive Hib disease persists among unimmunized and underimmunized children, highlighting the importance of full vaccination with the 2 or 3 injection (depending on the product) series between 2 and 6 months old and a single booster dose given between 12 and 15 months of age.

Certain additional doses may be indicated over 5 years of age depending on medical conditions, such as anatomic or functional asplenia, hematopoietic stem cell transplantation, or HIV infection. The Hib vaccine is very safe. The most common side effects are usually mild and consist of fever and rednesss, swelling, or warmth at the injection site. As with all current vaccines, significant advances and improvement in public health have been witnessed. It is incumbent upon each of us to maintain that success.

Antenatal Corticosteroid Use for Late Preterm Delivery

In 1972, Drs. Liggins and Howie published their landmark study demonstrating that antenatal corticosteroids administered to women 24-36 weeks of gestation reduced the incidence of respiratory distress syndrome and  neonatal mortality. Liggins had previously noted that lambs, treated with intrafetal  ACTH, cortisol, or dexamethasone, delivered prematurely, and sacrificed, demonstrated partially expanded  lungs.

Such alveolar stability was not typically noted until later in gestation. It suggested to Liggins that glucocorticoids might cause premature liberation of surfactant into the alveoli and served as the basis for his study. In the trial, the most significant difference in the incidence of respiratory distress syndrome among those treated vs. not treated with corticosteroids occurred in those gestations  less than 32 weeks.

Although those gestations treated between 32 and 37 weeks exhibited a decreased incidence of respiratory distress, the number did not reach statistical significance. Nevertheless, even at that time, Liggins postulated that mechanisms in addition to enhanced surfactant production and release might be responsible for the improved pulmonary function noted in more advanced gestations treated with antenatal corticosteroids.  

Interestingly, despite the findings of the initial study and similar results in multiple subsequent studies , the 1994 NIH Consensus report on the effect of corticosteroids for fetal maturation on perinatal outcomes found that only 20% of women who delivered newborns  501-1500 grams received the benefit of antenatal steroids. After a thorough review of available evidence, including  12 year neurodevelopmental follow up showing no adverse outcomes, the Consensus Panel felt  the benefits of antenatal administration of corticosteroids vastly outweigh the risks and all fetuses between 24 and 34 weeks gestation at risk of preterm delivery should be considered candidates for antenatal  treatment.

Only in those few pregnancies where corticosteroids would have an adverse effect on the mother or delivery was imminent  should steroid treatment be withheld. In addition, although Grade 1 evidence existed at the time to support the use of antenatal corticosteroids for gestations greater than 34 weeks, it was judged insufficient to recommend their use.

Since the Consensus statement, the use of antenatal corticosteroid use has become common and has resulted in considerable reduction in mortality and morbidity, as well as total health care costs. In addition, further neurodevelopmental follow up, including the original Auckland steroid trial participants, continues to demonstrate no adverse effects on psychological functioning and health-related quality of life. Other studies have demonstrated a decrease in overall respiratory disease in infants born beyond 34 weeks who had previously been exposed to antenatal corticosteroids when compared to unexposed infants born at similar gestations.

More than 300,000 pregnancies deliver in the late preterm period (34 0/7 – 36 6/7 weeks gestation) each year in the United States. Seventy per cent of Intensive Care Nursery admissions are late preterm newborns. Their increasing numbers and the broad range and severity of respiratory disorders with which they present beg for a re-evaluation of antenatal corticosteroid use in this range of gestations. This is especially appropriate with a better understanding of the multiple actions of corticosteroids as gestation approaches term.

A recent study, titled Antenatal Late Preterm Steroids (ALPS), a Randomized Trial to Reduce Neonatal Respiratory Morbidity, was published in The New England Journal of Medicine in April, 2016. The study enrolled over 2800 women with singleton pregnancies at high risk for late preterm delivery.

The participants were randomized to receive antenatal betamethasone by injection or a matching placebo. Greater than 80% of women in the trial delivered prior to 37 weeks gestation. The primary outcome was a neonatal composite of treatment in the first 72 hours (CPAP or High Flow Nasal Cannula for at least 2 hours, supplemental oxygen with fraction of inspired oxygen of at least 0.3 for at least 4 hours, mechanical ventilation, or ECMO) or stillbirth or neonatal death within 72 hours of birth.

The study found a significant decrease in neonatal respiratory complications in the group given the steroid treatment (11.6% vs. 14.4%). In addition, severe respiratory complications occurred significantly less frequently in the betamethasone group. The incidence of neonatal hypoglycemia  was increased in those treated with betamethasone (24% vs. 14.9%), but no other adverse neonatal outcomes were noted between the groups.

The study is authoritative due to its size, generalizability, and methodologic rigor. Although the issue of long term follow up cannot be specifically addressed, follow up studies of similar treatment in earlier gestations are reassuring. Late preterm births comprise a high risk group for hypoglycemia regardless of maternal antenatal steroid treatment and warrant vigilant monitoring during the newborn period.  In sum, the findings of the Antental Late Preterm Steroids study are consistent with other randomized controlled trials of antenatal corticosteroids administered at gestations less than 34 weeks.

Both the American College of Obstetrics and Gynecology with an endorsement by the American Academy of Pediatrics and the Society for Maternal-Fetal Medicine have addressed and published recommendations based on the study’s findings. Although the recommendations do not establish exclusive standards of care, the organizations approve the use of antenatal corticosteroids in certain defined late preterm pregnancies.  It is only with thoughtful application of the recommendations and further studies that the efficacy and safety of antenatal steroids in the late preterm pregnancy will be realized. It is a significant start.

Approaching a Birth Plan

Pregnancy is an exciting time for expectant parents, and childbirth is a miraculous event. Nevertheless,due to the innate unknowns, it can result in considerable anxiety and sense of loss of control. One means of combating these feelings is through thoughtful preparation of a birth plan based on realistic and trustful communication among all the parties who will be involved.

Since the early Roman period, pregnant women in labor had been attended by friends, relatives, or others experienced in aiding with childbirth. As time progressed, the management of the laboring woman became more involved and the advancement of technologies to better monitor the unborn child and the mother required a change in the birth place and the sophistication of the caregivers.

baby feet

 

Currently,the vast majority (>98%) of deliveries in the U.S. occur in the hospital setting and are attended by midwives or physicians. In association with these changes came the option of operative delivery (cesarean section) which in 2012 accounted for close to 30% of all births in the United States, according to the Centers for Disease Control and Prevention (CDC). Cesarean sections are known to be medically indicated for a number of reasons to safeguard the well being of baby and/or mother.

At the same time, for most pregnancies that are low risk, cesarean section may pose greater risks than vaginal delivery, especially risks related to future pregnancies. Due to the recent rapid increase in the cesarean section rate and concerns that operative delivery is overused without clear evidence of improved maternal or newborn outcomes, the American College of Obstetricians and Gynecologists (ACOG) issued in 2014 new recommendations targeted at preventing women from having cesarean sections with their first birth and at decreasing the national cesarean rate.

child in neonatal care

Pain management is a significant component of the birth plan. Although most mothers report only mild discomfort during early labor, as contractions become stronger, longer, and more frequent, pain intensifies and may require relief with either spinal or epidural anesthesia.

Although the medications are generally considered safe, very rare complications can occur. For those women opting for a more natural childbirth, the participation in a yoga program during pregnancy or the use of hypnosis have been described.

Whatever birth plan is developed for an individual pregnancy, it should always be tempered based onthe saying “the best laid plans of mice and men often go awry”. The overriding goal should always be a safe birth for both mother and baby. If communication and trust exist among all parties, childbirth can be a magnificent process.

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