Beyond basic resuscitation: What are the next steps to improve the outcomes of resuscitation at birth when resources are limited?

Neonatal Resuscitation and Delivery Room Care: A Changing Global Landscape

With 98% of neonatal deaths occurring in low- and middle-income countries (LMICs), leading health organizations continue to focus on global reduction of neonatal mortality. The presence of a skilled clinician at delivery has been shown to decrease mortality. However, there remain significant barriers to training and maintaining clinician skills and ensuring that facility-specific resources are consistently available to deliver the most essential, evidence-based newborn care. The dynamic nature of resource availability poses an additional challenge for essential newborn care educators in LMICs. With increasing access to advanced neonatal resuscitation interventions (ie, airway devices, code medications, umbilical line placement), the international health-care community is tasked to consider how to best implement these practices safely and effectively in lower-resourced settings. Current educational training programs do not provide specific instructions on how to scale these advanced neonatal resuscitation training components to match available materials, staff proficiency, and system infrastructure. Individual facilities are often faced with adapting content for their local context and capabilities. In this review, we discuss considerations surrounding curriculum adaptation to meet the needs of a rapidly changing landscape of resource availability in LMICs to ensure safety, equity, scalability, and sustainability.

Neonatal mortality and video assessment of resuscitation in four district hospitals in Pemba, Tanzania

BACKGROUND

We aimed to assess risk factors for neonatal mortality, quality of neonatal resuscitation (NR) on videos and identify potential areas for improvement.

METHODS

This prospective cohort study included women in childbirth and their newborns at four district hospitals in Pemba, Tanzania. Videos were analysed for quality-of-care. Questionnaires on quality-of-care indicators were answered by health workers (HW) and women. Risk factors for neonatal mortality were analysed in a binomial logistic regression model.

RESULTS

1440 newborns were enrolled. 34 newborns died within the neonatal period (23.6 per 1000 live births). Ninety neonatal resuscitations were performed, 20 cases on video. Positive pressure ventilation (PPV) was inadequate in 15 cases (75%). Half (10/20) did not have PPV initiated within the first minute, and in one case (5.0%), no PPV was performed. PPV was not sustained in 16/20 (80%) newborns. Of the 20 videos analysed, death occurred in 10 newborns: 8 after resuscitation attempts and two within the first 24 h. Most of HW 49/56 (87.5%) had received training in NR.

CONCLUSIONS

Video analysis of NR revealed significant deviations from guidelines despite 87.5% of HW being trained in NR. Videos provided direct evidence of gaps in the quality of care and areas for future education, particularly effective PPV.

IMPACT

Neonatal mortality in Pemba is 23.6 per 1000 livebirths, with more than 90% occurring in the first 24 h of life. Video assessment of neonatal resuscitation revealed deviations from guidelines and can add to understanding challenges and aid intervention design. The present study using video assessment of neonatal resuscitation is the first one performed at secondary-level hospitals where many of the world's births are conducted. Almost 90% of the health workers had received training in neonatal resuscitation, and the paper can aid intervention design by understanding the actual challenges in neonatal resuscitation.

Use of laryngeal mask for neonatal resuscitation in Brazil: A national survey

Background

The International Liaison Committee on Resuscitation suggests using the laryngeal mask airway (LMA) as an alternative to the face mask for performing positive pressure ventilation (PPV) in the delivery room in newborns ≥34 weeks. Because not much is known about the health professionals' familiarity in using LMA in Brazil, this study aimed to describe the health professionals' knowledge and practice of using LMA, who provide neonatal care in the country.

Methods

An online questionnaire containing 29 questions was sent to multi-healthcare professionals from different regions in the country through email and social media groups (WhatsApp®, Instagram®, Facebook®, ^and LinkedIn®). The participants anonymously answered the questions regarding their knowledge and expertise in using LMA to ventilate newborns in the delivery room.

Results

We obtained 749 responses from all the regions in Brazil, with 80% from health professionals working in public hospitals. Most respondents were neonatologists (73%) having > 15 years of clinical practice. Among the respondents, 92% recognized the usefulness of LMA for performing PPV in newborns, 59% did not have specific training in LMA insertion, and only 8% reported that they have already used LMA in the delivery room. In 90% of the hospitals, no written protocol was available to use LMA; and in 68% of the hospitals, LMA was not available for immediate use.

Conclusion

This nationwide survey showed that most professionals recognize the usefulness of LMA. However, the device is scarcely available and underused in the routine of ventilatory assistance for newborns in delivery rooms in Brazil.

Neonatal resuscitation from a global perspective

The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.

Laryngeal mask ventilation with chest compression during neonatal resuscitation: randomized, non-inferiority trial in lambs

BACKGROUND

Effective positive-pressure ventilation is a critical factor in newborn resuscitation. Neonatal endotracheal intubation (ETT) needs considerable training and experience, which poses a human factor challenge. Laryngeal mask airway (LMA) ventilation can be a secure and viable alternative during the initial stages of newborn resuscitation. However, there is limited evidence for its use during chest compression (CC).

METHODS

Seventeen lambs were randomized into LMA or ETT ventilation post cord occlusion induced cardiac arrest. After 5 min of cardiac arrest, resuscitation was initiated as per NRP recommendations. Ventilation, oxygenation, systemic and pulmonary hemodynamic parameters were recorded till the return of spontaneous circulation (ROSC) or 20 min.

RESULTS

Baseline characteristics were similar between the groups. The incidence of ROSC was 75% (6/8) in the LMA group and 56% (5/9) in the ETT group (p = 0.74). The median (IQR) time to achieve ROSC was 6.85 min (6 min-9.1 min) in the LMA group and 7.50 min (5.33 min-18 min) in the ETT group (p = 0.65).

CONCLUSION

LMA ventilation during CC is feasible and non-inferior to ETT in this model.

IMPACT

Laryngeal mask airway (LMA) ventilation with chest compression is feasible and non-inferior to endotracheal tube ventilation in this experimental near-term lamb model of asphyxial cardiac arrest. First translational study to evaluate the use of LMA as an airway device with chest compression. Evidence primer for clinical studies to evaluate and confirm the feasibility and efficacy of LMA ventilation with chest compression are necessary before randomized clinical trials in neonates. LMA use in neonatal cardiopulmonary resusciation (CPR) could have the potential to optimize advanced resuscitation, especially in resource-limited healthcare settings.

Impact of Optimizing the Emergency Care Process on the Emergency Effect and Prognosis of Patients with Hepatic Encephalopathy

Hepatic encephalopathy (HE) is a serious complication caused by liver disease and is one of the leading causes of death in patients. Studies have shown that proper emergency care for patients after the occurrence of HE can improve their prognosis and quality of life. Therefore, this study focuses on the effect of optimizing the emergency care process on the effectiveness and prognosis of emergency care for patients with hepatic encephalopathy. In this study, we set 32 patients with HE admitted to receive routine emergency care between May 2020 and March 2021 as the control group and 34 patients with HE admitted to receive optimized emergency care processes between April 2021 and February 2022 as the observation group. The satisfaction of patients' families with this care was assessed using a self-administered nursing satisfaction questionnaire to record the outcome of emergency care, quality of care, and prognosis of patients in the two groups of palliative care. The data collected were analyzed using SPSS17.0 software, and the results showed that the time spent on diagnosis, resuscitation, DTP, and DTT was much lower in the observation group than in the control group, and the scores related to the quality of care, such as ambulance technique, humanistic care, resuscitation efficiency, and resuscitation effect, were all higher than those of the control group, and the satisfaction of the family members in the observation group was also significantly higher than that of the control group (P < 0.05). The success rate of first aid in the observation group was 100.00%, which was higher than 93.72% in the control group, but the difference between the two groups was not significant (P > 0.05). It can be seen that the application of an optimized emergency nursing process in HE patients is effective, which can effectively improve the success rate of HE resuscitation, shorten the resuscitation time and condition diagnosis, improve the resuscitation effect, improve the quality of nursing care, and improve the prognosis of patients to a certain extent.

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation

BACKGROUND

Globally, the majority of newborns requiring resuscitation at birth are full term or late-preterm infants. These infants typically have their umbilical cord clamped early (ECC) before moving to a resuscitation platform, losing the potential support of the placental circulation. Physiologically based cord clamping (PBCC) is clamping the umbilical cord after establishing lung aeration and holds promise as a readily available means of improving early newborn outcomes. In mechanically ventilated lambs, PBCC improved cardiovascular stability and reduced hypoxia. We hypothesised that PBCC compared to ECC would result in higher heart rate (HR) in infants needing resuscitation, without compromising safety.

METHODS AND FINDINGS

Between 4 July 2018 and 18 May 2021, infants born at ≥32+0 weeks' gestation with a paediatrician called to attend were enrolled in a parallel-arm randomised trial at 2 Australian perinatal centres. Following initial stimulation, infants requiring further resuscitation were randomised within 60 seconds of birth using a smartphone-accessible web link. The intervention (PBCC) was to establish lung aeration, either via positive pressure ventilation (PPV) or effective spontaneous breathing, prior to cord clamping. The comparator was early cord clamping (ECC) prior to resuscitation. The primary outcome was mean HR between 60 to 120 seconds after birth, measured using 3-lead electrocardiogram, extracted from video recordings blinded to group allocation. Nonrandomised infants had deferred cord clamping (DCC) ≥120 seconds in the observational study arm. Among 508 at-risk infants enrolled, 123 were randomised (n = 63 to PBCC, n = 60 to ECC). Median (interquartile range, IQR) for gestational age was 39.9 (38.3 to 40.7) weeks in PBCC infants and 39.6 (38.4 to 40.4) weeks in ECC infants. Approximately 49% and 50% of the PBCC and ECC infants were female, respectively. Five infants (PBCC = 2, ECC = 3, 4% total) had missing primary outcome data. Cord clamping occurred at a median (IQR) of 136 (126 to 150) seconds in the PBCC arm and 37 (27 to 51) seconds in the ECC arm. Mean HR between 60 to 120 seconds after birth was 154 bpm (beats per minute) for PBCC versus 158 bpm for ECC (adjusted mean difference -6 bpm, 95% confidence interval (CI) -17 to 5 bpm, P = 0.39). Among 31 secondary outcomes, postpartum haemorrhage ≥500 ml occurred in 34% and 32% of mothers in the PBCC and ECC arms, respectively. Two hundred ninety-five nonrandomised infants (55% female) with median (IQR) gestational age of 39.6 (38.6 to 40.6) weeks received DCC. Data from these infants was used to create percentile charts of expected HR and oxygen saturation in vigorous infants receiving DCC. The trial was limited by the small number of infants requiring prolonged or advanced resuscitation. PBCC may provide other important benefits we did not measure, including improved maternal-infant bonding and higher iron stores.

CONCLUSIONS

In this study, we observed that PBCC resulted in similar mean HR compared to infants receiving ECC. The findings suggest that for infants ≥32+0 weeks' gestation who receive brief, effective resuscitation at closely monitored births, PBCC does not provide additional benefit over ECC (performed after initial drying and stimulation) in terms of key physiological markers of transition. PBCC was feasible using a simple, low-cost strategy at both cesarean and vaginal births. The percentile charts of HR and oxygen saturation may guide clinicians monitoring the transition of at-risk infants who receive DCC.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000621213.

Laryngeal Masks in Neonatal Resuscitation-A Narrative Review of Updates 2022

Positive pressure ventilation (PPV) is crucial to neonatal cardiopulmonary resuscitation because respiratory failure precedes cardiac failure in newborns affected by perinatal asphyxia. Prolonged ineffective PPV could lead to a need for advanced resuscitation such as intubation, chest compression, and epinephrine. Every 30 s delay in initiation of PPV increased the risk of death or morbidity by 16%. The most effective interface for providing PPV in the early phases of resuscitation is still unclear. Laryngeal masks (LMs) are supraglottic airway devices that provide less invasive and relatively stable airway access without the need for laryngoscopy which have been studied as an alternative to face masks and endotracheal tubes in the initial stages of neonatal resuscitation. A meta-analysis found that LM is a safe and more effective alternative to face mask ventilation in neonatal resuscitation. LM is recommended as an alternative secondary airway device for the resuscitation of infants > 34 weeks by the International Liaison Committee on Resuscitation. It is adopted by various national neonatal resuscitation guidelines across the globe. Recent good-quality randomized trials have enhanced our understanding of the utility of laryngeal masks in low-resource settings. Nevertheless, LM is underutilized due to its variable availability in delivery rooms, providers’ limited experience, insufficient training, preference for endotracheal tube, and lack of awareness.

Respiratory monitoring during neonatal resuscitation using a supraglottic airway device vs. a face mask

OBJECTIVE

To evaluate the respiratory function of asphyxiated infants resuscitated with i-gel supraglottic airway (SGA) vs. face mask (FM) in a low-resource setting.

METHODS

In this sub-study from the NeoSupra trial, respiratory function during the first 60 inflations was evaluated in 46 neonates (23 with SGA and 23 with FM) at the Mulago National Referral Hospital, Uganda. The primary outcome was the mask leak (%). The secondary outcomes included inspired (VTi) and expired (VTe) tidal volumes, and heart rate response to ventilation.

RESULTS

Median mask leak was 40% (IQR 22-52) with SGA and 39% (IQR 26-62) with FM (p = 0.38). Median VTe was 7.8 ml/kg (IQR 5.6-10.2) with SGA and 7.3 ml/kg (IQR 4.8-11.9) with FM (p = 0.84), while median VTi was 15.4 ml/kg (IQR 11-4-17.6) with SGA and 15.9 ml/kg (IQR 9.0-22.6) with FM (p = 0.68). A shorter time was needed to achieve heart rate > 100 bpm in SGA (median 13 s IQR 9-15) with respect to FM arm (median 61, IQR 33-140) (p = 0.0002).

CONCLUSION

Respiratory function was not statistically different between neonates resuscitated with SGA vs. FM. SGA was associated with faster heart rate recovery compared to FM in the subgroup of neonates with bradycardia. Further research is needed to investigate possible advantages of SGA on respiratory function at birth.

Digital tracheal intubation and finger palpation to confirm endotracheal tube tip position in neonates: A systematic review and meta-analysis

BACKGROUND

To evaluate digital tracheal intubation (DTI) when compared to laryngoscope-assisted TI; finger palpation of endotracheal tube (ETT) tip position when compared to any standard method.

DESIGN

A systematic review of Medline, Embase, CENTRAL, and CINAHL with synthesis of data using meta-analysis was performed.

MAIN OUTCOME MEASURE

The proportion of successful TI and correct ETT tip positioning were the main outcome measures.

RESULTS

Five studies (one observational study and four RCTs) enrolling 310 neonates were included. 94% (81%-98%) of the DTI were successful on the first attempt (certainty of evidence [CoE]: low). The proportion of successful intubation on the first attempt was higher with DTI when compared to laryngoscope-assisted TI (RR 95% CI: 1.81 [1.18; 2.76]) (CoE: very low). Time to successful TI with DTI was 7.4 (95% CI: 6.3, 8.5) s (CoE: low). Time to successful TI was significantly shorter with DTI when compared to laryngoscope assisted TI (MD [95% CI]: -4.9 [-7.3, -2.4] s) (CoE: very low). There was a trend towards a higher proportion of correct ETT tip positions with finger palpation when compared to weight-based formulae alone (RR 95% CI: 1.12 [0.96; 1.31]) (CoE: very low).

CONCLUSIONS

DTI and finger palpation to ascertain ETT tip position in neonates are promising strategies. Future studies with emphasis on their learning trajectory and generalizability are needed.

The BabySaver: Design of a New Device for Neonatal Resuscitation at Birth with Intact Placental Circulation

The initial bedside care of premature babies with an intact cord has been shown to reduce mortality; there is evidence that resuscitation of term babies with an intact cord may also improve outcomes. This process has been facilitated by the development of bedside resuscitation surfaces. These new devices are unaffordable, however, in most of sub-Saharan Africa, where 42% of the world’s 2.4 million annual newborn deaths occur. This paper describes the rationale and design of BabySaver, an innovative low-cost mobile resuscitation unit, which was developed iteratively over five years in a collaboration between the Sanyu Africa Research Institute (SAfRI) in Uganda and the University of Liverpool in the UK. The final BabySaver design comprises two compartments; a tray to provide a firm resuscitation surface, and a base to store resuscitation equipment. The design was formed while considering contextual factors, using the views of individual women from the community served by the local hospitals, medical staff, and skilled birth attendants in both Uganda and the UK.

A Randomized Trial of Laryngeal Mask Airway in Neonatal Resuscitation

BACKGROUND

Face-mask ventilation is the most common resuscitation method for birth asphyxia. Ventilation with a cuffless laryngeal mask airway (LMA) has potential advantages over face-mask ventilation during neonatal resuscitation in low-income countries, but whether the use of an LMA reduces mortality and morbidity among neonates with asphyxia is unknown.

METHODS

In this phase 3, open-label, superiority trial in Uganda, we randomly assigned neonates who required positive-pressure ventilation to be treated by a midwife with an LMA or with face-mask ventilation. All the neonates had an estimated gestational age of at least 34 weeks, an estimated birth weight of at least 2000 g, or both. The primary outcome was a composite of death within 7 days or admission to the neonatal intensive care unit (NICU) with moderate-to-severe hypoxic-ischemic encephalopathy at day 1 to 5 during hospitalization.

RESULTS

Complete follow-up data were available for 99.2% of the neonates. A primary outcome event occurred in 154 of 563 neonates (27.4%) in the LMA group and 144 of 591 (24.4%) in the face-mask group (adjusted relative risk, 1.16; 95% confidence interval [CI], 0.90 to 1.51; P = 0.26). Death within 7 days occurred in 21.7% of the neonates in the LMA group and 18.4% of those in the face-mask group (adjusted relative risk, 1.21; 95% CI, 0.90 to 1.63), and admission to the NICU with moderate-to-severe hypoxic-ischemic encephalopathy at day 1 to 5 during hospitalization occurred in 11.2% and 10.1%, respectively (adjusted relative risk, 1.27; 95% CI, 0.84 to 1.93). Findings were materially unchanged in a sensitivity analysis in which neonates with missing data were counted as having had a primary outcome event in the LMA group and as not having had such an event in the face-mask group. The frequency of predefined intervention-related adverse events was similar in the two groups.

CONCLUSIONS

In neonates with asphyxia, the LMA was safe in the hands of midwives but was not superior to face-mask ventilation with respect to early neonatal death and moderate-to-severe hypoxic-ischemic encephalopathy. (Funded by the Research Council of Norway and the Center for Intervention Science in Maternal and Child Health; NeoSupra ClinicalTrials.gov number, NCT03133572.).

Digital Health Innovations, Tools, and Resources to Support Helping Babies Survive Programs

The Helping Babies Survive (HBS) initiative features a suite of evidence-based curricula and simulation-based training programs designed to provide health workers in low- and middle-income countries (LMICs) with the knowledge, skills, and competencies to prevent, recognize, and manage leading causes of newborn morbidity and mortality. Global scale-up of HBS initiatives has been rapid. As HBS initiatives rolled out across LMIC settings, numerous bottlenecks, gaps, and barriers to the effective, consistent dissemination and implementation of the programs, across both the pre- and in-service continuums, emerged. Within the first decade of expansive scale-up of HBS programs, mobile phone ownership and access to cellular networks have also concomitantly surged in LMICs. In this article, we describe a number of HBS digital health innovations and resources that have been developed from 2010 to 2020 to support education and training, data collection for monitoring and evaluation, clinical decision support, and quality improvement. Helping Babies Survive partners and stakeholders can potentially integrate the described digital tools with HBS dissemination and implementation efforts in a myriad of ways to support low-dose high-frequency skills practice, in-person refresher courses, continuing medical and nursing education, on-the-job training, or peer-to-peer learning, and strengthen data collection for key newborn care and quality improvement indicators and outcomes. Thoughtful integration of purpose-built digital health tools, innovations, and resources may assist HBS practitioners to more effectively disseminate and implement newborn care programs in LMICs, and facilitate progress toward the achievement of Sustainable Development Goal health goals, targets, and objectives.

Effect of skill drills on neonatal ventilation performance in a simulated setting- observation study in Nepal

Aim

Maintaining neonatal resuscitation skills among health workers in low resource settings will require continuous quality improvement efforts. We aimed to evaluate the effect of skill drills and feedback on neonatal resuscitation and the optimal number of skill drills required to maintain the ventilation skill in a simulated setting.

Methods

An observational study was conducted for a period of 3 months in a referral hospital of Nepal. Sixty nursing staffs were trained on Helping Babies Breathe (HBB) 2.0 and daily skill drills using a high-fidelity manikin. The high-fidelity manikin had different clinical case scenarios and provided feedback as “well done” or “improvement required” based on the ventilation performance. Adequate ventilation was defined as bag-and-mask ventilation at the rate of 40–60 breaths per minute. The effective ventilation was defined as adequate ventilation with a “well done” feedback. We assessed the correlation of number skill drills and clinical case scenario with adequate ventilation rate using pearson’s correlation. We assessed the correlation of number of skill dills performed by each participant with effective ventilation using Mann Whitney test.

Results

Among the total of 60 nursing staffs, all of them were competent with an average score of 12.73 ± 1.09 out of 14 (p < 0.001) on bag-and-mask ventilation skill checklist. Among the trained staff, 47 staffs participated in daily skill drills who performed a total of 331 skill drills and 68.9% of the ventilations were done adequately. Among the 47 nursing staffs who performed the skill drills, 228 (68.9%) drills were conducted at a ventilation rate of 40–60 breathes per minute. There was no correlation of the adequate ventilation with skill drill category (p = 0.88) and the level of skill performed (p = 0.28). Out of 47 participants performing the skill drills, 74.5% of them had done effective ventilation with a mean average of 8 skill drills (SD ± 4.78) (p-value- 0.032).

Conclusion

In a simulated setting, participants who had an average skill drill of 8 in 3 months had effective ventilation. We demonstrated optimal skill drill sessions for maintain the neonatal resuscitation competency. Further evaluation will be required to validate the findings in a scale up setting.

Intact cord resuscitation versus early cord clamping in the treatment of depressed newborn infants during the first 10 minutes of birth (Nepcord III) - a randomized clinical trial

Background

Experiments have shown improved cardiovascular stability in lambs if umbilical cord clamping is postponed until positive pressure ventilation is started. Studies on intact cord resuscitation on human term infants are sparse. The purpose of this study was to evaluate differences in clinical outcomes in non-breathing infants between groups, one where resuscitation is initiated with an intact umbilical cord (intervention group) and one group where cord clamping occurred prior to resuscitation (control group).

Methods

Randomized controlled trial, inclusion period April to August 2016 performed at a tertiary hospital in Kathmandu, Nepal. Late preterm and term infants born vaginally, non-breathing and in need of resuscitation according to the ‘Helping Babies Breathe’ algorithm were randomized to intact cord resuscitation or early cord clamping before resuscitation. Main outcome measures were saturation by pulse oximetry (SpO₂), heart rate and Apgar at 1, 5 and 10 minutes after birth.

Results

At 10 minutes after birth, SpO₂ (SD) was significantly higher in the intact cord group compared to the early cord clamping group, 90.4 (8.1) vs 85.4 (2.7) %, P < .001). In the intact cord group, 57 (44%) had SpO₂ < 90% after 10 minutes, compared to 93 (100%) in the early cord clamping group, P < 0.001. SpO₂ was also significantly higher in the intervention (intact cord) group at one and five minutes after birth. Heart rate was lower in the intervention (intact cord) group at one and five minutes and slightly higher at ten minutes, all significant findings. Apgar score was significantly higher at one, five and ten minutes. At 5 minutes, 23 (17%) had Apgar score < 7 in the intervention (intact cord) group compared to 26 (27%) in the early cord clamping group, P < .07. Newborn infants in the intervention (intact cord) group started to breathe and establish regular breathing earlier than in the early cord clamping group.

Conclusions

This study provides new and important information on the effects of resuscitation with an intact umbilical cord. The findings of improved SpO₂ and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up.

Trial registration

Clinicaltrials.gov NCT02727517, 2016/4/4

Electronic supplementary material

The online version of this article (10.1186/s40748-019-0110-z) contains supplementary material, which is available to authorized users.