In a tertiary maternity hospital, when should a paediatrician be present in the delivery room?

OBJECTIVE

10% of newborns require positive pressure ventilation (PPV) at birth. There are few data on prenatal or early postnatal factors that are predictive of the need for a paediatrician in the delivery room. The study analysed prenatal obstetric and early postnatal factors associated with the requirement for paediatrician assistance in this setting.

METHODS

Over a three-month period, all consecutive births in a tertiary hospital's maternity unit were prospectively evaluated with regard to the need for paediatrician assistance (requested either before or after the delivery), the requirement for resuscitation, and transfer to a neonatal intensive care unit (NICU).

RESULTS

For a total of 584 consecutive births, paediatrician assistance was requested before delivery in 170 cases (30.5%) and after in 78 cases (13.3%). 78% of the newborns requiring PPV, 95.8% of those requiring endotracheal intubation and 86.3% of those requiring transfer to the NICU matched recently published prenatal criteria for paediatrician assistance. Along with a low Apgar score and a cord blood pH <7.20, these criteria covered 95% of the prenatal and early postnatal requests for paediatrician assistance.

CONCLUSIONS

These criteria for neonatal resuscitation in the delivery room would enable medical staff to anticipate the need for paediatrician assistance.

Additional double-wall roof in single-wall, closed, convective incubators: Impact on body heat loss from premature infants and optimal adjustment of the incubator air temperature

Radiant heat loss is high in low-birth-weight (LBW) neonates. Double-wall or single-wall incubators with an additional double-wall roof panel that can be removed during phototherapy are used to reduce Radiant heat loss. There are no data on how the incubators should be used when this second roof panel is removed. The aim of the study was to assess the heat exchanges in LBW neonates in a single-wall incubator with and without an additional roof panel. To determine the optimal thermoneutral incubator air temperature. Influence of the additional double-wall roof was assessed by using a thermal mannequin simulating a LBW neonate. Then, we calculated the optimal incubator air temperature from a cohort of human LBW neonate in the absence of the additional roof panel. Twenty-three LBW neonates (birth weight: 750-1800g; gestational age: 28-32 weeks) were included. With the additional roof panel, R was lower but convective and evaporative skin heat losses were greater. This difference can be overcome by increasing the incubator air temperature by 0.15-0.20°C. The benefit of an additional roof panel was cancelled out by greater body heat losses through other routes. Understanding the heat transfers between the neonate and the environment is essential for optimizing incubators.

[Evaluation of the measurement of hemoglobin by the Hemocue System® in the preterm neonate less than 28 days old]

BACKGROUND

Hemoglobin (Hb) measurement is essential for the monitoring of anemia in preterm neonates to assess if any bleeding (pulmonary, cerebral, digestive) is present. EDTA samples require 500 μL vs. 10 μL for the Hemocue(®) system. This system has been evaluated and validated in adults and children but not in preterm neonates with fetal hemoglobin. The aim of the study was to compare Hb measurement with the Hemocue(®) system vs. the EDTA laboratory system on fetal Hb in preterm neonates.

MATERIALS AND METHODS

This was a prospective study conducted in the preterm intensive care unit in the Amiens Hospital. Preterm neonates, before 28 days of life, requiring EDTA (Hb) measurement were included. Two Hemocues(®) were performed at the same time. Postnatal age (correlated to the fetal hemoglobin level decrease), blood sample site, and other factors that could influence the Hb result were evaluated.

RESULTS

Seventy-six EDTA and 152 Hemocue(®) samples from 38 preterm neonates were included. The term was 28.1±3.7 weeks of gestation, the birth weight was 1215.5±657 g. We found a good correlation between the Hemocue(®) and EDTA samples (Hemocue(®)=EDTA*0.94-0.4; R(2)=0.63; P<0.001). The influence of confounding factors was insignificant.

CONCLUSION

The use of the Hemocue(®) system showed a good correlation with the EDTA measurement of fetal Hb, with a moderate bias (-0.2±1.5 g/dL), which remained stable for the first 28 days of life.

A mean body temperature of 37°C for incubated preterm infants is associated with lower energy costs in the first 11 days of life

AIM

This randomised trial compared the energy costs of providing incubated preterm infants born before 32 weeks of gestation with homeothermia using either air temperature control (ATC) or skin servocontrol (SSC).

METHODS

We studied 38 incubated preterm infants for the first 11 days of life, calculating the frequency of hypothermia (<36.0°C), hyperthermia (>37.5°C) and thermal challenge, together with energy costs, based on a change in incubator air temperature of 2°C above or below thermoneutrality.

RESULTS

The daily mean incubator air temperature was higher in ATC than SSC (p < 0.05) for the first 6 days, and the mean body temperature was higher in ATC (37.0 ± 0.03°C) than SSC (36.8 ± 0.02; p < 0.01) over the whole study period. The frequency of moderate hyperthermia was higher in ATC (p < 0.001), whereas warm and cold thermal challenges were higher in SSC (p < 0.001). The two groups did not differ in terms of energy costs. The time to recover birthweight was shorter in ATC (p < 0.05).

CONCLUSION

In incubators using ATC, a body temperature of 37°C was associated with lower energy costs and greater weight gain at 11 days of life for preterm infants. Future studies should test SSC shielded abdominal skin temperature set to 37°C.

Impact of common treatments given in the perinatal period on the developing brain

BACKGROUND

Over the last decades, considerable progress has been made in the perinatal management of high-risk preterm neonates, changing the landscape of pathological conditions associated with neurological impairments. Major focal destructive lesions are now less common, and the predominant neuropathological lesion is diffuse white-matter damage in the most immature infants. Similarly, over the last few years, we have observed a trend towards a decrease in neurological impairment in the absence of treatments specifically aimed at neuroprotection.

OBJECTIVES

We examined whether recent changes in treatment strategies in perinatal care during the perinatal period could have had an indirect beneficial impact on the occurrence of brain lesions and their consequences.

METHODS

Thus, we reviewed the effects of the most common treatments administered during the perinatal period to the mother or to very preterm infants on brain damage and neurocognitive follow-up.

RESULTS

Antenatal steroids and exogenous surfactant are the two main treatments capable of leading to neuroprotection in very preterm infants. Randomized controlled trials are currently investigating the effects of inhaled nitric oxide and erythropoietin, while antenatal magnesium sulphate and caffeine are also likely to provide some neuroprotection, but this needs to be further investigated. Finally, other common treatments against pain, haemodynamic failure and patent ductus arteriosus have conflicting or no effects on the developing brain.

CONCLUSION

While specific neuroprotective drugs are still awaited, recent advances in perinatal care have been associated with an unexpected but significant decrease in the incidence of both severe brain lesions and neurological impairment.

Ketamine and atropine decrease pain for preterm newborn tracheal intubation in the delivery room: an observational pilot study

AIM

Various analgesic strategies are used before tracheal intubation of preterm newborns in the delivery room, due to the lack of a standard protocol and difficult venous access. This study evaluated the feasibility and efficacy of short venous catheter insertion and immediate ketamine analgesia for tracheal intubation of preterm newborns at birth in the delivery room.

METHODS

Prospective observational pilot study, with ketamine and atropine used at the paediatrician's discretion. Pain score, heart rate, SpO2 nadirs, procedure duration and neonatal intensive care unit morbidity were recorded.

RESULTS

Fifty-seven consecutive preterm newborns were included between January I and June 30, 2012: 15 in the no analgesia group and 39 in the intravenous ketamine group. Short catheter insertion failed in three newborns. The pain score was lower during laryngoscopy in the ketamine group (4 ± 0.7 vs. 2.9 ± 3.2 in the no analgesia group, p < 0.001). The heart rate nadir during tracheal intubation was 150.7 ± 29.6 bpm (vs. 112.6 ± 35.5 bpm in the no analgesia group, p < 0.01). Surfactant therapy was administered to 79.5% of newborns in the ketamine group (vs. 92.3%, p = 0.29) in the first 30 min of life.

CONCLUSION

Short venous catheter insertion with immediate ketamine analgesia plus atropine for tracheal intubation of preterm newborns in the delivery room was effective in decreasing pain and preventing vagal bradycardia.

Exogenous surfactant therapy in 2013: what is next? Who, when and how should we treat newborn infants in the future?

Background

Surfactant therapy is one of the few treatments that have dramatically changed clinical practice in neonatology. In addition to respiratory distress syndrome (RDS), surfactant deficiency is observed in many other clinical situations in term and preterm infants, raising several questions regarding the use of surfactant therapy.

Objectives

This review focuses on several points of interest, including some controversial or confusing topics being faced by clinicians together with emerging or innovative concepts and techniques, according to the state of the art and the published literature as of 2013. Surfactant therapy has primarily focused on RDS in the preterm newborn. However, whether this treatment would be of benefit to a more heterogeneous population of infants with lung diseases other than RDS needs to be determined. Early trials have highlighted the benefits of prophylactic surfactant administration to newborns judged to be at risk of developing RDS. In preterm newborns that have undergone prenatal lung maturation with steroids and early treatment with continuous positive airway pressure (CPAP), the criteria for surfactant administration, including the optimal time and the severity of RDS, are still under discussion. Tracheal intubation is no longer systematically done for surfactant administration to newborns. Alternative modes of surfactant administration, including minimally-invasive and aerosolized delivery, could thus allow this treatment to be used in cases of RDS in unstable preterm newborns, in whom the tracheal intubation procedure still poses an ethical and medical challenge.

Conclusion

The optimization of the uses and methods of surfactant administration will be one of the most important challenges in neonatal intensive care in the years to come.

[Maternal and neonatal factors associated with successful breastfeeding in very preterm infants]

OBJECTIVE

The main objective of this study was to evaluate the rate of breastfeeding at NICU discharge in a population of very preterm infants. The secondary objective was to identify maternal, gestational, and neonatal factors associated with successful breastfeeding at NICU discharge.

MATERIALS AND METHODS

This is a retrospective descriptive study. All live births before 32 weeks of gestational age (WGA) admitted to the NICU of the Amiens university hospital between 1 January 2009 and 30 June 2011 were included in the study, excluding infants who died during hospitalization or infants transferred to another hospital. Data on mothers and newborns were collected from the medical record. Statistical analysis was performed using the Chi(2) test for categorical variables and the Student t test for continuous variables. The significance threshold was set at P<0.05.

RESULTS

Seventy-seven infants were included in the study. While 66% of the mothers wished to breastfeed at birth, the success rate of breastfeeding at hospital discharge was only 38%. The proportion of married women was significantly higher in the "successful breastfeeding" group (P=0.029). No significant difference was demonstrated regarding maternal age, maternal profession, proportion of non-smoking mothers, parity, type of pregnancy, type of delivery, duration of invasive ventilation and oxygen dependency, and surgery during hospitalization.

CONCLUSION

The rate of breastfeeding of very preterm infants at hospital discharge is lower than the rates reported in the literature. The mother's marital status significantly influences the decision to breastfeed very preterm infants at discharge.

Pathophysiology of persistent pulmonary hypertension of the newborn: impact of the perinatal environment

The main cause of pulmonary hypertension in newborn babies results from the failure of the pulmonary circulation to dilate at birth, termed 'persistent pulmonary hypertension of the newborn' (PPHN). This syndrome is characterized by sustained elevation of pulmonary vascular resistance, causing extrapulmonary right-to-left shunting of blood across the ductus arteriosus and foramen ovale and severe hypoxaemia. It can also lead to life-threatening circulatory failure. There are many controversial and unresolved issues regarding the pathophysiology of PPHN, and these are discussed. PPHN is generally associated with factors such as congenital diaphragmatic hernia, birth asphyxia, sepsis, meconium aspiration and respiratory distress syndrome. However, the perinatal environment-exposure to nicotine and certain medications, maternal obesity and diabetes, epigenetics, painful stimuli and birth by Caesarean section-may also affect the maladaptation of the lung circulation at birth. In infants with PPHN, it is important to optimize circulatory function. Suggested management strategies for PPHN include: avoidance of environmental factors that worsen PPHN (e.g. noxious stimuli, lung overdistension); adequate lung recruitment and alveolar ventilation; inhaled nitric oxide (or sildenafil, if inhaled nitric oxide is not available); haemodynamic assessment; appropriate fluid and cardiovascular resuscitation and inotropic and vasoactive agents.

Impact of nursing care on temperature environment in preterm newborns nursed in closed convective incubators

AIMS

Very-low-birth-weight (VLBW) neonates require regular nursing procedures with frequent opening of the incubator resulting in a decrease in incubator air temperature. This study was designed to assess changes in the thermal status of VLBW neonates according to the type of nursing care and incubator openings.

METHODS

Thirty-one VLBW neonates (mean gestational age: 28.7 ± 0.3 weeks of gestation) were included. Over a 10-day period, each opening of the incubator was recorded together with details about caregiving. Body temperature was recorded continuously, and door opening and closing events were recorded by a video camera.

RESULTS

This study analysed 1,798 caregiving procedures with mean durations ranging from 6.2 ± 2.1 to 88.5 ± 33.4 min. Abdominal skin temperature decreased by up to 1.08°C/h for procedures such as tracheal intubation (p < 0.01). The temperature decrease was strongly correlated with the type of procedure (p < 0.01), incubator opening (p < 0.01) and procedure duration (p < 0.01). The procedure duration accounted for only 10% of the abdominal skin temperature change (p < 0.01).

CONCLUSIONS

For VLBW neonates nursed in skin temperature servo-control incubators, the decrease in abdominal skin temperature during caregiving was correlated with the type of procedure, incubator opening modalities and procedure duration. These parameters should be considered to optimize the thermal management of VLBW neonates.