*Corresponding Author: Sharon A.
McGrathMorrow,
MD, MBA, Division of Pulmonary and Sleep Medicine, Children’s Hospital
of Philadelphia, Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA, USA. Email: mcgrathmos@chop.edu
Funding/Support : This work was supported by a R03HD109442 (JMC,
SAM), the Johns Hopkins Eudowood Foundation (BCA: Fellowship grant).
The funding sources had no involvement in the writing of the manuscript
or the decision to submit.
Keywords: bronchopulmonary dysplasia, diuretics, outpatient
Running Head: Outpatient Diuretic use and BPD
Conflicts of Interests : none
Abbreviations: Neonatal Intensive Care Unit (NICU),
bronchopulmonary dysplasia (BPD), National Institute of Health (NIH)
Abstract
Introduction: During NICU hospitalization, children born
preterm with bronchopulmonary dysplasia (BPD) are frequently prescribed
diuretics for treatment of respiratory symptoms. However, less is known
about diuretic use and weaning in the outpatient setting. This study
sought to characterize clinical features associated with outpatient
diuretic use, and timing of diuretic weaning in children with BPD.
Methods : Data was obtained by chart review from registry 1224
participants born < 32 weeks gestation, discharged between
2008-2023 and recruited from outpatient BPD clinics at Johns
Hopkins Children’s Center and the Children’s Hospital of Philadelphia
(97.4% diagnosed with BPD). Data was analyzed using Chi-square tests,
t-tests, and ANOVA tests.
Results: Children with BPD prescribed diuretics as outpatients
(n=737), were more likely to have lower birth weights, earlier
gestational age, and severe BPD compared to those not on diuretics
(n=487). Of those prescribed diuretics, most children were on a thiazide
alone (46.4%) or a thiazide and a potassium sparing agent (44.8%) with
a minority on loop diuretics alone (3.3%) or loop diuretic combinations
(4.7%). Most children weaned off diuretics by two years of age. Public
insurance, earlier gestational age, technology dependence and loop
diuretics were associated with slower diuretic weaning.
Conclusion: Outpatient diuretic use is common in BPD with
> 75% of children being weaned by two years of age. No
difference was found in weaning of home oxygen between children on one
versus no diuretic. Thiazides were most commonly prescribed with slower
outpatient diuretic weaning associated with public insurance, technology
dependence and loop diuretic use.
Introduction
Bronchopulmonary dysplasia (BPD) is the most common cause of chronic
lung disease during infancy. (1) In infants with
evolving or severe BPD, diuretics are often used by healthcare providers
to improve gas-exchange abnormalities and mitigate pulmonary symptoms in
the inpatient setting. (2-4) The mechanisms of action of acute and
chronic diuretic use in preterm infants with BPD are not entirely
understood. Diuretic use in preterm infants with lung disease may
decrease pulmonary edema by promoting diuresis and reducing
intravascular fluid in the lungs. Furosemide has also been reported to
have a direct effect on the lungs through pulmonary vasodilation, which
may help improve pulmonary congestion.(5, 6)
Diuretics are also associated with side effects, including electrolyte
abnormalities, calcium imbalances and nephrocalcinosis.(7, 8) Indeed
despite their frequent use in the NICU, others have only reported
short-term benefits from diuretics in infants with BPD.(9) Currently, no
standardized guidelines for their use in the NICU exist, likely
contributing to significant practice variation across institutions.(10)
Further, no guidelines exist for outpatient use or weaning of diuretics
in children with BPD.
After initial hospital discharge, outpatient diuretic use is commonly
continued in children with BPD, without clear guidance for use or
weaning. Studies have revealed differences in weaning diuretics
practices between subspecialists and lack of established guidelines for
weaning diuretics in children with BPD on supplemental oxygen.(11, 12)
Several international societies have suggested diuretic weaning
strategies in children with BPD, however consensus between the groups
was not found. The American Thoracic Society guidelines suggest that
infants with BPD discharged on diuretics should have their medication
discontinued on an individual basis, since no standard methods currently
exist to stop diuretics.(13) The European Respiratory Society with very
low certainty evidence gave a conditional recommendation for letting
infants on diuretics outgrow their dose.(14) The Thoracic Society of
Australia and New Zealand however, offered no recommendations for long
term diuretic therapy or weaning in patients with BPD.(15)
In this study we identified associations between patient characteristics
in children with BPD and diuretic use and examined the type(s) of
diuretics being prescribed after initial hospital discharge. We also
examined how the number and type of prescribed diuretic(s) influenced
supplemental oxygen weaning in children with BPD in the outpatient
setting.
This analysis was performed through retrospective review of data from
1224 preterm children born < 32 weeks gestation. The vast
majority of children carried the diagnosis of BPD (97.4%), were born
between 2008-2023 and were recruited from outpatient BPD clinics across
two tertiary care centers.