1
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Bień A, Vermeulen J, Bączek G, Pięta M, Pięta B. Cord blood banking: Balancing hype and hope in stem cell therapy. Eur J Midwifery 2024; 8:EJM-8-59. [PMID: 39376486 PMCID: PMC11456975 DOI: 10.18332/ejm/192930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 08/10/2024] [Accepted: 09/03/2024] [Indexed: 10/09/2024] Open
Affiliation(s)
- Agnieszka Bień
- Faculty of Health Sciences, Medical University of Lublin, Lublin, Poland
| | - Joeri Vermeulen
- Department of Life sciences and Medicine, Faculty of Science, Technology and Medicine, University of Luxembourg, Eschsur-Alzette, Grand Duchy of Luxembourg
- Department of Public Health, Biostatistics and Medical Informatics Research group, Vrije Universiteit Brussel, Brussels, Belgium
| | - Grażyna Bączek
- Department of Obstetrics and Gynecology Didactics, Faculty of Health Sciences, Medical University of Warsaw, Warsaw, Poland
| | | | - Beata Pięta
- Department of Mother and Child Health, Poznan University of Medical Sciences, Poznan, Poland
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2
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Major GS, Unger V, Nagy R, Hernádfői M, Veres DS, Zolcsák Á, Szabó M, Garami M, Hegyi P, Varga P, Gasparics Á. Umbilical cord management in newborn resuscitation: a systematic review and meta-analysis. Pediatr Res 2024:10.1038/s41390-024-03496-7. [PMID: 39223253 DOI: 10.1038/s41390-024-03496-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Evidence supporting the benefits of delayed cord clamping is increasing; however, there is no clear recommendation on cord management during newborn resuscitation. This study aimed to investigate the effects of resuscitation initiated with an intact umbilical cord, hypothesizing it is a safe stabilization procedure that improves neonatal outcomes. METHODS Systematic search was conducted in MEDLINE, Embase, CENTRAL, and Web of Science from inception to March 1, 2024. Eligible articles compared neonatal outcomes in newborns receiving initial stabilization steps before and after cord clamping. RESULTS Twelve studies met our inclusion criteria, with six RCTs included in the quantitative analysis. No statistically significant differences were found in delivery room parameters, in-hospital mortality, or neonatal outcomes between the examined groups. However, intact cord resuscitation group showed higher SpO2 at 5 min after birth compared to cord clamping prior to resuscitation group (MD 6.67%, 95% CI [-1.16%, 14.50%]). There were no significant differences in early complications of prematurity (NEC ≥ stage 2: RR 2.05, 95% CI [0.34, 12.30], IVH: RR 1.25, 95% CI [0.77, 2.00]). CONCLUSION Intact cord management during resuscitation appears to be a safe intervention; its effect on early complications of prematurity remains unclear. Further high-quality RCTs with larger patient numbers are urgently needed. IMPACT Initiating resuscitation with an intact umbilical cord appears to be a safe intervention for newborns. No statistically significant differences were found in delivery room parameters, in-hospital mortality, and neonatal outcomes between the examined groups. The utilization of specialized resuscitation trolleys appears to be promising to reduce the risk of intraventricular hemorrhage in preterm infants. Further high-quality RCTs with larger sample sizes are urgently needed to refine recommendations.
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Affiliation(s)
- Gréta Sz Major
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Vivien Unger
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Csolnoky Ferenc Hospital, Veszprém, Hungary
| | - Rita Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Márk Hernádfői
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Bethesda Children's Hospital, Budapest, Hungary
| | - Dániel S Veres
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Ádám Zolcsák
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Miklós Szabó
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Neonatology, Semmelweis University, Budapest, Hungary
| | - Miklós Garami
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Péter Varga
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Neonatology, Semmelweis University, Budapest, Hungary
- Department of Obstetrics and Gynecology, Intensive Neonatal Care Unit, Semmelweis University, Budapest, Hungary
| | - Ákos Gasparics
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary.
- Department of Neonatology, Semmelweis University, Budapest, Hungary.
- Department of Obstetrics and Gynecology, Intensive Neonatal Care Unit, Semmelweis University, Budapest, Hungary.
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3
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van Wyk L, Austin T, Barzilay B, Bravo MC, Breindahl M, Czernik C, Dempsey E, de Boode WP, de Vries W, Eriksen BH, Fauchére JC, Kooi EMW, Levy PT, McNamara PJ, Mitra S, Nestaas E, Rabe H, Rabi Y, Rogerson SR, Savoia M, Schena F, Sehgal A, Schwarz CE, Thome U, van Laere D, Zaharie GC, Gupta S. A recommendation for the use of electrical biosensing technology in neonatology. Pediatr Res 2024:10.1038/s41390-024-03369-z. [PMID: 38977797 DOI: 10.1038/s41390-024-03369-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/17/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024]
Abstract
Non-invasive cardiac output monitoring, via electrical biosensing technology (EBT), provides continuous, multi-parameter hemodynamic variable monitoring which may allow for timely identification of hemodynamic instability in some neonates, providing an opportunity for early intervention that may improve neonatal outcomes. EBT encompasses thoracic (TEBT) and whole body (WBEBT) methods. Despite the lack of relative accuracy of these technologies, as compared to transthoracic echocardiography, the use of these technologies in neonatology, both in the research and clinical arena, have increased dramatically over the last 30 years. The European Society of Pediatric Research Special Interest Group in Non-Invasive Cardiac Output Monitoring, a group of experienced neonatologists in the field of EBT, deemed it appropriate to provide recommendations for the use of TEBT and WBEBT in the field of neonatology. Although TEBT is not an accurate determinant of cardiac output or stroke volume, it may be useful for monitoring longitudinal changes of hemodynamic parameters. Few recommendations can be made for the use of TEBT in common neonatal clinical conditions. It is recommended not to use WBEBT to monitor cardiac output. The differences in technologies, study methodologies and data reporting should be addressed in ongoing research prior to introducing EBT into routine practice. IMPACT STATEMENT: TEBT is not recommended as an accurate determinant of cardiac output (CO) (or stroke volume (SV)). TEBT may be useful for monitoring longitudinal changes from baseline of hemodynamic parameters on an individual patient basis. TEBT-derived thoracic fluid content (TFC) longitudinal changes from baseline may be useful in monitoring progress in respiratory disorders and circulatory conditions affecting intrathoracic fluid volume. Currently there is insufficient evidence to make any recommendations regarding the use of WBEBT for CO monitoring in neonates. Further research is required in all areas prior to the implementation of these monitors into routine clinical practice.
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Affiliation(s)
- Lizelle van Wyk
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
| | - Topun Austin
- Neonatal Intensive Care Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
| | - Bernard Barzilay
- Neonatal Intensive Care Unit, Assaf Harofeh Medical Center, Tzrifin, Israel
| | - Maria Carmen Bravo
- Department of Neonatology, La Paz University Hospital and IdiPaz, Madrid, Spain
| | - Morten Breindahl
- Department of Neonatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christoph Czernik
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Willem-Pieter de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Willem de Vries
- Division of Woman and Baby, Department of Neonatology, University Medical Centre Utrecht, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Beate Horsberg Eriksen
- Department of Paediatrics, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jean-Claude Fauchére
- Department of Neonatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Elisabeth M W Kooi
- Division of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Philip T Levy
- Department of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | - Subhabrata Mitra
- Institute for Women's Health, University College London, London, UK
| | - Eirik Nestaas
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Clinic of Paediatrics and Adolescence, Akershus University Hospital, Lørenskog, Norway
| | - Heike Rabe
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | | | - Sheryle R Rogerson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
| | - Marilena Savoia
- Neonatal Intensive Care Unit, S Maria Della Misericordia Hospital, Udine, Italy
| | | | - Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Christoph E Schwarz
- Department of Neonatology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Ulrich Thome
- Division of Neonatology, Department of Pediatrics, University of Leipzig Medical Centre, Leipzig, Germany
| | - David van Laere
- Neonatal Intensive Care Unit, Universitair Ziekenhuis, Antwerp, Belgium
| | - Gabriela C Zaharie
- Neonatology Department, University of Medicine and Pharmacy, Iuliu Hatieganu, Cluj -Napoca, Romania
| | - Samir Gupta
- Department of Engineering, Durham University, Durham, UK
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
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4
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Te Pas A. Measuring direct effect of cord clamping approaches: getting the right target group. Pediatr Res 2024; 96:5-6. [PMID: 38769402 DOI: 10.1038/s41390-024-03284-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024]
Affiliation(s)
- Arjan Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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5
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Amendolia B, Kilic N, Afridi F, Qari O, Bhat V, Nakhla D, Sadre S, Eckardt R, Nakhla T, Bhandari V, Aghai ZH. Delayed Cord Clamping for 45 Seconds in Very Low Birth Weight Infants: Impact on Hemoglobin at Birth and Close to Discharge. Am J Perinatol 2024; 41:e126-e132. [PMID: 35523407 DOI: 10.1055/a-1845-1816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To assess the impact of delayed cord clamping (DCC) for 45 seconds on hemoglobin at birth and close to discharge in very low birth weight (VLBW) infants and to compare modes of delivery in infants who received DCC. STUDY DESIGN In a retrospective study, 888 VLBW infants (≤1,500 g) who survived to discharge and received immediate cord clamping (ICC) were compared with infants who received DCC. Infants who received DCC and born via Cesarean section (C-section) were compared with those born via vaginal birth. RESULTS A total of 555 infants received ICC and 333 DCC. Only 188 out of 333 VLBW infants (56.5%) born during the DCC period received DCC. DCC was associated with higher hemoglobin at birth (15.9 vs. 14.9 g/dL, p = 0.001) and close to discharge (10.7 vs. 10.1 g/dL, p < 0.001) and reduced need for blood transfusion (39.4 vs. 54.9%, p < 0.001). In the DCC group, hemoglobin at birth and close to discharge was similar in infants born via C-section and vaginal birth. CONCLUSION DCC for 45 seconds increased hemoglobin at birth and close to discharge and reduced need for blood transfusion in VLBW infants. DCC for 45 seconds was equally effective for infants born by C-section and vaginal delivery. Approximately 44% of VLBW infants did not receive DCC even after implementing DCC guidelines. KEY POINTS · Studies to date have shown that DCC improves mortality and short- and long-term outcomes in VLBW infants.. · No consistent guidelines for the duration of DCC in preterm and term neonates.. · DCC for 45 seconds increased hemoglobin at birth and close to discharge in VLBW infants..
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Affiliation(s)
- Barbara Amendolia
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Nicole Kilic
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Faraz Afridi
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Omar Qari
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Vishwanath Bhat
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Daniel Nakhla
- Rutgers University, The State University of NJ, New Brunswick, New Jersey
| | - Sara Sadre
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Rebecca Eckardt
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Tarek Nakhla
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Zubair H Aghai
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, Pennsylvania
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6
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Odackal NJ, Caruso CG, Klitzman M, Rincon M, Byrne BJ, Winter J, Petroni GR, Fairchild KD, Warren JB. Video-Assisted Informed Consent in a Clinical Trial of Resuscitation of Extremely Preterm Infants: Lessons Learned. Am J Perinatol 2024; 41:e187-e192. [PMID: 35617960 PMCID: PMC11112601 DOI: 10.1055/a-1863-2141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Obtaining informed consent for clinical trials is challenging in acute clinical settings. For the VentFirst randomized clinical trial (assisting ventilation during delayed cord clamping for infants <29 weeks' gestation), we created an informational video that sites could choose to use to supplement the standard in-person verbal and written consent. Using a postconsent survey, we sought to describe the impact of the video on patient recruitment, satisfaction with the consent process, and knowledge about the study. STUDY DESIGN This is a descriptive survey-based substudy. RESULTS Of the sites participating in the VentFirst trial that obtained institutional review board (IRB) approval to allow use of the video to supplement the standard informed consent process, three elected to participate in the survey substudy. From February 2018 to January 2021, 82 women at these three sites were offered the video and completed the postconsent survey. Overall, 73 of these 82 women (89%) consented to participate in the primary study, 78 (95%) indicated the study was explained to them very well or extremely well, and the range of correct answers on five knowledge questions about the study was 63 to 98%. Forty-six (56%) of the 82 women offered the video chose to watch it. There were no major differences in study participation, satisfaction with the consent process, or knowledge about the study between the women who chose to watch or not watch the video. CONCLUSION Watching an optional video to supplement the standard informed consent process did not have a major impact on outcomes in this small substudy. The ways in which audiovisual tools might modify the traditional informed consent process deserve further study. KEY POINTS · Informed consent in acute clinical contexts is difficult.. · Videos offer an alternative communication tool.. · Continued research is necessary to optimize the consent process..
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Affiliation(s)
- Namrita J Odackal
- Department of Neonatology, North Denver Envision Group, Arvada, Colorado
| | - Catherine G Caruso
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Melissa Klitzman
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Monica Rincon
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Bobbi J Byrne
- Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jameel Winter
- Division of Neonatology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gina R Petroni
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Karen D Fairchild
- Division of Neonatology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Jamie B Warren
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
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7
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Fairchild KD, Petroni GR, Varhegyi NE, Strand ML, Josephsen JB, Niermeyer S, Barry JS, Warren JB, Rincon M, Fang JL, Thomas SP, Travers CP, Kane AF, Carlo WA, Byrne BJ, Underwood MA, Poulain FR, Law BH, Gorman TE, Leone TA, Bulas DI, Epelman M, Kline-Fath BM, Chisholm CA, Kattwinkel J. Ventilatory Assistance Before Umbilical Cord Clamping in Extremely Preterm Infants: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2411140. [PMID: 38758557 PMCID: PMC11102017 DOI: 10.1001/jamanetworkopen.2024.11140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/07/2024] [Indexed: 05/18/2024] Open
Abstract
Importance Providing assisted ventilation during delayed umbilical cord clamping may improve outcomes for extremely preterm infants. Objective To determine whether assisted ventilation in extremely preterm infants (23 0/7 to 28 6/7 weeks' gestational age [GA]) followed by cord clamping reduces intraventricular hemorrhage (IVH) or early death. Design, Setting, and Participants This phase 3, 1:1, parallel-stratified randomized clinical trial conducted at 12 perinatal centers across the US and Canada from September 2, 2016, through February 21, 2023, assessed IVH and early death outcomes of extremely preterm infants randomized to receive 120 seconds of assisted ventilation followed by cord clamping vs delayed cord clamping for 30 to 60 seconds with ventilatory assistance afterward. Two analysis cohorts, not breathing well and breathing well, were specified a priori based on assessment of breathing 30 seconds after birth. Intervention After birth, all infants received stimulation and suctioning if needed. From 30 to 120 seconds, infants randomized to the intervention received continuous positive airway pressure if breathing well or positive-pressure ventilation if not, with cord clamping at 120 seconds. Control infants received 30 to 60 seconds of delayed cord clamping followed by standard resuscitation. Main Outcomes and Measures The primary outcome was any grade IVH on head ultrasonography or death before day 7. Interpretation by site radiologists was confirmed by independent radiologists, all masked to study group. To estimate the association between study group and outcome, data were analyzed using the stratified Cochran-Mantel-Haenszel test for relative risk (RR), with associations summarized by point estimates and 95% CIs. Results Of 1110 women who consented to participate, 548 were randomized and delivered infants at GA less than 29 weeks. A total of 570 eligible infants were enrolled (median [IQR] GA, 26.6 [24.9-27.7] weeks; 297 male [52.1%]). Intraventricular hemorrhage or death occurred in 34.9% (97 of 278) of infants in the intervention group and 32.5% (95 of 292) in the control group (adjusted RR, 1.02; 95% CI, 0.81-1.27). In the prespecified not-breathing-well cohort (47.5% [271 of 570]; median [IQR] GA, 26.0 [24.7-27.4] weeks; 152 male [56.1%]), IVH or death occurred in 38.7% (58 of 150) of infants in the intervention group and 43.0% (52 of 121) in the control group (RR, 0.91; 95% CI, 0.68-1.21). There was no evidence of differences in death, severe brain injury, or major morbidities between the intervention and control groups in either breathing cohort. Conclusions and Relevance This study did not show that providing assisted ventilation before cord clamping in extremely preterm infants reduces IVH or early death. Additional study around the feasibility, safety, and efficacy of assisted ventilation before cord clamping may provide additional insight. Trial Registration ClinicalTrials.gov Identifier: NCT02742454.
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Affiliation(s)
- Karen D. Fairchild
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville
| | - Gina R. Petroni
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Nikole E. Varhegyi
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Marya L. Strand
- Division of Neonatology, Department of Pediatrics, St Louis University, St Louis, Missouri
| | - Justin B. Josephsen
- Division of Neonatology, Department of Pediatrics, St Louis University, St Louis, Missouri
| | - Susan Niermeyer
- Section of Neonatology, Department of Pediatrics, University of Colorado, Denver
| | - James S. Barry
- Section of Neonatology, Department of Pediatrics, University of Colorado, Denver
| | - Jamie B. Warren
- Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland
| | - Monica Rincon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland
| | - Jennifer L. Fang
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sumesh P. Thomas
- Section of Newborn Critical Care, Department of Pediatrics, University of Calgary, Alberta, Canada
| | - Colm P. Travers
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Andrea F. Kane
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Waldemar A. Carlo
- Division of Neonatology, Department of Pediatrics, University of Alabama at Birmingham
| | - Bobbi J. Byrne
- Division of Neonatology, Department of Pediatrics, Indiana University, Indianapolis
| | - Mark A. Underwood
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento
| | - Francis R. Poulain
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento
| | - Brenda H. Law
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Terri E. Gorman
- Division of Neonatology, Department of Pediatrics, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tina A. Leone
- Division of Neonatology, Department of Pediatrics, Columbia University, New York, New York
| | - Dorothy I. Bulas
- Department of Radiology, Children’s National Medical Center, Washington, DC
| | - Monica Epelman
- Department of Radiology, Nemours Children’s Hospital, Orlando, Florida
| | - Beth M. Kline-Fath
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Christian A. Chisholm
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Virginia, Charlottesville
| | - John Kattwinkel
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville
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8
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Dunne EA, O'Donnell CPF, Nakstad B, McCarthy LK. Thermoregulation for very preterm infants in the delivery room: a narrative review. Pediatr Res 2024; 95:1448-1454. [PMID: 38253875 PMCID: PMC11126394 DOI: 10.1038/s41390-023-02902-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/28/2023] [Accepted: 11/02/2023] [Indexed: 01/24/2024]
Abstract
Abnormal temperature in preterm infants is associated with increased morbidity and mortality. Infants born prematurely are at risk of abnormal temperature immediately after birth in the delivery room (DR). The World Health Organization (WHO) recommends that the temperature of newly born infants is maintained between 36.5-37.5oC after birth. When caring for very preterm infants, the International Liaison Committee on Resuscitation (ILCOR) recommends using a combination of interventions to prevent heat loss. While hypothermia remains prevalent, efforts to prevent it have increased the incidence of hyperthermia, which may also be harmful. Delayed cord clamping (DCC) for preterm infants has been recommended by ILCOR since 2015. Little is known about the effect of timing of DCC on temperature, nor have there been specific recommendations for thermal care before DCC. This review article focuses on the current evidence and recommendations for thermal care in the DR, and considers thermoregulation in the context of emerging interventions and future research directions. IMPACT: Abnormal temperature is common amongst very preterm infants after birth, and is an independent risk factor for mortality. The current guidelines recommend a combination of interventions to prevent heat loss after birth. Despite this, abnormal temperature is still a problem, across all climates and economies. New and emerging delivery room practice (i.e., delayed cord clamping, mobile resuscitation trolleys, early skin to skin care) may have an effect on infant temperature. This article reviews the current evidence and recommendations, and considers future research directions.
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Affiliation(s)
- Emma A Dunne
- Department of Neonatology, The National Maternity Hospital, Holles Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Colm P F O'Donnell
- Department of Neonatology, The National Maternity Hospital, Holles Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Britt Nakstad
- Division of Pediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Lisa K McCarthy
- Department of Neonatology, The National Maternity Hospital, Holles Street, Dublin, Ireland.
- School of Medicine, University College Dublin, Dublin, Ireland.
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9
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Soliman RM, Elgendy MM, Said RN, Shaarawy BI, Helal OM, Aly H. A Randomized Controlled Trial of a 30- versus a 120-Second Delay in Cord Clamping after Term Birth. Am J Perinatol 2024; 41:739-746. [PMID: 35170013 DOI: 10.1055/a-1772-4543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Delayed cord clamping (DCC) has been recently adopted in neonatal resuscitation. The immediate cardiac hemodynamic effects related to DCC more than 30 seconds was not studied. We aimed to study the effect of DCC at 120 seconds compared with 30 seconds on multiple hemodynamic variables in full-term infants using an electrical cardiometry (EC) device. STUDY DESIGN Present study is a randomized clinical trial. The study was conducted with full-term infants who were delivered at the Obstetrics and Gynecology Department in Cairo University Hospital. Sixty-eight full term infants were successfully enrolled in this trial. Cardiac output (CO) and other hemodynamic parameters were evaluated in this study by EC device. Hemoglobin, glucose, and bilirubin concentrations were measured at 24 hours. Newborn infants were assigned randomly into group 1: DCC at 30 seconds, and group 2: DCC at 120 seconds, based on the time of cord clamping. RESULTS Stroke volume (SV) (mL) and CO (L/min) were significantly higher in group 2 compared with group 1 at 5 minutes (6.71 vs. 5.35 and 1.09 vs. 0.75), 10 minutes (6.43 vs. 5.59 and 0.88 vs. 0.77), 15 minutes (6.45 vs. 5.60 and 0.89 vs. 0.76), and 24 hours (6.67 vs. 5.75 and 0.91vs. 0.81), respectively. Index of contractility (ICON; units) was significantly increased in group 2 at 5 minutes compared with group1 (114.2 vs. 83.8). Hematocrit (%) and total bilirubin concentrations (mg/dL) at 24 hours were significantly increased in group 2 compared with group 1 (51.5 vs. 40.5 and 3.8 vs. 2.9, respectively). CONCLUSION Stroke volume and cardiac output are significantly higher in neonates with DCC at 120 seconds compared with 30 seconds that continues for the first 24 hours. KEY POINTS · CO is significantly increased with DCC at 120 seconds.. · SV is significantly increased with DCC at 120 seconds.. · Such effects continued during the entire 24 hours of life in full-term infants..
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Affiliation(s)
- Reem M Soliman
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | - Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Reem N Said
- Department of Pediatrics, Cairo University, Cairo, Egypt
| | | | - Omneya M Helal
- Department of Obstetrics and Gynecology, Cairo University Obstetrics and Gynecology Hospital, Cairo, Egypt
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, Ohio
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10
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Tuttle Z, Roberts C, Davis P, Malhotra A, Tan K, Bhatia R, Zhou L, Baker E, Hodgson K, Blank D. Combining activity and grimace scores reflects perinatal stability in infants <32 weeks gestational age. Pediatr Res 2024:10.1038/s41390-024-03130-6. [PMID: 38519793 DOI: 10.1038/s41390-024-03130-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 01/12/2024] [Accepted: 03/01/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Over 95% of infants less than 32 weeks gestational age-very preterm infants (VPTI)-require cardiorespiratory support at birth. Clinical condition at birth is assessed by the Apgar score, but the precision and accuracy of activity and grimace has not been evaluated. We hypothesised activity and grimace could predict the level of cardiorespiratory support required for stabilisation. METHODS Two hundred twenty-nine videos of VPTI resuscitations at Monash Children's Hospital and The Royal Women's Hospital, Melbourne were evaluated, with 78 videos eligible for assessment. Activity and grimace were scored (0, 1, or 2) by seven consultant neonatologists, with inter-rater reliability assessed. Activity and grimace were correlated with the maximum level of cardiorespiratory support required for stabilisation. RESULTS Kendall's Coefficient of Concordance (W) showed strong interobserver agreement for activity (W = 0.644, p < 0.001) and grimace (W = 0.722, p < 0.001). Neither activity nor grimace independently predicted the level of cardiorespiratory support required. Combining activity and grimace showed non-vigorous infants (combined score <2) received more cardiorespiratory support than vigorous (combined score ≥ 2). CONCLUSION Scoring of activity and grimace was consistent between clinicians. Independently, activity and grimace did not correlate with perinatal stabilisation. Combined scoring showed non-vigorous infants had greater resuscitation requirements. IMPACT Our study evaluates the precision and accuracy of activity and grimace to predict perinatal stability, which has not been validated in infants <32 weeks gestational age. We found strong score agreement between assessors, indicating video review is a practical and precise method for grading of activity and grimace. Combined scoring to allow a dichotomous evaluation of infants as non-vigorous or vigorous showed the former group required greater cardiorespiratory support at birth.
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Affiliation(s)
- Zachary Tuttle
- The Ritchie Centre, Monash University, Clayton, VIC, Australia.
| | - Calum Roberts
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Peter Davis
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Atul Malhotra
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Kenneth Tan
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Risha Bhatia
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
| | - Lindsay Zhou
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
| | - Elizabeth Baker
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Kate Hodgson
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, VIC, Australia
| | - Douglas Blank
- The Ritchie Centre, Monash University, Clayton, VIC, Australia
- Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
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11
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Diggikar S, Ramaswamy VV, Koo J, Prasath A, Schmölzer GM. Positive Pressure Ventilation in Preterm Infants in the Delivery Room: A Review of Current Practices, Challenges, and Emerging Technologies. Neonatology 2024; 121:288-297. [PMID: 38467119 DOI: 10.1159/000537800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/05/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND A major proportion of preterm neonates require positive pressure ventilation (PPV) immediately after delivery. PPV may be administered through a face mask (FM) or nasal prongs. Current literature indicates that either of these are associated with similar outcomes. SUMMARY Nonetheless, FM remains the most utilized and the best choice. However, most available FM sizes are too large for extremely preterm infants, which leads to mask leak and ineffective PPV. Challenges to providing effective PPV include poor respiratory drive, complaint chest wall, weak thoracic muscle, delayed liquid clearance, and surfactant deficiency in preterm infants. Mask leak, airway obstruction, poor technique, and inappropriate size are correctable causes of ineffective PPV. Visual assessment of chest rise is often used to assess the efficacy of PPV. However, its accuracy is debatable. Though end tidal CO2 may adjudge the effectiveness of PPV, clinical studies are limited. The compliance of a preterm lung is highly dynamic. The inflating pressure set on T-piece is constant throughout the resuscitation, but the lung volume and dynamics changes with every breath. This leads to huge fluctuations of tidal volume delivery and can trigger inflammatory cascade in preterm infants leading to brain and lung injury. Respiratory function monitoring in the delivery room has potential for guiding and optimizing delivery room resuscitation. This is, however, limited by high costs, complex information that is difficult to interpret during resuscitation, and absence of clinical trials. KEY MESSAGES This review summarizes the existing literature on PPV in preterm infants, the various aspects related to it such as the pathophysiology, interfaces, devices utilized to deliver it, appropriate technique, emerging technologies, and future directions.
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Affiliation(s)
| | | | - Jenny Koo
- Sharp Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Arun Prasath
- Department of Neonatal-Perinatal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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12
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Wu Y, Ou J, Chen G, Zhu Y, Zhong X. Comparing two different placental transfusion strategies for very preterm infants at birth: a matched-pairs study. Ann Med 2024; 55:2301589. [PMID: 38242076 PMCID: PMC10802796 DOI: 10.1080/07853890.2023.2301589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/29/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To evaluate the clinical outcomes of using the extra-uterine placental transfusion (EPT) approach in very preterm infants (VPIs, gestational age <32 weeks) and compare this to delayed cord clamping (DCC) after birth. METHODS In this matched pairs study, we compared the clinical outcomes of the EPT group to those of the DCC group. EPT were performed in fifty-three VPIs, of whom 27 were singletons and 25 were twins. The singleton VPIs were matched for gestational age (±5 days) and delivery mode, and the twin VPIs were matched between each other with the first twin subjected to DCC and the second twin to EPT. Data on the infants were collected and analysed as an overall group. A twin subgroup consisting of DCC and EPT groups was also analysed separately. The primary study outcome was either death or major morbidities. RESULTS In total, 100 infants were included (n = 50 EPT group, n = 50 DCC group). The gestational ages of the DCC and EPT groups were (29.16 ± 1.76) and (29.12 ± 1.84) weeks, respectively. There were no differences in either deaths or major morbidities and other clinical outcomes, including the resuscitation variables, haemoglobin levels and red blood cell transfusion, between the two groups. In twin subgroups (gestational age 29.05 ± 1.89 weeks), EPT was associated with a higher rate of necrotizing enterocolitis (NEC) when compared with DCC (odds ratio = 7 (95% CI, 1.06 to 56.89), p = 0.031). CONCLUSIONS In twin subgroups, the incidence of NEC was higher in the EPT group when compared to the DCC group and therefore based on an abundance of caution the use of EPT in very preterm twins is not recommended.
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Affiliation(s)
- Yan Wu
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jiangfeng Ou
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Gongxue Chen
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yefang Zhu
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyun Zhong
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
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13
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Seidler AL, Aberoumand M, Hunter KE, Barba A, Libesman S, Williams JG, Shrestha N, Aagerup J, Sotiropoulos JX, Montgomery AA, Gyte GML, Duley L, Askie LM. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet 2023; 402:2209-2222. [PMID: 37977169 DOI: 10.1016/s0140-6736(23)02468-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth. METHODS We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640. FINDINGS We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality. INTERPRETATION This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Anna Lene Seidler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia.
| | - Mason Aberoumand
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Kylie E Hunter
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Angie Barba
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Sol Libesman
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Nipun Shrestha
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Jannik Aagerup
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
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14
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Alikhani VS, Thies-Lagergren L, Svedenkrans J, Elfvin A, Bolk J, Andersson O. Stabilisation and resuscitation with intact cord circulation is feasible using a wide variety of approaches; a scoping review. Acta Paediatr 2023; 112:2468-2477. [PMID: 37767916 DOI: 10.1111/apa.16985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
AIM This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section). METHODS A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022. RESULTS We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole. CONCLUSION We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches.
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Affiliation(s)
- Vesta Seyed Alikhani
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Jenny Svedenkrans
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Lund University, Lund, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jenny Bolk
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Ola Andersson
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Lund University, Lund, Sweden
- Department of Neonatology, Skåne University Hospital, Malmö, Sweden
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15
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Soll RF. Further Insights Into Cord Management. Pediatrics 2023; 152:e2023063505. [PMID: 37941448 DOI: 10.1542/peds.2023-063505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/10/2023] Open
Affiliation(s)
- Roger F Soll
- H. Wallace Professor of Neonatology, Vermont Oxford Network Institute for Evidence Based Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
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16
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Kuehne B, Grüttner B, Hellmich M, Hero B, Kribs A, Oberthuer A. Extrauterine Placental Perfusion and Oxygenation in Infants With Very Low Birth Weight: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2340597. [PMID: 37921769 PMCID: PMC10625045 DOI: 10.1001/jamanetworkopen.2023.40597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/17/2023] [Indexed: 11/04/2023] Open
Abstract
Importance An extrauterine placental perfusion (EPP) approach for physiological-based cord clamping (PBCC) may support infants with very low birth weight (VLBW) during transition without delaying measures of support. Objective To test whether EPP in resuscitation of infants with VLBW results in higher hematocrit levels, better oxygenation, or improved infant outcomes compared with delayed cord clamping (DCC). Design, Setting, and Participants This nonblinded, single-center randomized clinical trial was conducted at a tertiary care neonatal intensive care unit. Infants with a gestational age greater than 23 weeks and birth weight less than 1500 g born by cesarean delivery between May 2019 and June 2021 were included. Data were analyzed from October through December 2021. Intervention Prior to cesarean delivery, participants were allocated to receive EPP or DCC. In the EPP group, infant and placenta, connected by an intact umbilical cord, were detached from the uterus and transferred to the resuscitation unit. Respiratory support was initiated while holding the placenta over the infant. The umbilical cord was clamped when infants showed regular spontaneous breathing, stable heart rates greater than 100 beats/min, and adequate oxygen saturations. In the DCC group, cords were clamped 30 to 60 seconds after birth before infants were transferred to the resuscitation unit, where respiratory support was started. Main Outcomes and Measure The primary outcome was the mean hematocrit level in the first 24 hours after birth. Secondary prespecified outcome parameters comprised oxygenation during transition and short-term neonatal outcome. Results Among 60 infants randomized and included, 1 infant was excluded after randomization; there were 29 infants in the EPP group (mean [SD] gestational age, 27 weeks 6 days [15.0 days]; 14 females [48.3%]) and 30 infants in the DCC group (mean [SD] gestational age, 28 weeks 1 day [17.1 days]; 17 females [56.7%]). The mean (SD) birth weight was 982.8 (276.6) g and 970.2 (323.0) g in the EPP and DCC group, respectively. Intention-to-treat analysis revealed no significant difference in mean hematocrit level (mean difference [MD], 2.1 percentage points; [95% CI, -2.2 to 6.4 percentage points]). During transition, infants in the EPP group had significantly higher peripheral oxygen saturation as measured by pulse oximetry (adjusted MD at 5 minutes, 15.3 percentage points [95% CI, 2.0 to 28.6 percentage points]) and regional cerebral oxygen saturation (adjusted MD at 5 minutes, 11.3 percentage points [95% CI, 2.0 to 20.6 percentage points]). Neonatal outcome parameters were similar in the 2 groups. Conclusions and Relevance This study found that EPP resulted in similar hematocrit levels as DCC, with improved cerebral and peripheral oxygenation during transition. These findings suggest that EPP may be an alternative procedure for PBCC in infants with VLBW. Trial Registration ClinicalTrials.gov Identifier: NCT03916159.
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Affiliation(s)
- Benjamin Kuehne
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Berthold Grüttner
- Department of Gynecology and Obstetrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Barbara Hero
- Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Angela Kribs
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - André Oberthuer
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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17
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Roberts CT, O'Shea JE. Alternatives to neonatal intubation. Semin Fetal Neonatal Med 2023; 28:101488. [PMID: 38000926 DOI: 10.1016/j.siny.2023.101488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.
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Affiliation(s)
- Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
| | - Joyce E O'Shea
- Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
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18
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Edwards H, Dorner RA, Katheria AC. Optimizing transition: Providing oxygen during intact cord resuscitation. Semin Perinatol 2023; 47:151787. [PMID: 37380527 PMCID: PMC10529853 DOI: 10.1016/j.semperi.2023.151787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Delayed clamping and cutting of the umbilical cord at birth is standard practice for management for all newborns. Preterm infants may additionally benefit from a combination of ventilation and oxygen provision during intact cord resuscitation. This review highlights both the potential benefits of such a combined approach and the need for further rigorous studies, including randomized controlled trials, of delivery room management in this population.
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Affiliation(s)
- Hannah Edwards
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Rebecca A Dorner
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States.
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19
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Rabe H, Mercer J. Knowledge gaps in optimal umbilical cord management at birth. Semin Perinatol 2023:151791. [PMID: 37357042 DOI: 10.1016/j.semperi.2023.151791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
In 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.
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Affiliation(s)
- Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, University of Sussex, UK.
| | - Judith Mercer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego CA, USA; College of Nursing, University of Rhode Island, Kingston RI, USA
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20
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Tarnow-Mordi WO, Robledo K, Marschner I, Seidler L, Simes J. To guide future practice, perinatal trials should be much larger, simpler and less fragile with close to 100% ascertainment of mortality and other key outcomes. Semin Perinatol 2023:151789. [PMID: 37422415 DOI: 10.1016/j.semperi.2023.151789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
The Australian Placental Transfusion Study (APTS) randomised 1,634 fetuses to delayed (≥60 s) versus immediate (≤10 s) clamping of the umbilical cord. Systematic reviews with meta-analyses, including this and similar trials, show that delaying clamping in preterm infants reduces mortality and need for blood transfusions. Amongst 1,531 infants in APTS followed up at two years, aiming to delay clamping for 60 s or more reduced the relative risk of the primary composite outcome of death or disability by 17% (p = 0.01). However, this result is fragile because nominal statistical significance (p < 0.05) would be abolished by only 2 patients switching from a non-event to an event, and the primary composite outcome was missing in 112 patients (7%). To achieve more robust evidence, any future trials should emulate the large, simple trials co-ordinated from Oxford which reliably identified moderate, incremental improvements in mortality in tens of thousands of participants, with <1% missing data. Those who fund, regulate, and conduct trials that aim to change practice should repay the trust of those who consent to participate by doing everything possible to minimise missing data for key outcomes.
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Affiliation(s)
- William Odita Tarnow-Mordi
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia; Neonatal and Perinatal Trials, NHMRC Clinical Trials Centre, Medical Foundation Building, Medical Levels 4-6, 92-94 Parramatta Rd, Camperdown NSW 2050, Australia.
| | - Kristy Robledo
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - Ian Marschner
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - Lene Seidler
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - John Simes
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
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21
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Fairchild K. Assisted ventilation prior to umbilical cord clamping: Potential benefits, challenges, and research studies. Semin Perinatol 2023:151788. [PMID: 37380529 DOI: 10.1016/j.semperi.2023.151788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Delayed cord clamping (DCC) is beneficial for many infants, and the American College of Obstetrics and Gynecology recommends at least 30-60 seconds of DCC for both term and preterm vigorous infants. For newly born infants that are not vigorous, some evidence in animal models suggests that providing assisted ventilation prior to cord clamping (V-DCC) leads to a more stable transition of cerebral, pulmonary and systemic circulation and oxygenation and may confer not only short-term physiologic benefits but perhaps also improvement in clinically important outcomes. This review is based around 7 questions to help the reader understand the physiologic underpinnings and challenges of V-DCC as well as the published and ongoing research studies aimed at determining whether V-DCC is beneficial for preterm or term infants.
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Affiliation(s)
- Karen Fairchild
- Division of Neonatology, University of Virginia School of Medicine, PO Box 800386, Charlottesville, VA 22908, USA.
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Koo J, Aghai ZH, Katheria A. Cord management in non-vigorous newborns. Semin Perinatol 2023; 47:151742. [PMID: 37031034 PMCID: PMC10239342 DOI: 10.1016/j.semperi.2023.151742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
Cord management in non-vigorous newborns remains up for debate, as limited studies have validated strategies in this high-risk population. While multiple national and international governing bodies now recommend the routine practice of delayed cord clamping (DCC) in vigorous neonates, these organizations have not reached a consensus on the appropriate approach in non-vigorous neonates.1 Benefits of placental transfusion are greatly needed amongst non-vigorous neonates who are at risk of asphyxiation-associated mortality and morbidities, but the need for immediate resuscitation complicates matters. This chapter discusses the physiological benefits of placental transfusion for non-vigorous neonates and reviews the available literature on different umbilical cord management strategies for this population.
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Affiliation(s)
- Jenny Koo
- Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, CA, USA
| | - Zubair H Aghai
- Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Anup Katheria
- Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, CA, USA.
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Razak A, Patel W, Durrani NUR, Pullattayil AK. Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e237473. [PMID: 37052920 PMCID: PMC10102877 DOI: 10.1001/jamanetworkopen.2023.7473] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/23/2023] [Indexed: 04/14/2023] Open
Abstract
Importance Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials. Objective To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates. Data Sources MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions. Study Selection Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included. Data Extraction and Synthesis Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis. Main Outcomes and Measures The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury. Results A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]). Conclusions and Relevance Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.
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Affiliation(s)
- Abdul Razak
- Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Victoria, Australia
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Waseemoddin Patel
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
| | - Naveed Ur Rehman Durrani
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
- Department of Pediatrics, Weill Cornell Medicine–Qatar, Doha, Qatar
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Seidler AL, Hunter KE, Barba A, Aberoumand M, Libesman S, Williams JG, Shrestha N, Aagerup J, Gyte G, Montgomery A, Duley L, Askie L. Optimizing cord management for each preterm baby - Challenges of collating individual participant data and recommendations for future collaborative research. Semin Perinatol 2023:151740. [PMID: 37019711 DOI: 10.1016/j.semperi.2023.151740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
The optimal cord management strategy at birth for each preterm baby is still unknown, despite more than 100 randomized controlled trials (RCTs) undertaken on this question. To address this, we brought together all RCTs examining cord management strategies at preterm birth in the iCOMP (individual participant data on COrd Management at Preterm birth) Collaboration, to perform an individual participant data network meta-analysis. In this paper, we describe the trials and tribulations around obtaining individual participant data to resolve controversies around cord clamping, and we derive key recommendations for future collaborative research in perinatology. To reliably answer outstanding questions, future cord management research needs to be collaborative and coordinated, by aligning core protocol elements, ensuring quality and reporting standards are met, and carefully considering and reporting on vulnerable sub-populations. The iCOMP Collaboration is an example of the power of collaboration to address priority research questions, and ultimately improve neonatal outcomes worldwide.
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Affiliation(s)
- Anna Lene Seidler
- Senior Research Fellow, NHMRC Clinical Trials Centre, University of Sydney, Australia.
| | - Kylie E Hunter
- Human Mvt, Senior Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Angie Barba
- Senior Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Mason Aberoumand
- Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Sol Libesman
- Post Doctoral Research Associate, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Jonathan G Williams
- BMedBiotech, Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Nipun Shrestha
- Post Doctoral Research Associate, NHMRC Clinical Trials Center, University of Sydney, Australia
| | - Jannik Aagerup
- Research Administration Officer, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Gill Gyte
- Consumer Editor, Cochrane Pregnancy and Childbirth, University of Liverpool, UK
| | - Alan Montgomery
- Professor of Medical Statistics and Clinical Trials, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | | | - Lisa Askie
- MPH FAHMS FHEA, University of Sydney, Australia
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Song D, Jelks A, Narasimhan SR, Jegatheesan P. Cord management strategies in multifetal gestational births. Semin Perinatol 2023:151743. [PMID: 37005172 DOI: 10.1016/j.semperi.2023.151743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
Multifetal gestations are associated with high risks of neonatal mortality and morbidities primarily due to prematurity. Delayed cord clamping and cord milking facilitate the postnatal transition and improve outcomes. Limited evidence shows that delayed cord clamping for 30-60 s and cord milking are feasible without causing harm and potentially beneficial in uncomplicated multifetal deliveries. However, data on maternal bleeding from the limited studies are inconsistent. Based on current knowledge of the risk vs. benefits, it is reasonable to perform delayed cord clamping or cord milking (>28 weeks of gestation) in uncomplicated monochorionic and dichorionic multiples. Clearly defined criteria for suitable candidates, indications for clamping or milking the cord during delivery, and improved obstetric techniques in Cesarean deliveries are critical to minimize risks and optimize neonatal transition. Research is needed to identify safe and optimal cord-management strategies for improving survival and long-term outcomes in this high-risk population.
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Affiliation(s)
- Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Jelks
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sudha Rani Narasimhan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar J, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Gene Ong YK, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Pediatrics 2023; 151:189896. [PMID: 36325925 DOI: 10.1542/peds.2022-060463] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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Nevill E, Mildenhall LFJ, Meyer MP. Effect of Breathing Support in Very Preterm Infants Not Breathing During Deferred Cord Clamping: A Randomized Controlled Trial (The ABC Study). J Pediatr 2023; 253:94-100.e1. [PMID: 36152686 DOI: 10.1016/j.jpeds.2022.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine if providing respiratory support to very preterm infants who fail to breathe regularly during deferred cord clamping (DCC) decreased red cell transfusion. STUDY DESIGN Infants less than 31 weeks of gestation undergoing DCC who were apneic or not breathing regularly at 15 seconds underwent stratified randomization. Pale, limp, and nonresponsive infants were excluded. The standard group received gentle stimulation in a neutral position for 50 seconds; the intervention group received intermittent positive pressure ventilation via face mask and T piece from 20 to 50 seconds of age with a fractional inspired oxygen of 0.3. The primary outcome was the proportion transfused, with a secondary composite outcome of death, severe intraventricular hemorrhage, or chronic lung disease. RESULTS Of 311 assessed infants, 113 met the inclusion criteria and were studied; 57 received the intervention and 56 standard treatment. Patient characteristics were similar. Overall, 105 infants (93%) received the intended 50 seconds DCC (54 in the intervention group and 51 in the standard group). Rates of transfusion were similar (28% vs 30% in the intervention vs control groups), as were rates of the composite outcome (46% vs 38% in the intervention vs the control arms; P = .45). CONCLUSIONS Providing breathing support during 50 seconds of DCC in this single-center cohort seemed to be safe and feasible, but did not decrease the transfusion rates or improve outcomes. TRIAL REGISTRATION http://www.anzctr.org.au/ACTRN12615001026516.aspx.
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Affiliation(s)
| | - Lindsay F J Mildenhall
- Middlemore Hospital, Auckland, New Zealand; Department of Pediatrics, The University of Auckland, Auckland, New Zealand
| | - Michael P Meyer
- Middlemore Hospital, Auckland, New Zealand; Department of Pediatrics, The University of Auckland, Auckland, New Zealand
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Koo J, Kilicdag H, Katheria A. Umbilical cord milking-benefits and risks. Front Pediatr 2023; 11:1146057. [PMID: 37144151 PMCID: PMC10151786 DOI: 10.3389/fped.2023.1146057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.
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Affiliation(s)
- Jenny Koo
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, United States
| | - Hasan Kilicdag
- Divisions of Neonatology, Baskent University Faculty of Medicine, Ankara, Türkiye
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, United States
- Correspondence: Anup Katheria
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Blank DA, Crossley KJ, Thiel A, Rodgers KA, Zahra V, Kluckow M, Gill AW, Polglase GR, Hooper SB. Lung aeration reduces blood pressure surges caused by umbilical cord milking in preterm lambs. Front Pediatr 2023; 11:1073904. [PMID: 37025294 PMCID: PMC10071016 DOI: 10.3389/fped.2023.1073904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/17/2023] [Indexed: 04/08/2023] Open
Abstract
Background Umbilical cord milking (UCM) at birth causes surges in arterial blood pressure and blood flow to the brain, which may explain the high risk of intraventricular haemorrhage (IVH) in extremely preterm infants receiving UCM. This high risk of IVH has not been reported in older infants. Objective We hypothesized that lung aeration before UCM, reduces the surge in blood pressure and blood flow induced by UCM. Methods At 126 days' gestation, fetal lambs (N = 8) were exteriorised, intubated and instrumented to measure umbilical, pulmonary, cerebral blood flows, and arterial pressures. Prior to ventilation onset, the umbilical cord was briefly (2-3 s) occluded (8 times), which was followed by 8 consecutive UCMs when all physiological parameters had returned to baseline. Lambs were then ventilated. After diastolic pulmonary blood flow markedly increased in response to ventilation, the lambs received a further 8 consecutive UCMs. Ovine umbilical cord is shorter than the human umbilical cord, with ∼10 cm available for UCMs. Therefore, 8 UCMs/occlusions were done to match the volume reported in the human studies. Umbilical cord clamping occurred after the final milk. Results Both umbilical cord occlusions and UCM caused significant increases in carotid arterial blood flow and pressure. However, the increases in systolic and mean arterial blood pressure (10 ± 3 mmHg vs. 3 ± 2 mmHg, p = 0.01 and 10 ± 4 mmHg vs. 6 ± 2 mmHg, p = 0.048, respectively) and carotid artery blood flow (17 ± 6 ml/min vs. 10 ± 6 ml/min, p = 0.02) were significantly greater when UCM occurred before ventilation onset compared with UCM after ventilation. Conclusions UCM after ventilation onset significantly reduces the increases in carotid blood flow and blood pressure caused by UCM.
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Affiliation(s)
- Douglas A. Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
- The Department of Paediatrics, Monash University, Melbourne, VIC, Australia
- Correspondence: Douglas A. Blank
| | - Kelly J. Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- The Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Alison Thiel
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Karyn A. Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Valerie Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital and University of Sydney, Sydney NSW, Australia
| | - Andrew W. Gill
- Centre for Neonatal Research and Education, University of Western Australia, Perth, WA, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- The Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Stuart B. Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- The Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Chung SP, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Ong YKG, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM, Cartledge S, Dawson JA, Elgohary MM, Ersdal HL, Finan E, Flaatten HI, Flores GE, Fuerch J, Garg R, Gately C, Goh M, Halamek LP, Handley AJ, Hatanaka T, Hoover A, Issa M, Johnson S, Kamlin CO, Ko YC, Kule A, Leone TA, MacKenzie E, Macneil F, Montgomery W, O’Dochartaigh D, Ohshimo S, Palazzo FS, Picard C, Quek BH, Raitt J, Ramaswamy VV, Scapigliati A, Shah BA, Stewart C, Strand ML, Szyld E, Thio M, Topjian AA, Udaeta E, Vaillancourt C, Wetsch WA, Wigginton J, Yamada NK, Yao S, Zace D, Zelop CM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation 2022; 146:e483-e557. [PMID: 36325905 DOI: 10.1161/cir.0000000000001095] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimizing pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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Lung Aeration During Deferred Cord Clamping-No Additional Benefits in Infants Born Preterm? J Pediatr 2022; 255:11-15.e6. [PMID: 36463936 DOI: 10.1016/j.jpeds.2022.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
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Wyckoff MH, Greif R, Morley PT, Ng KC, Olasveengen TM, Singletary EM, Soar J, Cheng A, Drennan IR, Liley HG, Scholefield BR, Smyth MA, Welsford M, Zideman DA, Acworth J, Aickin R, Andersen LW, Atkins D, Berry DC, Bhanji F, Bierens J, Borra V, Böttiger BW, Bradley RN, Bray JE, Breckwoldt J, Callaway CW, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Phil Chung S, Considine J, Costa-Nobre DT, Couper K, Couto TB, Dainty KN, Davis PG, de Almeida MF, de Caen AR, Deakin CD, Djärv T, Donnino MW, Douma MJ, Duff JP, Dunne CL, Eastwood K, El-Naggar W, Fabres JG, Fawke J, Finn J, Foglia EE, Folke F, Gilfoyle E, Goolsby CA, Granfeldt A, Guerguerian AM, Guinsburg R, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hsu CH, Ikeyama T, Isayama T, Johnson NJ, Kapadia VS, Kawakami MD, Kim HS, Kleinman M, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lee HC, Lin YJ, Lockey AS, Maconochie IK, Madar RJ, Malta Hansen C, Masterson S, Matsuyama T, McKinlay CJD, Meyran D, Morgan P, Morrison LJ, Nadkarni V, Nakwa FL, Nation KJ, Nehme Z, Nemeth M, Neumar RW, Nicholson T, Nikolaou N, Nishiyama C, Norii T, Nuthall GA, O'Neill BJ, Gene Ong YK, Orkin AM, Paiva EF, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reis AG, Reynolds JC, Ristagno G, Rodriguez-Nunez A, Roehr CC, Rüdiger M, Sakamoto T, Sandroni C, Sawyer TL, Schexnayder SM, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Sugiura T, Tijssen JA, Trevisanuto D, Van de Voorde P, Wang TL, Weiner GM, Wyllie JP, Yang CW, Yeung J, Nolan JP, Berg KM, Cartledge S, Dawson JA, Elgohary MM, Ersdal HL, Finan E, Flaatten HI, Flores GE, Fuerch J, Garg R, Gately C, Goh M, Halamek LP, Handley AJ, Hatanaka T, Hoover A, Issa M, Johnson S, Kamlin CO, Ko YC, Kule A, Leone TA, MacKenzie E, Macneil F, Montgomery W, O’Dochartaigh D, Ohshimo S, Stefano Palazzo F, Picard C, Quek BH, Raitt J, Ramaswamy VV, Scapigliati A, Shah BA, Stewart C, Strand ML, Szyld E, Thio M, Topjian AA, Udaeta E, Vaillancourt C, Wetsch WA, Wigginton J, Yamada NK, Yao S, Zace D, Zelop CM. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Resuscitation 2022; 181:208-288. [PMID: 36336195 DOI: 10.1016/j.resuscitation.2022.10.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This is the sixth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. This summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. Topics covered by systematic reviews include cardiopulmonary resuscitation during transport; approach to resuscitation after drowning; passive ventilation; minimising pauses during cardiopulmonary resuscitation; temperature management after cardiac arrest; use of diagnostic point-of-care ultrasound during cardiac arrest; use of vasopressin and corticosteroids during cardiac arrest; coronary angiography after cardiac arrest; public-access defibrillation devices for children; pediatric early warning systems; maintaining normal temperature immediately after birth; suctioning of amniotic fluid at birth; tactile stimulation for resuscitation immediately after birth; use of continuous positive airway pressure for respiratory distress at term birth; respiratory and heart rate monitoring in the delivery room; supraglottic airway use in neonates; prearrest prediction of in-hospital cardiac arrest mortality; basic life support training for likely rescuers of high-risk populations; effect of resuscitation team training; blended learning for life support training; training and recertification for resuscitation instructors; and recovery position for maintenance of breathing and prevention of cardiac arrest. Members from 6 task forces have assessed, discussed, and debated the quality of the evidence using Grading of Recommendations Assessment, Development, and Evaluation criteria and generated consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections, and priority knowledge gaps for future research are listed.
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A newborn's "life line" - A review of umbilical cord management strategies. Semin Perinatol 2022; 46:151621. [PMID: 35697528 DOI: 10.1016/j.semperi.2022.151621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Literature supporting various umbilical management strategies have increased substantially over the past decade. Delayed cord clamping and umbilical cord milking are increasing embraced by obstetricians and neonatologists, and multiple international governing bodies now endorse these practices. This review summarizes the benefits and limitations of the different umbilical cord management strategies for term, near-term, and preterm neonates. Additional studies are underway to elucidate the safety profile of these practices, long term outcomes, and variations within these strategies that could potentially augment the benefits.
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Knol R, Brouwer E, van den Akker T, DeKoninck PLJ, Lopriore E, Onland W, Vermeulen MJ, van den Akker-van Marle ME, van Bodegom-Vos L, de Boode WP, van Kaam AH, Reiss IKM, Polglase GR, Hutten GJ, Prins SA, Mulder EEM, Hulzebos CV, van Sambeeck SJ, van der Putten ME, Zonnenberg IA, Hooper SB, Te Pas AB. Physiological-based cord clamping in very preterm infants: the Aeration, Breathing, Clamping 3 (ABC3) trial-study protocol for a multicentre randomised controlled trial. Trials 2022; 23:838. [PMID: 36183143 PMCID: PMC9526936 DOI: 10.1186/s13063-022-06789-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International guidelines recommend delayed umbilical cord clamping (DCC) up to 1 min in preterm infants, unless the condition of the infant requires immediate resuscitation. However, clamping the cord prior to lung aeration may severely limit circulatory adaptation resulting in a reduction in cardiac output and hypoxia. Delaying cord clamping until lung aeration and ventilation have been established (physiological-based cord clamping, PBCC) allows for an adequately established pulmonary circulation and results in a more stable circulatory transition. The decline in cardiac output following time-based delayed cord clamping (TBCC) may thus be avoided. We hypothesise that PBCC, compared to TBCC, results in a more stable transition in very preterm infants, leading to improved clinical outcomes. The primary objective is to compare the effect of PBCC on intact survival with TBCC. METHODS The Aeriation, Breathing, Clamping 3 (ABC3) trial is a multicentre randomised controlled clinical trial. In the interventional PBCC group, the umbilical cord is clamped after the infant is stabilised, defined as reaching heart rate > 100 bpm and SpO2 > 85% while using supplemental oxygen < 40%. In the control TBCC group, cord clamping is time based at 30-60 s. The primary outcome is survival without major cerebral and/or intestinal injury. Preterm infants born before 30 weeks of gestation are included after prenatal parental informed consent. The required sample size is 660 infants. DISCUSSION The findings of this trial will provide evidence for future clinical guidelines on optimal cord clamping management in very preterm infants at birth. TRIAL REGISTRATION ClinicalTrials.gov NCT03808051. First registered on January 17, 2019.
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Affiliation(s)
- Ronny Knol
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands. .,Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Emma Brouwer
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.,Athena Institute, VU University, Amsterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Enrico Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | | | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sandra A Prins
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Estelle E M Mulder
- Department of Neonatology, Isala Women and Children's Hospital, Zwolle, The Netherlands
| | - Christian V Hulzebos
- Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Sam J van Sambeeck
- Department of Paediatrics, Maxima Medical Center, Veldhoven, The Netherlands
| | - Mayke E van der Putten
- Department of Paediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Inge A Zonnenberg
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Lu J, Yue G, Wang Q, Zhou X, Ju R. A review on development of placental transfusion in term and preterm infants. Front Pediatr 2022; 10:890988. [PMID: 36186636 PMCID: PMC9520323 DOI: 10.3389/fped.2022.890988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/30/2022] [Indexed: 11/16/2022] Open
Abstract
In recent years, it has been verified that placental transfusion can replenish blood volume of neonates, improve organ perfusion in the early postnatal stage, and facilitate the transition from fetal circulation to adult circulation. Meanwhile, placental transfusion can reduce the need for blood transfusion and the onset of intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, and other complications. Furthermore, it can improve the iron store and the long-term prognosis of central nervous system, and reduce infant mortality. Different methods have been used, including delayed cord clamping, intact umbilical cord milking, and cut umbilical cord milking. The World Health Organization (WHO) and other academic organizations recommend the routine use of delayed cord clamping at birth for the most vigorous term and preterm neonates. However, details of placental transfusion should be clarified, and the short/long-term impacts of this technology on some infants with special conditions still require further study.
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Affiliation(s)
| | | | | | | | - Rong Ju
- Neonatal Department, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Wanous AA, Ibrahim J, Vats KR. Neonatal resuscitation. Semin Pediatr Surg 2022; 31:151204. [PMID: 36038213 DOI: 10.1016/j.sempedsurg.2022.151204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Amanda A Wanous
- Division of Newborn Medicine, Department of Pediatrics, Children and Magee Women's Hospital, University of Pittsburgh, 300 Halket Street, PA 12513, United States
| | - John Ibrahim
- Division of Newborn Medicine, Department of Pediatrics, Children and Magee Women's Hospital, University of Pittsburgh, 300 Halket Street, PA 12513, United States
| | - Kalyani R Vats
- Division of Newborn Medicine, Department of Pediatrics, Children and Magee Women's Hospital, University of Pittsburgh, 300 Halket Street, PA 12513, United States.
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A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol. BMC Pregnancy Childbirth 2022; 22:593. [PMID: 35883044 PMCID: PMC9315331 DOI: 10.1186/s12884-022-04915-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An intact umbilical cord allows the physiological transfusion of blood from the placenta to the neonate, which reduces infant iron deficiency and is associated with improved development during early childhood. The implementation of delayed cord clamping practice varies depending on mode of delivery, as well as gestational age and neonatal compromise. Emerging evidence shows that infants requiring resuscitation would benefit if respiratory support were provided with the umbilical cord intact. Common barriers to providing intact cord resuscitation is the availability of neonatal resuscitation equipment close to the mother, organizational readiness for change as well as attitudes and beliefs about placental transfusion within the multidisciplinary team. Hence, clinical evaluations of cord clamping practice should include implementation outcomes in order to develop strategies for optimal cord management practice. METHODS The Sustained cord circulation And Ventilation (SAVE) study is a hybrid type I randomized controlled study combining the evaluation of clinical outcomes with implementation and health service outcomes. In phase I of the study, a method for providing in-bed intact cord resuscitation was developed, in phase II of the study the intervention was adapted to be used in multiple settings. In phase III of the study, a full-scale multicenter study will be initiated with concurrent evaluation of clinical, implementation and health service outcomes. Clinical data on neonatal outcomes will be recorded at the labor and neonatal units. Implementation outcomes will be collected from electronic surveys sent to parents as well as staff and managers within the birth and neonatal units. Descriptive and comparative statistics and regression modelling will be used for analysis. Quantitative data will be supplemented by qualitative methods using a thematic analysis with an inductive approach. DISCUSSION The SAVE study enables the safe development and evaluation of a method for intact cord resuscitation in a multicenter trial. The study identifies barriers and facilitators for intact cord resuscitation. The knowledge provided from the study will be of benefit for the development of cord clamping practice in different challenging clinical settings and provide evidence for development of clinical guidelines regarding optimal cord clamping. TRIAL REGISTRATION Clinicaltrials.gov, NCT04070560 . Registered 28 August 2019.
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38
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Koo J, Katheria A. Cardiopulmonary Resuscitation with an Intact Umbilical Cord. Neoreviews 2022; 23:e388-e399. [PMID: 35641463 DOI: 10.1542/neo.23-6-e388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The body of literature supporting different umbilical management strategies has increased over the past decade as the role of cord management in neonatal transition is realized. Multiple international governing bodies endorse delayed cord clamping, and this practice is now widely accepted by obstetricians and neonatologists. Although term and preterm neonates benefit in some ways from delayed cord clamping, additional research on variations in this practice, including resuscitation with an intact cord, aim to find the optimal cord management practice that reduces mortality and major morbidities.
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Affiliation(s)
- Jenny Koo
- Sharp Mary Birch, Hospital for Women and Newborn, San Diego, CA.,Sharp Neonatal Research Institute, San Diego, CA
| | - Anup Katheria
- Sharp Mary Birch, Hospital for Women and Newborn, San Diego, CA.,Sharp Neonatal Research Institute, San Diego, CA.,Loma Linda University Medical Center, Loma Linda, CA
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Guinsburg R, de Almeida MFB, Finan E, Perlman JM, Wyllie J, Liley HG, Wyckoff MH, Isayama T. Tactile Stimulation in Newborn Infants With Inadequate Respiration at Birth: A Systematic Review. Pediatrics 2022; 149:185380. [PMID: 35257181 DOI: 10.1542/peds.2021-055067] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT For many years the International Liaison Committee on Resuscitation has recommended the use of tactile stimulation for initial management of infants born with inadequate respiratory effort at birth without systematically examining its effectiveness. OBJECTIVE Systematic review to compare the effectiveness of tactile stimulation with routine handling in newly born term and preterm infants. DATA SOURCES Medline, Embase, Cochrane CENTRAL, along with clinical trial registries. STUDY SELECTION Randomized and non-randomized studies were included based on predetermined criteria. DATA EXTRACTION Data were extracted independently by authors. Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) was used to assess risk of bias in non-randomized studies. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used to assess the certainty of evidence. RESULTS Among 2455 unique articles identified, 2 observational studies were eligible and qualitatively summarized. Because one of the studies was at critical risk of bias, only the other study including 243 preterm infants on continuous positive airway pressure with clinical indications for tactile stimulation was analyzed. It showed a reduction in tracheal intubation in infants receiving tactile stimulation compared with no tactile stimulation (12 of 164 vs 14 of 79, risk ratio of 0.41 [95% confidence interval 0.20 to 0.85]); however, the certainty of evidence was very low. LIMITATIONS The available data were limited and only from observational studies. CONCLUSIONS A potential benefit of tactile stimulation was identified but was limited by the very low certainty of evidence. More research is suggested to evaluate the effectiveness as well as the optimal type and duration of tactile stimulation.
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Affiliation(s)
- Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Emer Finan
- Department of Paediatrics, Sinai Health, Toronto, Ontario, Canada
| | - Jeffrey M Perlman
- Weill Cornell Medicine and New York-Presbyterian Komansky Children's Hospital, New York, New York
| | - Jonathan Wyllie
- Department of Paediatrics and Neonatology, James Cook University Hospital, South Tees National Health Services Foundation Trust, Middlesbrough, United Kingdom
| | - Helen G Liley
- Mater Research Institute and Mater Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Myra H Wyckoff
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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Robledo KP, Tarnow-Mordi WO, Rieger I, Suresh P, Martin A, Yeung C, Ghadge A, Liley HG, Osborn D, Morris J, Hague W, Kluckow M, Lui K, Soll R, Cruz M, Keech A, Kirby A, Simes J, Popat H, Reid S, Gordon A, De Waal K, Wright IM, Wright A, Buchan J, Stubbs M, Newnham J, Simmer K, Young C, Loh D, Kok Y, Gill A, Strunk T, Jeffery M, Chen Y, Morris S, Sinhal S, Cornthwaite K, Walker SP, Watkins AM, Collins CL, Holberton JR, Noble EJ, Sehgal A, Yeomans E, Elsayed K, Mohamed AL, Broom M, Koh G, Lawrence A, Gardener G, Fox J, Cartwright DW, Koorts P, Pritchard MA, McKeown L, Lainchbury A, Shand AW, Michalowski J, Smyth JP, Bolisetty S, Adno A, Lee G, Seidler AL, Askie LM, Groom KM, Eaglen DA, Baker EC, Patel H, Wilkes N, Gullam JE, Austin N, Leishman DE, Weston P, White N, Cooper NA, Broadbent R, Stitely M, Dawson P, El-Naggar W, Furlong M, Hatfield T, de Luca D, Benachi A, Letamendia-Richard E, Escourrou G, Dell'Orto V, Sweet D, Millar M, Shah S, Sheikh L, Ariff S, Morris EA, Young L, Evans SK, Belfort M, Aagaard K, Pammi M, Mandy G, Gandhi M, Davey J, Shenton E, Middleton J, Black R, Cheng A, Murdoch J, Jacobs C, Meyer L, Medlin K, Woods H, O'Connor KA, Bice C, Scott K, Hayes M, Cruickshank D, Sam M, Ireland S, Dickinson C, Poulsen L, Fucek A, Hegarty J, Rogers J, Sanchez D, Zupan Simunek V, Hanif B, Pahl A, Metayer J, Duley L, Marlow N, Schofield D, Bowen J. Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): a multicentre, randomised clinical trial. THE LANCET CHILD & ADOLESCENT HEALTH 2022; 6:150-157. [DOI: 10.1016/s2352-4642(21)00373-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/04/2021] [Accepted: 11/17/2021] [Indexed: 01/07/2023]
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Kilicdag H, Parlakgumus D, Demir SC, Satar M. Effects of spontaneous first breath on placental transfusion in term neonates born by cesarean section: A randomized controlled trial. Front Pediatr 2022; 10:925656. [PMID: 36177452 PMCID: PMC9513210 DOI: 10.3389/fped.2022.925656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of umbilical cord management in placental transfusion in cesarean section (CS) requires clarification. The spontaneous first breath may be more important than the timing of cord clamping for placental transfusion in neonates born by CS. OBJECTIVE This study aimed to evaluate the impact of cord clamping after the first spontaneous breath on placental transfusion in neonates born by CS. METHODS We recruited women with a live singleton pregnancy at ≥37.0 weeks of gestation admitted for CS. The interventions performed, such as physiologic-based cord clamping (PBCC), intact-umbilical cord milking (I-UCM), 30-s delay in cord clamping (30-s DCC), and 60-s delay in cord clamping (60-s DCC), were noted and placed in a sealed envelope. The sealed envelope was opened immediately before delivery to perform randomization. RESULTS A total of 123 infants were eligible for evaluation. Of these, 31, 30, 32, and 30 were assigned to the PBCC, I-UCM, 30-s DCC, and 60-s DCC groups, respectively. The mean hemoglobin (Hb) and mean hematocrit (Hct) were significantly higher in the 60-s DCC group than in the PBCC group (p = 0.028 and 0.019, respectively), but no difference was noted among the I-UCM, 30-s DCC, and PBCC groups at 36 h of age. Further, no significant differences were observed in the mean Hb and mean Hct among the I-UCM, 60-s DCC, and 30-s DCC groups. Peak total serum bilirubin (TSB) levels were higher in the 60-s DCC group than in the I-UCM and PBCC groups (p = 0.017), but there was no difference between the 60-s DCC and 30-s DCC groups during the first week of life. The phototherapy requirement was higher in 60-s DCC than in IUCM and 30-sDCC (p = 0.001). CONCLUSIONS Our findings demonstrated that PBCC, 30-s DCC, and I-UCM in neonates born by CS had no significant differences from each other on placental transfusion. The Hb and Hct in the neonates were higher after 60-s DCC than after PBCC.
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Affiliation(s)
- Hasan Kilicdag
- Division of Neonatology, Department of Pediatrics, Acibadem Adana Hospital, Adana, Turkey
| | | | - Suleyman Cansun Demir
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cukurova University, Adana, Turkey
| | - Mehmet Satar
- Division of Neonatology, Department of Pediatrics, Cukurova University, Adana, Turkey
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Deng R, Wu Y, Xiao G, Zhong X, Gong H, Chen W, Zhou L, Shen B, Wang Q. With or Without Nasal Continuous Positive Airway Pressure During Delayed Cord Clamping in Premature Infants <32 Weeks: A Randomized Controlled Trial Using an Intention-To-Treat Analysis. Front Pediatr 2022; 10:843372. [PMID: 35433539 PMCID: PMC9008252 DOI: 10.3389/fped.2022.843372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 02/03/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To assess whether providing nasal continuous positive airway pressure (nCPAP) during delayed cord clamping is beneficial for preterm infants <32 weeks. STUDY DESIGN A randomized controlled trial was performed from March 2020 to May 2021. Premature infants (<32 weeks of gestational age; n = 160) were allocated to receive at least 60 s of delayed cord clamping with nCPAP (DCC+nCPAP; n = 80) or without nCPAP (DCC only; n = 80). For both groups, after the umbilical cord was clamped, the infants were carried immediately to the resuscitation room to continue receiving standard transition. The primary outcome was the mechanical ventilation (MV) rate within 24 h of life. The measurements related to early respiratory support effect before cord clamping including positive end-expiratory pressure (PEEP) and FiO2 during transition/leaving the delivery room, intubation rate during transition, pulmonary surfactant (PS) administration ≥2 times after birth, extubation failure, and incidence of bronchopulmonary dysplasia (BPD) were collected as the secondary outcomes. Furthermore, other neonatal short-term outcomes and safety assessment were also included. RESULTS The measurements were calculated using intention-to-treat analysis. The median time for cord clamping were 60 s with interquartile range (IQR) (60.00-60.00 vs. 60.00-70.00) in both groups. There were no difference in the primary outcome of MV rate within 24 h of life (p = 0.184). The arterial blood gas pH at 1 h after birth in the DCC+nCPAP group was 7.28 ± 0.08 vs. 7.25 ± 0.07 in the control group (mean difference = 0.01, 95% CI: -0.01-0.05, p = 0.052), which approached statistical significance. There was no significant statistical difference in the other short-term neonatal outcomes and the safety indicators between the two groups. CONCLUSIONS Our study showed that delayed cord clamping with nCPAP was feasible and safe in preterm infants with gestational age <32 weeks. Although there was a trend toward a higher arterial blood gas pH at 1 h after birth in the DCC+nCPAP group, DCC+nCPAP neither resulted in a corresponding measurable clinical improvement nor did it reduce subsequent neonatal morbidity. A larger multi-center study including more infants with gestational age <28 weeks is needed to evaluate the full effects of DCC in combination with nCPAP in preterm infants.
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Affiliation(s)
- Rui Deng
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Yan Wu
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Guiyuan Xiao
- Chongqing Health Center for Women and Children, Chongqing, China
| | - Xiaoyun Zhong
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Hua Gong
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Wen Chen
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Ligang Zhou
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Biao Shen
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
| | - Qi Wang
- Neonatal Department, Chongqing Health Center for Women and Children, Chongqing, China
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Management of Placental Transfusion to Neonates After Delivery. Obstet Gynecol 2022; 139:121-137. [PMID: 34856560 DOI: 10.1097/aog.0000000000004625] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022]
Abstract
This review summarizes high-quality evidence supporting delayed umbilical cord clamping to promote placental transfusion to preterm and term neonates. In preterm neonates, delayed cord clamping may decrease mortality and the need for blood transfusions. Although robust data are lacking to guide cord management strategies in many clinical scenarios, emerging literature is reviewed on numerous topics including delivery mode, twin gestations, maternal comorbidities (eg, gestational diabetes, red blood cell alloimmunization, human immunodeficiency virus [HIV] infection, and severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and neonatal complications (eg, fetal growth restriction, congenital heart disease, and the depressed neonate). Umbilical cord milking is an alternate method of rapid placental transfusion, but has been associated with severe intraventricular hemorrhage in extremely preterm neonates. Data on long-term outcomes are discussed, as well as potential contraindications to delayed cord clamping. Overall, delayed cord clamping offers potential benefits to the estimated 140 million neonates born globally every year, emphasizing the importance of this simple and no-cost strategy.
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Owen LS, Manley BJ, Hodgson KA, Roberts CT. Impact of early respiratory care for extremely preterm infants. Semin Perinatol 2021; 45:151478. [PMID: 34474939 DOI: 10.1016/j.semperi.2021.151478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.
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Affiliation(s)
- Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kate A Hodgson
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
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Schwaberger B, Urlesberger B, Schmölzer GM. Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review. CHILDREN-BASEL 2021; 8:children8100882. [PMID: 34682147 PMCID: PMC8534639 DOI: 10.3390/children8100882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.
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Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada
- Correspondence: ; Tel.: +1-780-735-4660
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46
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Stimulating and maintaining spontaneous breathing during transition of preterm infants. Pediatr Res 2021; 90:722-730. [PMID: 31216570 DOI: 10.1038/s41390-019-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 01/30/2023]
Abstract
Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
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Bianchi A, Jacobsson B, Mol BW. FIGO good practice recommendations on delayed umbilical cord clamping. Int J Gynaecol Obstet 2021; 155:34-36. [PMID: 34520061 PMCID: PMC9290637 DOI: 10.1002/ijgo.13841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Delayed cord clamping in the first minute in preterm infants born before 34 weeks of gestation improves neonatal hematologic measures and may reduce mortality without increasing any other morbidity. In term-born babies, it also seems to improve both the short- and long-term outcomes and shows favorable scores in fine motor and social domains. However, there is insufficient evidence to show what duration of delay is best. The current evidence supports not clamping the cord before 30 seconds for preterm births. Future trials could compare different lengths of delay. Until then, a period of 30 seconds to 3 minutes seems justified for term-born babies.
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Affiliation(s)
- Ana Bianchi
- Perinatal Department, Pereira Rossell Hospital Public Health and University Hospital, Montevideo, Uruguay
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Science, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Australia.,Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Claassen CC, Strand ML, Williams HL, Hillman NH. Use of the RAM Cannula with Early Bubble Continuous Positive Airway Pressure Requires Higher Pressures: Clinical and In vitro Evaluations. Am J Perinatol 2021; 38:1167-1173. [PMID: 32446255 DOI: 10.1055/s-0040-1710557] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Early bubble continuous positive airway pressure (bCPAP) in the delivery room (DR) reduces early intubation, mechanical ventilation, and bronchopulmonary dysplasia. The RAM cannula, adopted for ease of patient care, is a high resistance nasal interface that, when used with bCPAP, only transmits a portion of set pressures and attenuates the bubble effects. This study aimed to review early bCPAP pressures and bCPAP failure with the RAM cannula interface over a 6-year period. STUDY DESIGN Retrospective, single-center study of infants delivered <1,250 g from 2013 to 2018 (n = 735) begun on bCPAP in the DR with the RAM cannula. In vitro testing of bCPAP pressure transmission was also performed for multiple nasal interfaces and nasal occlusion percentages. RESULTS The percentage of infants intubated in the DR decreased over time (59 to 42%), while the average bCPAP pressure increased from 5.3 to 6.8 cmH2O. A total of 355 infants (48%) were admitted to the neonatal intensive care unit (NICU) from the DR on BCPAP. The failure rate for bCPAP in NICU within 72 hours decreased from 45 to 24% as the maximum CPAP increased from 5.8 to 7.6 cmH2O. Pneumothorax rates did not change. CPAP pressure transmission decreased with all sizes of the RAM cannula. CONCLUSION When utilizing the RAM cannula for bCPAP, higher CPAP levels were associated with decreases in DR intubations and CPAP failure within the first 72 hours. If clinicians choose to use the RAM cannula for bCPAP, they will need higher set pressures to achieve lung inflation and the beneficial oscillatory effect will be diminished. KEY POINTS · The transmission of the pressure oscillations from bubble CPAP is diminished with the RAM cannula.. · Increasing set CPAP pressures was associated with a decreased delivery room intubation rate and a decreased CPAP failure rate within 72 hours.. · Clinicians using the RAM cannula for bCPAP will need to increase pressures to obtain adequate lung inflation or change to a nasal interface designed for bCPAP..
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Affiliation(s)
- Colleen C Claassen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Marya L Strand
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Howard L Williams
- SSM Health Systems, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | - Noah H Hillman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
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Katheria A, Lee HC, Knol R, Irvine L, Thomas S. A review of different resuscitation platforms during delayed cord clamping. J Perinatol 2021; 41:1540-1548. [PMID: 33850283 PMCID: PMC8042840 DOI: 10.1038/s41372-021-01052-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/10/2021] [Accepted: 03/29/2021] [Indexed: 12/02/2022]
Abstract
There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital, San Diego, CA, USA.
| | - Henry C Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ronny Knol
- Department of Pediatrics, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Leigh Irvine
- Foothills Medical Centre, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Sumesh Thomas
- Foothills Medical Centre, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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UshaDevi R, Mangalabharathi S, Prakash V, Thanigainathan S, Shobha S. Delivery room care and neonatal resuscitation while on intact placental circulation: an open-label, single-arm study. J Perinatol 2021; 41:1558-1565. [PMID: 33510419 DOI: 10.1038/s41372-021-00918-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess feasibility, safety, usability and learnability of delivery room care and resuscitation with intact placental circulation (RIPC) at mother's bedside. MATERIALS AND METHODS We included neonates ≥24 weeks GA after parental consent. Both in vigorous and babies requiring resuscitation, appropriate steps of resuscitation were provided with intact cord till 3 min using RIPC warmer. Outcomes were assessed by set criteria and standard system usability scale. RESULTS Of 380 enrolled, intervention was feasible in 376 babies (98.9%). Safety criteria were met in all 376 babies received onto the trolley (100%). Median GA was 38 (37-39) weeks and median BW 2740 (2330-3120) g. Of 376, 92 required resuscitation; 90 (97.8%) PPV, 49 (53.2%) intubations and 13 (14.1%) chest compressions. System Usability Score rated >68 (good) in 90% and 52-68 (fair) in 10%. Temperature at 5 min was 36.5 ± 0.1. CONCLUSIONS Delivery room care and neonatal RIPC is feasible and safe across gestations.
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Affiliation(s)
- R UshaDevi
- Department of Neonatology, Madras Medical College, Chennai, Tamilnadu, India
- Department of Neonatology, Chettinad Academy of Research and Education, Chengalpet, Tamilnadu, India
| | - S Mangalabharathi
- Department of Neonatology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamilnadu, India.
| | - V Prakash
- Department of Neonatology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamilnadu, India
| | - S Thanigainathan
- Department of Neonatology, Madras Medical College, Chennai, Tamilnadu, India
- Department of Neonatology, AIIMS, Jodhpur, Rajasthan, India
| | - S Shobha
- Department of Obstetrics & Gynaecology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamilnadu, India
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