Repeated lumbar or ventricular punctures in newborns with intraventricular haemorrhage

Andrew Whitelaw; Richard Lee‐Kelland

doi:10.1002/14651858.CD000216.pub2

Повторные люмбальные или вентрикулярные пункции у новорожденных с внутрижелудочковым кровоизлиянием

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Referencias

References to studies included in this review

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Anwar M, Kadam S, Hiatt IM, Hegyi T. Serial lumbar punctures in prevention of post‐hemorrhagic hydrocephalus in preterm infants. Journal of Pediatrics 1985;107(3):446‐50.

Dykes FD, Dunbar B, Lazarra A, Ahmann PA. Posthemorrhagic hydrocephalus in high risk infants: Natural history, management, and long‐term outcome. Journal of Pediatrics 1989;114(4 Pt 1):611‐8.

Mantovani JF, Pasternak JF, Mathew OP, Allen WC, Mills MT, Casper J, et al. Failure of daily lumbar punctures to prevent the development of hydrocephalus following intraventricular hemorrhage. Journal of Pediatrics 1980;97(2):278‐81.

Ventriculomegaly Trial Group. Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation. Archives of Disease in Childhood 1990;65(1 Spec No):3‐10.

Ventriculomegaly Trial Group. Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation: results at 30 months. Archives of Disease in Childhood. Fetal and Neonatal Edition 1994;70(2):F129‐36.

References to studies excluded from this review

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Kreusser KL, Tarby TJ, Kovnar E, Taylor DA, Hill A, Volpe JJ. Serial lumbar punctures for at least temporary amelioration of neonatal posthemorrhagic hydrocephalus. Pediatrics 1985;75(4):719‐24.

Lipscomb A, Thorburn R, Stewart AL, Reynolds EO, Hope PL. Early treatment for rapidly progressive posthaemorrhagic hydrocephalus. Lancet 1983;1(8339):1438‐9.

Papile LA, Burstein J, Burstein R, Koffler H, Koops BL, Johnson JD. Posthemorrhagic hydrocephalus in low‐birth‐weight infants: treatment by serial lumbar punctures. Journal of Pediatrics 1980;97(2):273‐7.

References to ongoing studies

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ISRCTN43171322. A multicentre randomised controlled trial of low versus high threshold treatment in preterm infants with progressive posthaemorrhagic ventricular dilatation (PHVD). http://www.isrctn.com/ISRCTN43171322 (first received 27 January 2006). [DOI: 10.1186/ISRCTN43171322]

Additional references

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Bassan H, Eshel R, Golan I, Kohelet D, Ben Sira L, Mandel D, et al. Timing of external ventricular drainage and neurodevelopmental outcome in preterm infants with posthemorrhagic hydrocephalus. European Journal of Paediatric Neurology 2012;16(6):662‐70.

Cherian S, Whitelaw A, Thoresen M, Love S. The pathogenesis of neonatal post‐hemorrhagic hydrocephalus. Brain Pathology 2004;14(3):305‐11.

de Vries LS, Liem KD, van Dijk K, Smit BJ, Sie L, Rademaker KJ, et al. Early versus late treatment of posthaemorrhagic ventricular dilatation: results of a retrospective study from five neonatal intensive care units in The Netherlands. Acta Paediatrica 2002;91(2):212‐7.

GRADE Working Group, McMaster University. GRADEpro [www.gradepro.org]. Version accessed 24 March 2016. Hamilton (ON): GRADE Working Group, McMaster University, 2014.

Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.

Hislop JE, Dubowitz LM, Kaiser AM, Singh MP, Whitelaw AG. Outcome of infants shunted for post‐haemorrhagic ventricular dilatation. Developmental Medicine and Child Neurology 1988;30(4):451‐6.

Klebermass‐Schrehof K, Rona Z, Waldhör T, Czaba C, Beke A, Weninger M, et al. Can neurophysiological assessment improve timing of intervention in posthaemorrhagic ventricular dilatation?. Archives of Disease in Childhood. Fetal and Neonatal Edition 2013;98(4):F291‐7.

Levene MI. Measurement of the growth of the lateral ventricle in preterm infants with real time ultrasound. Archives of Disease in Childhood 1981;56(12):900‐4.

Olischar M, Klebermass K, Hengl B, Hunt RW, Waldhoer T, Pollak A, et al. Cerebrospinal fluid drainage in posthaemorrhagic ventricular dilatation leads to improvement in amplitude‐integrated electroencephalographic activity. Acta Paediatrica 2009;98(6):1002‐9.

Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager 5 (RevMan 5). Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Savman K, Nilsson UA, Blennow M, Kjellmer I, Whitelaw A. Non‐protein‐bound iron is elevated in cerebrospinal fluid from preterm infants with posthemorrhagic ventricular dilatation. Pediatric Research 2001;49(2):208‐12.

Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE Working Group. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. Available from www.guidelinedevelopment.org/handbook (accessed 24 March 2016).

Sävman K, Blennow M, Hagberg H, Tarkowski E, Thoresen M, Whitelaw A. Cytokine response in cerebrospinal fluid from preterm infants with posthaemorrhagic ventricular dilatation. Acta Paediatrica 2002;91(12):1357‐63.

Taylor AG, Peter JC. Advantages of delayed VP shunting in post‐haemorrhagic hydrocephalus seen in low‐birth‐weight infants. Child's Nervous System 2001;17(6):328‐33.

Tuli S, Drake J, Lamberti‐Pasculli M. Long‐term outcome of hydrocephalus management in myelomeningoceles. Child's Nervous System 2003;19(5‐6):286‐91.

Whitelaw A, Kennedy CR, Brion LP. Diuretic therapy for newborn infants with posthemorrhagic ventricular dilatation. Cochrane Database of Systematic Reviews 2001, Issue 2. [DOI: 10.1002/14651858.CD002270]

Whitelaw A, Odd DE. Intraventricular streptokinase after intraventricular hemorrhage in newborn infants. Cochrane Database of Systematic Reviews 2007, Issue 4. [DOI: 10.1002/14651858.CD000498]

Whitelaw A, Jary S, Kmita G, Wroblewska J, Musialik‐Swietlinska E, Mandera M, et al. Randomized trial of drainage, irrigation and fibrinolytic therapy for premature infants with posthemorrhagic ventricular dilatation: developmental outcome at 2 years. Pediatrics 2010;125(4):e852‐8.

References to other published versions of this review

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Whitelaw A. Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage. Cochrane Database of Systematic Reviews 1998, Issue 3. [DOI: 10.1002/14651858.CD000216]

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Whitelaw A. Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage. Cochrane Database of Systematic Reviews 2001, Issue 1. [DOI: 10.1002/14651858.CD000216]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

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Anwar 1985

Methods	Open randomised clinical trial
Participants	Preterm infants with grade 3 or 4 intraventricular haemorrhage (IVH) on ultrasound scan
Interventions	Daily lumbar puncture starting at 7 to 10 days. Cerebrospinal fluid (CSF) was drained until flow stopped. Lumbar punctures were continued until the ventricular size decreased, remained unchanged for 2 consecutive weeks, or if the infant developed hydrocephalus requiring a ventricular drain or shunt.
Outcomes	Hydrocephalus, defined as a progressive increase in ventricular size as measured by ultrasound, in association with either signs of increased intracranial pressure (ICP) or an increase in head circumference > 2 cm/week for at least 2 weeks. Shunt or ventricular reservoir. Death before discharge from hospital. Death.
Notes	This trial used a random number table for treatment allocation.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	The trial used a random number table to allocate participants to treatment.
Allocation concealment (selection bias)	Unclear risk	The trial authors did not give any information regarding allocation concealment.
Blinding (performance bias and detection bias) All outcomes	Unclear risk	The trial authors reported that the ultrasonographers were blinded to study classification. However, the trial defined hydrocephalus as an outcome by ultrasound and clinical signs of raised ICP. The trial authors did not give any information as to whether the assessors of the clinical signs of raised ICP were blinded to treatment allocation.
Incomplete outcome data (attrition bias) All outcomes	Low risk	The trial included almost all participants to the end of the trial.
Selective reporting (reporting bias)	Low risk	The trial authors reported on the main outcomes of hydrocephalus, death, and shunt placement. The trial did not test the neurodevelopmental outcome.
Other bias	Low risk	No other sources of bias identified

Dykes 1989

Methods	Open randomised clinical trial using random number tables
Participants	Neonates with asymptomatic severe posthaemorrhagic hydrocephalus (PHH)
Interventions	Daily lumbar punctures, taking enough CSF to lower the CSF pressure by half. Volumes ranged from 2 to 21 mL. Duration 1 to 3 weeks.
Outcomes	Hydrocephalus management failure, defined as increasing head circumference, progressive decrease in cortical mantle (for example, occipital cortical mantle < 1 cm), signs of raised ICP. Placement of ventriculoperitoneal shunt (VPS). Death during follow‐up. Assessment at 3 to 6 years into no major handicap, single system disability, and multiple disability.
Notes	The trial authors did not state whether the paediatric neurologists and the psychologist were blind to early treatment allocation.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	The trial used a random number table to allocate participants to treatment.
Allocation concealment (selection bias)	Unclear risk	The trial authors did not give any information regarding allocation concealment.
Blinding (performance bias and detection bias) All outcomes	Unclear risk	The trial authors did not give any information regarding whether or not the observers of outcomes (neurologists and psychologist) were blinded to treatment group.
Incomplete outcome data (attrition bias) All outcomes	Low risk	The trial included all children for the outcome of hydrocephalus management failure. Regarding neurodevelopmental follow‐up, 1/15 children in the close observation group were lost to follow‐up at 1 to 2 years. None of the 16 children in the LP group were lost to follow‐up. At 3 to 6 years, 1/15 children in the close observation group and 1/16 children in the LP group were lost to follow‐up. This small proportion of missing data is unlikely to have a significant bias to the outcome.
Selective reporting (reporting bias)	Low risk	The trial reported the main outcomes of death, hydrocephalus, shunt placement, and disability.
Other bias	Low risk	No other sources of bias identified

Mantovani 1980

Methods	Open clinical trial with alternation of treatment
Participants	Infants weighing less than 2000 g with grade 2 or 3 IVH on computed tomography (CT) scan
Interventions	Daily lumbar punctures starting 24 hours after diagnosis of IVH. 3 to 5 mL CSF was removed daily. Lumbar punctures were continued until the CSF was clear and protein concentration was < 180 mg/dL.
Outcomes	Hydrocephalus was defined as 2 CT scans with progressively enlarging ventricles. Placement of VPS. Death before discharge from hospital.
Notes	Not true randomisation. The trial authors did not state whether or not the observers of outcomes were blinded to early treatment allocation.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	High risk	The trial used an alternation method to assign participants to treatment.
Allocation concealment (selection bias)	High risk	Alternation method, allocation method not concealed to researchers.
Blinding (performance bias and detection bias) All outcomes	Unclear risk	The trial authors did not state whether or not the outcome observers were blinded to treatment allocation.
Incomplete outcome data (attrition bias) All outcomes	Low risk	The trial authors analysed almost all participants recruited to the trial.
Selective reporting (reporting bias)	Low risk	The trial authors commented on the main outcomes of hydrocephalus, shunt placement, and death. The trial did not test neurodevelopmental outcomes.
Other bias	Low risk	No other sources of bias identified

Ventriculomegaly 1990

Methods	Open randomised multicentre clinical trial at 15 neonatal intensive care units in England, Ireland, and Switzerland. Randomisation by telephoning and registering the infant before hearing the allocation.
Participants	Neonates with IVH, with progressive increase in ventricular size and whose ventricular width had increased to 4 mm over the 97th centile.
Interventions	Repeated lumbar puncture taking as much CSF as possible, maximum 2% body weight, carried out daily or less frequently to prevent further increases in ventricular size. If not more than 2 mL of CSF could be obtained, ventricular tapping was carried out in the same way and often enough to hold the ventricular width constant.
Outcomes	Permanent shunting if there was failure to control head size despite medical management or if repeated tapping was necessary for more than 4 weeks. Death. Placement of VPS. Neurodevelopmental assessment at 12 months post‐term. Neurodevelopmental status at 30 months by a developmental paediatrician.
Notes	The developmental paediatrician that assessed the survivors at 12 and 30 months was blinded to early treatment allocation.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	The trial used a telephone method to allocate participants to treatment.
Allocation concealment (selection bias)	Low risk	The trial used a telephone method to allocate participants to treatment.
Blinding (performance bias and detection bias) All outcomes	Low risk	The developmental paediatrician that assessed survivors was blinded to treatment allocation.
Incomplete outcome data (attrition bias) All outcomes	Low risk	At 12 months follow‐up, 3/79 children in the early tapping group and 3/78 children in the conservative group were lost to follow‐up. By 30 months, a further 3 in the early tapping group and 4 in the conservative management group were lost to follow‐up. This small proportion of missing data is unlikely to have significantly biased the outcome.
Selective reporting (reporting bias)	Low risk	The trial authors reported the main outcomes of interest: death, hydrocephalus, shunt placement, and disability.
Other bias	Low risk	No other sources of bias identified

Abbreviations: CT: computed tomography; ICP: intracranial pressure; IVH: intraventricular haemorrhage; PHH: posthaemorrhagic hydrocephalus; RCT: randomised controlled trial; VPS: ventriculoperitoneal shunt.

Characteristics of excluded studies [ordered by study ID]

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Study	Reason for exclusion
Kreusser 1985	Not a randomised controlled trial (RCT).
Lipscomb 1983	Not a RCT.
Papile 1980	Not a RCT.

Abbreviations: RCT: randomised controlled trial.

Characteristics of ongoing studies [ordered by study ID]

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ISRCTN43171322

Trial name or title	A multicentre randomised controlled trial of low versus high threshold treatment in preterm infants with progressive posthaemorrhagic ventricular dilatation (PHVD)
Methods	The infants are randomly allocated to the low threshold group or the high threshold group. Those in the low threshold group are treated when the ventricles reach a lower size threshold compared with the high threshold group. Treatment consists of lumbar punctures, where a needle is inserted into the lower part of the spine to drain fluid. If lumbar punctures are still needed over 28 days after the first one, a shunt is inserted into the brain to drain fluid. The two groups are compared with regard to how many infants need a shunt and their brain development at two years of age.
Participants	Premature infants with: 1. A gestational age equal to or below 34 weeks 2. An intraventricular haemorrhage grade III according to Volpe (>50% of the ventricle) and grade IV haemorrhage 3. A progressive posthaemorrhagic ventricular enlargement above the 97th centile for gestational age according to Levene and a diagonal width enlargement of the frontal horn above 6 mm according to Davies
Interventions	Comparison: low threshold versus high threshold intervention. Low threshold: intervention when an increase in ventricular width according to Levene above the 97th centile towards the P97 + 4 but without crossing the >P97 + 4 and an increase in diagonal width according to Davies above 6 mm towards 10 mm, but not above 10 mm. High threshold: intervention after an increase in ventricular width according to Levene above the P97 + 4 and an increase in diagonal width according to Davies above 10 mm. Intervention: Lumbar punctures (LP; 10 ml/kg) on 2 days. Cranial ultrasound is repeated daily. If on the third day a LP is still required, a subcutaneous reservoir will be inserted. Daily 10 cc/kg will be drained in 2 taps a day. Punctures from the reservoir will be continued over the next days or weeks. The amount of CSF drained will be increased or decreased in order to reach and keep the ventricular index according to Levene <P97 and diagonal anterior horn width <6 mm. If punctures are still necessary exceeding 28 days after the first LP, a ventriculoperitoneal shunt is inserted. If the bodyweight of the infant is less than 2.5 kg, the insertion of the shunt will be postponed until the bodyweight is over 2.5 kg, if CSF drainage is still needed then.
Outcomes	Primary: Need for ventriculoperitoneal shunt Secondary: 1. Neurodevelopmental outcome on the Bayley Scales of Infant Development at 24 months corrected age, assessed by a ‘blinded’ developmental psychologist 2. Number of (lumbar) punctures, reservoirs, reservoir dysfunctions, reservoir infections and reservoir revisions, drains, drain dysfunctions, drain infections and drain revisions
Starting date	January 27, 2006
Contact information	LS de Vries MD, PhD, [email protected]
Notes

Data and analyses

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Comparison 1. Lumbar punctures or ventricular punctures versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Placement of a hydrocephalus shunt Show forest plot	3	233	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.73, 1.26]
Open in figure viewer Analysis 1.1 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 1 Placement of a hydrocephalus shunt.
2 Death prior to 12‐month follow‐up Show forest plot	4	280	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.53, 1.44]
Open in figure viewer Analysis 1.2 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 2 Death prior to 12‐month follow‐up.
3 Major disability in survivors Show forest plot	2	141	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.81, 1.18]
Open in figure viewer Analysis 1.3 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 3 Major disability in survivors.
4 Multiple disability in survivors Show forest plot	2	141	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.66, 1.24]
Open in figure viewer Analysis 1.4 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 4 Multiple disability in survivors.
5 Death or disability Show forest plot	2	180	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.86, 1.14]
Open in figure viewer Analysis 1.5 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 5 Death or disability.
6 Death or shunt Show forest plot	3	233	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.75, 1.11]
Open in figure viewer Analysis 1.6 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 6 Death or shunt.
7 Infection of CSF presurgery Show forest plot	2	195	Risk Ratio (M‐H, Fixed, 95% CI)	1.73 [0.53, 5.67]
Open in figure viewer Analysis 1.7 Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 7 Infection of CSF presurgery.

Figure 1

Study flow diagram: review update

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Figure 2

'Risk of bias' graph: review authors' judgements about each 'Risk of bias' item presented as percentages across all included studies

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Figure 3

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

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Analysis 1.1

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 1 Placement of a hydrocephalus shunt.

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Analysis 1.2

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 2 Death prior to 12‐month follow‐up.

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Analysis 1.3

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 3 Major disability in survivors.

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Analysis 1.4

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 4 Multiple disability in survivors.

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Analysis 1.5

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 5 Death or disability.

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Analysis 1.6

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 6 Death or shunt.

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Analysis 1.7

Comparison 1 Lumbar punctures or ventricular punctures versus control, Outcome 7 Infection of CSF presurgery.

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Summary of findings for the main comparison. Repeated lumbar or ventricular punctures compared to conservative treatment in newborns with intraventricular haemorrhage

Repeated lumbar or ventricular punctures compared to conservative management for infants with intraventricular haemorrhage (IVH)
Population: preterm infants less than three months of age with either: a) IVH demonstrated by ultrasound or computed tomography (CT) scan; or b) infants with IVH followed by progressive ventricular dilatation. Settings: neonatal intensive care units. Intervention: serial lumbar puncture, ventricular puncture, or tapping from a subcutaneous reservoir. Comparison: conservative management.
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)
	Risk with conservative treatment	Risk with serial lumbar or ventricular punctures
Hydrocephalus shunt	Study population		RR 0.96 (0.73 to 1.26)	233 (3 RCTs)	⊕⊕⊕⊝ moderate¹
	469 per 1000	450 per 1000 (342 to 591)
Death	Study population		RR 0.88 (0.53 to 1.44)	280 (4 RCTs)	⊕⊕⊝⊝ low^1,2
	199 per 1000	175 per 1000 (105 to 286)
Major disability in survivors	Study population		RR 0.98 (0.81 to 1.18)	141 (2 RCTs)	⊕⊕⊕⊕ high
	761 per 1000	746 per 1000 (617 to 898)
Multiple disability in survivors	Study population		RR 0.90 (0.66 to 1.24)	141 (2 RCTs)	⊕⊕⊕⊕ high
	537 per 1000	484 per 1000 (355 to 666)
Death or disability	Study population		RR 0.99 (0.86 to 1.14)	180 (2 RCTs)	⊕⊕⊕⊕ high
	814 per 1000	806 per 1000 (700 to 928)
Death or shunt	Study population		RR 0.91 (0.75 to 1.11)	233 (3 RCTs)	⊕⊕⊕⊝ moderate¹
	646 per 1000	588 per 1000 (485 to 717)
Infection of CSF presurgery	Study population		RR 1.73 (0.53 to 5.67)	195 (2 RCTs)	⊕⊕⊝⊝ low^2,3
	43 per 1000	74 per 1000 (23 to 241)
The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). Abbreviations:* CI: confidence interval; CSF: cerebrospinal fluid; CT: computed tomography; IVH: intraventricular haemorrhage; RCT: randomised controlled trial; RR: risk ratio.
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.
¹Downgraded by 1 as Mantovani 1980 used an alternation method for random sequence generation. ²Downgraded by 1 due to imprecision, which is present because the width of the CI is consistent with both important benefit and harm. ³Downgraded by 1 due to inconsistency between studies. Dykes 1989 reported no cases of CSF infection. Ventriculomegaly 1990 reported infection in 10/157 cases.

Summary of findings for the main comparison. Repeated lumbar or ventricular punctures compared to conservative treatment in newborns with intraventricular haemorrhage

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Comparison 1. Lumbar punctures or ventricular punctures versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Placement of a hydrocephalus shunt Show forest plot	3	233	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.73, 1.26]

2 Death prior to 12‐month follow‐up Show forest plot	4	280	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.53, 1.44]

3 Major disability in survivors Show forest plot	2	141	Risk Ratio (M‐H, Fixed, 95% CI)	0.98 [0.81, 1.18]

4 Multiple disability in survivors Show forest plot	2	141	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.66, 1.24]

5 Death or disability Show forest plot	2	180	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.86, 1.14]

6 Death or shunt Show forest plot	3	233	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.75, 1.11]

7 Infection of CSF presurgery Show forest plot	2	195	Risk Ratio (M‐H, Fixed, 95% CI)	1.73 [0.53, 5.67]

Comparison 1. Lumbar punctures or ventricular punctures versus control

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Referencias

References to studies included in this review

Anwar 1985 {published data only}

Dykes 1989 {published data only}

Mantovani 1980 {published data only}

Ventriculomegaly 1990 {published data only}

References to studies excluded from this review

Kreusser 1985 {published data only}

Lipscomb 1983 {published data only}

Papile 1980 {published data only}

References to ongoing studies

ISRCTN43171322 {published data only}

Additional references

Bassan 2012

Cherian 2004

de Vries 2002

GRADEpro GDT 2014 [Computer program]

Higgins 2011

Hislop 1988

Klebermass‐Schrehof 2013

Levene 1981

Olischar 2009

Review Manager 2014 [Computer program]

Savman 2001

Schünemann 2013

Sävman 2002

Taylor 2001

Tuli 2003

Whitelaw 2001b

Whitelaw 2007

Whitelaw 2010

References to other published versions of this review

Whitelaw 1998

Whitelaw 2001a

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Characteristics of ongoing studies [ordered by study ID]

Data and analyses

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