Elevated midline head positioning of extremely low birth weight infants: effects on cardiopulmonary function and the incidence of periventricular-intraventricular hemorrhage

Care bundle for preventing intraventricular hemorrhage in premature infants: a best practice implementation project

INTRODUCTION

Intraventricular hemorrhages remain a major problem in neonatology, because their complications affect neonatal morbidity, mortality, and long-term neurodevelopmental outcomes.

AIM

The aim of this project was to prevent intraventricular hemorrhage in premature infants during their first days of life in a neonatal intensive care unit (NICU).

METHODS

This pre- and post-implementation clinical audit project used the JBI Evidence Implementation Framework and was conducted in a tertiary-level Spanish NICU with a consecutive sample. A baseline audit was conducted using 13 audit criteria derived from JBI summaries of the best available evidence. This was followed by the implementation of an action plan, which included a care bundle and health care professionals' education. These improvement strategies were then evaluated using a follow-up audit.

RESULTS

The baseline and follow-up audits evaluated 54 and 56 infants, respectively. The follow-up audit showed 100% improvement for Criteria 2, 3, 6, and 7, which covered sleep safety and noise. Criteria 12 and 13, which covered cord clamping and positioning the infant, improved by 25.99%. Criterion 9, on antenatal corticosteroids, showed a slight improvement of 5.56%.

CONCLUSIONS

This study increased compliance with an evidence-based, family-centered care approach to preventing intraventricular hemorrhage in premature infants. This was achieved by conducting a baseline and follow-up audit, implementing a training program, and keeping more comprehensive nursing records. Further studies could assess the long-term effectiveness of interventions and/or the incidence of intraventricular hemorrhage and neurodevelopmental disorders in premature infants.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A262.

Early skin-to-skin contact and the risk of intraventricular haemorrhage and sepsis in preterm infants

AIM

This study aimed to investigate the risks of intraventricular haemorrhage (IVH) or sepsis in extremely and very preterm infants exposed to early skin-to-skin contact (SSC).

METHODS

Data from the Swedish Neonatal Quality Register from 2015 to 2021 were extracted to compare the proportions of infants exposed and not exposed to SSC on day 0 and/or 1 in life that developed IVH or sepsis.

RESULTS

A total of 2514 infants, 1005 extremely preterm and 1509 very preterm, were included. This amounted to 69% of all extremely and very preterm infants born during the study period. The proportion of infants with IVH exposed and not exposed to early SSC was 11% and 27%, an adjusted odds ratio (aOR) of 0.67 (95%CI 0.52-0.86, p = 0.002). The proportion of infants with sepsis exposed and not exposed to early SSC was 16% and 30%, an aOR of 0.94 (95%CI 0.75-1.2, p = 0.60). For extremely preterm infants, the proportion with sepsis when exposed and not exposed to early SSC was 29% and 44%, an aOR of 0.65 (95%CI 0.46-0.92, p = 0.015).

CONCLUSION

In the current setting, the risk of IVH or sepsis is not increased when an extremely or very preterm infant is exposed to early SSC.

Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review

Importance

Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology.

Objective

To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting.

Evidence Review

A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus.

Findings

Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented.

Conclusions and Relevance

These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.

Clinical Variables Associated With Grade III and IV Intraventricular Hemorrhage (IVH) in Preterm Infants Weighing Less Than 750 Grams

BACKGROUND

Despite innovative advances in neonatal medicine, intraventricular hemorrhage (IVH) continues to be a significant complication in neonatal intensive care units globally.

OBJECTIVE

The study aimed to discern the variables heightening the risk of severe IVH (Grade III and IV) in extremely premature infants weighing less than 750 grams. We postulated that a descending hematocrit (Hct) trend during the first week of life could serve as a predictive marker for the development of severe IVH in this vulnerable population.

METHODS

This retrospective case-control study encompassed infants weighing less than 750 grams at birth, diagnosed with Grade III and/or IV IVH, and born in a tertiary center from 2009 to 2014. A group of 17 infants with severe IVH was compared with 14 gestational age-matched controls. Acid-base status, glucose, fluid goal, urine output, and nutrient (caloric and protein) intake during the first four days of life were meticulously evaluated. Statistically significant variables from baseline data were further analyzed via univariable and multivariable logistic regression analyses, ensuring control for potential confounding variables.

RESULTS

The univariate logistic regression model delineated odds ratios (ORs) of 0.842 for day 2 average Hct (confidence interval [CI], 0.718-0.987) and 0.16 for urine output on day 3 (CI, 0.024-1.056), with the remaining six variables demonstrating no significant association. In the post-multivariable regression analysis, day 2 Hct was the only significant variable (OR, 0.731; 95% CI, 0.537-0.995; P=0.04). The receiver operating characteristic (ROC) curve analysis portrayed an area under the curve of 71% for the day 2 Hct variable.

CONCLUSION

The study revealed that a dip in Hct on day 2 of life augments the likelihood of Grade III and IV IVH among extremely premature infants with a birth weight of less than 750 grams. This insight amplifies our understanding of risk factors associated with severe IVH development in extremely preterm infants, potentially aiding in refining preventive strategies and optimizing clinical management and treatment of these affected infants.

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.

Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis

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.

The Effectiveness of interventions to prevent intraventricular haemorrhage in premature infants: A systematic review and network meta-analysis

BACKGROUND

Intraventricular haemorrhage (IVH) is a common problem in preterm infants, being a major cause of morbidity and mortality. Despite many randomised controlled trials comparing interventions to prevent IVH, the best prevention remains unclear. This study aims to review all the interventions which intended to reduce the incidence of IVH and compare them in a network meta-analysis.

METHODS

A search on MEDLINE, EMBASE, Emcare, and CENTRAL was performed. Randomised controlled trials which evaluated neonatal interventions with a primary aim to reduce incidence of IVH in preterm infants were eligible. A surface under a cumulative ranking curve (SUCRA) was produced to indicate the intervention's likelihood of being the most effective for preventing IVH.

RESULTS

40 studies were eligible, enrolling over 6760 infants. Twelve intervention groups were found, including delayed cord clamping, erythropoietin, ethamsylate, fresh frozen plasma, heparin, ibuprofen, indomethacin, magnesium, nursing interventions, sedation, tranexamic acid, and vitamin E. Vitamin E and indomethacin had the highest probability of being the best interventions to prevent IVH in premature infants, but interpretation of these results is difficult due to study limitations.

CONCLUSION

Despite the impact of IVH, we were unable to identify a clearly beneficial treatment to reduce its incidence. Interpretation of the network meta-analysis was limited due to differences within studied populations, wide range of therapies trialled, and underlying advances in neonatal care between units, and over time. Although vitamin E and indomethacin appear to be promising candidates, contemporaneous trials of these, or novel agents, enrolling the most at-risk infants is needed urgently.

Prevention of severe brain injury in very preterm neonates: A quality improvement initiative

OBJECTIVE

To determine the impact of neuroprotection interventions bundle on the incidence of severe brain injury or early death (intraventricular hemorrhage grade 3/4 or death by 7 days or ventriculomegaly or cystic periventricular leukomalacia on 1-month head ultrasound, primary composite outcome) in very preterm (27^0/7 to ≤ 29^6/7 weeks gestational age) infants.

STUDY DESIGN

Prospective quality improvement initiative, from April 2017-September 2019, with neuroprotection interventions bundle including cerebral NIRS, TcCO₂, and HeRO monitoring-based management algorithm, indomethacin prophylaxis, protocolized bicarbonate and inotropes use, noise reduction, and neutral positioning.

RESULT

There was a decrease in the incidence of the primary composite outcome in the intervention period on unadjusted (N = 11/99, pre-intervention to N = 0/127, intervention period, p < 0.001) and adjusted analysis (adjusted for birthweight and Apgar score <5 at 5 min, aOR = 0.042, 95% CI = 0.003-0.670, p = 0.024).

CONCLUSIONS

Neuroprotection interventions bundle was associated with significant decrease in severe brain injury or early death in very preterm infants.

The effect of head positioning on brain tissue oxygenation in preterm infants: a randomized clinical trial study

BACKGROUND

CNS injury in preterm infants is still one of the leading causes of mortality and morbidity. Routine care events might affect the perfusion and cerebral oxygenation of preterm infants. Although positioning the infant's head in a particular condition to improve brain oxygenation is included in many institutions, there is no robust clinical evidence to support this intervention's effectiveness.

OBJECTIVE

The present study aimed to determine the effect of head positioning on brain tissue oxygenation in preterm infants.

METHODS

This study is a randomized clinical trial. In the first 48 h after birth, 39 infants who met the study inclusion criteria underwent head positioning intervention. In this case, the infants were placed in the supine position, and every 2 h, the head position was changed continuously to one of six randomized modes [using random modes generated by SPSS]. During each head positioning, brain tissue oxygenation was recorded by NIRS.

RESULTS

The findings showed a significant difference in brain tissue oxygen saturation among these positions (P < 0.001). Dunn's test showed that the brain tissue oxygen saturation in the third position (head rotates 45-60 degrees from the midline to the right and the head of the bed is zero degrees) was significantly lower than the baseline (P = 0.029; Mean difference = 2.3). Also, in the third position, compared to the first position (P = 0.002; Mean difference = 1.9) and compared to the fourth position (P = 0.003; Mean difference = -2.1), and in the second position compared to the first position (P = 0.046; Mean difference = 1.3), the brain tissue oxygen saturation of the infants was lower.

CONCLUSION

Based on the results of the present study, head positioning was effective on brain tissue oxygenation in preterm infants in the first 48 h after birth; Therefore, it is recommended when possible, not to rotate the infant's head during the first 48 h after birth while the head of the bed is at 0°.

A Quality Improvement Bundle to Improve Outcomes in Extremely Preterm Infants in the First Week

OBJECTIVES

Our objective with this quality improvement initiative was to reduce rates of severe intracranial hemorrhage (ICH) or death in the first week after birth among extremely preterm infants.

METHODS

The quality improvement initiative was conducted from April 2014 to September 2020 at the University of Alabama at Birmingham's NICU. All actively treated inborn extremely preterm infants without congenital anomalies from 22 + 0/7 to 27 + 6/7 weeks' gestation with a birth weight ≥400 g were included. The primary outcome was severe ICH or death in the first 7 days after birth. Balancing measures included rates of acute kidney injury and spontaneous intestinal perforation. Outcome and process measure data were analyzed by using p-charts.

RESULTS

We studied 820 infants with a mean gestational age of 25 + 3/7 weeks and median birth weight of 744 g. The rate of severe ICH or death in the first week after birth decreased from the baseline rate of 27.4% to 15.0%. The rate of severe ICH decreased from a baseline rate of 16.4% to 10.0%. Special cause variation in the rate of severe ICH or death in the first week after birth was observed corresponding with improvement in carbon dioxide and pH targeting, compliance with delayed cord clamping, and expanded use of indomethacin prophylaxis.

CONCLUSIONS

Implementation of a bundle of evidence-based potentially better practices by using specific electronic order sets was associated with a lower rate of severe ICH or death in the first week among extremely preterm infants.

Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review

OBJECTIVE

To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation).

STUDY DESIGN

PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale.

RESULTS

Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation.

CONCLUSIONS

The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.

Evaluating the Effect of a Neonatal Care Bundle for the Prevention of Intraventricular Hemorrhage in Preterm Infants

Germinal matrix intraventricular hemorrhage (IVH) remains a severe and common complication in preterm infants. A neonatal care bundle (NCB) was implemented as an in-house guideline at a tertiary neonatal intensive care unit to reduce the incidence of IVH in preterm infants. The NCB was applied either to preterm infants <1250 g birth weight or <30 weeks gestational age or both, and standardized patient positioning, nursing care, and medical procedures within the first week of life. A retrospective cohort study was performed to investigate the effect of the NCB and other known risk factors on the occurrence and severity of IVH. Data from 229 preterm infants were analyzed. The rate of IVH was 26.2% before and 27.1% after implementing the NCB. The NCB was associated neither with reducing the overall rate of IVH (odds ratio (OR) 1.02; 95% confidence interval (CI) 0.57–1.84; p = 0.94) nor with severe IVH (OR 1.0; 95% CI 0.67–1.55; p = 0.92). After adjustment for group differences and other influencing factors, amnion infection syndrome and early intubation were associated with an increased risk for IVH. An NCB focusing on patient positioning, nursing care, and medical interventions had no impact on IVH in preterm infants. Known risk factors for IVH were confirmed.

Germinal Matrix-Intraventricular Hemorrhage: A Tale of Preterm Infants

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a common intracranial complication in preterm infants, especially those born before 32 weeks of gestation and very-low-birth-weight infants. Hemorrhage originates in the fragile capillary network of the subependymal germinal matrix of the developing brain and may disrupt the ependymal lining and progress into the lateral cerebral ventricle. GM-IVH is associated with increased mortality and abnormal neurodevelopmental outcomes such as posthemorrhagic hydrocephalus, cerebral palsy, epilepsy, severe cognitive impairment, and visual and hearing impairment. Most affected neonates are asymptomatic, and thus, diagnosis is usually made using real-time transfontanellar ultrasound. The present review provides a synopsis of the pathogenesis, grading, incidence, risk factors, and diagnosis of GM-IVH in preterm neonates. We explore brief literature related to outcomes, management interventions, and pharmacological and nonpharmacological prevention strategies for GM-IVH and posthemorrhagic hydrocephalus.

Elevated supine midline head position for prevention of intraventricular hemorrhage in VLBW and ELBW infants: a retrospective multicenter study

OBJECTIVE

To evaluate the impact of elevated supine midline head position on intraventricular hemorrhage (IVH) in very-low-birth-weight (VLBW) infants.

STUDY DESIGN

We reviewed data from four Level III/IV units. Two of these units (mid-line group) cared for infants in midline position and the other two (routine care group) provided routine care. We compared incidence of any and severe IVH in two groups using multivariate logistic regression analyses.

RESULTS

Of 2201 VLBW infants, 1041 were extremely-low-birth-weight (ELBW). Odds of any IVH were not different either for VLBW or ELBW infants. Odds of severe IVH were higher for VLBW infants in mid-line group (OR 1.43, 95% CI 1.007-2.02; p value 0.046) but not for ELBW infants (OR 0.9, 95% CI 0.6-1.4; p value 0.73).

CONCLUSIONS

The incidence of any IVH was similar in the two groups but the incidence of severe IVH was higher in VLBW infants in mid-line group.

Impact of bundle implementation on the incidence of peri/intraventricular hemorrhage among preterm infants: a pre-post interventional study

BACKGROUND

Peri/intraventricular hemorrhage (PIVH) is a frequent cause of death and morbidity among preterm infants. Few studies have addressed the use of bundles for preventing PIVH.

OBJECTIVE

To evaluate the efficacy of a bundle of interventions designed to decrease the incidence of intraventricular hemorrhage at hospital discharge among preterm infants.

DESIGN AND SETTING

Pre-post interventional study with retrospective and prospective data collection performed before and after bundle implementation in the neonatal intensive care unit of a university hospital.

METHODS

Infants with gestational age < 32 weeks without malformations, who survived > 6 days were included. The bundle consisted of the following actions during the first 72 hours of life: maintenance of head in neutral position with the body in supine position, minimal handling, including delay of lumbar puncture until after 72 hours and absence of respiratory therapy maneuvers. Cranial ultrasound was performed on days 3, 7 and 28, or later if needed. The effect of the bundle was analyzed through logistic regression and results were adjusted for confounding variables.

RESULTS

167 infants met the inclusion criteria; 146 (87%) were analyzed. Bundle implementation was associated with decreased chances of PIVH at hospital discharge (odds ratio 0.29; 95% confidence interval 0.13-0.65). Cerebrospinal fluid collection within the first 72 hours increased the odds of PIVH of any grade during the hospital stay fourfold, after adjustment for all variables included in the model.

CONCLUSION

Implementation of a bundle of interventions to avoid intraventricular hemorrhage was effective for decreasing the incidence of all grades of PIVH in preterm infants.

Risk factors for the deterioration of periventricular-intraventricular hemorrhage in preterm infants

Preterm infants with periventricular–intraventricular hemorrhage (PV–IVH) have a high risk of neurological sequelae, with severity depending on the severity of the PV–IVH. Previous studies on the pathogenesis of PV–IVH have focused mainly on comparisons of perinatal risk factors between patients with and without PV–IVH. Notably, most cases of PV–IVH occur within the first 3 days after birth, and the condition may worsen within 1 week following the initial diagnosis. However, the risk factors that contribute to the deterioration of PV–IVH have not been investigated. In this cohort study, 514 PV–IVH infants with a gestational age (GA) < 32 weeks were enrolled. The dependent variable was initially diagnosed as mild PV–IVH (grade I or II) that subsequently progressed to severe PV–IVH (grade III or IV) within 1 week. A stepwise forward multivariate logistic regression model was adopted to select potential or related factors that affected the deterioration of PV–IVH in preterm infants. Overall, 42 of the 514 infants with PV–IVH (8.2%) showed deterioration within 1 week. The results showed that maternal lower genital tract infection (OR 3.73, 95% CI 1.75–7.95) was an independent risk factor for PV–IVH deterioration. Higher GA (OR 0.62, 95% CI 0.48–0.80) was a protective factor. Our results suggest that maternal lower genital tract infection and a lower GA may contribute to PV–IVH deterioration in preterm infants.

Intraventricular Hemorrhage in Very Preterm Infants: A Comprehensive Review

Germinal matrix-intraventricular-intraparenchymal hemorrhage (GMH-IVH-IPH) is a major complication of very preterm births before 32 weeks of gestation (WG). Despite progress in clinical management, its incidence remains high before 27 WG. In addition, severe complications may occur such as post-hemorrhagic hydrocephalus and/or periventricular intraparenchymal hemorrhage. IVH is strongly associated with subsequent neurodevelopmental disabilities. For this review, an automated literature search and a clustering approach were applied to allow efficient filtering as well as topic clusters identification. We used a programmatic literature search for research articles related to intraventricular hemorrhage in preterms that were published between January 1990 and February 2020. Two queries ((Intraventricular hemorrhage) AND (preterm)) were used in PubMed. This search resulted in 1093 articles. The data manual curation left 368 documents that formed 12 clusters. The presentation and discussion of the clusters provide a comprehensive overview of existing data on the pathogenesis, complications, neuroprotection and biomarkers of GMH-IVH-IPH in very preterm infants. Clinicians should consider that the GMH-IVH-IPH pathogenesis is mainly due to developmental immaturity of the germinal matrix and cerebral autoregulation impairment. New multiomics investigations of intraventricular hemorrhage could foster the development of predictive biomarkers for the benefit of very preterm newborns.

Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular haemorrhage in preterm infants

BACKGROUND

Head position during care may affect cerebral haemodynamics and contribute to the development of germinal matrix-intraventricular haemorrhage (GM-IVH) in very preterm infants. Turning the head toward one side may occlude jugular venous drainage while increasing intracranial pressure and cerebral blood volume. It is suggested that cerebral venous pressure is reduced and hydrostatic brain drainage improved if the infant is cared for in the supine 'head midline' position.

OBJECTIVES

To assess whether head midline position is more effective than other head positions for preventing (or preventing extension) of GM-IVH in very preterm infants (< 32 weeks' gestation at birth).

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 9), MEDLINE via PubMed (1966 to 12 September 2019), Embase (1980 to 12 September 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 12 September 2019). We searched clinical trials databases, conference proceedings, and reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing caring for very preterm infants in a supine head midline position versus a prone or lateral decubitus position, or undertaking a strategy of regular position change, or having no prespecified position. We included trials enrolling infants with existing GM-IVH and planned to assess extension of haemorrhage in a subgroup of infants. We planned to analyse horizontal (flat) versus head elevated positions separately for all body positions.

DATA COLLECTION AND ANALYSIS

We used standard methods of Cochrane Neonatal. For each of the included trials, two review authors independently extracted data and assessed risk of bias. The primary outcomes were GM-IVH, severe IVH, and neonatal death. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Three RCTs, with a total of 290 infants (either < 30 weeks' gestational age or < 1000 g body weight), met the inclusion criteria. Two trials compared supine midline head position versus head rotated 90° with the cot flat. One trial compared supine midline head position versus head rotated 90° with the bed tilted at 30°. We found no trials that compared supine versus prone midline head position. Meta-analysis of three trials (290 infants) did not show an effect on rates of GM-IVH (RR 1.11, 95% confidence interval (CI) 0.78 to 1.56; I² = 0%) and severe IVH (RR 0.71, 95% CI 0.37 to 1.33; I² = 0%). Neonatal mortality (RR 0.49, 95% CI 0.25 to 0.93; I² = 0%; RD -0.09, 95% CI -0.16 to -0.01) and mortality until hospital discharge (typical RR 0.50, 95% CI 0.28 to 0.90; I² = 0%; RD -0.10, 95% CI -0.18 to -0.02) were lower in the supine midline head position. The certainty of the evidence was very low for all outcomes because of limitations in study design and imprecision of estimates. We identified one ongoing study.

AUTHORS' CONCLUSIONS

We found few trial data on the effects of head midline position on GM-IVH in very preterm infants. Although meta-analyses suggest that mortality might be reduced, the certainty of the evidence is very low and it is unclear whether any effect is due to cot tilting (a co-intervention in one trial). Further high-quality RCTs would be needed to resolve this uncertainty.

Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: a multicentre cohort study

OBJECTIVE

To investigate the effect of a nursing intervention bundle, applied during the first 72 hours of life, on the incidence of germinal matrix-intraventricular haemorrhage (GMH-IVH) in very preterm infants.

DESIGN

Multicentre cohort study.

SETTING

Two Dutch tertiary neonatal intensive care units.

PATIENTS

The intervention group consisted of 281 neonates, whereas 280 infants served as historical controls (gestational age for both groups <30 weeks).

INTERVENTIONS

After a training period, the nursing intervention bundle was implemented and applied during the first 72 hours after birth. The bundle consisted of maintaining the head in the midline, tilting the head of the incubator and avoidance of flushing/rapid withdrawal of blood and sudden elevation of the legs.

MAIN OUTCOME MEASURES

The incidence of GMH-IVH occurring and/or increasing after the first ultrasound (but within 72 hours), cystic periventricular leukomalacia and/or in-hospital death was the primary composite outcome measure. Logistic regression analysis was used to explore differences between groups.

RESULTS

The nursing intervention bundle was associated with a lower risk of developing a GMH-IVH (any degree), cystic periventricular leukomalacia and/or mortality (adjusted OR 0.42, 95% CI 0.27 to 0.65). In the group receiving the bundle, also severe GMH-IVH, cystic periventricular leukomalacia and/or death were less often observed (adjusted OR 0.54, 95% CI 0.33 to 0.91).

CONCLUSIONS

The application of a bundle of nursing interventions is associated with reduced risk of developing a new/progressive (severe) GMH-IVH, cystic periventricular leukomalacia and/or mortality in very preterm infants when applied during the first 72 hours postnatally.

Single-centre prospective observational study on postdelivery room care

OBJECTIVES

As quality of care in the delivery room has major impact on outcome of preterm infants, multiple guidelines have been established in recent years. There is, however, little evidence on how to proceed during postdelivery room care, the time of transfer and admission to the neonatal intensive care unit (NICU). The aim of this study was to identify processes taking place during this period with potential impact on outcome.

STUDY DESIGN

Prospective observational study.

SETTING

Single-centre German tertiary NICU.

PATIENTS

40 inborn preterm infants undergoing postdelivery room care.

MAIN OUTCOME

Prevalence of prolonged duration of postdelivery room care, disconnections from the ventilator and positioning of preterm infants.

RESULTS

Total duration of postdelivery room care and NICU admission procedures were shorter in infants transferred in a transport incubator compared with using a NICU care station from birth. Extremely low birth weight (ELBW) infants spend 8% of the time in prone position in contrast to 39% in non-ELBW. Total duration of disconnection from the ventilator was 50 s and was ten times longer in infants who had nasal CPAP compared with infants intratracheally intubated. Infants with nCPAP had longer duration of disconnection from the ventilator if body weight was >1000 g or if they were transferred in a transport incubator.

CONCLUSIONS

Multiple parameters like birth weight or type of transport affect neonatal care during the postdelivery room period. Prospective studies are needed to identify and optimise parameters within this period that affect long-term outcome.