Interventions for the Management of Respiratory Distress in Late Preterm and Term Infants Experiencing Delayed Respiratory Transition: A Systematic Review

Perinatal predictors of clinical instability at birth in late-preterm and term infants

To identify characteristics associated with delivery room clinical instability in at-risk infants. Prospective cohort study. Two perinatal centres in Melbourne, Australia. Infants born at ≥ 35⁺⁰ weeks' gestation with a first-line paediatric doctor requested to attend. Clinical instability defined as any one of heart rate < 100 beats per minute for ≥ 20 s in the first 10 min after birth, maximum fraction of inspired oxygen of ≥ 0.70 in the first 10 min after birth, 5-min Apgar score of < 7, intubated in the delivery room or admitted to the neonatal unit for respiratory support. Four hundred and seventy-three infants were included. The median (IQR) gestational age at birth was 39⁺⁴ (38⁺⁴-40⁺⁴) weeks. Eighty (17%) infants met the criteria for clinical instability. Independent risk factors for clinical instability were labour without oxytocin administration, presence of a medical pregnancy complication, difficult extraction at birth and unplanned caesarean section in labour. Decision tree analysis determined that infants at highest risk were those whose mothers did not receive oxytocin during labour (25% risk). Infants at lowest risk were those whose mothers received oxytocin during labour and did not have a medical pregnancy complication (7% risk).

CONCLUSIONS

We identified characteristics associated with clinical instability that may be useful in alerting less experienced clinicians to call for senior assistance early. The decision trees provide intuitive visual aids but require prospective validation.

WHAT IS KNOWN

• First-line clinicians attending at-risk births may need to call senior colleagues for assistance depending on the infant's condition. • Delays in effectively supporting a compromised infant at birth is an important cause of neonatal morbidity and infant-mother separation.

WHAT IS NEW

• This study identifies risk factors for delivery room clinical instability in at-risk infants born at ≥ 35⁺⁰ weeks' gestation. • The decision trees presented provide intuitive visual tools to aid in determining the need for senior paediatric presence.

Respiratory support after delayed cord clamping: a prospective cohort study of at-risk births at ≥35+0 weeks gestation

OBJECTIVE

To identify risk factors associated with delivery room respiratory support in at-risk infants who are initially vigorous and received delayed cord clamping (DCC).

DESIGN

Prospective cohort study.

SETTING

Two perinatal centres in Melbourne, Australia.

PATIENTS

At-risk infants born at ≥35⁺⁰ weeks gestation with a paediatric doctor in attendance who were initially vigorous and received DCC for >60 s.

MAIN OUTCOME MEASURES

Delivery room respiratory support defined as facemask positive pressure ventilation, continuous positive airway pressure and/or supplemental oxygen within 10 min of birth.

RESULTS

Two hundred and ninety-eight infants born at a median (IQR) gestational age of 39⁺³ (38⁺²-40⁺²) weeks were included. Cord clamping occurred at a median (IQR) of 128 (123-145) s. Forty-four (15%) infants received respiratory support at a median of 214 (IQR 156-326) s after birth. Neonatal unit admission for respiratory distress occurred in 32% of infants receiving delivery room respiratory support vs 1% of infants who did not receive delivery room respiratory support (p<0.001). Risk factors independently associated with delivery room respiratory support were average heart rate (HR) at 90-120 s after birth (determined using three-lead ECG), mode of birth and time to establish regular cries. Decision tree analysis identified that infants at highest risk had an average HR of <165 beats per minute at 90-120 s after birth following caesarean section (risk of 39%). Infants with an average HR of ≥165 beats per minute at 90-120 s after birth were at low risk (5%).

CONCLUSIONS

We present a clinical decision pathway for at-risk infants who may benefit from close observation following DCC. Our findings provide a novel perspective of HR beyond the traditional threshold of 100 beats per minute.

Bi-Level Positive Airway Pressure for Non-invasive Respiratory Support of Foals

Respiratory insufficiency and pulmonary health are important considerations in equine neonatal care. As the majority of foals are bred for athletic pursuits, strategies for respiratory support of compromised foals are of particular importance. The administration of supplementary oxygen is readily implemented in equine practice settings, but does not address respiratory insufficiency due to inadequate ventilation and is no longer considered optimal care for hypoxia in critical care settings. Non-invasive ventilatory strategies including continuous or bi-level positive airway pressure are effective in human and veterinary studies, and may offer improved respiratory support in equine clinical practice. The current study was conducted to investigate the use of a commercial bi-level positive airway pressure (BiPAP) ventilator, designed for home care of people with obstructive respiratory conditions, for respiratory support of healthy foals with pharmacologically induced respiratory insufficiency. A two sequence (administration of supplementary oxygen with, or without, BiPAP), two phase, cross-over experimental design was used in a prospective study with six foals. Gas exchange and mechanics of breathing (increased tidal volume, decreased respiratory rate and increased peak inspiratory flow) were improved during BiPAP relative to administration of supplementary oxygen alone or prior studies using continuous positive airway pressure, but modest hypercapnia was observed. Clinical observations, pulse oximetry and monitoring of expired carbon dioxide was of limited benefit in identification of foals responding inappropriately to BiPAP, and improved methods to assess and monitor respiratory function are required in foals.

Current Resources for Evidence-Based Practice, May 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.