Less is not necessarily more in treating premature infants with respiratory insufficiency, according to University of Chicago Medicine neonatologists Michael Schreiber, MD, chief of neonatology, and Jeremy Marks, MD, PhD. In a recent editorial in the New England Journal of Medicine, Schreiber and Marks caution neonatologists to “critically appraise the indications for noninvasive ventilation in every preterm infant” based on the findings of a new Australian study that showed that noninvasive techniques such as continuous positive airway pressure (CPAP) did not improve long-term respiratory function in extremely preterm infants.
As use of noninvasive nasal CPAP and supplemental oxygen increased in the modern era, so, the investigators found, did the incidence of bronchopulmonary dysplasia, the debilitating chronic lung disease suffered by premature infants. According to the research, which examined long-term respiratory outcomes of preterm infants over the past 30 years, children in the modern era exhibit worse lung function at eight years of age compared with children born in the 1990s. Although current neonatal practice promotes noninvasive ventilation to protect immature lungs from injury, Schreiber and Marks write that the “study provides the evidence that our modern use of prolonged, noninvasive support and oxygen therapy is associated with unanticipated adverse outcomes.”
A neonatal ethicist, William Meadow's world is different than most ethicists—he deals not in abstract issues, but real decisions in real time for real people. Meadow is working to develop better means of predicting outcomes for babies in the NICU so their parents can make more informed decisions about their care. Of micropreemies born at 1½ pounds and 24 weeks gestation, 50 percent will survive, and of those survivors, half will have no obvious problems. “Our job is to counsel people in these situations,” Meadow says. Watch the video to learn more about his work.
Not only is the one-year-old Family Birth Center a state-of-the-art facility for birthing, it has the added advantage of being located inside Comer Children’s with easy access to the Neonatal Intensive Care Unit (NICU).
Being in the same building has strengthened our MFM/NICU partnership.
~ Sarosh Rana, MD, MPH
“This is the only hospital I’ve worked at where the NICU is only a short walk from labor and delivery,” says Sarosh Rana, MD, MPH, chief of maternal-fetal medicine (MFM) at the University of Chicago Medicine. “It’s a tremendous benefit to our patients, especially those whose babies are premature and/or have complications.”
Rana adds, “Being in the same building has strengthened our MFM/NICU partnership and our ability to provide exceptional multidisciplinary care for these babies.”
While many scientists have looked at the association between an unhealthy microbiome and diseases such as necrotizing enterocolitis in preterm infants, the lab of neonatologist Erika Claud, MD, is one of the first to examine the impact of a healthy microbiome on early brain and intestinal development.
Her work ties into a new University of Chicago Medicine initiative, supported with a significant gift from the Duchossois family, to form an institute that will focus on the role of the microbiome in wellness.
In one study, a group of researchers led by Claud investigated the effect of the preterm infant microbiome on intestinal development using germ-free mice transplanted with the early microbiota from human preterm infants. Using weight gain as a surrogate marker for health, they found that early microbiota from a preterm infant with normal weight gain induced increased villus height and crypt depth, cell proliferation, and numbers of goblet cells and Paneth cells, as well as enhanced tight junctions. In contrast, early microbiota from a preterm infant with poor weight gain failed to induce these changes. The data demonstrate that microbial communities have differential effects on intestinal development.
In another study, Claud and a UChicago Medicine research team hypothesized that early microbiota influenced both growth phenotype and brain development, contributing to long-term neurodevelopmental potential. Using the same germ-free mouse model, they examined the effects of preterm infant microbiota known to induce either high-growth or low-growth phenotypes on postnatal brain development.
The microbiome that induced the low-growth phenotype was associated with decreases in the neuronal markers NeuN and neurofilament-L, as well as the myelination marker MBP, when compared to the microbiome associated with the high-growth phenotype. In addition, the microbiota inducing the poor-growth phenotype was associated with increased neuroinflammation marked by increased Nos1, as well as an alteration in IGF-1 pathway including decreased circulating and brain IGF-1, decreased circulating IGFBP3 and increased Igfbp3 brain mRNA expression. These data suggest that growth-associated microbiota can influence early neuron and oligodendrocyte development, and this effect may be mediated by effects on neuroinflammation and circulating IGF-1.
Claud says the key point about the microbiome is that it’s modifiable. “If we carry this research far enough, we will be able to identify interventions for individual children to improve their long-term outcomes,” she says.
Ameth Aguirre, MD, MPH
Basharat Buchh, MD
Lei Lu, MD
William L. Meadow, MD, PhD