Change in neonatal resuscitation guidelines and trends in incidence of meconium aspiration syndrome in California

Outcomes of Nonvigorous Neonates Born through Meconium-Stained Amniotic Fluid after a Practice Change to No Routine Endotracheal Suctioning from a Developing Country

OBJECTIVE

The International Liaison Committee on Resuscitation (ILCOR) 2015 gave a weak recommendation based on low certainty of evidence against routine endotracheal (ET) suctioning in non-vigorous (NV) neonates born through meconium-stained amniotic fluid (MSAF) and suggested for immediate resuscitation without direct laryngoscopy. A need for ongoing surveillance post policy change has been stressed upon. This study compared the outcomes of NV MSAF neonates before and after implementation of the ILCOR 2015 recommendation.

STUDY DESIGN

This was a prospective cohort study of term NV MSAF neonates who underwent immediate resuscitation without ET suctioning (no ET group, July 2018 to June 2019, n = 276) compared with historical control who underwent routine ET suction (ET group, July 2015 to June 2016, n = 271).

RESULTS

Baseline characteristics revealed statistically significant higher proportion of male gender and small for gestational age neonates in the prospective cohort. There was no significant difference in the incidence of primary outcome of meconium aspiration syndrome (MAS) between the groups (no ET group: 27.2% vs ET group: 25.1%; p = 0.57). NV MSAF neonates with hypoxic ischemic encephalopathy (HIE) was significantly lesser in the prospective cohort (no ET group: 19.2% vs ET group: 27.3%; p = 0.03). Incidence of air leaks and need for any respiratory support significantly increased after policy change. In NV MSAF neonates with MAS, need for mechanical ventilation (MV) (no ET group: 24% vs ET group: 39.7%; p = 0.04) and mortality (no ET group: 18.7% vs ET group: 33.8%; p = 0.04) were significantly lesser.

CONCLUSION

Current study from a developing country indicates that immediate resuscitation and no routine ET suctioning of NV MSAF may not be associated with increased risk of MAS and may be associated with decreased risk of HIE. Increased requirement of any respiratory support and air leak post policy change needs further deliberation. Decreased risk of MV and mortality among those with MAS was observed.

KEY POINTS

· Not performing ET suction in NV MSAF infants is not associated with increase in the incidence of MAS.. · Initiating immediate resuscitation without ET suctioning was associated with decreased risk of HIE but increased receipt of any respiratory support and air leak.. · Large multicentric trial is required to generate robust evidence..

Neonatal Outcomes since the Implementation of No Routine Endotracheal Suctioning of Meconium-Stained Nonvigorous Neonates

OBJECTIVE

This study aimed to evaluate the effect of the 2015 Neonatal Resuscitation Program recommendations of no routine endotracheal suctioning for nonvigorous neonates on the incidence of meconium aspiration syndrome (MAS) and death. We hypothesized that the revised guidelines have not changed the outcome of MAS/death.

STUDY DESIGN

This was a single-center retrospective cohort study. We recorded data on nonvigorous neonates born at gestational age > 37 weeks, who were divided into period 1, n = 95 (before the new guidelines, January 1, 2013-December 31, 2015) and prospective period 2, n = 91 (after the implementation of new guidelines, January 1, 2017-December 31, 2020). Primary outcomes included MAS and death. Secondary outcomes included respiratory neonatal intensive care unit (NICU) admission, length of NICU stay, and feeding difficulties.

RESULTS

No significant differences in the occurrence of MAS (11 vs. 17%) (odds ratio [OR] of 1.46 [95% confidence interval [CI]: 0.59-3.55]) or death (1 vs. 3%) (OR of 2.00 [95% CI: 0.18-21.57]) among the two periods were observed. In period 2, there was an increased NICU respiratory admission (37 vs. 61%), with an OR of 2.31 (95% CI: 1.10-4.84). More neonates in period 2 required subsequent intubation for respiratory failure in the delivery room (12 vs. 28%) with an OR of 2.03 (95% CI: 1.02-4.51); p-value of 0.05.

CONCLUSION

Our study did not observe a significant difference in the incidence of MAS or death between the two periods since the 2015 guidelines. However, the incidence of NICU respiratory admission increased.

KEY POINTS

· Nonvigorous neonates born through MSAF who did not undergo ET suctioning soon after birth did not have increased incidence of MAS or death, but had increased NICU respiratory admissions.. · A large Multi-center RCT may give more clear verdict on the outcomes of these newborns..

Characteristics and spending patterns of high-cost child patients: findings from Fujian in China

BACKGROUND

The health condition during childhood has been shown to influence an individual's health and socioeconomic status in adulthood. Understanding the concentration and persistence patterns in children's healthcare expenditures is crucial for providing risk protection and promoting the well-being of children. Studies regarding the concentration and persistence of health expenditures have focused mainly on elderly individuals in developed regions. To gain insights into factors that contribute to childhood health expenditures, this article examined children with high costs (that is, in the top 10% of the expenditure distribution) and explored the characteristics and spending patterns that distinguished them from other patients in the context of the largest developing economy-China.

METHODS

By using a unique individual-level administrative claims dataset over a 5-year observation period, this study identified spending concentrations and the proportion of children whose costs remained high over five years using a linear probability model and logit regression analysis.

RESULTS

Teenagers from 12 to 17 years old were more likely to persist in the high-cost group than any other age groups in the study. Pediatric complex chronic conditions and other severe health ailments were predictive factors for entry into and persistence in the high-cost category. More than half of the total health expenditures were attributed to children in the top 10% expenditure group. In addition, risk protection and healthcare insurance support for high-cost children was found to be inadequate, particularly for children from low-income families.

CONCLUSIONS

Healthcare support for children impacts individual development and family financial status. This study described the characteristics and spending patterns of children patients in the largest developing country. The fact that over half of total expenditures are concentrated toward 10% of patients makes it valuable to consider relevant support for this group, especially for families whose medical costs are higher than income.

[The evolution of approach in the resuscitation of neonates born with meconium-stained amniotic fluid: a tale of two countries, China and U.S.A., in the past 60 years]

Neonates born through meconium-stained amniotic fluid (MSAF) may develop complications including meconium aspiration syndrome, persistent pulmonary hypertension of newborn and death. The approach to the resuscitation of these neonates has significantly evolved for the past few decades. Initially, under direct visualization technique, neonates with MSAF were commonly suctioned below the vocal cords soon after delivery. Since 2015, Neonatal Resuscitation Program (NRP^®) of the American Academy of Pediatrics has recommended against "routine" endotracheal suctioning of non-vigorous neonates with MSAF but favored immediate resuscitation with positive pressure ventilation via face-mask bagging. However, the China neonatal resuscitation 2021 guidelines continue to recommend routine endotracheal suctioning of non-vigorous neonates born with MSAF at birth. This review article discusses the differences and the rationales in the approach in the resuscitation of neonates with MSAF between Chinese and American NRP^® guidelines over the past 60 years.

Perinatal risk factors associated with the need for resuscitation in newborns born through meconium-stained amniotic fluid

OBJECTIVE

The Neonatal Life Support 2020 guidelines emphasize that meconium-stained amniotic fluid (MSAF) remains a significant risk factor for a newborn to receive advanced resuscitation, especially if additional risk factors are present at the time of birth. However, these additional perinatal risk factors are not clearly identified. The purpose of this study was to evaluate the importance of additional independent ante- and intrapartum risk factors in the era of no routine endotracheal suctioning that determine the need for resuscitation in newborns born through MSAF.

METHODS

This retrospective cohort study included deliveries ≥ 35 weeks' gestation associated with MSAF that occurred between January 1, 2017 and December 31, 2019. The newborns needing resuscitation (any intervention beyond the initial steps) were compared to those not needing resuscitation. Among newborns needing resuscitation, those needing advanced resuscitation (continuous positive airway pressure/ positive pressure ventilation or beyond) were compared to those not needing advanced resuscitation.

RESULTS

Logistic regression analysis revealed that among various perinatal factors, primigravida, thick meconium, fetal distress, chorioamnionitis, rupture of membranes ≥ 18 hours, post-term (gestational age ≥ 42 weeks), cesarean section or shoulder dystocia independently significantly increased the odds of a meconium-stained newborn needing resuscitation. Among these factors, fetal distress, chorioamnionitis or cesarean section independently further increased the odds of needing advanced resuscitation.

CONCLUSION

Risk stratification of perinatal factors associated with the need for newborn resuscitation and advanced resuscitation in the deliveries associated with MSAF may help neonatal teams and resources to be appropriately prioritized and optimally utilized.

Determinants of meconium aspiration syndrome among neonates admitted to neonatal intensive care unit at Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital, South Ethiopia: Unmatched case-control study

Objective:

To identify determinants of meconium aspiration syndrome among neonates admitted to the neonatal intensive care unit at Nigist Eleni Mohammed Memorial Comprehensive Specialized Hospital, South Ethiopia, in 2022.

Method:

A facility-based unmatched case–control study was used to identify meconium aspiration syndrome with a total sample size of 249 from January to April 2022. Data were entered by using EpiData version 3.1 and analyzed using SPSS version 24 software. Descriptive findings were presented by frequency tables and percentages. Multicollinearity was checked and the goodness of fit test was done. To determine the independent determinants associated with meconium aspiration syndrome, bivariate analysis was done and variables with a p value of <0.05 were taken to multivariate logistic regression analysis. Adjusted odds ratio with a 95% confidence interval was calculated, and statistical significance was declared at a p value less than 0.05.

Result:

Two hundred forty-nine (83 cases and 166 controls) mothers with their respective neonates were included in this study and that made the overall response rate 100%. Preeclampsia (adjusted odds ratio: 3.35, 95% confidence interval: 1.02, 10.97), antepartum hemorrhage (adjusted odds ratio: 3.63, 95% confidence interval: 1.50, 8.78), duration of labor (adjusted odds ratio: 4.34, 95% confidence interval: 1.83, 10.30), premature rupture of membrane (adjusted odds ratio: 16.02, 95% confidence interval: 5.66, 45.29), and obstructed labor (adjusted odds ratio: 4.57, 95% confidence interval: 1.42, 14.70) were determinants of meconium aspiration syndrome.

Conclusion:

In this study, preeclampsia, antepartum hemorrhage, duration of labor, premature rupture of membrane, and obstructed labor were determinants of meconium aspiration syndrome. Therefore, to reduce the risk of meconium aspiration syndrome, prevention, early identification, and management of these obstetrical factors may help to reduce meconium aspiration syndrome locally.

Neonatal outcomes of non-vigorous neonates with meconium-stained amniotic fluid before and after change in tracheal suctioning recommendation

OBJECTIVE

To evaluate the short-term outcomes of non-vigorous infants born through meconium-stained amniotic fluid (MSAF) before and after implementation of no-tracheal suctioning guidelines.

STUDY DESIGN

Single-center retrospective study of ≥36-week gestation neonates with MSAF.

RESULTS

During routine-suction era (9/2013-12/2014), 280/2306 neonates (12%) were born through MSAF and 39 (14%) were non-vigorous. Thirty (77%) of non-vigorous infants underwent tracheal suctioning. In the no-suction era (1/2017-12/2018), 282/2918 neonates (9.7%) were born through MSAF and 30 (10.6%) were non-vigorous and one needed intubation. Admissions for meconium aspiration syndrome (15% vs 53%) and respiratory distress (18% vs 57%) were significantly higher among non-vigorous infants in the no-suction era.

CONCLUSIONS

In this single-center study, non-vigorous infants born through MSAF without routine-tracheal suctioning had a higher incidence of NICU admission for MAS and respiratory distress compared to the routine-suction era. Multicenter randomized trials evaluating tracheal suction in non-vigorous infants with MSAF are warranted.

Appropriate Management of the Nonvigorous Meconium-Stained Newborn Meconium

Before 2015, major changes in Neonatal Resuscitation Program (NRP) recommendations not supporting previously endorsed antepartum, intrapartum and postpartum interventions to prevent meconium aspiration syndrome were based on adequately powered multicenter randomized controlled trials. The 2015 and 2020 American Heart Association guidelines and 7th and 8th edition of NRP suggest not performing routine intubation and tracheal suctioning of nonvigorous meconium-stained newborns. However, this was given as a weak recommendation with low-certainty evidence. The purpose of this review is to summarize the evidence and explore the question of appropriate delivery room management for nonvigorous meconium-stained newborns.

Updates for the Neonatal Resuscitation Program and Resuscitation Guidelines

Although most newborns require no assistance to successfully transition to extrauterine life, the large number of births each year and limited ability to predict which newborns will need assistance means that skilled clinicians must be prepared to respond quickly and efficiently for every birth. A successful outcome is dependent on a rapid response from skilled staff who have mastered the cognitive, technical, and behavioral skills of neonatal resuscitation. Since its release in 1987, over 4.5 million clinicians have been trained by the American Heart Association and American Academy of Pediatrics Neonatal Resuscitation Program®. The guidelines used to develop this program were updated in 2020 and the Textbook of Neonatal Resuscitation, 8th edition, was released in June 2021. The updated guidelines have not changed the basic approach to neonatal resuscitation, which emphasizes the importance of anticipation, preparation, teamwork, and effective ventilation. Several practices have changed, including the prebirth questions, initial steps, use of electronic cardiac monitors, the initial dose of epinephrine, the flush volume after intravascular epinephrine, and the duration of resuscitation with an absent heart rate. In addition, the program has enhanced components of the textbook to improve learning, added new course delivery options, and offers 2 course levels to allow learners to study the material that is most relevant to their role during neonatal resuscitation. This review summarizes the recent changes to the resuscitation guidelines, the textbook, and the Neonatal Resuscitation Program course.

Frequency of Extracorporeal Membrane Oxygenation Support and Outcomes After Implementation of a Structured PICU Network in Neonates and Children: A Prospective Population-Based Study in the West of France

OBJECTIVES

To describe the frequency and outcomes on the use of extracorporeal membrane oxygenation (ECMO) among critically ill neonates and children within a structured pediatric critical care network in the West of France. To assess the optimality of decision-making process for patients primarily admitted in non-ECMO centers.

DESIGN

Observational prospective population-based study from January 2015 to December 2019.

PATIENTS

Neonates over 34 weeks of gestational age, weighing more than 2,000 g and children under 15 years and 3 months old admitted in one of the 10 units belonging to a Regional Pediatric Critical Care Network.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eight-thousand one hundred eighty-nine children and 3,947 newborns were admitted within one of the 10 units of the network over the study period. Sixty-five children (8.1% [95% CI, 6.2-10‰]) and 35 newborns (9.4% [95% CI, 6.4-12%]) required ECMO support. Of these patients, 31 were first admitted to a non-ECMO center, where 20 were cannulated in situ (outside the regional ECMO center) and 11 after transfer to the ECMO regional center. Cardiogenic shock, highest serum lactate level, and cardiac arrest prior to first phone call with the regional ECMO center were associated with higher rate of in situ cannulation. During the study period, most of the patients were cannulated for underlying cardiac issue (42/100), postoperative cardiac surgery instability (38/100), and pediatric (10/100) and neonatal (10/100) respiratory distress syndrome. Patients primarily admitted in non-ECMO centers or not had similar 28-day post-ICU survival rates compared with those admitted in the referral ECMO center (58% vs 51%; p = 0.332). Pre-ECMO cardiac arrest, ECMO, and lower pH at ECMO onset were associated with lower 28-day post-ICU survival.

CONCLUSIONS

Our local results suggest that a structured referral network for neonatal and pediatric ECMO in the region of Western France facilitated escalation of care with noninferior (or similar) early mortality outcome. Our data support establishing referral networks in other equivalent regions.

Resuscitation of non-vigorous neonates born through meconium-stained amniotic fluid: post policy change impact analysis

BACKGROUND

We investigated the impact of policy change in delivery room resuscitation from routine endotracheal (ET) suctioning of non-vigorous neonates born through meconium-stained amniotic fluid (MSAF) to immediate non-invasive respiratory support.

DESIGN

Single-centre cohort study. Prospective group (October 2016-September 2017)-non-vigorous neonates born through MSAF managed according to the current (2015) guidance of commencing respiratory support without prior suctioning. Retrospective group (August 2015-July 2016)-non-vigorous neonates born through MSAF who underwent routine ET suctioning.

RESULTS

1138 neonates born through MSAF were analysed. No differences in the incidence of meconium aspiration syndrome (MAS), requirement of mechanical ventilation, inhaled nitric oxide or surfactant therapy were found between groups. Less neonatal intensive care unit (NICU) admissions were necessary in the prospective cohort compared with the retrospective group (19.1% vs 55.6%, respectively; p<0.05).

CONCLUSION

The policy change towards not routinely suctioning non-vigorous neonates born through MSAF at birth was not associated with an increase in the local incidence of MAS and was associated with fewer NICU admissions.

European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

Meconium Aspiration Syndrome: A Narrative Review

Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. Worldwide, the incidence has declined in developed countries thanks to improved obstetric practices and perinatal care while challenges persist in developing countries. Despite the improved survival rate over the last decades, long-term morbidity among survivors remains a major concern. Since the 1960s, relevant changes have occurred in the perinatal and postnatal management of such patients but the most appropriate approach is still a matter of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management and prognosis of infants with meconium aspiration syndrome.

[Newborn resuscitation and support of transition of infants at birth]

The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.

2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Delivery Room Management of Asphyxiated Term and Near-Term Infants

Approximately 800,000 newborns die annually due to birth asphyxia. The resuscitation of asphyxiated term newly born infants often occurs unexpected and is challenging for healthcare providers as it demands experience and knowledge in neonatal resuscitation. Current neonatal resuscitation guidelines often focus on resuscitation of extremely and/or very preterm infants; however, the recommendations for asphyxiated term newborn infants differ in some aspects to those for preterm infants (i.e., respiratory support, supplemental oxygen, and temperature management). Since the update of the neonatal resuscitation guidelines in 2015, several studies examining various resuscitation approaches to improve the outcome of asphyxiated infants have been published. In this review, we discuss current recommendations and recent findings and provide an overview of delivery room management of asphyxiated term newborn infants.

Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.