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Repeated lumbar or ventricular punctures for preventing disability or shunt dependence in newborn infants with
1Child Health, University of Bristol, Southmead Hospital, Bristol, UK, BS10 5NB. andrew.whitelaw@bristol.ac.uk
Insights
Repeated cerebrospinal fluid (CSF) tapping in neonates with post-hemorrhagic hydrocephalus (PHH) did not reduce the risk of shunt dependence, disability, or death. This intervention may even increase the risk of CSF infection.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Clinical Trials
Background:
- Post-hemorrhagic hydrocephalus (PHH) is a serious complication in neonates, often following intraventricular hemorrhage (IVH).
- Management of PHH aims to prevent or reduce permanent shunt dependence, neurodevelopmental disability, and mortality.
- Cerebrospinal fluid (CSF) tapping was hypothesized to clear obstructive proteins and blood, thereby improving CSF absorption.
Purpose of the Study:
- To evaluate the efficacy of repeated CSF tapping (lumbar puncture or ventricular tap) in reducing shunt dependence, neurodevelopmental disability, or death in at-risk neonates.
- To assess the safety and effectiveness of CSF tapping as an early intervention for PHH.
Main Methods:
- A systematic review of controlled trials was conducted, including randomized and alternative allocation studies.
- Four trials involving neonates with IVH were identified and analyzed.
- Data on patient selection, allocation, interventions (CSF tapping vs. conservative treatment), and outcomes (shunt placement, death, disability) were extracted.
Main Results:
- Combining data from the trials showed no statistically significant reduction in the relative risk for shunt placement, death, disability, or multiple disability when comparing repeated CSF tapping to conservative treatment.
- The relative risks for these outcomes were consistently close to 1.0.
- Evidence suggests that repeated CSF tapping may increase the risk of cerebrospinal fluid (CSF) infection.
Conclusions:
- Early and repeated CSF tapping is not recommended for neonates at risk of, or developing, post-hemorrhagic hydrocephalus.
- The intervention showed no benefit in preventing shunt dependence or improving other adverse outcomes.
- Potential increased risk of infection necessitates caution with this treatment approach.
Background:
This section is under preparation and will be included in the next issue.
Objectives:
To determine whether repeated CSF tapping, by lumbar puncture or ventricular tap, reduced the risk of permanent shunt dependence, neurodevelopmental disability or death in neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus (PHH). This form of treatment was based on the hypothesis that repeated tapping removed protein and blood from the CSF, thus clearing obstruction from the channels of CSF absorption.
Search Strategy:
Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976, as well as the Medline database. Personal contacts were used.
Selection Criteria:
Four controlled trials ( with five published papers) were identified, three being randomised and the fourth using alternative allocation. Two trials evaluated repeated lumbar punctures in neonates with intraventricular hemorrhage (IVH) and two trials evaluated repeated CSF tapping infants with IVH followed by progressive ventricular dilatation.
Data Collection And Analysis:
In addition to details of the patient selection and patient allocation, the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, disability, multiple disability and death or disability.
Main Results:
The studies were sufficiently similar in the question they were asking and the interventions were sufficiently in common that they could be combined when assessing the effect of the intervention. When repeated CSF tapping was compared to conservative treatment, the relative risks for shunt placement, death, disability and multiple disability were very close to 1.0 with no statistically significant effect. There is also evidence that this form of treatment increased the risk of CSF infection.
Reviewer'S Conclusions:
Early repeated CSF tapping cannot be recommended for neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus.