Towards evidence-based resuscitation of the newborn infant

Effective resuscitation of the newborn infant has the potential to save many lives around the world and reduce disabilities in children who survive peripartum asphyxia. In this Series paper, we highlight some of the important advances in the understanding of how best to resuscitate newborn infants, which includes monitoring techniques to guide resuscitative efforts, increasing awareness of the adverse effects of hyperoxia, delayed umbilical cord clamping, the avoidance of routine endotracheal intubation for extremely preterm infants, and therapeutic hypothermia for hypoxic-ischaemic encephalopathy. Despite the challenges of performing high-quality clinical research in the delivery room, researchers continue to refine and advance our knowledge of effective resuscitation of newborn infants through scientific experiments and clinical trials.

The evolution of modern respiratory care for preterm infants

Preterm birth rates are rising, and many preterm infants have breathing difficulty after birth. Treatments for infants with prolonged breathing difficulty include oxygen therapy, exogenous surfactant, various modes of respiratory support, and postnatal corticosteroids. In this Series paper, we review the history of neonatal respiratory care and its effect on long-term outcomes, and we outline the future direction of the research field. The delivery and monitoring of oxygen therapy remains controversial, despite being in use for more than 50 years. Exogenous surfactant replacement has been used for 25 years and has dramatically reduced mortality and morbidity, but more research on when and how it is administered is needed. Methods and techniques of neonatal respiratory support are evolving. Clinicians are moving away from routine intubation and ventilation, and new modes of non-invasive support are being investigated. Postnatal corticosteroids have a limited role in infants with evolving bronchopulmonary dysplasia, but more research is needed to identify the best timing, type, dose, and method of administration. Despite advances in neonatal care in the past 50 years, bronchopulmonary dysplasia, with all its adverse short-term and long-term consequences, is still a serious problem in neonatal care. The challenge remains to support breathing in preterm infants, with special attention to risk factors in the subpopulation of infants that are at highest risk of bronchopulmonary dysplasia, without damaging their lungs or adversely affecting their long-term health.

Interventions to Improve Rates of Successful Extubation in Preterm Infants: A Systematic Review and Meta-analysis

Importance

Clinicians aim to extubate preterm infants as early as possible, to minimize the risks of mechanical ventilation. Extubation is often unsuccessful owing to lung disease or inadequate respiratory drive.

Objective

To conduct a systematic review and meta-analysis of interventions to improve rates of successful extubation in preterm infants.

Data Sources

Searches were undertaken in PubMed and The Cochrane Library.

Study Selection

The review was conducted using the methods of the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were randomized clinical trials published in English, enrolled intubated preterm infants (born <37 weeks' gestation), and reported 1 or both of the primary outcomes.

Data Extraction and Synthesis

One thousand three hundred seventy-nine titles were screened independently by 2 investigators to assess need for full-text review. Disagreements were resolved via consensus of all authors. Where no Cochrane Review existed for an intervention, or not all identified studies were included, a new pooled analysis was performed.

Main Outcomes and Measures

Primary outcomes were treatment failure or reintubation within 7 days of extubation.

Results

Fifty studies were eligible for inclusion. Continuous positive airway pressure reduced extubation failure in comparison with head-box oxygen (risk ratio [RR], 0.59; 95% CI, 0.48-0.72; number needed to treat [NNT], 6; 95% CI, 3-9). Nasal intermittent positive pressure ventilation was superior to continuous positive airway pressure in preventing extubation failure (RR, 0.70; 95% CI, 0.60-0.81; NNT, 8; 95% CI, 5-13). High-flow nasal cannula therapy and continuous positive airway pressure had similar efficacy (RR, 1.11; 95% CI, 0.84-1.47). Methylxanthines reduced extubation failure (RR, 0.48; 95% CI, 0.32-0.71; NNT, 4; 95% CI, 2-7) compared with placebo or no treatment. Corticosteroids (RR, 0.18; 95% CI, 0.04-0.97; NNT, 12; 95% CI, 6-100) and chest physiotherapy (RR, 0.32; 95% CI, 0.13-0.82; NNT, 15; 95% CI, 7-50) both reduced extubation failure rates but were associated with significant adverse effects. Doxapram did not aid successful extubation (RR, 0.80; 95% CI, 0.22-2.97).

Conclusions and Relevance

Preterm infants should be extubated to noninvasive respiratory support. Caffeine should be used routinely, while corticosteroids should be used judiciously, weighing up the competing risks of bronchopulmonary dysplasia and neurodevelopmental harm.

Nasal High-Flow Therapy for Preterm Infants: Review of Neonatal Trial Data

Heated, humidified, nasal high-flow (HF) therapy is a promising treatment for preterm infants, and almost certainly has a place in the clinical care of this population. It is only in the last few years that data have become available from randomized trials comparing HF with other noninvasive respiratory support modes, particularly nasal continuous positive airway pressure. This article discusses the evidence for HF use from randomized clinical trials in preterm infants and proposes recommendations for evidence-based practice.

Nasal High-Flow Therapy for Primary Respiratory Support in Preterm Infants

BACKGROUND

Treatment with nasal high-flow therapy has efficacy similar to that of nasal continuous positive airway pressure (CPAP) when used as postextubation support in neonates. The efficacy of high-flow therapy as the primary means of respiratory support for preterm infants with respiratory distress has not been proved.

METHODS

In this international, multicenter, randomized, noninferiority trial, we assigned 564 preterm infants (gestational age, ≥28 weeks 0 days) with early respiratory distress who had not received surfactant replacement to treatment with either nasal high-flow therapy or nasal CPAP. The primary outcome was treatment failure within 72 hours after randomization. Noninferiority was determined by calculating the absolute difference in the risk of the primary outcome; the chosen margin of noninferiority was 10 percentage points. Infants in whom high-flow therapy failed could receive rescue CPAP; infants in whom CPAP failed were intubated and mechanically ventilated.

RESULTS

Trial recruitment stopped early at the recommendation of the independent data and safety monitoring committee because of a significant difference in the primary outcome between treatment groups. Treatment failure occurred in 71 of 278 infants (25.5%) in the high-flow group and in 38 of 286 infants (13.3%) in the CPAP group (risk difference, 12.3 percentage points; 95% confidence interval [CI], 5.8 to 18.7; P<0.001). The rate of intubation within 72 hours did not differ significantly between the high-flow and CPAP groups (15.5% and 11.5%, respectively; risk difference, 3.9 percentage points; 95% CI, -1.7 to 9.6; P=0.17), nor did the rate of adverse events.

CONCLUSIONS

When used as primary support for preterm infants with respiratory distress, high-flow therapy resulted in a significantly higher rate of treatment failure than did CPAP. (Funded by the National Health and Medical Research Council and others; Australian New Zealand Clinical Trials Registry number, ACTRN12613000303741 .).

High-flow support in very preterm infants in Australia and New Zealand

BACKGROUND

Randomised trials suggest that high-flow (HF) therapy is comparable with continuous positive airway pressure (CPAP) for postextubation respiratory support in neonates, and HF has been widely adopted in neonatal intensive care.

METHODS

We conducted a population-based study of very preterm infants born <32 weeks' gestation within the Australian and New Zealand Neonatal Network (ANZNN) data set from 2009 to 2012, who received respiratory support with HF.

RESULTS

3372 very preterm infants were treated with HF. HF use in this population increased significantly from 15% in 2009 to 35% in 2012. In 2012, 53% (542/1029) of extremely preterm infants born <28 weeks' gestation received HF. 98% (3308/3372) of infants had received endotracheal ventilation or CPAP prior to receiving HF. The maximum HF gas flow was ≤8 L/min in almost all infants.

CONCLUSIONS

HF use in extremely preterm and very preterm infants increased significantly within the ANZNN from 2009 to 2012.

Lost in translation: evidence to improve outcomes of very preterm infants

Vulnerable babies and their mothers are missing out on simple and effective interventions

Extubating Extremely Preterm Infants: Predictors of Success and Outcomes following Failure

OBJECTIVES

To identify variables that predict extubation success in extremely preterm infants born <28 weeks gestational age (GA), and to compare outcomes between those who had successful or failed extubation.

STUDY DESIGN

A secondary analysis of data from a randomized trial of postextubation respiratory support that included 174 extremely preterm infants. "Extubation success" was defined as not requiring reintubation within 7 days, and "extubation failure" the converse. Predictive variables that were different between groups were included in a multivariable logistic regression model.

RESULTS

Sixty-eight percent of infants were successfully extubated. Compared with those infants who had extubation failure, they had a higher GA and birth weight, were extubated earlier, were more often exposed to prolonged ruptured membranes, more often avoided intubation in the delivery room, had a higher pre-extubation pH, and had lower mean pre-extubation fraction of inspired oxygen and partial pressure of carbon dioxide (PCO2). Only GA and PCO2 remained significant in the multivariable analysis (area under a receiver operating characteristic curve = 0.81). Extubation failure was associated with death, bronchopulmonary dysplasia, severe retinopathy of prematurity, patent ductus arteriosus ligation, and longer durations of respiratory support, oxygen supplementation, and hospitalization. When adjusted for allocated treatment in the randomized trial, GA, and birth weight z-score, extubation failure remained associated with death before discharge and prolonged respiratory support and hospitalization.

CONCLUSIONS

In extremely preterm infants, higher GA and lower pre-extubation PCO2 predicted extubation success. Infants in whom extubation failed were more likely to die and have prolonged respiratory support and hospitalization.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Network: ACTRN12610000166077.

The effects of non-invasive respiratory support on oropharyngeal temperature and humidity: a neonatal manikin study

OBJECTIVE

Heating and humidification of inspired gases is routine during neonatal non-invasive respiratory support. However, little is known about the temperature and humidity delivered to the upper airway. The International Standards Organization (ISO) specifies that for all patients with an artificial airway humidifiers should deliver ≥33 g/m(3) absolute humidity (AH). We assessed the oropharyngeal temperature and humidity during different non-invasive support modes in a neonatal manikin study.

METHODS

Six different modes of non-invasive respiratory support were applied at clinically relevant settings to a neonatal manikin, placed in a warmed and humidified neonatal incubator. Oropharyngeal temperature and relative humidity (RH) were assessed using a thermohygrometer. AH was subsequently calculated.

RESULTS

Measured temperature and RH varied between devices. Bubble and ventilator continuous positive airway pressure (CPAP) produced temperatures >34°C and AH >38 g/m(3). Variable flow CPAP resulted in lower levels of AH than bubble or ventilator CPAP, and AH decreased with higher gas flow. High-flow (HF) therapy delivered by Optiflow Junior produced higher AH with higher gas flow, whereas with Vapotherm HF the converse was true.

CONCLUSIONS

Different non-invasive devices deliver inspiratory gases of variable temperature and humidity. Most AH levels were above the ISO recommendation; however, with some HF and variable flow CPAP devices at higher gas flow this was not achieved. Clinicians should be aware of differences in the efficacy of heating and humidification when choosing modes of non-invasive respiratory support.

High flow nasal cannula for respiratory support in preterm infants

BACKGROUND

High flow nasal cannulae (HFNC) are small, thin, tapered binasal tubes that deliver oxygen or blended oxygen/air at gas flows of more than 1 L/min. HFNC are increasingly being used as a form of non-invasive respiratory support for preterm infants.

OBJECTIVES

To compare the safety and efficacy of HFNC with other forms of non-invasive respiratory support in preterm infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 1 January 2016), EMBASE (1980 to 1 January 2016), and CINAHL (1982 to 1 January 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing HFNC with other non-invasive forms of respiratory support in preterm infants immediately after birth or following extubation.

DATA COLLECTION AND ANALYSIS

The authors extracted and analysed data, and calculated risk ratio, risk difference and number needed to treat for an additional beneficial outcome.

MAIN RESULTS

We identified 15 studies for inclusion in the review. The studies differed in the interventions compared (nasal continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation (NIPPV), non-humidified HFNC, models for delivering HFNC), the gas flows used and the indications for respiratory support (primary support from soon after birth, post-extubation support, weaning from CPAP support). When used as primary respiratory support after birth compared to CPAP (4 studies, 439 infants), there were no differences in the primary outcomes of death (typical risk ratio (RR) 0.36, 95% CI 0.01 to 8.73; 4 studies, 439 infants) or chronic lung disease (CLD) (typical RR 2.07, 95% CI 0.64 to 6.64; 4 studies, 439 infants). HFNC use resulted in longer duration of respiratory support, but there were no differences in other secondary outcomes. One study (75 infants) showed no differences between HFNC and NIPPV as primary support. Following extubation (total 6 studies, 934 infants), there were no differences between HFNC and CPAP in the primary outcomes of death (typical RR 0.77, 95% CI 0.43 to 1.36; 5 studies, 896 infants) or CLD (typical RR 0.96, 95% CI 0.78 to 1.18; 5 studies, 893 infants). There was no difference in the rate of treatment failure (typical RR 1.21, 95% CI 0.95 to 1.55; 5 studies, 786 infants) or reintubation (typical RR 0.91, 95% CI 0.68 to 1.20; 6 studies, 934 infants). Infants randomised to HFNC had reduced nasal trauma (typical RR 0.64, 95% CI 0.51 to 0.79; typical risk difference (RD) -0.14, 95% CI -0.20 to -0.08; 4 studies, 645 infants). There was a small reduction in the rate of pneumothorax (typical RR 0.35, 95% CI 0.11 to 1.06; typical RD -0.02, 95% CI -0.03 to -0.00; 5 studies 896 infants) in infants treated with HFNC. Subgroup analysis found no difference in the rate of the primary outcomes between HFNC and CPAP in preterm infants in different gestational age subgroups, though there were only small numbers of extremely preterm and late preterm infants. One trial (28 infants) found similar rates of reintubation for humidified and non-humidified HFNC, and two other trials (100 infants) found no difference between different models of equipment used to deliver humidified HFNC. For infants weaning from non-invasive respiratory support (CPAP), two studies (149 infants) found that preterm infants randomised to HFNC had a reduced duration of hospitalisation compared with infants who remained on CPAP.

AUTHORS' CONCLUSIONS

HFNC has similar rates of efficacy to other forms of non-invasive respiratory support in preterm infants for preventing treatment failure, death and CLD. Most evidence is available for the use of HFNC as post-extubation support. Following extubation, HFNC is associated with less nasal trauma, and may be associated with reduced pneumothorax compared with nasal CPAP. Further adequately powered randomised controlled trials should be undertaken in preterm infants comparing HFNC with other forms of primary non-invasive support after birth and for weaning from non-invasive support. Further evidence is also required for evaluating the safety and efficacy of HFNC in extremely preterm and mildly preterm subgroups, and for comparing different HFNC devices.

Higher Rates of Retinopathy of Prematurity after Increasing Oxygen Saturation Targets for Very Preterm Infants: Experience in a Single Center

Randomized trials of oxygen saturation target ranges for extremely preterm infants showed increased survival but increased retinopathy of prematurity with higher compared with lower target ranges. In our center, changing from a target range of 88%-92% to 91%-95% has been associated with increased rates and severity of retinopathy of prematurity.

A multicentre, randomised controlled, non-inferiority trial, comparing high flow therapy with nasal continuous positive airway pressure as primary support for preterm infants with respiratory distress (the HIPSTER trial): study protocol

INTRODUCTION

High flow (HF) therapy is an increasingly popular mode of non-invasive respiratory support for preterm infants. While there is now evidence to support the use of HF to reduce extubation failure, there have been no appropriately designed and powered studies to assess the use of HF as primary respiratory support soon after birth. Our hypothesis is that HF is non-inferior to the standard treatment--nasal continuous positive airway pressure (NCPAP)--as primary respiratory support for preterm infants.

METHODS AND ANALYSIS

The HIPSTER trial is an unblinded, international, multicentre, randomised, non-inferiority trial. Eligible infants are preterm infants of 28-36(+6) weeks' gestational age (GA) who require primary non-invasive respiratory support for respiratory distress in the first 24 h of life. Infants are randomised to treatment with either HF or NCPAP. The primary outcome is treatment failure within 72 h after randomisation, as determined by objective oxygenation, blood gas, and apnoea criteria, or the need for urgent intubation and mechanical ventilation. Secondary outcomes include the incidence of intubation, pneumothorax, bronchopulmonary dysplasia, nasal trauma, costs associated with hospital care and parental stress. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 90% power, the study requires 375 infants per group (total 750 infants).

ETHICS AND DISSEMINATION

Ethical approval has been granted by the relevant human research ethics committees at The Royal Women's Hospital (13/12), The Royal Children's Hospital (33144A), The Mercy Hospital for Women (R13/34), and the South-Eastern Norway Regional Health Authority (2013/1657). The trial is currently recruiting at 9 centres in Australia and Norway. The trial results will be published in peer-reviewed international journals, and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry ID: ACTRN12613000303741.

Fifty years in neonatology

Neonatology, the care and study of newborn infants, is a 'young' specialty. Over the last 50 years, there have been many advances in the way that neonatologists care for newborn infants, particularly those born preterm, leading to dramatic improvements in mortality. To illustrate these advances, we describe four eras in neonatology from the point of view of the junior hospital doctor.

Nursing perceptions of high-flow nasal cannulae treatment for very preterm infants

AIM

This study aims to assess nursing perceptions of high-flow nasal cannulae (HFNC) in comparison with nasal continuous positive airway pressure (NCPAP) as post-extubation respiratory support for very preterm infants.

METHODS

A standardised questionnaire form was distributed in person to nursing staff in The Royal Women's Hospital neonatal unit, where HFNC had been recently introduced in the context of a clinical trial. Nursing staff were eligible to participate if they routinely cared for infants receiving respiratory support.

RESULTS

The survey was completed by 99/144 eligible nurses. The majority of the 99 nurses surveyed felt that HFNC was less likely than NCPAP to prevent re-intubation of infants 24-26 weeks' gestation but equally likely to prevent re-intubation of infants 28-30 weeks' gestation. Nurses preferred NCPAP for post-extubation support of 24- and 26-week infants, and HFNC for 28- and 30-week infants, despite being less experienced with HFNC. Perceptions of HFNC compared with NCPAP included increased ease-of-use, improved infant comfort and reduced nasal trauma.

CONCLUSIONS

Neonatal nurses preferred NCPAP for post-extubation support of infants <28 weeks' gestation and HFNC for infants of 28 or 30 weeks' gestation. Nurses accurately predicted varying efficacy of HFNC across different gestational ages, consistent with the findings of a contemporaneous randomised trial. In the context of clinical non-inferiority, as shown in the randomised trial, nursing preference for HFNC over NCPAP in preterm infants ≥28 weeks' gestation supports the use of HFNC as post-extubation support in this population.

Are high flow nasal cannulae noisier than bubble CPAP for preterm infants?

BACKGROUND

Noise exposure in the neonatal intensive care unit is believed to be a risk factor for hearing loss in preterm neonates. Continuous positive airway pressure (CPAP) devices exceed recommended noise levels. High flow nasal cannulae (HFNC) are an increasingly popular alternative to CPAP for treating preterm infants, but there are no in vivo studies assessing noise production by HFNC.

OBJECTIVE

To study whether HFNC are noisier than bubble CPAP (BCPAP) for preterm infants.

METHODS

An observational study of preterm infants receiving HFNC or BCPAP. Noise levels within the external auditory meatus (EAM) were measured using a microphone probe tube connected to a calibrated digital dosimeter. Noise was measured across a range of frequencies and reported as decibels A-weighted (dBA).

RESULTS

A total of 21 HFNC and 13 BCPAP noise measurements were performed in 21 infants. HFNC gas flows were 2-5 L/min, and BCPAP gas flows were 6-10 L/min with set pressures of 5-7 cm of water. There was no evidence of a difference in average noise levels measured at the EAM: mean difference (95% CI) of -1.6 (-4.0 to 0.9) dBA for HFNC compared to BCPAP. At low frequency (500 Hz), HFNC was mean (95% CI) 3.0 (0.3 to 5.7) dBA quieter than BCPAP. Noise increased with increasing BCPAP gas flow (p=0.007), but not with increasing set pressure. There was a trend to noise increasing with increasing HFNC gas flows.

CONCLUSIONS

At the gas flows studied, HFNC are not noisier than BCPAP for preterm infants.

Are high flow nasal cannulae noisier than bubble CPAP for preterm infants?

BACKGROUND

Noise exposure in the neonatal intensive care unit is believed to be a risk factor for hearing loss in preterm neonates. Continuous positive airway pressure (CPAP) devices exceed recommended noise levels. High flow nasal cannulae (HFNC) are an increasingly popular alternative to CPAP for treating preterm infants, but there are no in vivo studies assessing noise production by HFNC.

OBJECTIVE

To study whether HFNC are noisier than bubble CPAP (BCPAP) for preterm infants.

METHODS

An observational study of preterm infants receiving HFNC or BCPAP. Noise levels within the external auditory meatus (EAM) were measured using a microphone probe tube connected to a calibrated digital dosimeter. Noise was measured across a range of frequencies and reported as decibels A-weighted (dBA).

RESULTS

A total of 21 HFNC and 13 BCPAP noise measurements were performed in 21 infants. HFNC gas flows were 2-5 L/min, and BCPAP gas flows were 6-10 L/min with set pressures of 5-7 cm of water. There was no evidence of a difference in average noise levels measured at the EAM: mean difference (95% CI) of -1.6 (-4.0 to 0.9) dBA for HFNC compared to BCPAP. At low frequency (500 Hz), HFNC was mean (95% CI) 3.0 (0.3 to 5.7) dBA quieter than BCPAP. Noise increased with increasing BCPAP gas flow (p=0.007), but not with increasing set pressure. There was a trend to noise increasing with increasing HFNC gas flows.

CONCLUSIONS

At the gas flows studied, HFNC are not noisier than BCPAP for preterm infants.

High-flow nasal cannulae in very preterm infants after extubation

BACKGROUND

The use of high-flow nasal cannulae is an increasingly popular alternative to nasal continuous positive airway pressure (CPAP) for noninvasive respiratory support of very preterm infants (gestational age, <32 weeks) after extubation. However, data on the efficacy or safety of such cannulae in this population are lacking.

METHODS

In this multicenter, randomized, noninferiority trial, we assigned 303 very preterm infants to receive treatment with either high-flow nasal cannulae (5 to 6 liters per minute) or nasal CPAP (7 cm of water) after extubation. The primary outcome was treatment failure within 7 days. Noninferiority was determined by calculating the absolute difference in the risk of the primary outcome; the margin of noninferiority was 20 percentage points. Infants in whom treatment with high-flow nasal cannulae failed could be treated with nasal CPAP; infants in whom nasal CPAP failed were reintubated.

RESULTS

The use of high-flow nasal cannulae was noninferior to the use of nasal CPAP, with treatment failure occurring in 52 of 152 infants (34.2%) in the nasal-cannulae group and in 39 of 151 infants (25.8%) in the CPAP group (risk difference, 8.4 percentage points; 95% confidence interval, -1.9 to 18.7). Almost half the infants in whom treatment with high-flow nasal cannulae failed were successfully treated with CPAP without reintubation. The incidence of nasal trauma was significantly lower in the nasal-cannulae group than in the CPAP group (P=0.01), but there were no significant differences in rates of serious adverse events or other complications.

CONCLUSIONS

Although the result for the primary outcome was close to the margin of noninferiority, the efficacy of high-flow nasal cannulae was similar to that of CPAP as respiratory support for very preterm infants after extubation. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Network number, ACTRN12610000166077.).

High-flow nasal cannulae for respiratory support of preterm infants: a review of the evidence

BACKGROUND

High-flow nasal cannulae (HFNC) are gaining in popularity as a form of non-invasive respiratory support for preterm infants in neonatal intensive care units around the world. They are proposed as an alternative to nasal continuous positive airway pressure (NCPAP) in a variety of clinical situations, including post-extubation support, primary therapy from birth and 'weaning' from NCPAP.

OBJECTIVES

To present and discuss the available evidence for the use of HFNC in the preterm population.

METHODS

An internet-based literature search for relevant, original research articles (both randomised studies and not) on the use of HFNC in preterm infants was undertaken.

RESULTS

A total of 19 studies were included in the review. Distending pressure generated by HFNC in preterm infants increases with increasing flow rate and decreasing infant size and varies according to the amount of leak around the prongs. HFNC may be as effective as NCPAP at improving respiratory parameters such as tidal volume and work of breathing in preterm infants, but probably only at flow rates >2 litres/min. The efficacy and safety of HFNC in preterm infants remain to be determined.

CONCLUSIONS

There is growing evidence of the feasibility of HFNC as an alternative to other forms of non-invasive ventilation in preterm infants. However, there remains uncertainty about the efficacy and safety of HFNC in this population. Until the results of larger randomised trials are known, widespread use of HFNC to treat preterm infants cannot be recommended.

High-flow nasal cannulae and nasal continuous positive airway pressure use in non-tertiary special care nurseries in Australia and New Zealand

AIM

Non-tertiary centres (NTCs) in Australia and New Zealand are increasingly providing non-invasive respiratory support, including high-flow nasal cannulae (HFNC) and nasal continuous positive airway pressure (nCPAP), to newborn infants. We aimed to determine the proportion of NTCs in these countries treating newborn infants with HFNC and nCPAP, and how these therapies are used.

METHODS

We surveyed public and private NTCs in Australia and public NTCs in New Zealand. The survey, directed at senior medical and nursing staff, consisted of questions regarding unit demographics, HFNC and nCPAP use.

RESULTS

One hundred seventeen responses were received regarding HFNC use, from 88% (80/91) of public hospitals and 64% (37/58) of private hospitals surveyed. Ten (8.5%) responders (nine public and one private) used HFNC; all used the Fisher & Paykel system. HFNC was used for respiratory distress syndrome from birth (9/10 units), as a weaning mode from nCPAP (5/10 units) and as treatment for apnoea (3/10 units). Flow rates used ranged from 1 to 8 L/min, with typical minimum flow of 1 L/min and maximum of 4-6 L/min. The main perceived advantage of HFNC was 'ease of use'. In the units treating newborn infants with nCPAP, it was used either in an ongoing fashion (43 units), short term or episodically (four units), or only for stabilisation prior to transfer (11 units). Excluding those units using nCPAP only for stabilisation and non-responders, 47/108 (44%) units were using nCPAP.

CONCLUSIONS

HFNC is being used in NTCs in Australia and New Zealand, and the use of nCPAP has increased over time.

High-dose docosahexaenoic acid supplementation of preterm infants: respiratory and allergy outcomes

BACKGROUND

Docosahexaenoic acid (DHA) has been associated with downregulation of inflammatory responses.

OBJECTIVE

To report the effect of DHA supplementation on long-term atopic and respiratory outcomes in preterm infants.

METHODS

This study is a multicenter, randomized controlled trial comparing the outcomes for preterm infants <33 weeks' gestation who consumed expressed breast milk from mothers taking either tuna oil (high-DHA diet) or soy oil (standard-DHA) capsules. Data collected included incidence of bronchopulmonary dysplasia (BPD) and parental reporting of atopic conditions over the first 18 months of life.

RESULTS

Six hundred fifty-seven infants were enrolled (322 to high-DHA diet, 335 to standard), and 93.5% completed the 18-month follow-up. There was a reduction in BPD in boys (relative risk [RR]: 0.67 [95% confidence interval (CI): 0.47-0.96]; P=.03) and in all infants with a birth weight of <1250 g (RR: 0.75 [95% CI: 0.57-0.98]; P=.04). There was no effect on duration of respiratory support, admission length, or home oxygen requirement. There was a reduction in reported hay fever in all infants in the high-DHA group at either 12 or 18 months (RR: 0.41 [95% CI: 0.18-0.91]; P=.03) and at either 12 or 18 months in boys (RR: 0.15 [0.03-0.64]; P=.01). There was no effect on asthma, eczema, or food allergy.

CONCLUSIONS

DHA supplementation for infants of <33 weeks' gestation reduced the incidence of BPD in boys and in all infants with a birth weight of <1250 g and reduced the incidence of reported hay fever in boys at either 12 or 18 months.

Clinical assessment of extremely premature infants in the delivery room is a poor predictor of survival

BACKGROUND

Some neonatologists state that at the delivery of extremely premature infants they rely on "how the baby looks" when deciding whether to initiate resuscitation. Previous studies have reported poor correlation between early clinical signs and prognosis.

OBJECTIVE

To determine if neonatologists can accurately predict survival to discharge of extremely premature infants on the basis of observations in the first minutes after birth.

METHODS

We showed videos of the resuscitation of 10 extremely premature infants (<26 weeks' gestation) to attending neonatologists and fellows from the 3 major perinatal centers in Melbourne, Australia. Antenatal information was available to the observers. A monitor visible in each video displayed the heart rate and oxygen saturation of the infant. Observers were asked to estimate the likelihood of survival to discharge for each infant at 3 time points: 20 seconds, 2 minutes, and 5 minutes after birth. The predictive ability of observers was expressed as the area (95% confidence interval [CI]) under the receiver-operating-characteristic curve.

RESULTS

Seventeen attending neonatologists and 17 neonatal fellows completed the study. Receiver-operating-characteristic curves were generated for the combined and individual groups. Observers' ability to predict survival was poor (combined results): 0.61 (95% CI: 0.54-0.67) at 20 seconds, 0.59 (95% CI: 0.52-0.64) at 2 minutes, and 0.61 (95% CI: 0.55-0.67) at 5 minutes. Level of experience did not affect the observers' accuracy of predicting survival.

CONCLUSION

Neonatologists' reliance on initial appearance and early response to resuscitation in predicting survival for extremely premature infants is misplaced.