Accurate neonatal heart rate monitoring using a new wireless, cap mounted device

Fast and accurate newborn heart rate monitoring at birth: A systematic review

Aim

To examine speed and accuracy of newborn heart rate measurement by various assessment methods employed at birth.

Methods

A search of Medline, SCOPUS, CINAHL and Cochrane was conducted between January 1, 1946, to until August 16, 2023. (CRD 42021283364) Study selection was based on predetermined criteria. Reviewers independently extracted data, appraised risk of bias and assessed certainty of evidence.

Results

Pulse oximetry is slower and less precise than ECG for heart rate assessment. Both auscultation and palpation are imprecise for heart rate assessment. Other devices such as digital stethoscope, Doppler ultrasound, an ECG device using dry electrodes incorporated in a belt, photoplethysmography and electromyography are studied in small numbers of newborns and data are not available for extremely preterm or bradycardic newborns receiving resuscitation. Digital stethoscope is fast and accurate. Doppler ultrasound and dry electrode ECG in a belt are fast, accurate and precise when compared to conventional ECG with gel adhesive electrodes.

Limitations

Certainty of evidence was low or very low for most comparisons.

Conclusion

If resources permit, ECG should be used for fast and accurate heart rate assessment at birth. Pulse oximetry and auscultation may be reasonable alternatives but have limitations. Digital stethoscope, doppler ultrasound and dry electrode ECG show promise but need further study.

A clinical evaluation and acceptability study of the innovative SurePulse VS wireless heart rate monitor across the neonatal journey

Background

The SurePulse vital signs (VS) device is an innovative wireless heart rate monitor designed for neonatal patients. This study evaluates the application of SurePulse VS technology in clinical practice.

Methods

Data were collected about the quantitative metrics of the device itself when deployed on real infants and qualitative feedback from perinatal professionals and parents regarding their experiences using this novel technology.

Results

This study recruited 101 infants and achieved target completion rates of 101 healthcare professional (HCP) and 51 parent questionnaires over the seven-month study period. The SurePulse device was deployed across a range of gestational ages (34-39 weeks) and birth weights (1.8-3.5 kg). Device deployment was performed across a range of clinical environments, with 51% of deployments at delivery and 47% within the neonatal unit. The data show clinically acceptable timings from device deployment to heart rate signal acquisition [median 20 s (IQR 15-76 s)]. HCP feedback rated SurePulse monitoring as "Always" or "Mostly" reliable in 80% of cases. Parental feedback reported that having the SurePulse device was reassuring, convenient and beneficial to them. These positive comments were reflected across device deployment in the delivery room and within the neonatal unit.

Conclusions

The study findings show that the SurePulse device has potential to be a significant advancement in the way neonatal patients are monitored in a variety of post-delivery circumstances. This study has demonstrated that the SurePulse device has utility throughout the neonatal journey, enabling accurate heart rate monitoring in a manner that promotes parent-infant contact and bonding.

Skin-interfacing wearable biosensors for smart health monitoring of infants and neonates

Health monitoring of infant patients in intensive care can be especially strenuous for both the patient and their caregiver, as testing setups involve a tangle of electrodes, probes, and catheters that keep the patient bedridden. This has typically involved expensive and imposing machines, to track physiological metrics such as heart rate, respiration rate, temperature, blood oxygen saturation, blood pressure, and ion concentrations. However, in the past couple of decades, research advancements have propelled a world of soft, wearable, and non-invasive systems to supersede current practices. This paper summarizes the latest advancements in neonatal wearable systems and the different approaches to each branch of physiological monitoring, with an emphasis on smart skin-interfaced wearables. Weaknesses and shortfalls are also addressed, with some guidelines provided to help drive the further research needed.

Accuracy of Wireless Pulse Oximeter on Preterm or <2.5 kg Infants

OBJECTIVE

 Monitoring heart rate (HR) and oxygen saturation (SpO2) in infants is essential in the neonatal intensive care unit. Wireless pulse oximeter technology has been advancing but with limited accuracy data on preterm infants. This observational study compared HR and SpO2 of the wireless Owlet Smart Sock 3 (OSS3) to the wired Masimo SET (Masimo) pulse oximeter in preterm or <2.5 kg infants.

STUDY DESIGN

 Twenty-eight eligible infants were enrolled. They weighed between 1.7 and 2.5 kg and were without anomalies or medical instability. OSS3 and Masimo simultaneously monitored HR and SpO2 for 60 minutes. The data were aligned by time epoch and filtered for poor tracings. The agreement was compared using the Pearson's correlation coefficient, the Bland-Altman method, average root mean square (ARMS), and prevalence and bias adjusted kappa (PABAK) analyses.

RESULTS

 Two infants' data were excluded due to motion artifacts or device failures. The corrected gestational age and current weights were 35 ± 3 weeks and 2.0 ± 0.2 kg (mean ± standard deviation), respectively. Over 21 hours of data showed that HR was strongly correlated between the two devices (r = 0.98, p < 0.001), with a difference of -1.3 beats per minute (bpm) and the limit of agreement (LOA) -6.3 to 3.4 bpm based on the Bland-Altman method. SpO2 was positively correlated between the two devices (r = 0.71, p < 0.001) with a SpO2 bias of 0.3% (LOA: -4.6 to 4.5%). The estimated ARMS of OSS3 compared with Masimo was 2.3% for SpO2 in the 70 to 100% range. The precision decreased with lower SpO2. A strong agreement (PABAK = 0.94) was between the two devices on whether SpO2 was above or below 90%.

CONCLUSION

 OSS3 provided comparable HR and SpO2 accuracy to Masimo in preterm or <2.5 kg infants. Motion artifacts, lack of arterial blood gas comparisons, and lack of racial and ethnic diversity are the study limitations. More OSS3 data on the Lower HR and SpO2 ranges were needed before implementing inpatient use.

KEY POINTS

· Pulse oximeters are vital for monitoring preterm infants' HR and SpO2 levels.. · Limited data exist on the accuracy of the wireless OSS3 on preterm infants.. · This observational study found that the OSS3 is comparable to the Masimo SET in measuring HR and SpO2 in preterm or <2.5 kg infants..

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Back vs. chest ECG electrode placement in neonatal resuscitation: A pilot randomized controlled trial

BACKGROUND

The recent Neonatal Resuscitation Program advises the early utilization of an electrocardiogram (ECG) for non-vigorous newborns in the delivery room. However, placing ECG electrodes on the chest may delay obtaining a reliable heart rate (HR) and could interfere with chest compressions. Our previous study showed that preset ECG electrodes, attached to the back of the newborn, are quicker than a pulse oximeter (POX) for detecting HR.

AIM

To compare time to detect a reliable HR using back-placed ECG electrodes versus standard front placement.

METHODS

Infants were randomly assigned to back (n = 85) or chest (n = 89) electrode placement. Time measurement began upon placing infants on a Panda warmer ResusView. Failure was defined as no HR detected within 5 minutes. Intention-to-treat analysis compared HR signal acquisition time between groups.

RESULTS

Both groups showed similar proportions of detectable HR within the first minute. Median (IQR) time to obtain HR was 26 (13,38) seconds for the chest group and 21 (12,54) seconds for the back group (p = 0.91). A large number of vigorous infants were included. In the chest group, these vigorous infants had shorter HR acquisition times than non-vigorous infants (Mean ± SD of 34 ± 48 seconds vs. 50 ± 44 seconds respectively; p = 0.049). Failure rates and time to acquire a HR for infants who were non-vigorous and required advanced resuscitation were similar between the back and chest groups (p = 0.51).

CONCLUSION

Preset back ECG electrodes have shown encouraging results in neonates requiring advanced resuscitation. Further studies are needed to enhance guidance during neonatal resuscitation.

Wireless monitoring devices in hospitalized children: a scoping review

The purpose of this study is to provide a structured overview of existing wireless monitoring technologies for hospitalized children. A systematic search of the literature published after 2010 was conducted in Medline, Embase, Scielo, Cochrane, and Web of Science. Two investigators independently reviewed articles to determine eligibility for inclusion. Information on study type, hospital setting, number of participants, use of a reference sensor, type and number of vital signs monitored, duration of monitoring, type of wireless information transfer, and outcomes of the wireless devices was extracted. A descriptive analysis was applied. Of the 1130 studies identified from our search, 42 met eligibility for subsequent analysis. Most included studies were observational studies with sample sizes of 50 or less published between 2019 and 2022. Common problems pertaining to study methodology and outcomes observed were short duration of monitoring, single focus on validity, and lack information on wireless transfer and data management.  Conclusion: Research on the use of wireless monitoring for children in hospitals has been increasing in recent years but often limited by methodological problems. More rigorous studies are necessary to establish the safety and accuracy of novel wireless monitoring devices in hospitalized children. What is Known: • Continuous monitoring of vital signs using wired sensors is the standard of care for hospitalized pediatric patients. However, the use of wires may pose significant challenges to optimal care. What is New: • Interest in wireless monitoring for hospitalized pediatric patients has been rapidly growing in recent years. • However, most devices are in early stages of clinical testing and are limited by inconsistent clinical and technological reporting.

Forehead monitoring of heart rate in neonatal intensive care

Heart rate is an extremely important physiological parameter to measure in critically unwell infants, as it is the main physiological marker that changes in response to a change in infant condition. Heart rate is routinely measured peripherally on a limb with a pulse oximeter. However, when infants are critically unwell, the blood supply to these peripheries is reduced in preference for central perfusion of vital organs such as the brain and heart. Measurement of heart rate with a reflection mode photoplethysmogram (PPG) sensor on the forehead could help minimise this problem and make it easier for other important medical equipment, such as cannulas, to be placed on the limbs. This study compares heart rates measured with a forehead-based PPG sensor against a wrist-based PPG sensor in 19 critically unwell infants in neonatal intensive care collecting 198 h of data. The two heart rates were compared using positive percentage agreement, Spearman's correlation coefficient and Bland-Altman analysis. The forehead PPG sensor showed good agreement with the wrist-based PPG sensor with limits of agreement of 8.44 bpm, bias of -0.22 bpm; positive percentage agreement of 98.87%; and Spearman's correlation coefficient of 0.9816. The analysis demonstrates that the forehead is a reliable alternative location for measuring vital signs using the PPG.

Artificial intelligence-driven wearable technologies for neonatal cardiorespiratory monitoring: Part 1 wearable technology

With the development of Artificial Intelligence techniques, smart health monitoring is becoming more popular. In this study, we investigate the trend of wearable sensors being adopted and developed in neonatal cardiorespiratory monitoring. We performed a search of papers published from the year 2000 onwards. We then reviewed the advances in sensor technologies and wearable modalities for this application. Common wearable modalities included clothing (39%); chest/abdominal belts (25%); and adhesive patches (15%). Popular singular physiological information from sensors included electrocardiogram (15%), breathing (24%), oxygen saturation and photoplethysmography (13%). Many studies (46%) incorporated a combination of these signals. There has been extensive research in neonatal cardiorespiratory monitoring using both single and multi-parameter systems. Poor data quality is a common issue and further research into combining multi-sensor information to alleviate this should be investigated. IMPACT STATEMENT: State-of-the-art review of sensor technology for wearable neonatal cardiorespiratory monitoring. Review of the designs for wearable neonatal cardiorespiratory monitoring. The use of multi-sensor information to improve physiological data quality has been limited in past research. Several sensor technologies have been implemented and tested on adults that have yet to be explored in the newborn population.

Non-invasive sensor methods used in monitoring newborn babies after birth, a clinical perspective

Background

Reducing the global new-born mortality is a paramount challenge for humanity. There are approximately 786,323 live births in the UK each year according to the office for National Statistics; around 10% of these newborn infants require assistance during this transition after birth. Each year around, globally around 2.5 million newborns die within their first month. The main causes are complications due to prematurity and during delivery. To act in a timely manner and prevent further damage, health professionals should rely on accurate monitoring of the main vital signs heart rate and respiratory rate.

Aims

To present a clinical perspective on innovative, non-invasive methods to monitor heart rate and respiratory rate in babies highlighting their advantages and limitations in comparison with well-established methods.

Methods

Using the data collected in our recently published systematic review we highlight the barriers and facilitators for the novel sensor devices in obtaining reliable heart rate measurements. Details about difficulties related to the application of sensors and interfaces, time to display, and user feedback are explored. We also provide a unique overview of using a non-invasive respiratory rate monitoring method by extracting RR from the pulse oximetry trace of newborn babies.

Results

Novel sensors to monitor heart rate offer the advantages of minimally obtrusive technologies but have limitations due to movement artefact, bad sensor coupling, intermittent measurement, and poor-quality recordings compared to gold standard well established methods. Respiratory rate can be derived accurately from pleth recordings in infants.

Conclusion

Some limitations have been identified in current methods to monitor heart rate and respiratory rate in newborn babies. Novel minimally invasive sensors have advantages that may help clinical practice. Further research studies are needed to assess whether they are sufficiently accurate, practical, and reliable to be suitable for clinical use.

Feasibility of handheld ultrasound to assess heart rate in newborn nursery

BACKGROUND AND OBJECTIVES

Heart rate (HR) assessment is important during neonatal resuscitation. The most reliable ways of assessing HR at birth are pulse oximetry (PO) and/or electrocardiograph (ECG). However, delayed recording time due to poor perfusion or probe and electrode placement has been a concern. Point-of-care ultrasound (POCUS) provides a real-time instant view of the heart. The aim of this study was to look at the feasibility of POCUS in assessing the heart rate of stable, healthy, term neonates.

METHODS

The study was approved by the institutional review board, and informed consent was obtained from the subject's mother. A real-time video image was obtained from the POCUS probe using the app on the smartphone. The principal investigator (PI) counted the heart beats for six seconds using a stopwatch, which was then multiplied by 10 to give the HR per minute. The assistant recorded the simultaneous HR using the PO. The HRs obtained from both methods were recorded and then compared using the Pearson correlation and Bland-Altman plot.

RESULTS

A total of 30 HR observations were made using the POCUS and PO simultaneously. The correlation coefficient (r) was noted to be 0.75 with a p-value of <0.0001 for pairwise correlation. A strong agreement was noted between the two methods using Bland-Altman Plot.

CONCLUSION

We were able to demonstrate the feasibility of using handheld POCUS in assessing the HR of stable NB infants in the newborn nursery. A follow-up study is planned to evaluate its feasibility in the delivery room.

Multicentre paired non-inferiority study of the cardiorespiratory monitoring performance of the wireless and non-adhesive Bambi® belt measuring diaphragm activity in neonates: study protocol

INTRODUCTION

Cardiorespiratory monitoring is used in the neonatal intensive care unit (NICU) to assess the clinical status of newborn infants and detect critical deteriorations in cardiorespiratory function. Currently, heart rate (HR) is monitored by electrocardiography (ECG) and respiration by chest impedance (CI). Disadvantages of current monitoring techniques are usage of wired adhesive electrodes which may damage the skin and hinder care. The Bambi® belt is a wireless and non-adhesive alternative that enables cardiorespiratory monitoring by measuring electrical activity of the diaphragm via transcutaneous electromyography. A previous study showed feasibility of the Bambi® belt and this study compares the belt performance to ECG and CI.

METHODS AND ANALYSIS

This multicentre non-inferiority paired study will be performed in the NICU of the Máxima Medical Center (MMC) in Veldhoven and the Emma Children's Hospital, Amsterdam University Medical Centre (AmsterdamUMC) in Amsterdam, The Netherlands. 39 infants in different postmenstrual age groups (minimally 10 infants<30 weeks, between 30-32 weeks and >32 weeks) will be recruited. These infants will be monitored with the Bambi® belt in addition to standard ECG and CI for 24 hours. The primary outcome is the HR, studied with three criteria: (1) the limits of agreement of the HR measurements in terms of the second-to-second difference in the HR between the belt and standard ECG, (2) the detection of cardiac events consisting of bradycardia and tachycardia and (3) the quality of HR-monitoring. The secondary outcome is the respiratory rate (RR), studied with the criteria (1) agreement in RR-trend monitoring, (2) apnoea and tachypnoea detection and (3) reliable registrations.

ETHICS AND DISSEMINATION

This protocol was approved by the Medical Ethical Committee of the MMC and the Central Committee for Human Research. The MMC started patient recruitment in July and the AmsterdamUMC in August 2021. The results will be presented at conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NL9480.

Toward greater nuance in delayed cord clamping

PURPOSE OF REVIEW

For over a decade, the International Liaison Committee on Resuscitation has recommended delayed cord clamping (DCC), but implementation has been variable due to lack of consensus on details of technique and concerns for risks in certain patient populations. This review summarizes recent literature on the benefits and risks of DCC in term and preterm infants and examines alternative approaches such as physiologic-based cord clamping or intact cord resuscitation (ICR) and umbilical cord milking (UCM).

RECENT FINDINGS

DCC improves hemoglobin/hematocrit among term infants and may promote improved neurodevelopment. In preterms, DCC improves survival compared to early cord clamping; however, UCM has been associated with severe intraventricular hemorrhage in extremely preterm infants. Infants of COVID-19 positive mothers, growth-restricted babies, multiples, and some infants with cardiopulmonary anomalies can also benefit from DCC. Large randomized trials of ICR will clarify safety and benefits in nonvigorous neonates. These have the potential to dramatically change the sequence of events during neonatal resuscitation.

SUMMARY

Umbilical cord management has moved beyond simple time-based comparisons to nuances of technique and application in vulnerable sub-populations. Ongoing research highlights the importance of an individualized approach that recognizes the physiologic equilibrium when ventilation is established before cord clamping.

A Textile Sleeve for Monitoring Oxygen Saturation Using Multichannel Optical Fibre Photoplethysmography

Textile-based systems are an attractive prospect for wearable technology as they can provide monitoring of key physiological parameters in a comfortable and unobtrusive form. A novel system based on multichannel optical fibre sensor probes integrated into a textile sleeve is described. The system measures the photoplethysmogram (PPG) at two wavelengths (660 and 830 nm), which is then used to calculate oxygen saturation (SpO₂). In order to achieve reliable measurement without adjusting the position of the garment, four plastic optical fibre (POF) probes are utilised to increase the likelihood that a high-quality PPG is obtained due to at least one of the probes being positioned over a blood vessel. Each probe transmits and receives light into the skin to measure the PPG and SpO₂. All POFs are integrated in a stretchable textile sleeve with a circumference of 15 cm to keep the sensor in contact with the subject’s wrist and to minimise motion artefacts. Tests on healthy volunteers show that the multichannel PPG sensor faithfully provides an SpO₂ reading in at least one of the four sensor channels in all cases with no need for adjusting the position of the sleeve. This could not be achieved using a single sensor alone. The multichannel sensor is used to monitor the SpO₂ of 10 participants with an average wrist circumference of 16.0 ± 0.6 cm. Comparing the developed sensor’s SpO₂ readings to a reference commercial oximeter (reflectance Masimo Radical-7) illustrates that the mean difference between the two sensors’ readings is −0.03%, the upper limit of agreement (LOA) is 0.52% and the lower LOA is −0.58%. This multichannel sensor has the potential to achieve reliable, unobtrusive and comfortable textile-based monitoring of both heart rate and SpO₂ during everyday life.

Heart Rate Variability in the Perinatal Period: A Critical and Conceptual Review

Neonatal intensive care units (NICUs) greatly expand the use of technology. There is a need to accurately diagnose discomfort, pain, and complications, such as sepsis, mainly before they occur. While specific treatments are possible, they are often time-consuming, invasive, or painful, with detrimental effects for the development of the infant. In the last 40 years, heart rate variability (HRV) has emerged as a non-invasive measurement to monitor newborns and infants, but it still is underused. Hence, the present paper aims to review the utility of HRV in neonatology and the instruments available to assess it, showing how HRV could be an innovative tool in the years to come. When continuously monitored, HRV could help assess the baby’s overall wellbeing and neurological development to detect stress-/pain-related behaviors or pathological conditions, such as respiratory distress syndrome and hyperbilirubinemia, to address when to perform procedures to reduce the baby’s stress/pain and interventions, such as therapeutic hypothermia, and to avoid severe complications, such as sepsis and necrotizing enterocolitis, thus reducing mortality. Based on literature and previous experiences, the first step to efficiently introduce HRV in the NICUs could consist in a monitoring system that uses photoplethysmography, which is low-cost and non-invasive, and displays one or a few metrics with good clinical utility. However, to fully harness HRV clinical potential and to greatly improve neonatal care, the monitoring systems will have to rely on modern bioinformatics (machine learning and artificial intelligence algorithms), which could easily integrate infant’s HRV metrics, vital signs, and especially past history, thus elaborating models capable to efficiently monitor and predict the infant’s clinical conditions. For this reason, hospitals and institutions will have to establish tight collaborations between the obstetric, neonatal, and pediatric departments: this way, healthcare would truly improve in every stage of the perinatal period (from conception to the first years of life), since information about patients’ health would flow freely among different professionals, and high-quality research could be performed integrating the data recorded in those departments.