BACKGROUND: Cerebral palsy is an umbrella term encompassing disorders of movement and posture, attributed to non-progressive disturbances occurring in the developing fetal or infant brain. As there are diverse risk factors and causes, no one strategy will prevent all cerebral palsy. Therefore, there is a need to systematically consider all potentially relevant interventions for their contribution to prevention.
OBJECTIVES: To summarise the evidence from Cochrane reviews regarding the effects of antenatal and intrapartum interventions for preventing cerebral palsy.
METHODS: We searched the Cochrane Database of Systematic Reviews on 7 August 2016, for reviews of antenatal or intrapartum interventions reporting on cerebral palsy. Two authors assessed reviews for inclusion, extracted data, assessed review quality, using AMSTAR and ROBIS, and quality of the evidence, using the GRADE approach. We organised reviews by topic, and summarised findings in text and tables. We categorised interventions as effective (high-quality evidence of effectiveness); possibly effective (moderate-quality evidence of effectiveness); ineffective (high-quality evidence of harm or of lack of effectiveness); probably ineffective (moderate-quality evidence of harm or of lack of effectiveness); and no conclusions possible (low- to very low-quality evidence).
MAIN RESULTS: We included 15 Cochrane reviews. A further 62 reviews pre-specified the outcome cerebral palsy in their methods, but none of the included randomised controlled trials (RCTs) reported this outcome. The included reviews were high quality and at low risk of bias. They included 279 RCTs; data for cerebral palsy were available from 27 (10%) RCTs, involving 32,490 children. They considered interventions for: treating mild to moderate hypertension (two) and pre-eclampsia (two); diagnosing and preventing fetal compromise in labour (one); preventing preterm birth (four); preterm fetal maturation or neuroprotection (five); and managing preterm fetal compromise (one). Quality of evidence ranged from very low to high. Effective interventions: high-quality evidence of effectivenessThere was a reduction in cerebral palsy in children born to women at risk of preterm birth who received magnesium sulphate for neuroprotection of the fetus compared with placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.54 to 0.87; five RCTs; 6145 children). Probably ineffective interventions: moderate-quality evidence of harmThere was an increase in cerebral palsy in children born to mothers in preterm labour with intact membranes who received any prophylactic antibiotics versus no antibiotics (RR 1.82, 95% CI 0.99 to 3.34; one RCT; 3173 children). There was an increase in cerebral palsy in children, who as preterm babies with suspected fetal compromise, were born immediately compared with those for whom birth was deferred (RR 5.88, 95% CI 1.33 to 26.02; one RCT; 507 children). Probably ineffective interventions: moderate-quality evidence of lack of effectivenessThere was no clear difference in the presence of cerebral palsy in children born to women at risk of preterm birth who received repeat doses of corticosteroids compared with a single course (RR 1.03, 95% CI 0.71 to 1.50; four RCTs; 3800 children). No conclusions possible: low- to very low-quality evidenceLow-quality evidence found there was a possible reduction in cerebral palsy for children born to women at risk of preterm birth who received antenatal corticosteroids for accelerating fetal lung maturation compared with placebo (RR 0.60, 95% CI 0.34 to 1.03; five RCTs; 904 children). There was no clear difference in the presence of cerebral palsy with interventionist care for severe pre-eclampsia versus expectant care (RR 6.01, 95% CI 0.75 to 48.14; one RCT; 262 children); magnesium sulphate for pre-eclampsia versus placebo (RR 0.34, 95% CI 0.09 to 1.26; one RCT; 2895 children); continuous cardiotocography for fetal assessment during labour versus intermittent auscultation (average RR 1.75, 95% CI 0.84 to 3.63; two RCTs; 13,252 children); prenatal progesterone for prevention of preterm birth versus placebo (RR 0.14, 95% CI 0.01 to 3.48; one RCT; 274 children); and betamimetics for inhibiting preterm labour versus placebo (RR 0.19, 95% CI 0.02 to 1.63; one RCT; 246 children).Very low-quality found no clear difference for the presence of cerebral palsy with any antihypertensive drug (oral beta-blockers) for treatment of mild to moderate hypertension versus placebo (RR 0.33, 95% CI 0.01 to 8.01; one RCT; 110 children); magnesium sulphate for prevention of preterm birth versus other tocolytic agents (RR 0.13, 95% CI 0.01 to 2.51; one RCT; 106 children); and vitamin K and phenobarbital prior to preterm birth for prevention of neonatal periventricular haemorrhage versus placebo (RR 0.77, 95% CI 0.33 to 1.76; one RCT; 299 children).
AUTHORS' CONCLUSIONS: This overview summarises evidence from Cochrane reviews on the effects of antenatal and intrapartum interventions on cerebral palsy, and can be used by researchers, funding bodies, policy makers, clinicians and consumers to aid decision-making and evidence translation. We recommend that readers consult the included Cochrane reviews to formally assess other benefits or harms of included interventions, including impacts on risk factors for cerebral palsy (such as the reduction in intraventricular haemorrhage for preterm babies following exposure to antenatal corticosteroids).Magnesium sulphate for women at risk of preterm birth for fetal neuroprotection can prevent cerebral palsy. Prophylactic antibiotics for women in preterm labour with intact membranes, and immediate rather than deferred birth of preterm babies with suspected fetal compromise, may increase the risk of cerebral palsy. Repeat doses compared with a single course of antenatal corticosteroids for women at risk of preterm birth do not clearly impact the risk of cerebral palsy.Cerebral palsy is rarely diagnosed at birth, has diverse risk factors and causes, and is diagnosed in approximately one in 500 children. To date, only a small proportion of Cochrane reviews assessing antenatal and intrapartum interventions have been able to report on this outcome. There is an urgent need for long-term follow-up of RCTs of interventions addressing risk factors for cerebral palsy, and consideration of the use of relatively new interim assessments (including the General Movements Assessment). Such RCTs must be rigorous in their design, and aim for consistency in cerebral palsy outcome measurement and reporting to facilitate pooling of data, to focus research efforts on prevention.
Dexamethasone has been proposed as an alternative in the treatment of acute asthma exacerbation in children. It allows shortening the duration of treatment, reducing costs and adverse effects. However, it is not clear whether its efficacy is similar to the traditional steroid regimen. To answer this question, we searched in Epistemonikos database, which is maintained by screening multiple information sources. We identified six systematic reviews including 10 randomized trials. We extracted data, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. We concluded dexamethasone has probably fewer adverse effects than others corticosteroids, and might be equally effective in reducing hospitalizations and revisits.
Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes. A single course of corticosteroids is recommended for pregnant women between 24 0/7 weeks and 33 6/7 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations. It also may be considered for pregnant women starting at 23 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family's decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number. Administration of betamethasone may be considered in pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation who are at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids. A single repeat course of antenatal corticosteroids should be considered in women who are less than 34 0/7 weeks of gestation who are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously. Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario. Continued surveillance of long-term outcomes after in utero corticosteroid exposure should be supported. Quality improvement strategies to optimize appropriate and timely antenatal corticosteroid administration are encouraged.
During an episode of sepsis, the systemic inflammatory response phenomenon triggers a deficit in the action and/or secretion of cortisol. It has been suggested that the use of corticosteroids may have a role in the management of sepsis, but there is no consensus. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 16 systematic reviews including 66 randomized controlled trials addressing the question of this article. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded the use of corticosteroids during a sepsis episode probably favors reversal of shock, briefly shortens the stay in intensive care unit and might reduce mortality, with few clinically relevant adverse effects.
Bacterial meningitis and meningococcal sepsis are rare conditions with high case fatality rates. Early recognition and prompt treatment saves lives. In 1999 the British Infection Society produced a consensus statement for the management of immunocompetent adults with meningitis and meningococcal sepsis. Since 1999 there have been many changes. We therefore set out to produce revised guidelines which provide a standardised evidence-based approach to the management of acute community acquired meningitis and meningococcal sepsis in adults. A working party consisting of infectious diseases physicians, neurologists, acute physicians, intensivists, microbiologists, public health experts and patient group representatives was formed. Key questions were identified and the literature reviewed. All recommendations were graded and agreed upon by the working party. The guidelines, which for the first time include viral meningitis, are written in accordance with the AGREE 2 tool and recommendations graded according to the GRADE system. Main changes from the original statement include the indications for pre-hospital antibiotics, timing of the lumbar puncture and the indications for neuroimaging. The list of investigations has been updated and more emphasis is placed on molecular diagnosis. Approaches to both antibiotic and steroid therapy have been revised. Several recommendations have been given regarding the follow-up of patients.
Mortality rates for severe community-acquired pneumonia (CAP) range from 17 to 48 % in published studies.In this review, we searched PubMed for relevant papers published between 1981 and June 2016 and relevant files. We explored how early and aggressive management measures, implemented within 24 hours of recognition of severe CAP and carried out both in the emergency department and in the ICU, decrease mortality in severe CAP.These measures begin with the use of severity assessment tools and the application of care bundles via clinical decision support tools. The bundles include early guideline-concordant antibiotics including macrolides, early haemodynamic support (lactate measurement, intravenous fluids, and vasopressors), and early respiratory support (high-flow nasal cannulae, lung-protective ventilation, prone positioning, and neuromuscular blockade for acute respiratory distress syndrome).While the proposed interventions appear straightforward, multiple barriers to their implementation exist. To successfully decrease mortality for severe CAP, early and close collaboration between emergency medicine and respiratory and critical care medicine teams is required. We propose a workflow incorporating these interventions.
OBJECTIVE: The objective of this study is to summarize the principal findings in the literature about acute asthma management in children.
METHODS: Systematic reviews of randomized clinical trials (SRCTs) with or without meta-analysis in children (1-18 years) admitted to the emergency department (ED) were retrieved using five data bases. Methodological quality was determined using the AMSTAR tool.
RESULTS: One hundred and three studies were retrieved. Among those, 28 SRCTs were included: seven SRCTs related to short-acting beta2-agonists (SABA), three to ipratropium bromide (IB), eight to corticosteroids, one to racemic adrenaline, one to leukotriene receptor antagonists (LTRA), four to magnesium sulfate, one to intravenous (IV) SABA, one to IV aminophylline, one to IV ketamine, and one to antibiotics. It was determined that administering SABA by MDI-VHC is superior to using a nebulizer, because it decreases the hospital admission rate, improves the clinical score, results in a shorter time in the ED, and causes fewer adverse effects. Levalbuterol and albuterol were similar. In patients with moderate to severe exacerbations, IB+SABA was superior to SABA, decreasing hospital admission and improving the clinical score. SABA heliox administered by nebulizer decreased exacerbation severity compared to oxygen. Inhaled corticosteroids (ICS), especially administered by nebulizer, showed results similar to oral corticosteroids (OCS) with respect to reducing hospital admission, unscheduled visits, and the requirement of additional systemic corticosteroids. ICS or OCS following ED discharge was similar with regard to relapse. Compared with a placebo, IV magnesium reduced hospital admission and improved lung function.
CONCLUSIONS: SRCTs are useful for guiding decisions in acute asthma treatment.
PURPOSE: Multiple interventions have been tested in acute respiratory distress syndrome (ARDS). We examined the entire agenda of published randomized controlled trials (RCTs) in ARDS that reported on mortality and of respective meta-analyses.
METHODS: We searched PubMed, the Cochrane Library, and Web of Knowledge until July 2013. We included RCTs in ARDS published in English. We excluded trials of newborns and children; and those on short-term interventions, ARDS prevention, or post-traumatic lung injury. We also reviewed all meta-analyses of RCTs in this field that addressed mortality. Treatment modalities were grouped in five categories: mechanical ventilation strategies and respiratory care, enteral or parenteral therapies, inhaled/intratracheal medications, nutritional support, and hemodynamic monitoring.
RESULTS: We identified 159 published RCTs of which 93 had overall mortality reported (n = 20,671 patients)--44 trials (14,426 patients) reported mortality as a primary outcome. A statistically significant survival benefit was observed in eight trials (seven interventions) and two trials reported an adverse effect on survival. Among RCTs with more than 50 deaths in at least one treatment arm (n = 21), two showed a statistically significant mortality benefit of the intervention (lower tidal volumes and prone positioning), one showed a statistically significant mortality benefit only in adjusted analyses (cisatracurium), and one (high-frequency oscillatory ventilation) showed a significant detrimental effect. Across 29 meta-analyses, the most consistent evidence was seen for low tidal volumes and prone positioning in severe ARDS.
CONCLUSIONS: There is limited supportive evidence that specific interventions can decrease mortality in ARDS. While low tidal volumes and prone positioning in severe ARDS seem effective, most sporadic findings of interventions suggesting reduced mortality are not corroborated consistently in large-scale evidence including meta-analyses.
OBIETTIVO: Per fornire un aggiornamento alla "Surviving Sepsis Campaign Linee guida per la gestione della sepsi grave e shock settico," last pubblicati nel 2008.
DESIGN: Un comitato di consenso di 68 esperti internazionali in rappresentanza di 30 organizzazioni internazionali, è stato convocato. Gruppi nominali sono stati assemblati in chiave incontri internazionali (per i membri della commissione presenti alla conferenza). Un conflitto formale della politica di interessi è stato sviluppato presso l'inizio del processo e applicato in tutto. Il processo di intere linee guida è stato condotto indipendentemente da qualsiasi finanziamento dell'industria. Un incontro stand-alone è svolta per tutte le teste dei sottogruppi, cooperazione e vicepresidenti, e gli individui selezionati. Teleconferenze e discussione elettronica basata tra sottogruppi e tra l'intero comitato serviti come parte integrante dello sviluppo.
METODI: Gli autori sono stati invitati a seguire i principi della classificazione delle raccomandazioni di valutazione, il sistema (GRADE) Sviluppo e valutazione per guidare la valutazione di qualità delle prove da alto (A) a molto basso (D) e per determinare la forza delle raccomandazioni forte (1) o debole (2). I potenziali svantaggi di fare raccomandazioni forti in presenza di evidenze di bassa qualità sono stati sottolineati. Alcune raccomandazioni sono state non classificate (UG). Raccomandazioni sono stati classificati in tre gruppi: 1) coloro che sono direttamente di mira sepsi grave; 2) quelli di targeting cura generale del paziente critico e prioritario considerato nella sepsi grave; e 3) considerazioni pediatrici.
RISULTATI: raccomandazioni chiave e suggerimenti, elencati per categoria, sono: precoce rianimazione quantitativa del paziente settico durante le prime 6 ore dopo il riconoscimento (1C); emocolture prima terapia antibiotica (1C); studi di imaging eseguite prontamente a confermare una potenziale fonte di infezione (UG); la somministrazione di una terapia antimicrobici ad ampio spettro entro 1 ora di riconoscimento dello shock settico (1B) e sepsi severa senza shock settico (1C), come l'obiettivo della terapia; rivalutazione della terapia antimicrobica giorno per de-escalation, se del caso (1B); controllo del codice sorgente di infezione con attenzione per l'equilibrio dei rischi e benefici del metodo scelto entro 12 ore dalla diagnosi (1C); fluido rianimazione iniziale con cristalloidi (1B) e considerazione l'aggiunta di albumina in pazienti che continuano a richiedere notevoli quantità di cristalloidi per mantenere un'adeguata pressione media arteriosa (2C) ed evitare formulazioni hetastarch (1C); sfida fluido iniziale nei pazienti con ipoperfusione tissutale indotta dalla sepsi e sospetto di ipovolemia per ottenere un minimo di 30 ml / kg di cristalloidi (gestione più rapida e una maggiore quantità di liquido può essere necessario in alcuni pazienti) (1C); fluido tecnica sfida continuato fino a quando il miglioramento emodinamico, come sulla base sia variabili dinamiche o statiche (UG); noradrenalina come la prima scelta vasopressori per mantenere la pressione arteriosa media ≥ 65 mmHg (1B); adrenalina quando un agente supplementare è necessario per mantenere un'adeguata pressione sanguigna (2B); vasopressina (0,03 U / min) può essere aggiunto alla noradrenalina per aumentare sia la pressione arteriosa media di indirizzare o diminuire la dose noradrenalina ma non dovrebbe essere usato come vasocostrittore iniziale (UG); dopamina non è raccomandato salvo in circostanze altamente selezionati (2C); dobutamina infusioni o aggiunti alla vasopressori in presenza di a) disfunzione miocardica come suggerito da elevate pressioni cardiaci riempimento e bassa portata cardiaca, o b) segni corso di ipoperfusione nonostante conseguire un adeguato volume intravascolare e adeguata pressione arteriosa media (1C); evitando l'impiego di idrocortisone per via endovenosa nei pazienti con shock settico adulti se un'adeguata reintegrazione dei liquidi e la terapia vasopressoria sono in grado di ripristinare la stabilità emodinamica (2C); target di emoglobina di 7-9 g / dl in assenza di ipoperfusione tissutale, ischemico malattia coronarica, o emorragia acuta (1B); basso volume corrente (1A) e la limitazione della pressione plateau inspiratorio (1B) per sindrome da distress respiratorio acuto (ARDS); applicazione di almeno una quantità minima di pressione positiva di fine espirazione (PEEP) in ARDS (1B); superiore, piuttosto che più basso livello di PEEP nei pazienti con ARDS moderata o grave sepsi indotta (2C); manovre di reclutamento di pazienti con sepsi con grave ipossiemia refrattaria a causa di ARDS (2C); posizione prona in sepsi indotta ARDS pazienti con un rapporto PaO2 / FIO2 di ≤ 100 mm Hg in strutture che hanno esperienza con queste pratiche (2C); elevazione head-of-letto in pazienti ventilati meccanicamente meno controindicato (1B); una strategia conservativa fluido per i pazienti con ARDS affermati che non hanno evidenza di ipoperfusione tissutale (1C); protocolli per lo svezzamento e la sedazione (1A); riducendo al minimo l'uso di una sedazione intermittente in bolo o per infusione continua sedazione mirato alcune endpoint titolazione (1B); evitare bloccanti neuromuscolari, se possibile nel paziente settico senza ARDS (1C); un breve ciclo di bloccante neuromuscolare (non più di 48 ore) per i pazienti con ARDS precoce e una PaO2 / FIO2 <150 mmHg (2C); un approccio protocolized alla gestione di glucosio nel sangue che inizia il dosaggio di insulina quando due livelli di glucosio nel sangue consecutivi sono> 180 mg / dL, l'obiettivo di una glicemia superiore ≤ 180 mg / dL (1A); equivalenza di emofiltrazione continua veno-venosa o emodialisi intermittente (2B); profilassi per la trombosi venosa profonda (1B); uso di una profilassi dell'ulcera da stress per prevenire il sanguinamento gastrointestinale superiore in pazienti con fattori di rischio di sanguinamento (1B); orale o enterale (se necessario) alimentazioni, come tollerato, piuttosto che sia digiuno completa o fornitura di solo glucosio per via endovenosa entro le prime 48 ore dopo una diagnosi di sepsi grave / shock settico (2C); e affrontare obiettivi di cura, compresi i piani di trattamento e di fine del ciclo di vita pianificazione (a seconda dei casi) (1B), già nel possibile, ma entro 72 ore dal ricovero nell'unità di terapia intensiva (2C). Raccomandazioni specifiche per pediatrica sepsi grave includono: la terapia con maschera di ossigeno, flusso elevato cannula nasale di ossigeno, o nasofaringeo PEEP continuo in presenza di insufficienza respiratoria e ipossiemia (2C), uso di esame fisico endpoint terapeutiche come riempimento capillare (2C); per shock settico associato ipovolemia, l'uso di cristalloidi o albumina per fornire un bolo di 20 ml / kg di cristalloidi (o equivalente) albumina durata da 5 a 10 minuti (2C); uso più comune di inotropi e vasodilatatori per bassa gittata cardiaca shock settico associate a elevata resistenza vascolare sistemica (2C); e l'uso di idrocortisone solo nei bambini con sospetta o accertata 'insufficienza surrenalica "assoluto" (2C).
In conclusione, forte accordo esisteva tra un'ampia coorte di esperti internazionali per quanto riguarda molti di livello 1 le raccomandazioni per la migliore cura dei pazienti con sepsi grave. Anche se un numero significativo di aspetti della cura ha il supporto relativamente debole, le raccomandazioni basate sull'evidenza per quanto riguarda la gestione della fase acuta della sepsi e shock settico sono alla base del miglioramento dei risultati di questo importante gruppo di pazienti in condizioni critiche.
Cerebral palsy is an umbrella term encompassing disorders of movement and posture, attributed to non-progressive disturbances occurring in the developing fetal or infant brain. As there are diverse risk factors and causes, no one strategy will prevent all cerebral palsy. Therefore, there is a need to systematically consider all potentially relevant interventions for their contribution to prevention.
OBJECTIVES:
To summarise the evidence from Cochrane reviews regarding the effects of antenatal and intrapartum interventions for preventing cerebral palsy.
METHODS:
We searched the Cochrane Database of Systematic Reviews on 7 August 2016, for reviews of antenatal or intrapartum interventions reporting on cerebral palsy. Two authors assessed reviews for inclusion, extracted data, assessed review quality, using AMSTAR and ROBIS, and quality of the evidence, using the GRADE approach. We organised reviews by topic, and summarised findings in text and tables. We categorised interventions as effective (high-quality evidence of effectiveness); possibly effective (moderate-quality evidence of effectiveness); ineffective (high-quality evidence of harm or of lack of effectiveness); probably ineffective (moderate-quality evidence of harm or of lack of effectiveness); and no conclusions possible (low- to very low-quality evidence).
MAIN RESULTS:
We included 15 Cochrane reviews. A further 62 reviews pre-specified the outcome cerebral palsy in their methods, but none of the included randomised controlled trials (RCTs) reported this outcome. The included reviews were high quality and at low risk of bias. They included 279 RCTs; data for cerebral palsy were available from 27 (10%) RCTs, involving 32,490 children. They considered interventions for: treating mild to moderate hypertension (two) and pre-eclampsia (two); diagnosing and preventing fetal compromise in labour (one); preventing preterm birth (four); preterm fetal maturation or neuroprotection (five); and managing preterm fetal compromise (one). Quality of evidence ranged from very low to high. Effective interventions: high-quality evidence of effectivenessThere was a reduction in cerebral palsy in children born to women at risk of preterm birth who received magnesium sulphate for neuroprotection of the fetus compared with placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.54 to 0.87; five RCTs; 6145 children). Probably ineffective interventions: moderate-quality evidence of harmThere was an increase in cerebral palsy in children born to mothers in preterm labour with intact membranes who received any prophylactic antibiotics versus no antibiotics (RR 1.82, 95% CI 0.99 to 3.34; one RCT; 3173 children). There was an increase in cerebral palsy in children, who as preterm babies with suspected fetal compromise, were born immediately compared with those for whom birth was deferred (RR 5.88, 95% CI 1.33 to 26.02; one RCT; 507 children). Probably ineffective interventions: moderate-quality evidence of lack of effectivenessThere was no clear difference in the presence of cerebral palsy in children born to women at risk of preterm birth who received repeat doses of corticosteroids compared with a single course (RR 1.03, 95% CI 0.71 to 1.50; four RCTs; 3800 children). No conclusions possible: low- to very low-quality evidenceLow-quality evidence found there was a possible reduction in cerebral palsy for children born to women at risk of preterm birth who received antenatal corticosteroids for accelerating fetal lung maturation compared with placebo (RR 0.60, 95% CI 0.34 to 1.03; five RCTs; 904 children). There was no clear difference in the presence of cerebral palsy with interventionist care for severe pre-eclampsia versus expectant care (RR 6.01, 95% CI 0.75 to 48.14; one RCT; 262 children); magnesium sulphate for pre-eclampsia versus placebo (RR 0.34, 95% CI 0.09 to 1.26; one RCT; 2895 children); continuous cardiotocography for fetal assessment during labour versus intermittent auscultation (average RR 1.75, 95% CI 0.84 to 3.63; two RCTs; 13,252 children); prenatal progesterone for prevention of preterm birth versus placebo (RR 0.14, 95% CI 0.01 to 3.48; one RCT; 274 children); and betamimetics for inhibiting preterm labour versus placebo (RR 0.19, 95% CI 0.02 to 1.63; one RCT; 246 children).Very low-quality found no clear difference for the presence of cerebral palsy with any antihypertensive drug (oral beta-blockers) for treatment of mild to moderate hypertension versus placebo (RR 0.33, 95% CI 0.01 to 8.01; one RCT; 110 children); magnesium sulphate for prevention of preterm birth versus other tocolytic agents (RR 0.13, 95% CI 0.01 to 2.51; one RCT; 106 children); and vitamin K and phenobarbital prior to preterm birth for prevention of neonatal periventricular haemorrhage versus placebo (RR 0.77, 95% CI 0.33 to 1.76; one RCT; 299 children).
AUTHORS' CONCLUSIONS:
This overview summarises evidence from Cochrane reviews on the effects of antenatal and intrapartum interventions on cerebral palsy, and can be used by researchers, funding bodies, policy makers, clinicians and consumers to aid decision-making and evidence translation. We recommend that readers consult the included Cochrane reviews to formally assess other benefits or harms of included interventions, including impacts on risk factors for cerebral palsy (such as the reduction in intraventricular haemorrhage for preterm babies following exposure to antenatal corticosteroids).Magnesium sulphate for women at risk of preterm birth for fetal neuroprotection can prevent cerebral palsy. Prophylactic antibiotics for women in preterm labour with intact membranes, and immediate rather than deferred birth of preterm babies with suspected fetal compromise, may increase the risk of cerebral palsy. Repeat doses compared with a single course of antenatal corticosteroids for women at risk of preterm birth do not clearly impact the risk of cerebral palsy.Cerebral palsy is rarely diagnosed at birth, has diverse risk factors and causes, and is diagnosed in approximately one in 500 children. To date, only a small proportion of Cochrane reviews assessing antenatal and intrapartum interventions have been able to report on this outcome. There is an urgent need for long-term follow-up of RCTs of interventions addressing risk factors for cerebral palsy, and consideration of the use of relatively new interim assessments (including the General Movements Assessment). Such RCTs must be rigorous in their design, and aim for consistency in cerebral palsy outcome measurement and reporting to facilitate pooling of data, to focus research efforts on prevention.
