Primary prevention of ROP: more can be done in all settings

ABSTRACT

Introduction

Primary prevention of retinopathy of prematurity (ROP) is sparingly covered in recent literature but is both possible and highly cost-effective

Areas covered

The variation in incidence of ROP between neonatal units (NICUs) in large neonatal networks provides clues as to primary prevention of ROP. Differences in beneficial evidence-based care practices include use of antenatal corticosteroids, labor ward care, use of caffeine, facilitating human milk feeding, improved nutrition, and prevention of sepsis. Recent large trials show oxygen saturation targets should be higher than 85–89% to improve survival of very preterm infants, whilst avoiding fluctuations in oxygenation. Multifaceted quality improvement programs in neonatal networks that focus on using known evidence-based practices and addressing attitudes, knowledge, and clinical biases have resulted in steady improvement in ROP rates over several years. Consistently, better performing NICUs have a positive ‘culture’ that fosters team work, camaraderie, and learning opportunities. In poorly resourced low and middle-income countries (LMICs), increasing awareness of ROP and undertaking data collection are important first steps, and there are several low-cost measures that can be taken to reduce ROP rates. Literature searches were undertaken through PubMed.

Expert opinion

ROP has a multifactorial etiology, and a multifaceted approach is required for prevention.

KEYWORDS:

• Retinopathy of prematurity (ROP)
• very preterm infant
• prevention
• antenatal corticosteroids
• oxygen saturation targeting
• neonatal networks
• quality improvement programs
• low and middle income countries

Article highlights

• Relatively few publications directly address primary prevention of ROP, although a great deal more can be achieved in this regard and would be highly cost-effective.

• The variation in incidence of ROP between similar NICUs in neonatal networks provides clues to primary prevention, including differences in evidence-based care practices and the unit ‘culture.’

• Obstetric care measures to reduce preterm births, providing antenatal corticosteroids when preterm birth is inevitable, and facilitating delayed cord clamping, prevention of hypothermia and gentle resuscitation measures at birth will all help to prevent ROP.

• Too little oxygen (a saturation target of 85% to 89%) is not good for very preterm infants, increasing death and NEC, whilst higher targets (91–95%) do increase the risk of ROP, but this can be mitigated by other measures and appropriate retinal examination and treatment.

• Most (97%) of infants with severe ROP are on oxygen for 6 weeks or more and spend more hours with SpO₂ 97–100%, which is potentially modifiable.

• Caffeine, given for apnea of prematurity, is one of very few therapies shown in a RCT to significantly decrease the rate of severe ROP; functional visual outcomes were also improved at 11 years of age.

• Receipt of breast milk, improved early growth velocity and prevention of sepsis have all been associated with prevention of ROP in a range of studies.

• Treatments which held early promise of preventing ROP, inositol, lactoferrin, light reduction, and physiological replacement of IGF-1 have not been proven to be beneficial in RCTs.

• Ensuring baseline vitamin A intake ≤1500 IU/Kg and achieving the right balance of omega-3 (docosahexaenoic acid) and omega-6 (arachidonic acid) LC-PUFA supplementation are two care practices showing promise of preventing ROP but require more study.

• Multifaceted quality improvement programs in neonatal networks increase the use of evidence-based practices and address attitudes, knowledge, and clinical biases, with consistent improvement in mortality and morbidities, including ROP.

• Despite the political, socio-economic, cultural, and public health challenges of preventing ROP in LMICs, several low-cost interventions have been shown to be beneficial.

• Consistently better performing NICUs provide a culture and environment that fosters team work, camaraderie, and sustained learning opportunities.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.