1
|
Smolich JJ, Kenna KR, Mynard JP. Returning to evidence-based mechanisms and concepts in preterm birth transition physiology. J Physiol 2024; 602:4329-4331. [PMID: 39151045 DOI: 10.1113/jp287169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/18/2024] Open
Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Department of Biomedical Engineering, University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
2
|
Smolich JJ, Kenna KR, Mynard JP. Extended period of ventilation before delayed cord clamping augments left-to-right shunting and decreases systemic perfusion at birth in preterm lambs. J Physiol 2024; 602:1791-1813. [PMID: 38532618 DOI: 10.1113/jp285799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
Previous studies have suggested that an extended period of ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. However, it is unknown whether this greater rise in PA flow is accompanied by increases in left ventricular (LV) output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale (FO), with decreased systemic arterial perfusion. Using an established preterm lamb birth transition model, this study compared the effect of a short (∼40 s, n = 11), moderate (∼2 min, n = 11) or extended (∼5 min, n = 12) period of initial mechanical lung ventilation before DCC on flow probe-derived perinatal changes in PA flow, LV output, total systemic arterial blood flow, ductal shunting and FO shunting. The LV output was relatively stable during initial ventilation but increased after DCC, with similar responses in all groups. Systemic arterial flow patterns displayed only minor differences during brief and moderate periods of initial ventilation and were similar after DCC. However, an increase in PA flow was augmented with an extended initial ventilation (P < 0.001), owing to an earlier onset of left-to-right ductal and FO shunting (P < 0.001), and was accompanied by a pronounced reduction in total systemic arterial flow (P = 0.005) that persisted for 4 min after DCC (P ≤ 0.039). These findings suggest that, owing to increased left-to-right shunting and a greater reduction in systemic arterial perfusion, an extended period of ventilation before DCC does not result in greater perinatal circulatory benefits than shorter periods of initial ventilation in the birth transition. KEY POINTS: Previous studies suggest that an extended period of initial ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. It is unknown whether this greater rise in PA flow is accompanied by an increased left ventricular output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale, with decreased systemic arterial perfusion. Anaesthetized preterm fetal lambs instrumented with central arterial flow probes underwent a brief (∼40 s), moderate (∼2 min) or extended (∼5 min) period of ventilation before DCC. Perinatal changes in left ventricular output were similar in all groups, but extended initial ventilation augmented both perinatal increases in PA flow, owing to earlier onset and greater left-to-right ductal and foramen ovale shunting, and perinatal reductions in total systemic arterial perfusion. Extended ventilation before DCC does not confer a greater perinatal circulatory benefit than shorter periods of initial ventilation.
Collapse
Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
3
|
Gaertner VD, Büchler VL, Waldmann A, Bassler D, Rüegger CM. Deciphering Mechanisms of Respiratory Fetal-to-Neonatal Transition in Very Preterm Infants. Am J Respir Crit Care Med 2024; 209:738-747. [PMID: 38032260 DOI: 10.1164/rccm.202306-1021oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/30/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: The respiratory mechanisms of a successful transition of preterm infants after birth are largely unknown. Objectives: To describe intrapulmonary gas flows during different breathing patterns directly after birth. Methods: Analysis of electrical impedance tomography data from a previous randomized trial in preterm infants at 26-32 weeks gestational age. Electrical impedance tomography data for individual breaths were extracted, and lung volumes as well as ventilation distribution were calculated for end of inspiration, end of expiratory braking and/or holding maneuver, and end of expiration. Measurements and Main Results: Overall, 10,348 breaths from 33 infants were analyzed. We identified three distinct breath types within the first 10 minutes after birth: tidal breathing (44% of all breaths; sinusoidal breathing without expiratory disruption), braking (50%; expiratory brake with a short duration), and holding (6%; expiratory brake with a long duration). Only after holding breaths did end-expiratory lung volume increase: Median (interquartile range [IQR]) = 2.0 AU/kg (0.6 to 4.3), 0.0 (-1.0 to 1.1), and 0.0 (-1.1 to 0.4), respectively; P < 0.001]. This was mediated by intrathoracic air redistribution to the left and non-gravity-dependent parts of the lung through pendelluft gas flows during braking and/or holding maneuvers. Conclusions: Respiratory transition in preterm infants is characterized by unique breathing patterns. Holding breaths contribute to early lung aeration after birth in preterm infants. This is facilitated by air redistribution during braking/holding maneuvers through pendelluft flow, which may prevent lung liquid reflux in this highly adaptive situation. This study deciphers mechanisms for a successful fetal-to-neonatal transition and increases our pathophysiological understanding of this unique moment in life. Clinical trial registered with www.clinicaltrials.gov (NCT04315636).
Collapse
Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
- Division of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Vanessa L Büchler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Andreas Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| |
Collapse
|
4
|
Seidler AL, Aberoumand M, Hunter KE, Barba A, Libesman S, Williams JG, Shrestha N, Aagerup J, Sotiropoulos JX, Montgomery AA, Gyte GML, Duley L, Askie LM. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet 2023; 402:2209-2222. [PMID: 37977169 DOI: 10.1016/s0140-6736(23)02468-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth. METHODS We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640. FINDINGS We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality. INTERPRETATION This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations. FUNDING Australian National Health and Medical Research Council.
Collapse
Affiliation(s)
- Anna Lene Seidler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia.
| | - Mason Aberoumand
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Kylie E Hunter
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Angie Barba
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Sol Libesman
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Nipun Shrestha
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Jannik Aagerup
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| |
Collapse
|
5
|
Kuypers KLAM, Hopman A, Cramer SJE, Dekker J, Visser R, Hooper SB, Te Pas AB. Effect of initial and subsequent mask applications on breathing and heart rate in preterm infants at birth. Arch Dis Child Fetal Neonatal Ed 2023; 108:594-598. [PMID: 37080734 DOI: 10.1136/archdischild-2022-324835] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 03/29/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE Application of a face mask may provoke the trigeminocardiac reflex, leading to apnoea and bradycardia. This study investigates whether re-application of a face mask in preterm infants at birth alters the risk of apnoea compared with the initial application, and identify factors that influence this risk. METHODS Resuscitation videos and respiratory function monitor data collected from preterm infants <30 weeks gestation between 2018 and 2020 were reviewed. Breathing and heart rate before and after the initial and subsequent mask applications were analysed. RESULTS In total, 111 infants were included with 404 mask applications (102 initial and 302 subsequent mask applications). In 254/404 (63%) applications, infants were breathing prior to mask application, followed by apnoea after 67/254 (26%) mask applications. Apnoea and bradycardia occurred significantly more often after the initial mask application compared with subsequent applications (apnoea initial: 32/67 (48%) and subsequent: 44/187 (24%), p<0.001; bradycardia initial: 61% and subsequent 21%, p<0.001). Apnoea was followed by bradycardia in 73% and 71% of the initial and subsequent mask applications, respectively (p=0.607).In a logistic regression model, a lower breathing rate (OR 0.908 (95% CI 0.847 to 0.974), p=0.007) and heart rate (OR 0.935 (95% CI 0.901 to 0.970), p<0.001) prior to mask application were associated with an increased likelihood of becoming apnoeic following subsequent mask applications. CONCLUSION In preterm infants at birth, apnoea and bradycardia occurs more often after an initial mask application than subsequent applications, with lower heart and breathing rates increasing the risk of apnoea in subsequent applications.
Collapse
Affiliation(s)
- Kristel L A M Kuypers
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anouk Hopman
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sophie J E Cramer
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Janneke Dekker
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Remco Visser
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, The Hudson Institute for Medical Research, Clayton, Victoria, Australia
- Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, The Netherlands
| |
Collapse
|
6
|
Heuchan AM, O'Shea JE, Aitken J. Respiratory and cardiovascular stabilisation prior to deferred umbilical cord clamping in premature infants: a feasibility and safety study. Arch Dis Child Fetal Neonatal Ed 2023; 108:548-549. [PMID: 37173120 DOI: 10.1136/archdischild-2023-325360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Anne Marie Heuchan
- Department of Neonatal Medicine, Royal Hospital for Children, Glasgow, G51 4TF, UK
| | - Joyce E O'Shea
- Department of Neonatal Medicine, Royal Hospital for Children, Glasgow, G51 4TF, UK
| | - Julie Aitken
- Department of Neonatal Medicine, Royal Hospital for Children, Glasgow, G51 4TF, UK
| |
Collapse
|
7
|
Suciu LM, Prelipcean I, Făgărășan A, Giesinger RE, McNamara PJ. Normative echocardiography data of myocardial adaptation to extrauterine life: a review of prospective studies. Front Pediatr 2023; 11:1192618. [PMID: 37397152 PMCID: PMC10312083 DOI: 10.3389/fped.2023.1192618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/06/2023] [Indexed: 07/04/2023] Open
Abstract
Recent research has increased focus and interest in characterizing the physiology of the transition circulation using echocardiography. Critique of published normative neonatal echocardiography data among healthy term neonates has not been performed. We have performed a comprehensive literature review using the key terms: cardiac adaptation, hemodynamics, neonatal transition, term newborns. Studies were included if they had reported echocardiography indices of cardiovascular function in the presence of maternal diabetes, intrauterine growth restricted newborns and prematurity and had a comparison group of healthy term newborns within first seven postnatal days. Sixteen published studies evaluating transitional circulation in healthy newborns were included. There was marked heterogeneity in the methodologies used; specifically, inconsistency in time of evaluation and imaging techniques used makes it challenging to determine specific trends of expected physiologic changes. Some studies revealed nomograms for echocardiography indices, though limitations persist in terms of sample size, number of reported parameters and consistency of measurement technique. A comprehensive standardized echocardiography framework which includes consistent techniques for assessment dimensions, function, blood flow, pulmonary/systemic vascular resistance, and shunts pattern is warranted to ensure consistency in the use of echocardiography to guide care of healthy and sick newborns.
Collapse
Affiliation(s)
- Laura Mihaela Suciu
- Department of Pediatrics, University of Medicine Pharmacy Science and Technology George Emil Palade of Targu Mures, Targu Mures, Romania
| | - Irina Prelipcean
- Department of Neonatology, University of Rochester Medical Center Golisano Children’s Hospital at Strong, Rochester, NY, United States
| | - Amalia Făgărășan
- Department of Pediatrics, University of Medicine Pharmacy Science and Technology George Emil Palade of Targu Mures, Targu Mures, Romania
| | - Regan E. Giesinger
- Department of Pediatrics, University of Iowa Stead Family Children’s Hospital, Iowa City, IA, United States
| | - Patrick J. McNamara
- Department of Pediatrics, University of Iowa Stead Family Children’s Hospital, Iowa City, IA, United States
| |
Collapse
|
8
|
Koo J, Aghai ZH, Katheria A. Cord management in non-vigorous newborns. Semin Perinatol 2023; 47:151742. [PMID: 37031034 PMCID: PMC10239342 DOI: 10.1016/j.semperi.2023.151742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
Cord management in non-vigorous newborns remains up for debate, as limited studies have validated strategies in this high-risk population. While multiple national and international governing bodies now recommend the routine practice of delayed cord clamping (DCC) in vigorous neonates, these organizations have not reached a consensus on the appropriate approach in non-vigorous neonates.1 Benefits of placental transfusion are greatly needed amongst non-vigorous neonates who are at risk of asphyxiation-associated mortality and morbidities, but the need for immediate resuscitation complicates matters. This chapter discusses the physiological benefits of placental transfusion for non-vigorous neonates and reviews the available literature on different umbilical cord management strategies for this population.
Collapse
Affiliation(s)
- Jenny Koo
- Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, CA, USA
| | - Zubair H Aghai
- Thomas Jefferson University/Nemours, Philadelphia, PA, USA
| | - Anup Katheria
- Sharp Mary Birch Hospital for Women and Newborns, Sharp Neonatal Research Institute, San Diego, CA, USA.
| |
Collapse
|
9
|
Balázs G, Balajthy A, Seri I, Hegyi T, Ertl T, Szabó T, Röszer T, Papp Á, Balla J, Gáll T, Balla G. Prevention of Chronic Morbidities in Extremely Premature Newborns with LISA-nCPAP Respiratory Therapy and Adjuvant Perinatal Strategies. Antioxidants (Basel) 2023; 12:1149. [PMID: 37371878 DOI: 10.3390/antiox12061149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Less invasive surfactant administration techniques, together with nasal continuous airway pressure (LISA-nCPAP) ventilation, an emerging noninvasive ventilation (NIV) technique in neonatology, are gaining more significance, even in extremely premature newborns (ELBW), under 27 weeks of gestational age. In this review, studies on LISA-nCPAP are compiled with an emphasis on short- and long-term morbidities associated with prematurity. Several perinatal preventative and therapeutic investigations are also discussed in order to start integrated therapies as numerous organ-saving techniques in addition to lung-protective ventilations. Two thirds of immature newborns can start their lives on NIV, and one third of them never need mechanical ventilation. With adjuvant intervention, these ratios are expected to be increased, resulting in better outcomes. Optimized cardiopulmonary transition, especially physiologic cord clamping, could have an additively beneficial effect on patient outcomes gained from NIV. Organ development and angiogenesis are strictly linked not only in the immature lung and retina, but also possibly in the kidney, and optimized interventions using angiogenic growth factors could lead to better morbidity-free survival. Corticosteroids, caffeine, insulin, thyroid hormones, antioxidants, N-acetylcysteine, and, moreover, the immunomodulatory components of mother's milk are also discussed as adjuvant treatments, since immature newborns deserve more complex neonatal interventions.
Collapse
Affiliation(s)
- Gergely Balázs
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - András Balajthy
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - István Seri
- First Department of Pediatrics, School of Medicine, Semmelweis University, 1083 Budapest, Hungary
- Keck School of Medicine of USC, Children's Hospital of Los Angeles, Los Angeles, CA 90033, USA
| | - Thomas Hegyi
- Department of Pediatrics, Division of Neonatology, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ 08903, USA
| | - Tibor Ertl
- Departments of Neonatology and Obstetrics & Gynecology, University of Pécs Medical School, 7624 Pécs, Hungary
- MTA-PTE Human Reproduction Scientific Research Group, University of Pécs, 7624 Pécs, Hungary
| | - Tamás Szabó
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Röszer
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Ágnes Papp
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - József Balla
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- ELKH-UD Vascular Pathophysiology Research Group, Hungarian Academy of Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Gáll
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - György Balla
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- ELKH-UD Vascular Pathophysiology Research Group, Hungarian Academy of Sciences, University of Debrecen, 4032 Debrecen, Hungary
| |
Collapse
|
10
|
Kukka AJ, Berkelhamer SK, Eilevstjønn J, Wood TR, Basnet O, Kc A. Observational study comparing heart rate in crying and non-crying but breathing infants at birth. BMJ Paediatr Open 2023; 7:e001886. [PMID: 37028906 PMCID: PMC10083872 DOI: 10.1136/bmjpo-2023-001886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 03/08/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Stimulating infants to elicit a cry at birth is common but could result in unnecessary handling. We evaluated heart rate in infants who were crying versus non-crying but breathing immediately after birth. METHODS This was single-centre observational study of singleton, vaginally born infants at ≥33 weeks of gestation. Infants who were crying or non-crying but breathing within 30 s after birth were included. Background demographic data and delivery room events were recorded using tablet-based applications and synchronised with continuous heart rate data recorded by a dry-electrode electrocardiographic monitor. Heart rate centile curves for the first 3 min of life were generated with piecewise regression analysis. Odds of bradycardia and tachycardia were compared using multiple logistic regression. RESULTS 1155 crying and 54 non-crying but breathing neonates were included in the final analyses. There were no significant differences in the demographic and obstetric factors between the cohorts. Non-crying but breathing infants had higher rates of early cord clamping <60 s after birth (75.9% vs 46.5%) and admission to the neonatal intensive care unit (13.0% vs 4.3%). There were no significant differences in median heart rates between the cohorts. Non-crying but breathing infants had higher odds of bradycardia (heart rate <100 beats/min, adjusted OR 2.64, 95% CI 1.34 to 5.17) and tachycardia (heart rate ≥200 beats/min, adjusted OR 2.86, 95% CI 1.50 to 5.47). CONCLUSION Infants who are quietly breathing but do not cry after birth have an increased risk of both bradycardia and tachycardia, and admission to the neonatal intensive care unit. TRIAL REGISTRATION NUMBER ISRCTN18148368.
Collapse
Affiliation(s)
- Antti Juhani Kukka
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- Department of Pediatrics, Region Gävleborg, Gävle, Sweden
| | - Sara K Berkelhamer
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | - Joar Eilevstjønn
- Strategic Research, Laerdal Global Health, Stavanger, Rogaland, Norway
| | - Thomas Ragnar Wood
- Division of Neonatology, Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Center on Human Development and Disability, University of Washington, Seattle, Washington, USA
| | | | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
- School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| |
Collapse
|
11
|
May RW, Maso Talou GD, Clark AR, Mynard JP, Smolich JJ, Blanco PJ, Müller LO, Gentles TL, Bloomfield FH, Safaei S. From fetus to neonate: A review of cardiovascular modeling in early life. WIREs Mech Dis 2023:e1608. [DOI: 10.1002/wsbm.1608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/31/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
|
12
|
Gien J. Timing of umbilical cord clamping in infants with congenital diaphragmatic hernia. Semin Perinatol 2023:151746. [PMID: 36997450 DOI: 10.1016/j.semperi.2023.151746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth anomaly where a defect in the diaphragm allows abdominal organs to herniate into the chest with compression of the intrathoracic structures, specifically the lungs and heart. Pulmonary and left ventricular hypoplasia result in respiratory insufficiency after birth with disordered transition and persistent pulmonary hypertension of the newborn (PPHN). As a result, infants need immediate intervention after birth to support the transition. Delayed cord clamping (DCC) is recommended for all healthy newborns and improves outcomes in infants born preterm and in infants with congenital heart disease; however, DCC may not be feasible in newborns needing immediate intervention after birth. Recent studies have explored resuscitation with intact umbilical cords, to determine feasibility, safety, and efficacy in infants with CDH, with promising results. In this report we discuss the physiologic basis for intact cord resuscitation in infants with CDH and review the above reports with a view to determining optimal timing of umbilical cord clamping in infants with CDH.
Collapse
Affiliation(s)
- Jason Gien
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, 13121 E. 17th Avenue, MS 8402, Room 4304, Aurora, CO 80045, USA.
| |
Collapse
|
13
|
Nevill E, Mildenhall LFJ, Meyer MP. Effect of Breathing Support in Very Preterm Infants Not Breathing During Deferred Cord Clamping: A Randomized Controlled Trial (The ABC Study). J Pediatr 2023; 253:94-100.e1. [PMID: 36152686 DOI: 10.1016/j.jpeds.2022.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine if providing respiratory support to very preterm infants who fail to breathe regularly during deferred cord clamping (DCC) decreased red cell transfusion. STUDY DESIGN Infants less than 31 weeks of gestation undergoing DCC who were apneic or not breathing regularly at 15 seconds underwent stratified randomization. Pale, limp, and nonresponsive infants were excluded. The standard group received gentle stimulation in a neutral position for 50 seconds; the intervention group received intermittent positive pressure ventilation via face mask and T piece from 20 to 50 seconds of age with a fractional inspired oxygen of 0.3. The primary outcome was the proportion transfused, with a secondary composite outcome of death, severe intraventricular hemorrhage, or chronic lung disease. RESULTS Of 311 assessed infants, 113 met the inclusion criteria and were studied; 57 received the intervention and 56 standard treatment. Patient characteristics were similar. Overall, 105 infants (93%) received the intended 50 seconds DCC (54 in the intervention group and 51 in the standard group). Rates of transfusion were similar (28% vs 30% in the intervention vs control groups), as were rates of the composite outcome (46% vs 38% in the intervention vs the control arms; P = .45). CONCLUSIONS Providing breathing support during 50 seconds of DCC in this single-center cohort seemed to be safe and feasible, but did not decrease the transfusion rates or improve outcomes. TRIAL REGISTRATION http://www.anzctr.org.au/ACTRN12615001026516.aspx.
Collapse
Affiliation(s)
| | - Lindsay F J Mildenhall
- Middlemore Hospital, Auckland, New Zealand; Department of Pediatrics, The University of Auckland, Auckland, New Zealand
| | - Michael P Meyer
- Middlemore Hospital, Auckland, New Zealand; Department of Pediatrics, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
14
|
Schwaberger B, Pichler G, Baik-Schneditz N, Kurath-Koller S, Sallmon H, Singh Y. Editorial: Cardio-circulatory support of neonatal transition. Front Pediatr 2023; 11:1146395. [PMID: 36861075 PMCID: PMC9969124 DOI: 10.3389/fped.2023.1146395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 01/25/2023] [Indexed: 02/15/2023] Open
Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Stefan Kurath-Koller
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Hannes Sallmon
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria.,Department of Pediatric Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Cambridge University Hospitals NHS Foundation Trust and University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom.,Department of Pediatrics - Division of Neonatology, Loma Linda University Children's Hospital and Loma Linda University School of Medicine, Loma Linda, CA, United States
| |
Collapse
|
15
|
Koo J, Kilicdag H, Katheria A. Umbilical cord milking-benefits and risks. Front Pediatr 2023; 11:1146057. [PMID: 37144151 PMCID: PMC10151786 DOI: 10.3389/fped.2023.1146057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/03/2023] [Indexed: 05/06/2023] Open
Abstract
The most common methods for providing additional placental blood to a newborn are delayed cord clamping (DCC) and umbilical cord milking (UCM). However, DCC carries the potential risk of hypothermia due to extended exposure to the cold environment in the operating room or delivery room, as well as a delay in performing resuscitation. As an alternative, umbilical cord milking (UCM) and delayed cord clamping with resuscitation (DCC-R) have been studied, as they allow for immediate resuscitation after birth. Given the relative ease of performing UCM compared to DCC-R, UCM is being strongly considered as a practical option in non-vigorous term and near-term neonates, as well as preterm neonates requiring immediate respiratory support. However, the safety profile of UCM, particularly in premature newborns, remains a concern. This review will highlight the currently known benefits and risks of umbilical cord milking and explore ongoing studies.
Collapse
Affiliation(s)
- Jenny Koo
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, United States
| | - Hasan Kilicdag
- Divisions of Neonatology, Baskent University Faculty of Medicine, Ankara, Türkiye
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, United States
- Correspondence: Anup Katheria
| |
Collapse
|
16
|
Increased risk of bradycardia in vigorous infants receiving early as compared to delayed cord clamping at birth. J Perinatol 2022:10.1038/s41372-022-01593-1. [PMID: 36587054 DOI: 10.1038/s41372-022-01593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 12/14/2022] [Accepted: 12/21/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To compare HR pattern of vigorous newborns during the first 180 s with early (≤60 s, ECC) or delayed (>60 s, DCC) cord clamping. STUDY DESIGN Observational study including dry-electrode ECG monitoring of 610 vaginally-born singleton term and late-preterm (≥34 weeks) who were vigorous after birth. RESULTS 198 received ECC while 412 received DCC with median cord clamping at 37 s and 94 s. Median HR remained stable from 30 to 180 s with DCC (172 and 170 bpm respectively) but increased with ECC (169 and 184 bpm). The proportion with bradycardia was higher among ECC than DCC at 30 s and fell faster in the DCC through 60 s. After adjusting for factors affecting timing of cord clamping, ECC had significant risk of bradycardia compared to DCC (aRR 1.51; 95% CI; 1.01-2.26). CONCLUSION Early heart instability and higher risk of bradycardia with ECC as compared to DCC supports the recommended clinical practice of DCC.
Collapse
|
17
|
Lung Aeration During Deferred Cord Clamping-No Additional Benefits in Infants Born Preterm? J Pediatr 2022; 255:11-15.e6. [PMID: 36463936 DOI: 10.1016/j.jpeds.2022.11.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
|
18
|
Knol R, Brouwer E, van den Akker T, DeKoninck PLJ, Lopriore E, Onland W, Vermeulen MJ, van den Akker-van Marle ME, van Bodegom-Vos L, de Boode WP, van Kaam AH, Reiss IKM, Polglase GR, Hutten GJ, Prins SA, Mulder EEM, Hulzebos CV, van Sambeeck SJ, van der Putten ME, Zonnenberg IA, Hooper SB, Te Pas AB. Physiological-based cord clamping in very preterm infants: the Aeration, Breathing, Clamping 3 (ABC3) trial-study protocol for a multicentre randomised controlled trial. Trials 2022; 23:838. [PMID: 36183143 PMCID: PMC9526936 DOI: 10.1186/s13063-022-06789-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND International guidelines recommend delayed umbilical cord clamping (DCC) up to 1 min in preterm infants, unless the condition of the infant requires immediate resuscitation. However, clamping the cord prior to lung aeration may severely limit circulatory adaptation resulting in a reduction in cardiac output and hypoxia. Delaying cord clamping until lung aeration and ventilation have been established (physiological-based cord clamping, PBCC) allows for an adequately established pulmonary circulation and results in a more stable circulatory transition. The decline in cardiac output following time-based delayed cord clamping (TBCC) may thus be avoided. We hypothesise that PBCC, compared to TBCC, results in a more stable transition in very preterm infants, leading to improved clinical outcomes. The primary objective is to compare the effect of PBCC on intact survival with TBCC. METHODS The Aeriation, Breathing, Clamping 3 (ABC3) trial is a multicentre randomised controlled clinical trial. In the interventional PBCC group, the umbilical cord is clamped after the infant is stabilised, defined as reaching heart rate > 100 bpm and SpO2 > 85% while using supplemental oxygen < 40%. In the control TBCC group, cord clamping is time based at 30-60 s. The primary outcome is survival without major cerebral and/or intestinal injury. Preterm infants born before 30 weeks of gestation are included after prenatal parental informed consent. The required sample size is 660 infants. DISCUSSION The findings of this trial will provide evidence for future clinical guidelines on optimal cord clamping management in very preterm infants at birth. TRIAL REGISTRATION ClinicalTrials.gov NCT03808051. First registered on January 17, 2019.
Collapse
Affiliation(s)
- Ronny Knol
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands. .,Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Emma Brouwer
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.,Athena Institute, VU University, Amsterdam, The Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Enrico Lopriore
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | | | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Sophia Children's Hospital, Erasmus MC University Medical Center, P.O. Box 2060, 3000 CB, Rotterdam, The Netherlands
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sandra A Prins
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Estelle E M Mulder
- Department of Neonatology, Isala Women and Children's Hospital, Zwolle, The Netherlands
| | - Christian V Hulzebos
- Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - Sam J van Sambeeck
- Department of Paediatrics, Maxima Medical Center, Veldhoven, The Netherlands
| | - Mayke E van der Putten
- Department of Paediatrics, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Inge A Zonnenberg
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
19
|
Tan-Koay AG, Libesman S, Kluckow M, Gill AW, de Waal K, Tarnow-Mordi W, Robledo KP, Seidler AL, Liley HG. Protocol for a Nested, Retrospective Study of the Australian Placental Transfusion Study Cohort. Cureus 2022; 14:e27693. [PMID: 36081962 PMCID: PMC9440991 DOI: 10.7759/cureus.27693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 11/09/2022] Open
Abstract
Background Neonates, particularly if born preterm or with congenital anomalies, are among the pediatric patients most likely to need blood transfusion. However, they are also particularly vulnerable to adverse consequences of blood transfusion. Aiming to clamp the umbilical cord for at least a minute after birth is a simple safe procedure that is being increasingly adopted worldwide, although may be associated with increased rates of polycythemia and jaundice. It may also reduce the proportion of preterm babies who need a blood transfusion. The mechanisms for this are not fully understood. Potential mechanisms could include an increased volume of blood transfusion from the placenta to the baby after birth, and an overall reduction in the severity of illness in the first weeks after birth, which could lead to fewer blood tests and greater tolerance of anemia, or enhanced erythropoiesis. Objectives To investigate the mechanism behind the reduced need for blood transfusions after deferral of cord clamping. Methodology This protocol outlines the methods and data analysis plan for a study using nested retrospective data from a large randomized trial combined with additional data collected from patient medical and pathology records. The additional data items to be collected all relate to the receipt of transfusion and the factors that affect the risk for transfusion in preterm babies. The analysis will include all randomized babies from Australia and New Zealand for whom data are available. Causal mediation analysis is planned to estimate the effects of mediators on the relationship between the timing of cord clamping and the need for blood transfusion. The analysis is designed to discern whether initial severity of illness or the magnitude of placental transfusion mediates red blood cell transfusion dependence. Anticipated outcomes and dissemination We expect the study will identify potential strategies for reducing blood transfusions and associated negative outcomes in preterm infants. This will be relevant to researchers, clinicians, and parents. The results will be disseminated through publications, presentations, and inclusion in evidence-based guidelines.
Collapse
|
20
|
A hybrid type I, multi-center randomized controlled trial to study the implementation of a method for Sustained cord circulation And VEntilation (the SAVE-method) of late preterm and term neonates: a study protocol. BMC Pregnancy Childbirth 2022; 22:593. [PMID: 35883044 PMCID: PMC9315331 DOI: 10.1186/s12884-022-04915-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An intact umbilical cord allows the physiological transfusion of blood from the placenta to the neonate, which reduces infant iron deficiency and is associated with improved development during early childhood. The implementation of delayed cord clamping practice varies depending on mode of delivery, as well as gestational age and neonatal compromise. Emerging evidence shows that infants requiring resuscitation would benefit if respiratory support were provided with the umbilical cord intact. Common barriers to providing intact cord resuscitation is the availability of neonatal resuscitation equipment close to the mother, organizational readiness for change as well as attitudes and beliefs about placental transfusion within the multidisciplinary team. Hence, clinical evaluations of cord clamping practice should include implementation outcomes in order to develop strategies for optimal cord management practice. METHODS The Sustained cord circulation And Ventilation (SAVE) study is a hybrid type I randomized controlled study combining the evaluation of clinical outcomes with implementation and health service outcomes. In phase I of the study, a method for providing in-bed intact cord resuscitation was developed, in phase II of the study the intervention was adapted to be used in multiple settings. In phase III of the study, a full-scale multicenter study will be initiated with concurrent evaluation of clinical, implementation and health service outcomes. Clinical data on neonatal outcomes will be recorded at the labor and neonatal units. Implementation outcomes will be collected from electronic surveys sent to parents as well as staff and managers within the birth and neonatal units. Descriptive and comparative statistics and regression modelling will be used for analysis. Quantitative data will be supplemented by qualitative methods using a thematic analysis with an inductive approach. DISCUSSION The SAVE study enables the safe development and evaluation of a method for intact cord resuscitation in a multicenter trial. The study identifies barriers and facilitators for intact cord resuscitation. The knowledge provided from the study will be of benefit for the development of cord clamping practice in different challenging clinical settings and provide evidence for development of clinical guidelines regarding optimal cord clamping. TRIAL REGISTRATION Clinicaltrials.gov, NCT04070560 . Registered 28 August 2019.
Collapse
|
21
|
Smolich JJ. Understanding the physiology of immediate and delayed umbilical cord clamping at birth: Need for evidence-based pathway to reduce confusion. J Physiol 2022; 600:3627-3631. [PMID: 35819860 DOI: 10.1113/jp283393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, University of Melbourne, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| |
Collapse
|
22
|
Zhao Y, Wang Y, Liu C, Jiang Y, Wei Y, Meng H, Jian S, Zhu X, Pei L, Bai X, Feng F, Lv Y, Zhou X, Qi Q, Li J, Ma L. Ex utero intrapartum therapy in infants with congenital diaphragmatic hernia: a propensity score matching analysis. WORLD JOURNAL OF PEDIATRIC SURGERY 2022; 5:e000425. [DOI: 10.1136/wjps-2022-000425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 05/04/2022] [Indexed: 11/04/2022] Open
Abstract
ObjectivePrevious studies have shown that ex utero intrapartum therapy (EXIT) is safe and feasible for newborns with congenital diaphragmatic hernia (CDH). This study reports our experience with EXIT in fetuses with CDH in an attempt to explore the efficacy of EXIT on the survival rate of this population.MethodsA retrospective analysis of the clinical data of 116 children with CDH was conducted. The children were assigned to EXIT and non-EXIT groups. Propensity score matching (PSM) toward clinical data was performed, and the clinical characteristics and outcomes were compared. Taking survival at discharge as the main outcome, logistic regression analysis was carried out to explore the efficacy of EXIT on survival.ResultsDuring the study period, 30 of 116 children received EXIT. After PSM, the survival rates of the EXIT group and the non-EXIT group were 82.76% (24/29) and 48.28% (14/29), respectively (p=0.006). EXIT (OR=0.083, 95% CI=0.013to 0.525, p=0.008), liver herniation (OR=16.955, 95% CI=2.342 to 122.767, p=0.005), and gestational age at diagnosis (OR=0.662, 95% CI=0.497 to 0.881, p=0.005) were independent mortality-related risk factors of all children with CDH. Ninety-nine of 116 children underwent surgery. After PSM, the postoperative survival rates of the EXIT group and non-EXIT group were 84.6% (22/26) and 76.9% (20/26), respectively (p=0.754). Liver herniation (OR=10.451, 95% CI=1.641 to 66.544, p=0.013) and gestational age at diagnosis (OR=0.736, 95% CI=0.577 to 0.938, p=0.013) were independent mortality-related risk factors of children after surgery.ConclusionEXIT can be performed safely for selected prenatally diagnosed CDH neonates with potentially better survival and does not cause more maternal complications compared with traditional cesarean section.
Collapse
|
23
|
Ott F, Kribs A, Stelzl P, Kyvernitakis I, Ehlen M, Schmidtke S, Rawnaq-Möllers T, Rath W, Berger R, Maul H. Resuscitation of Term Compromised and Asphyctic Newborns: Better with Intact Umbilical Cord? Geburtshilfe Frauenheilkd 2022; 82:706-718. [PMID: 35815099 PMCID: PMC9262631 DOI: 10.1055/a-1804-3268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/18/2022] [Indexed: 10/27/2022] Open
Abstract
AbstractThe authors hypothesize that particularly severely compromised and asphyctic term infants in need of resuscitation may benefit from delayed umbilical cord clamping (after several minutes).
Although evidence is sparse, the underlying pathophysiological mechanisms support this assumption. For this review the authors have analyzed the available research. Based on these data they
conclude that it may be unfavorable to immediately clamp the cord of asphyctic newborns (e.g., after shoulder dystocia) although recommended in current guidelines to provide quick
neonatological support. Compression of the umbilical cord or thorax obstructs venous flow to the fetus more than arterial flow to the placenta. The fetus is consequently cut off from a
supply of oxygenated, venous blood. This may cause not only hypoxemia and consecutive hypoxia during delivery but possibly also hypovolemia. Immediate cord clamping may aggravate the
situation of the already compromised newborn, particularly if the cord is cut before the lungs are ventilated. By contrast, delayed cord clamping leads to fetoplacental transfusion of
oxygenated venous blood, which may buffer an existing acidosis. Furthermore, it may enhance blood volume by up to 20%, leading to higher levels of various blood components, such as red and
white blood cells, thrombocytes, mesenchymal stem cells, immunoglobulins, and iron. In addition, the resulting increase in pulmonary perfusion may compensate for an existing hypoxemia or
hypoxia. Early cord clamping before lung perfusion reduces the preload of the left ventricle and hinders the establishment of sufficient circulation. Animal models and clinical trials
support this opinion. The authors raise the question whether it would be better to resuscitate compromised newborns with intact umbilical cords. Obstetric and neonatal teams need to work
even closer together to improve neonatal outcomes.
Collapse
Affiliation(s)
- Friederike Ott
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
- Asklepios Medical School, Hamburg, Germany
| | - Angela Kribs
- Klinik für Neonatologie und pädiatrische Intensivmedizin, Universitätskinderklinik, Köln, Germany
| | - Patrick Stelzl
- Frauenklinik, Kepler Universitätsklinikum Linz, Linz, Austria
| | - Ioannis Kyvernitakis
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
| | - Michael Ehlen
- Klinik für Kinder- und Jugendmedizin, Marienhaus Klinikum Bendorf – Neuwied – Waldbreitbach, Neuwied, Germany
| | - Susanne Schmidtke
- Klinik für Neonatologie und pädiatrische Intensivmedizin, Asklepios Kliniken Barmbek und Nord-Heidberg, Hamburg, Germany
| | - Tamina Rawnaq-Möllers
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
| | - Werner Rath
- Universitätsfrauenklinik, Universitätsklinikum Schleswig Holstein, Kiel, Germany
| | - Richard Berger
- Frauenklinik, Marienhaus Klinikum Neuwied, Neuwied, Germany
| | - Holger Maul
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
- Asklepios Medical School, Hamburg, Germany
| |
Collapse
|
24
|
Badurdeen S, Davis PG, Hooper SB, Donath S, Santomartino GA, Heng A, Zannino D, Hoq M, Omar F Kamlin C, Kane SC, Woodward A, Roberts CT, Polglase GR, Blank DA. Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation. PLoS Med 2022; 19:e1004029. [PMID: 35737735 PMCID: PMC9269938 DOI: 10.1371/journal.pmed.1004029] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 07/08/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Globally, the majority of newborns requiring resuscitation at birth are full term or late-preterm infants. These infants typically have their umbilical cord clamped early (ECC) before moving to a resuscitation platform, losing the potential support of the placental circulation. Physiologically based cord clamping (PBCC) is clamping the umbilical cord after establishing lung aeration and holds promise as a readily available means of improving early newborn outcomes. In mechanically ventilated lambs, PBCC improved cardiovascular stability and reduced hypoxia. We hypothesised that PBCC compared to ECC would result in higher heart rate (HR) in infants needing resuscitation, without compromising safety. METHODS AND FINDINGS Between 4 July 2018 and 18 May 2021, infants born at ≥32+0 weeks' gestation with a paediatrician called to attend were enrolled in a parallel-arm randomised trial at 2 Australian perinatal centres. Following initial stimulation, infants requiring further resuscitation were randomised within 60 seconds of birth using a smartphone-accessible web link. The intervention (PBCC) was to establish lung aeration, either via positive pressure ventilation (PPV) or effective spontaneous breathing, prior to cord clamping. The comparator was early cord clamping (ECC) prior to resuscitation. The primary outcome was mean HR between 60 to 120 seconds after birth, measured using 3-lead electrocardiogram, extracted from video recordings blinded to group allocation. Nonrandomised infants had deferred cord clamping (DCC) ≥120 seconds in the observational study arm. Among 508 at-risk infants enrolled, 123 were randomised (n = 63 to PBCC, n = 60 to ECC). Median (interquartile range, IQR) for gestational age was 39.9 (38.3 to 40.7) weeks in PBCC infants and 39.6 (38.4 to 40.4) weeks in ECC infants. Approximately 49% and 50% of the PBCC and ECC infants were female, respectively. Five infants (PBCC = 2, ECC = 3, 4% total) had missing primary outcome data. Cord clamping occurred at a median (IQR) of 136 (126 to 150) seconds in the PBCC arm and 37 (27 to 51) seconds in the ECC arm. Mean HR between 60 to 120 seconds after birth was 154 bpm (beats per minute) for PBCC versus 158 bpm for ECC (adjusted mean difference -6 bpm, 95% confidence interval (CI) -17 to 5 bpm, P = 0.39). Among 31 secondary outcomes, postpartum haemorrhage ≥500 ml occurred in 34% and 32% of mothers in the PBCC and ECC arms, respectively. Two hundred ninety-five nonrandomised infants (55% female) with median (IQR) gestational age of 39.6 (38.6 to 40.6) weeks received DCC. Data from these infants was used to create percentile charts of expected HR and oxygen saturation in vigorous infants receiving DCC. The trial was limited by the small number of infants requiring prolonged or advanced resuscitation. PBCC may provide other important benefits we did not measure, including improved maternal-infant bonding and higher iron stores. CONCLUSIONS In this study, we observed that PBCC resulted in similar mean HR compared to infants receiving ECC. The findings suggest that for infants ≥32+0 weeks' gestation who receive brief, effective resuscitation at closely monitored births, PBCC does not provide additional benefit over ECC (performed after initial drying and stimulation) in terms of key physiological markers of transition. PBCC was feasible using a simple, low-cost strategy at both cesarean and vaginal births. The percentile charts of HR and oxygen saturation may guide clinicians monitoring the transition of at-risk infants who receive DCC. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000621213.
Collapse
Affiliation(s)
- Shiraz Badurdeen
- Newborn Research Centre, The Royal Women’s Hospital, Melbourne, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- * E-mail:
| | - Peter G. Davis
- Newborn Research Centre, The Royal Women’s Hospital, Melbourne, Australia
- Clinical Epidemiology and Biostatistics Unit and Clinical Sciences Research, Murdoch Children’s Research Institute, Melbourne, Australia
- The University of Melbourne, Department of Obstetrics and Gynaecology, Melbourne, Australia
| | - Stuart B. Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Departments of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Susan Donath
- Clinical Epidemiology and Biostatistics Unit and Clinical Sciences Research, Murdoch Children’s Research Institute, Melbourne, Australia
| | | | - Alissa Heng
- Departments of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Diana Zannino
- Clinical Epidemiology and Biostatistics Unit and Clinical Sciences Research, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Monsurul Hoq
- Clinical Epidemiology and Biostatistics Unit and Clinical Sciences Research, Murdoch Children’s Research Institute, Melbourne, Australia
| | - C. Omar F Kamlin
- Newborn Research Centre, The Royal Women’s Hospital, Melbourne, Australia
| | - Stefan C. Kane
- The University of Melbourne, Department of Obstetrics and Gynaecology, Melbourne, Australia
- Division of Maternity Services and Department of Maternal Fetal Medicine, The Royal Women’s Hospital, Melbourne, Australia
| | - Anthony Woodward
- Division of Maternity Services and Department of Maternal Fetal Medicine, The Royal Women’s Hospital, Melbourne, Australia
| | - Calum T. Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Departments of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Douglas A. Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
| | | |
Collapse
|
25
|
Smolich JJ, Kenna KR. Divergent effects of initial ventilation with delayed cord clamping on systemic and pulmonary arterial flows in the birth transition of preterm lambs. J Physiol 2022; 600:3585-3601. [PMID: 35482416 DOI: 10.1113/jp282934] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/22/2022] [Indexed: 11/08/2022] Open
Abstract
A current view that delayed cord clamping (DCC) results in greater haemodynamic stability at birth than immediate cord clamping (ICC) is based on comparison of DCC vs. ICC followed by an asphyxial (∼2 min) cord clamp-to-ventilation (CC-V) interval. More recent data suggest that relatively minor perinatal differences in heart rate and blood pressure fluctuations exist between DCC and ICC with a non-asphyxial (<45 s) CC-V interval, but it is unknown how ventricular output and central arterial blood flow effects of DCC compare with those of non-asphyxial ICC. Anaesthetized preterm fetal lambs instrumented with flow probes on major central arteries were ventilated for 97 (7) s (mean (SD)) before DCC at birth (n = 10), or underwent ICC 40 (6) s before ventilation (n = 10). Compared to ICC, initial ventilation and DCC was accompanied by (1) redistribution of a similar level of ascending aortic flow away from cephalic arteries and towards the aortic isthmus after ventilation; (2) a lower right ventricular output after cord clamping that was redistributed towards the lungs, thereby maintaining the absolute contribution of this output to a similar increase in pulmonary arterial flow after birth; and (3) a lower descending thoracic aortic flow after birth, related to a more rapid decline in phasic right-to-left ductal flow only partially offset by increased aortic isthmus flow. However, systemic arterial flows were similar between DCC and non-asphyxial ICC within 5 min after birth. These findings suggest that compared to non-asphyxial ICC, initial ventilation with DCC transiently redistributed central arterial flows, resulting in lower perinatal systemic arterial, but not pulmonary arterial, flows. KEY POINTS: A current view that delayed cord clamping (DCC) results in greater haemodynamic stability at birth than immediate cord clamping (ICC) is based on comparison of DCC vs. ICC with an asphyxial (∼2 min) cord clamp-to-ventilation (CC-V) interval. Recent data suggest that relatively minor perinatal differences in heart rate and blood pressure fluctuations exist between DCC and ICC with a non-asphyxial (<45 s) CC-V interval, but how central arterial blood flow effects of DCC compare with those of non-asphyxial ICC is unknown. Anaesthetized preterm fetal lambs instrumented with central arterial flow probes underwent initial ventilation for ∼90 s before DCC at birth, or ICC for ∼40 s before ventilation. Compared to non-asphyxial ICC, initial ventilation with DCC redistributed central blood flows, resulting in lower systemic, but not pulmonary, arterial flows during this period of transition. This flow redistribution was transitory, however, with systemic arterial flows similar between DCC and non-asphyxial ICC within minutes after birth.
Collapse
Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| |
Collapse
|
26
|
Tewari VV, Saurabh S, Tewari D, Gaurav K, Kunwar BRB, Khashoo R, Tiwari N, Yadav L, Bharti U, Vardhan S. Effect of Delayed Umbilical Cord Clamping on Hemodynamic Instability in Preterm Neonates below 35 Weeks. J Trop Pediatr 2022; 68:6580718. [PMID: 35512365 DOI: 10.1093/tropej/fmac035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Delaying umbilical cord clamping facilitates postnatal transition in neonates but evidence on its effect in reducing hemodynamic instability in preterm neonates is inconclusive. AIMS To evaluate delayed cord clamping (DCC) in reducing the incidence of hemodynamic instability in preterm neonates below 35 weeks gestational age admitted to the neonatal intensive care unit. METHODS Neonates between 25 weeks and 34 weeks and 6 days gestation were enrolled. Hemodynamic and respiratory parameters were monitored over 48 h. Hemodynamic instability was defined as persistent tachycardia and/or hypotension necessitating therapy. RESULTS The DCC cohort included 62 neonates with an equal number in the non-DCC group. The birth weight [mean ± standard deviation (SD)] was 1332.90 ± 390.05 g and the gestational age (mean ± SD) was 31.64 ± 2.52 weeks. Hemodynamic instability was noted in 18/62 (29%) neonates in the DCC cohort and 29/62 (46.7%) in the non-DCC group; relative risk (RR) 0.62 [95% confidence interval (CI) 0.38-0.99] (p = 0.023). The duration of inotrope requirement in the DCC cohort (mean ± SD) was 38.38 ± 16.99 h compared to 49.13 ± 22.90 h in the non-DCC cohort (p = 0.090). Significantly higher systolic, diastolic and mean arterial pressures were noted from 6 h to 48 h in the DCC cohort (p < 0.001). The severity of respiratory distress and FiO2 requirement was also less in the first 24 h. There was no difference in the incidence of patent ductus arteriosus, late-onset sepsis or mortality. CONCLUSION Delaying umbilical cord clamping at birth by 60 s resulted in significantly lower hemodynamic instability in the first 48 h and higher blood pressure parameters.
Collapse
Affiliation(s)
| | | | - Dhruv Tewari
- Undergraduate Wing, University College of Medical Sciences, New Delhi 110095, India
| | - Kumar Gaurav
- Armed Forces Medical College, Pune 411040, India
| | | | - Rishabh Khashoo
- Undergraduate Wing, University College of Medical Sciences, New Delhi 110095, India
| | - Neha Tiwari
- Armed Forces Medical College, Pune 411040, India
| | | | - Urmila Bharti
- Department of Pediatrics, NICU, Command Hospital (SC), Pune 411040, India
| | - Shakti Vardhan
- Department of Obstetrics and Gynecology, Armed Forces Medical College, Pune 411040, India
| |
Collapse
|
27
|
Horn-Oudshoorn EJJ, Knol R, Vermeulen MJ, Te Pas AB, Hooper SB, Cochius-den Otter SCM, Wijnen RMH, Crossley KJ, Rafat N, Schaible T, de Boode WP, Debeer A, Urlesberger B, Roberts CT, Kipfmueller F, Reiss IKM, DeKoninck PLJ. Physiological-based cord clamping versus immediate cord clamping for infants born with a congenital diaphragmatic hernia (PinC): study protocol for a multicentre, randomised controlled trial. BMJ Open 2022; 12:e054808. [PMID: 35304395 PMCID: PMC8935184 DOI: 10.1136/bmjopen-2021-054808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Pulmonary hypertension is a major determinant of postnatal survival in infants with a congenital diaphragmatic hernia (CDH). The current care during the perinatal stabilisation period in these infants might contribute to the development of pulmonary hypertension after birth-in particular umbilical cord clamping before lung aeration. An ovine model of diaphragmatic hernia demonstrated that cord clamping after lung aeration, called physiological-based cord clamping (PBCC), avoided the initial high pressures in the lung vasculature while maintaining adequate blood flow, thereby avoiding vascular remodelling and aggravation of pulmonary hypertension. We aim to investigate if the implementation of PBCC in the perinatal stabilisation period of infants born with a CDH could reduce the incidence of pulmonary hypertension in the first 24 hours after birth. METHODS AND ANALYSIS We will perform a multicentre, randomised controlled trial in infants with an isolated left-sided CDH, born at ≥35.0 weeks. Before birth, infants will be randomised to either PBCC or immediate cord clamping, stratified by treatment centre and severity of pulmonary hypoplasia on antenatal ultrasound. PBCC will be performed using a purpose-built resuscitation trolley. Cord clamping will be performed when the infant is considered respiratory stable, defined as a heart rate >100 bpm, preductal oxygen saturation >85%, while using a fraction of inspired oxygen of <0.5. The primary outcome is pulmonary hypertension diagnosed in the first 24 hours after birth, based on clinical and echocardiographic parameters. Secondary outcomes include neonatal as well as maternal outcomes. ETHICS AND DISSEMINATION Central ethical approval was obtained from the Medical Ethical Committee of the Erasmus MC, Rotterdam, The Netherlands (METC 2019-0414). Local ethical approval will be obtained by submitting the protocol to the regulatory bodies and local institutional review boards. TRIAL REGISTRATION NUMBER NCT04373902.
Collapse
Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Suzan C M Cochius-den Otter
- Department of Paediatric Surgery and Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rene M H Wijnen
- Department of Paediatric Surgery and Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
| | - Neysan Rafat
- Department of Neonatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Department of Neonatology, University Medical Centre Mannheim, Mannheim, Germany
| | - Willem P de Boode
- Division of Neonatology, Department of Paediatrics, Radboudumc University Medical Center, Nijmegen, The Netherlands
| | - Anne Debeer
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| | - Florian Kipfmueller
- Department of Neonatology and Paediatric Intensive Care Medicine, University of Bonn Children's Hospital, Bonn, Germany
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, Victoria, Australia
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
28
|
Kilicdag H, Parlakgumus D, Demir SC, Satar M. Effects of spontaneous first breath on placental transfusion in term neonates born by cesarean section: A randomized controlled trial. Front Pediatr 2022; 10:925656. [PMID: 36177452 PMCID: PMC9513210 DOI: 10.3389/fped.2022.925656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The role of umbilical cord management in placental transfusion in cesarean section (CS) requires clarification. The spontaneous first breath may be more important than the timing of cord clamping for placental transfusion in neonates born by CS. OBJECTIVE This study aimed to evaluate the impact of cord clamping after the first spontaneous breath on placental transfusion in neonates born by CS. METHODS We recruited women with a live singleton pregnancy at ≥37.0 weeks of gestation admitted for CS. The interventions performed, such as physiologic-based cord clamping (PBCC), intact-umbilical cord milking (I-UCM), 30-s delay in cord clamping (30-s DCC), and 60-s delay in cord clamping (60-s DCC), were noted and placed in a sealed envelope. The sealed envelope was opened immediately before delivery to perform randomization. RESULTS A total of 123 infants were eligible for evaluation. Of these, 31, 30, 32, and 30 were assigned to the PBCC, I-UCM, 30-s DCC, and 60-s DCC groups, respectively. The mean hemoglobin (Hb) and mean hematocrit (Hct) were significantly higher in the 60-s DCC group than in the PBCC group (p = 0.028 and 0.019, respectively), but no difference was noted among the I-UCM, 30-s DCC, and PBCC groups at 36 h of age. Further, no significant differences were observed in the mean Hb and mean Hct among the I-UCM, 60-s DCC, and 30-s DCC groups. Peak total serum bilirubin (TSB) levels were higher in the 60-s DCC group than in the I-UCM and PBCC groups (p = 0.017), but there was no difference between the 60-s DCC and 30-s DCC groups during the first week of life. The phototherapy requirement was higher in 60-s DCC than in IUCM and 30-sDCC (p = 0.001). CONCLUSIONS Our findings demonstrated that PBCC, 30-s DCC, and I-UCM in neonates born by CS had no significant differences from each other on placental transfusion. The Hb and Hct in the neonates were higher after 60-s DCC than after PBCC.
Collapse
Affiliation(s)
- Hasan Kilicdag
- Division of Neonatology, Department of Pediatrics, Acibadem Adana Hospital, Adana, Turkey
| | | | - Suleyman Cansun Demir
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Cukurova University, Adana, Turkey
| | - Mehmet Satar
- Division of Neonatology, Department of Pediatrics, Cukurova University, Adana, Turkey
| |
Collapse
|
29
|
Management of Placental Transfusion to Neonates After Delivery. Obstet Gynecol 2022; 139:121-137. [PMID: 34856560 DOI: 10.1097/aog.0000000000004625] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/23/2021] [Indexed: 12/19/2022]
Abstract
This review summarizes high-quality evidence supporting delayed umbilical cord clamping to promote placental transfusion to preterm and term neonates. In preterm neonates, delayed cord clamping may decrease mortality and the need for blood transfusions. Although robust data are lacking to guide cord management strategies in many clinical scenarios, emerging literature is reviewed on numerous topics including delivery mode, twin gestations, maternal comorbidities (eg, gestational diabetes, red blood cell alloimmunization, human immunodeficiency virus [HIV] infection, and severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] infection) and neonatal complications (eg, fetal growth restriction, congenital heart disease, and the depressed neonate). Umbilical cord milking is an alternate method of rapid placental transfusion, but has been associated with severe intraventricular hemorrhage in extremely preterm neonates. Data on long-term outcomes are discussed, as well as potential contraindications to delayed cord clamping. Overall, delayed cord clamping offers potential benefits to the estimated 140 million neonates born globally every year, emphasizing the importance of this simple and no-cost strategy.
Collapse
|
30
|
Meyer MP, O'Connor KL, Meyer JH. Thresholds for blood transfusion in extremely preterm infants: A review of the latest evidence from two large clinical trials. Front Pediatr 2022; 10:957585. [PMID: 36204671 PMCID: PMC9530179 DOI: 10.3389/fped.2022.957585] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
There are two recently completed large randomized clinical trials of blood transfusions in the preterm infants most at risk of requiring them. Liberal and restrictive strategies were compared with composite primary outcome measures of death and neurodevelopmental impairment. Infants managed under restrictive guidelines fared no worse in regard to mortality and neurodevelopment in early life. The studies had remarkably similar demographics and used similar transfusion guidelines. In both, there were fewer transfusions in the restrictive arm. Nevertheless, there were large differences between the studies in regard to transfusion exposure with almost 3 times the number of transfusions per participant in the transfusion of prematures (TOP) study. Associated with this, there were differences between the studies in various outcomes. For example, the combined primary outcome of death or neurodevelopmental impairment was more likely to occur in the TOP study and the mortality rate itself was considerably higher. Whilst the reasons for these differences are likely multifactorial, it does raise the question as to whether they could be related to the transfusions themselves? Clearly, every effort should be made to reduce exposure to transfusions and this was more successful in the Effects of Transfusion Thresholds on Neurocognitive Outcomes (ETTNO) study. In this review, we look at factors which may explain these transfusion differences and the differences in outcomes, in particular neurodevelopment at age 2 years. In choosing which guidelines to follow, centers using liberal guidelines should be encouraged to adopt more restrictive ones. However, should centers with more restrictive guidelines change to ones similar to those in the studies? The evidence for this is less compelling, particularly given the wide range of transfusion exposure between studies. Individual centers already using restrictive guidelines should assess the validity of the findings in light of their own transfusion experience. In addition, it should be remembered that the study guidelines were pragmatic and acceptable to a large number of centers. The major focus in these guidelines was on hemoglobin levels which do not necessarily reflect tissue oxygenation. Other factors such as the level of erythropoiesis should also be taken into account before deciding whether to transfuse.
Collapse
Affiliation(s)
- Michael P Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Kristin L O'Connor
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Jill H Meyer
- Department of Biomedicine and Medical Diagnostics, Auckland University of Technology, Auckland, New Zealand
| |
Collapse
|
31
|
Schwaberger B, Ribitsch M, Pichler G, Krainer M, Avian A, Baik-Schneditz N, Ziehenberger E, Mileder LP, Martensen J, Mattersberger C, Wolfsberger CH, Urlesberger B. Does physiological-based cord clamping improve cerebral tissue oxygenation and perfusion in healthy term neonates? - A randomized controlled trial. Front Pediatr 2022; 10:1005947. [PMID: 36699304 PMCID: PMC9869382 DOI: 10.3389/fped.2022.1005947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/30/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES To evaluate cerebral tissue oxygenation index (cTOI) during neonatal transition in a group of healthy full-term neonates receiving either a physiological-based approach of deferred cord clamping (CC) after the onset of stable regular breathing (PBCC group) or a standard approach of time-based CC < 1 min (control group). Secondary aim was to evaluate changes in cerebral blood volume (ΔCBV), peripheral arterial oxygen saturation (SpO2) and heart rate (HR) in those neonates. MATERIALS AND METHODS We conducted a randomized controlled trial (clinicaltrials.gov: NCT02763436) including vaginally delivered healthy full-term neonates. Continuous measurements of cTOI and ΔCBV using near-infrared spectroscopy, and of SpO2 and HR using pulse oximetry were performed within the first 15 min after birth. Data of each minute of the PBCC group were compared to those of the control group. RESULTS A total of 71 full-term neonates (PBCC: n = 35, control: n = 36) with a mean (SD) gestational age of 40.0 (1.0) weeks and a birth weight of 3,479 (424) grams were included. Median (IQR) time of CC was 275 (197-345) seconds and 58 (35-86) seconds in the PBCC and control group, respectively (p < 0.001). There were no significant differences between the two groups regarding cTOI (p = 0.319), ΔCBV (p = 0.814), SpO2 (p = 0.322) and HR (p = 0.878) during the first 15 min after birth. CONCLUSION There were no significant differences in the course of cTOI as well as ΔCBV, SpO2 and HR during the first 15 min after birth in a group of healthy full-term neonates, who received either deferred CC after the onset of stable regular breathing or standard CC < 1 min. Thus, deferring CC ≥ 1 min following a physiological-based approach offers no benefits regarding cerebral tissue oxygenation and perfusion after uncomplicated vaginal delivery compared to a time-based CC approach.
Collapse
Affiliation(s)
- Bernhard Schwaberger
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Mirjam Ribitsch
- Pediatric Intensive Care Unit, Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Gerhard Pichler
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Marlies Krainer
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Alexander Avian
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Nariae Baik-Schneditz
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Evelyn Ziehenberger
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Lukas Peter Mileder
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Johann Martensen
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christian Mattersberger
- Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christina Helene Wolfsberger
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Research Unit for Cerebral Development and Oximetry, Medical University of Graz, Graz, Austria.,Research Unit for Neonatal Micro- and Macrocirculation, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| |
Collapse
|
32
|
Niemuth M, Küster H, Simma B, Rozycki H, Rüdiger M, Solevåg AL. A critical appraisal of tools for delivery room assessment of the newborn infant. Pediatr Res 2021:10.1038/s41390-021-01896-7. [PMID: 34969993 DOI: 10.1038/s41390-021-01896-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/19/2021] [Indexed: 11/09/2022]
Abstract
Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.
Collapse
Affiliation(s)
- Mara Niemuth
- Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Helmut Küster
- Clinic for Pediatric Cardiology, Intensive Care and Neonatology, University Medical Center Göttingen, Göttingen, Germany
| | - Burkhard Simma
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Henry Rozycki
- Division of Neonatal Medicine, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Anne Lee Solevåg
- The Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
| |
Collapse
|
33
|
Owen LS, Manley BJ, Hodgson KA, Roberts CT. Impact of early respiratory care for extremely preterm infants. Semin Perinatol 2021; 45:151478. [PMID: 34474939 DOI: 10.1016/j.semperi.2021.151478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.
Collapse
Affiliation(s)
- Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kate A Hodgson
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| |
Collapse
|
34
|
Te Pas A, Roehr CC, Foglia EE, Hooper S. Neonatal resuscitation research: closing the gap. Pediatr Res 2021; 90:1117-1119. [PMID: 33627819 DOI: 10.1038/s41390-021-01403-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Arjan Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Charles Christopher Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitalsl, NHS Foundation Trust, Oxford, UK.,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Elizabeth E Foglia
- Division of Neonatology, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash, University, Melbourne, VIC, Australia
| |
Collapse
|
35
|
Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Resuscitation 2021; 169:229-311. [PMID: 34933747 PMCID: PMC8581280 DOI: 10.1016/j.resuscitation.2021.10.040] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
Collapse
|
36
|
Wyckoff MH, Singletary EM, Soar J, Olasveengen TM, Greif R, Liley HG, Zideman D, Bhanji F, Andersen LW, Avis SR, Aziz K, Bendall JC, Berry DC, Borra V, Böttiger BW, Bradley R, Bray JE, Breckwoldt J, Carlson JN, Cassan P, Castrén M, Chang WT, Charlton NP, Cheng A, Chung SP, Considine J, Costa-Nobre DT, Couper K, Dainty KN, Davis PG, de Almeida MF, de Caen AR, de Paiva EF, Deakin CD, Djärv T, Douma MJ, Drennan IR, Duff JP, Eastwood KJ, El-Naggar W, Epstein JL, Escalante R, Fabres JG, Fawke J, Finn JC, Foglia EE, Folke F, Freeman K, Gilfoyle E, Goolsby CA, Grove A, Guinsburg R, Hatanaka T, Hazinski MF, Heriot GS, Hirsch KG, Holmberg MJ, Hosono S, Hsieh MJ, Hung KKC, Hsu CH, Ikeyama T, Isayama T, Kapadia VS, Kawakami MD, Kim HS, Kloeck DA, Kudenchuk PJ, Lagina AT, Lauridsen KG, Lavonas EJ, Lockey AS, Malta Hansen C, Markenson D, Matsuyama T, McKinlay CJD, Mehrabian A, Merchant RM, Meyran D, Morley PT, Morrison LJ, Nation KJ, Nemeth M, Neumar RW, Nicholson T, Niermeyer S, Nikolaou N, Nishiyama C, O'Neil BJ, Orkin AM, Osemeke O, Parr MJ, Patocka C, Pellegrino JL, Perkins GD, Perlman JM, Rabi Y, Reynolds JC, Ristagno G, Roehr CC, Sakamoto T, Sandroni C, Sawyer T, Schmölzer GM, Schnaubelt S, Semeraro F, Skrifvars MB, Smith CM, Smyth MA, Soll RF, Sugiura T, Taylor-Phillips S, Trevisanuto D, Vaillancourt C, Wang TL, Weiner GM, Welsford M, Wigginton J, Wyllie JP, Yeung J, Nolan JP, Berg KM. 2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group. Circulation 2021; 145:e645-e721. [PMID: 34813356 DOI: 10.1161/cir.0000000000001017] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.
Collapse
|
37
|
Gurung R, Sunny AK, Paudel P, Bhattarai P, Basnet O, Sharma S, Shrestha D, Sharma S, Malla H, Singh D, Mishra S, Kc A. Predictors for timely initiation of breastfeeding after birth in the hospitals of Nepal- a prospective observational study. Int Breastfeed J 2021; 16:85. [PMID: 34715883 PMCID: PMC8555201 DOI: 10.1186/s13006-021-00431-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022] Open
Abstract
Background Timely initiation of breastfeeding can reduce neonatal morbidities and mortality. We aimed to study predictors for timely initiation of breastfeeding (within 1 h of birth) among neonates born in hospitals of Nepal. Method A prospective observational study was conducted in four public hospitals between July and October 2018. All women admitted in the hospital for childbirth and who consented were included in the study. An independent researchers observed whether the neonates were placed in skin-to-skin contact, delay cord clamping and timely initiation of breastfeeding. Sociodemographic variables, obstetric and neonate information were extracted from the maternity register. We analysed predictors for timely initiation of breastfeeding with Pearson chi-square test and multivariate logistic regression. Results Among the 6488 woman-infant pair observed, breastfeeding was timely initiated in 49.5% neonates. The timely initiation of breastfeeding was found to be higher among neonates who were placed skin-to-skin contact (34.9% vs 19.9%, p - value < 0.001). The timely initiation of breastfeeding was higher if the cord clamping was delayed than early cord clamped neonates (44.5% vs 35.3%, p - value < 0.001). In multivariate analysis, a mother with no obstetric complication during admission had 57% higher odds of timely initiation of breastfeeding (aOR 1.57; 95% CI 1.33, 1.86). Multiparity was associated with less timely initiation of breastfeeding (aOR 1.56; 95% CI 1.35, 1.82). Similarly, there was more common practice of timely initiation of breastfeeding among low birthweight neonates (aOR 1.46; 95% CI 1.21, 1.76). Neonates who were placed skin-to-skin contact with mother had more than two-fold higher odds of timely breastfeeding (aOR 2.52; 95% CI 2.19, 2.89). Likewise, neonates who had their cord intact for 3 min had 37% higher odds of timely breastfeeding (aOR 1.37; 95% CI 1.21, 1.55). Conclusions The rate of timely initiation of breastfeeding practice is low in the health facilities of Nepal. Multiparity, no obstetric complication at admission, neonates placed in skin-to-skin contact and delay cord clamping were strong predictors for timely initiation of breastfeeding. Quality improvement intervention can improve skin-to-skin contact, delayed cord clamping and timely initiation of breastfeeding.
Collapse
Affiliation(s)
- Rejina Gurung
- Golden Community, Lalitpur, Nepal.,Department of Women's and Children's Health, Uppsala University, Dag Hammarskjöldsväg 14B, Uppsala, Sweden
| | | | - Prajwal Paudel
- Paropakar Maternity and Women's Hospital, Kathmandu, Nepal
| | | | | | | | | | | | | | - Dela Singh
- Pokhara Academy of Health Sciences, Pokhara, Nepal
| | | | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Dag Hammarskjöldsväg 14B, Uppsala, Sweden. .,Paropakar Maternity and Women's Hospital, Kathmandu, Nepal.
| |
Collapse
|
38
|
Sunny AK, Paudel P, Tiwari J, Bagale BB, Kukka A, Hong Z, Ewald U, Berkelhamer S, Ashish Kc. A multicenter study of incidence, risk factors and outcomes of babies with birth asphyxia in Nepal. BMC Pediatr 2021; 21:394. [PMID: 34507527 PMCID: PMC8431921 DOI: 10.1186/s12887-021-02858-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 08/25/2021] [Indexed: 12/20/2022] Open
Abstract
Background Perinatal events which result in compromised oxygen delivery to the fetus can lead to Birth Asphyxia (BA). While the incidence, risk factors and outcomes of BA have been characterized, less is known in low resource settings. Aim To determine the incidence of Birth Asphyxia (BA) in Nepal and to evaluate associated risk factors and outcomes of this condition. Methods A nested observational study was conducted in 12 hospitals of Nepal for a period of 14 months. Babies diagnosed as BA at ≥37 weeks of gestation were identified and demographics were reviewed. Data were analyzed using binary logistic regression followed by multiple logistic regression analysis. Results The incidence of BA in this study was 6 per 1000 term livebirths and was higher among women 35 years and above. Predictors for BA were instrumented vaginal delivery (aOR:4.4, 95% CI, 3.1–6.1), fetal distress in labour (aOR:1.9, 95% CI, 1.0–3.6), malposition (aOR:1.8, 95% CI, 1.0–3.0), birth weight less than 2500 g (aOR:2.0, 95% CI, 1.3–2.9), gestational age ≥ 42 weeks (aOR:2.0, 95% CI, 1.3–3.3) and male gender (aOR:1.6, 95% CI, 1.2–2.0). The risk of pre-discharge mortality was 43 times higher in babies with BA (aOR:42.6, 95% CI, 32.2–56.3). Conclusion The incidence of Birth asphyxia in Nepal higher than in more resourced setting. A range of obstetric and neonatal risk factors are associated with BA with an associated high risk of pre-discharge mortality. Interventions to improve management and decrease rates of BA could have marked impact on outcomes in low resource settings.
Collapse
Affiliation(s)
| | | | | | | | - Antti Kukka
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Department of Paediatrics, Länssjukhuset Gävle-Sandviken, Gävle, Sweden
| | - Zhou Hong
- Department of Maternal and Child Health, Peking University of Health Sciences, Peking, China
| | - Uwe Ewald
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sara Berkelhamer
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
39
|
Smolich JJ, Kenna KR, Phillips SE, Mynard JP, Cheung MMM, Lambert GW. Characteristics and physiological basis of falls in ventricular outputs after immediate cord clamping at delivery in preterm fetal lambs. J Physiol 2021; 599:3755-3770. [PMID: 34101823 DOI: 10.1113/jp281693] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/07/2021] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Controversy exists about the physiological mechanism(s) underlying decreases in cardiac output after immediate clamping of the umbilical cord at birth. To define these mechanisms, the four major determinants of ventricular output (afterload, preload, heart rate and contractility) were measured concurrently in fetal lambs at 15 s intervals over a 2 min period after cord clamping and before ventilation following delivery. After cord clamping, right (but not left) ventricular output fell by 20% in the initial 30 s, due to increased afterload associated with higher arterial blood pressures, but both outputs then halved over 45 s, due to a falling heart rate and deteriorating ventricular contractility accompanying rapid declines in arterial oxygenation to asphyxial levels. Ventricular outputs subsequently plateaued from 75 to 120 s, associated with rebound rises in ventricular contractility accompanying asphyxia-induced surges in circulating catecholamines. These findings provide a physiological basis for the clinical recommendation that effective ventilation should occur within 60 s after immediate cord clamping. ABSTRACT Controversy exists about the physiological mechanism(s) underlying large decreases in cardiac output after immediate clamping of the umbilical cord at birth. To define these mechanisms, anaesthetized preterm fetal lambs (127(1)d, n = 12) were instrumented with flow probes and catheters in major central arteries, and a left ventricular (LV) micromanometer-conductance catheter. Following immediate cord clamping at delivery, haemodynamics, LV and right ventricular (RV) outputs, and LV contractility were measured at 15 s intervals during a 2 min non-ventilatory period, with aortic blood gases and circulating catecholamine (noradrenaline and adrenaline) concentrations measured at 30 s intervals. After cord clamping, (1) RV (but not LV) output fell by 20% in the initial 30 s, due to a reduced stroke volume associated with increased arterial blood pressures, (2) both outputs then halved over the next 45 s, associated with falls in heart rate, arterial blood pressures and ventricular contractility accompanying a rapid decline in arterial oxygenation to asphyxial levels, (3) reduced outputs subsequently plateaued from 75 to 120 s, associated with rebound rises in blood pressures and ventricular contractility accompanying exponential surges in circulating catecholamines. These findings are consistent with a time-dependent decline of ventricular outputs after immediate cord clamping, which comprised (1) an initial, minor fall in RV output related to altered loading conditions, (2) ensuing large decreases in both LV and RV outputs related to the combination of bradycardia and ventricular dysfunction during emergence of an asphyxial state, and (3) subsequent stabilization of reduced LV and RV outputs during ongoing asphyxia, supported by cardiovascular stimulatory effects of marked sympathoadrenal activation.
Collapse
Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Sarah E Phillips
- Iverson Health Innovations Research Institute, Swinburne University of Technology, Hawthorn, Victoria, Australia.,Human Neurotransmitters Laboratory, Baker Heart and Diabetes Institute, Prahran, Victoria, Australia
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Cardiology, Royal Children's Hospital, Parkville, Victoria, Australia.,Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
| | - Michael M M Cheung
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Cardiology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Gavin W Lambert
- Iverson Health Innovations Research Institute, Swinburne University of Technology, Hawthorn, Victoria, Australia.,Human Neurotransmitters Laboratory, Baker Heart and Diabetes Institute, Prahran, Victoria, Australia
| |
Collapse
|
40
|
UshaDevi R, Mangalabharathi S, Prakash V, Thanigainathan S, Shobha S. Delivery room care and neonatal resuscitation while on intact placental circulation: an open-label, single-arm study. J Perinatol 2021; 41:1558-1565. [PMID: 33510419 DOI: 10.1038/s41372-021-00918-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 10/21/2020] [Accepted: 01/14/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess feasibility, safety, usability and learnability of delivery room care and resuscitation with intact placental circulation (RIPC) at mother's bedside. MATERIALS AND METHODS We included neonates ≥24 weeks GA after parental consent. Both in vigorous and babies requiring resuscitation, appropriate steps of resuscitation were provided with intact cord till 3 min using RIPC warmer. Outcomes were assessed by set criteria and standard system usability scale. RESULTS Of 380 enrolled, intervention was feasible in 376 babies (98.9%). Safety criteria were met in all 376 babies received onto the trolley (100%). Median GA was 38 (37-39) weeks and median BW 2740 (2330-3120) g. Of 376, 92 required resuscitation; 90 (97.8%) PPV, 49 (53.2%) intubations and 13 (14.1%) chest compressions. System Usability Score rated >68 (good) in 90% and 52-68 (fair) in 10%. Temperature at 5 min was 36.5 ± 0.1. CONCLUSIONS Delivery room care and neonatal RIPC is feasible and safe across gestations.
Collapse
Affiliation(s)
- R UshaDevi
- Department of Neonatology, Madras Medical College, Chennai, Tamilnadu, India
- Department of Neonatology, Chettinad Academy of Research and Education, Chengalpet, Tamilnadu, India
| | - S Mangalabharathi
- Department of Neonatology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamilnadu, India.
| | - V Prakash
- Department of Neonatology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamilnadu, India
| | - S Thanigainathan
- Department of Neonatology, Madras Medical College, Chennai, Tamilnadu, India
- Department of Neonatology, AIIMS, Jodhpur, Rajasthan, India
| | - S Shobha
- Department of Obstetrics & Gynaecology, Institute of Obstetrics and Gynaecology, Madras Medical College, Chennai, Tamilnadu, India
| |
Collapse
|
41
|
Stenning FJ, Polglase GR, te Pas AB, Crossley KJ, Kluckow M, Gill AW, Wallace EM, McGillick EV, Binder C, Blank DA, Roberts C, Hooper SB. Effect of maternal oxytocin on umbilical venous and arterial blood flows during physiological-based cord clamping in preterm lambs. PLoS One 2021; 16:e0253306. [PMID: 34138957 PMCID: PMC8211207 DOI: 10.1371/journal.pone.0253306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 06/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Delayed umbilical cord clamping (UCC) after birth is thought to cause placental to infant blood transfusion, but the mechanisms are unknown. It has been suggested that uterine contractions force blood out of the placenta and into the infant during delayed cord clamping. We have investigated the effect of uterine contractions, induced by maternal oxytocin administration, on umbilical artery (UA) and venous (UV) blood flows before and after ventilation onset to determine whether uterine contractions cause placental transfusion in preterm lambs. METHODS AND FINDINGS At ~128 days of gestation, UA and UV blood flows, pulmonary arterial blood flow (PBF) and carotid arterial (CA) pressures and blood flows were measured in three groups of fetal sheep during delayed UCC; maternal oxytocin following mifepristone, mifepristone alone, and saline controls. Each successive uterine contraction significantly (p<0.05) decreased UV (26.2±6.0 to 14.1±4.5 mL.min-1.kg-1) and UA (41.2±6.3 to 20.7 ± 4.0 mL.min-1.kg-1) flows and increased CA pressure and flow (47.1±3.4 to 52.8±3.5 mmHg and 29.4±2.6 to 37.3±3.4 mL.min-1.kg-1). These flows and pressures were partially restored between contractions, but did not return to pre-oxytocin administration levels. Ventilation onset during DCC increased the effects of uterine contractions on UA and UV flows, with retrograde UA flow (away from the placenta) commonly occurring during diastole. CONCLUSIONS We found no evidence that amplification of uterine contractions with oxytocin increase placental transfusion during DCC. Instead they decreased both UA and UV flow and caused a net loss of blood from the lamb. Uterine contractions did, however, have significant cardiovascular effects and reduced systemic and cerebral oxygenation.
Collapse
Affiliation(s)
- Fiona J. Stenning
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Graeme R. Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Arjan B. te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Kelly J. Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Martin Kluckow
- Department of Neonatalogy, Royal North Shore Hospital and University of Sydney, Sydney, New South Wales, Australia
| | - Andrew W. Gill
- Centre for Neonatal Research and Education, The University of Western Australia, Perth, Western Australia, Australia
| | - Euan M. Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Erin V. McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Corinna Binder
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
| | - Douglas A. Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Newborn Research, The Royal Women’s Hospital, Melbourne, Australia
| | - Calum Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Paediatrics, Monash University, Melbourne, Australia
| | - Stuart B. Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
- * E-mail:
| |
Collapse
|
42
|
Narasimhan SR, Flaherman V, McLean M, Nudelman M, Vallejo M, Song D, Jegatheesan P. Practice Variations in Diagnosis and Treatment of Hypoglycemia in Asymptomatic Newborns. Hosp Pediatr 2021; 11:595-604. [PMID: 34011565 DOI: 10.1542/hpeds.2020-004101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To describe variations in the practice of hypoglycemia screening and treatment in asymptomatic infants in the United States. METHODS During the time period from February 2018 to June 2018, we surveyed representatives of hospitals participating in the Better Outcomes through Research for Newborns Network, a national research network of clinicians providing hospital care to term and late-preterm newborns. The survey included 22 questions evaluating practices related to hypoglycemia screening and management of asymptomatic infants. RESULTS Of 108 network sites, 84 (78%) responded to the survey; 100% had a hypoglycemia protocol for screening at-risk infants in the well-baby nursery. There were wide variations between sites regarding the definition of hypoglycemia (mg/dL) (<45 [24%]; <40 [23%]; <40 [0-4 hours] and <45 [4-24 hours] [27%]; <25 [0-4 hours] and <35 [4-24 hours] [8%]), timing of first glucose check (<1 hour [18%], 1-2 hours [30%], 30 minutes post feed [48%]), and threshold glucose level for treatment (<45 [19%]; <40 [18%]; <40 [0-4 hours] and <45 [4-24 hours] [20%]; <25 [0-4 hours] and <35 [4-24 hours] [15%]). All respondents used breast milk as a component of initial therapy. Criteria for admission to the NICU for hypoglycemia included the need for dextrose containing intravenous fluids (52%), persistent hypoglycemia despite treatment (49%), and hypoglycemia below a certain value (37%). CONCLUSIONS There is a significant practice variation in hypoglycemia screening and management across the United States.
Collapse
Affiliation(s)
- Sudha Rani Narasimhan
- Department of Pediatrics, Newborn Medicine, Santa Clara Valley Medical Center, San Jose, California;
| | - Valerie Flaherman
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | | | - Matthew Nudelman
- Department of Pediatrics, Newborn Medicine, Santa Clara Valley Medical Center, San Jose, California
- Department of Pediatrics, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Maricela Vallejo
- Department of Pediatrics, Newborn Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Dongli Song
- Department of Pediatrics, Newborn Medicine, Santa Clara Valley Medical Center, San Jose, California
| | - Priya Jegatheesan
- Department of Pediatrics, Newborn Medicine, Santa Clara Valley Medical Center, San Jose, California
| |
Collapse
|
43
|
Meyer MP, Nevill E. The Assisted Breathing before Cord Clamping (ABC) Study Protocol. CHILDREN (BASEL, SWITZERLAND) 2021; 8:336. [PMID: 33925838 PMCID: PMC8146121 DOI: 10.3390/children8050336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 12/19/2022]
Abstract
Major physiologic changes occur during the transition after birth. For preterm infants, current understanding favours allowing the initial changes to occur prior to cord clamping. Amongst other improved outcomes, systematic reviews have indicated a significant reduction in neonatal blood transfusions following delayed cord clamping. This may be due to a placental transfusion, facilitated by the onset of respiration. If breathing is compromised, placental transfusion may be reduced, resulting in a greater red cell transfusion rate. We designed a randomised trial to investigate whether assisting respiration in this high-risk group of babies would decrease blood transfusion and improve outcomes. The Assisted Breathing before Cord Clamping (ABC) study is a single-centre randomised controlled trial. Preterm infants < 31 weeks that have not established regular breathing before 15 s are randomised to a standard or intervention group. The intervention is intermittent positive pressure ventilation via T piece for 30 s, whilst standard management consists of 30 s of positioning and gentle stimulation. The cord is clamped at 50 s in both groups. The primary outcome is the proportion of infants in each group receiving blood transfusion during the neonatal admission. Secondary outcomes include requirement for resuscitation, the assessment of circulatory status and neonatal outcomes.
Collapse
Affiliation(s)
- Michael P. Meyer
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland 2025, New Zealand;
- Department of Paediatrics, University of Auckland, Auckland 2025, New Zealand
| | - Elizabeth Nevill
- Neonatal Unit, KidzFirst, Middlemore Hospital, Auckland 2025, New Zealand;
| |
Collapse
|
44
|
European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
Collapse
|
45
|
Sehgal A, Allison BJ, Miller SL, Polglase GR, McNamara PJ, Hooper SB. Impact of Acute and Chronic Hypoxia-Ischemia on the Transitional Circulation. Pediatrics 2021; 147:peds.2020-016972. [PMID: 33622795 DOI: 10.1542/peds.2020-016972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2020] [Indexed: 11/24/2022] Open
Abstract
The transition from intrauterine life to extrauterine existence encompasses significant cardiorespiratory adaptations. These include rapid lung aeration and increase in pulmonary blood flow (PBF). Perinatal asphyxia and fetal growth restriction can severely hamper this transition. Hypoxia is the common denominator in these 2 disease states, with the former characterized by acute insult and the latter by utero-placental insufficiency and a chronic hypoxemic state. Both may manifest as hemodynamic instability. In this review, we emphasize the role of physiologic-based cord clamping in supplementing PBF during transition. The critical role of lung aeration in initiating pulmonary gas exchange and increasing PBF is discussed. Physiologic studies in animal models have enabled greater understanding of the mechanisms and effects of various therapies on transitional circulation. With data from sheep models, we elaborate instrumentation for monitoring of cardiovascular and pulmonary physiology and discuss the combined effect of chest compressions and adrenaline in improving transition at birth. Lastly, physiologic adaptation influencing management in human neonatal cohorts with respect to cardiac and vascular impairments in hypoxic-ischemic encephalopathy and growth restriction is discussed. Impairments in right ventricular function and vascular mechanics hold the key to prognostication and understanding of therapeutic rationale in these critically ill cohorts. The right ventricle and pulmonary circulation seem to be especially affected and may be explored as therapeutic targets. The role of comprehensive assessments using targeted neonatal echocardiography as a longitudinal, reliable, and easily accessible tool, enabling precision medicine facilitating physiologically appropriate treatment choices, is discussed.
Collapse
Affiliation(s)
- Arvind Sehgal
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia; .,Departments of Paediatrics and
| | - Beth J Allison
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Suzanne L Miller
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Graeme R Polglase
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa; and.,Internal Medicine, University of Iowa Health Care, Iowa City, Iowa
| | - Stuart B Hooper
- Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| |
Collapse
|
46
|
Abstract
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.
Collapse
|
47
|
Kc A, Budhathoki SS, Thapa J, Niermeyer S, Gurung R, Singhal N. Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study. BMJ Paediatr Open 2021; 5:e001207. [PMID: 34660914 PMCID: PMC8488701 DOI: 10.1136/bmjpo-2021-001207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/08/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Stimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates. METHODS This is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression. RESULTS Among non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p<0.0001). The use of bag-and-mask ventilation was lower among those who were stimulated with the cord intact than those who were stimulated with cord clamped (18.0% vs 32.4%, p<0.0001). The proportion of neonates with Apgar Score ≤3 at 1 min was lower with the cord intact than with cord clamped (7.6% vs 11.5%, p=0.001). In multivariate analysis, neonates with intact cord had 84% increased odds of spontaneous breathing (adjusted OR, 1.84; 95% CI: 1.48 to 2.29) compared with those with cord clamped. CONCLUSIONS Stimulation of non-crying neonates with intact cord was associated with more spontaneous breathing than among infants who were stimulated with cord clamped. Intact cord stimulation may help establish spontaneous breathing in apnoeic neonates, but residual confounding variables may be contributing to the findings. This study provides evidence for further controlled research to evaluate the effect of initial steps of resuscitation with cord intact.
Collapse
Affiliation(s)
- Ashish Kc
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Shyam Sundar Budhathoki
- Department of Primary Care and Public Health, Imperial College London, London, UK.,Research Divison, Golden Community, Jawgal, Lalitpur, Nepal
| | - Jeevan Thapa
- Department of Community Health Sciences, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Susan Niermeyer
- Pediatrics, University of Colorado Denver School of Medicine, Aurora, Colorado, USA
| | - Rejina Gurung
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Research Divison, Golden Community, Jawgal, Lalitpur, Nepal
| | - Nalini Singhal
- Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
48
|
Celen S, Horn-Oudshoorn EJJ, Knol R, van der Wilk EC, Reiss IKM, DeKoninck PLJ. Implementation of Delayed Cord Clamping for 3 Min During Term Cesarean Sections Does Not Influence Maternal Blood Loss. Front Pediatr 2021; 9:662538. [PMID: 34239848 PMCID: PMC8257925 DOI: 10.3389/fped.2021.662538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
Background: To assess maternal safety outcomes after a local protocol adjustment to change the interval of cord clamping to 3 min after term cesarean section. Design, Setting, and Patients: A retrospective cohort study in a tertiary referral hospital (Erasmus MC, Rotterdam). We included pregnant women who gave birth at term after cesarean section. A cohort (Nov 2016-Oct 2017) prior to the protocol implementation was compared to a cohort after its implementation (Nov 2017-Nov 2018). The study population covered 789 women (n = 376 pre-cohort; n = 413 post-cohort). Interventions: Implementation of a local protocol changing the interval of cord clamping to 3 min in all term births. Main outcome measures: Primary outcomes were the estimated maternal blood loss and the occurrence of postpartum hemorrhage (blood loss >1,000 ml). Secondary outcomes included both maternal as well as neonatal outcomes. Results: Estimated maternal blood loss was not significantly different between the pre-cohort and post-cohort (400 mL [300-600] vs. 400 mL [300-600], p = 0.52). The incidence of postpartum hemorrhage (26 [6.9%] vs. 35 (8.5%), OR 1.24, 95% CI 0.73-2.11) and maternal blood transfusion (9 [2%] vs. 13 (3%), OR 1.33, 95% CI 0.56-3.14) were not different. Hemoglobin change was significantly higher in the post-cohort (-0.8 mmol/L [-1.3 to -0.5] vs. -0.9 mmol/L [-1.4 to -0.6], p = 0.01). In the post-cohort, neonatal hematocrit levels were higher (51 vs. 55%, p = 0.004) and need for phototherapy was increased (OR 1.95, 95% CI 0.99-3.84). Conclusion: Implementation of delayed cord clamping for 3 min in term cesarean sections was not associated with increased maternal bleeding complications.
Collapse
Affiliation(s)
- Stefanie Celen
- Department of Pediatrics, University Hospital Gent, Ghent, Belgium.,Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Eline C van der Wilk
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Pediatrics, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| |
Collapse
|
49
|
Sæther E, Gülpen FRV, Jensen C, Myklebust TÅ, Eriksen BH. Neonatal transitional support with intact umbilical cord in assisted vaginal deliveries: a quality-improvement cohort study. BMC Pregnancy Childbirth 2020; 20:496. [PMID: 32854647 PMCID: PMC7457264 DOI: 10.1186/s12884-020-03188-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 08/19/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Deferring cord clamping has proven benefits for both term and preterm infants, and recent studies have demonstrated better cardio-respiratory stability if clamping is based on the infant's physiology, and whether the infant has breathed. Nevertheless, current guidelines for neonatal resuscitation still recommend early cord clamping (ECC) for compromised babies, unless equipment and competent personnel to resuscitate the baby are available at the mother's bedside. The objective of this quality improvement cohort study was to evaluate whether implementing a new delivery room protocol involving mobile resuscitation equipment (LifeStart™) reduced the prevalence of ECC in assisted vaginal deliveries. METHODS Data on cord clamping and transitional care were collected 8 months before and 8 months after implementing the new protocol. The Model for Improvement was applied to identify drivers and obstacles to practice change. Statistical Process Control analysis was used to demonstrate signals of improvement, and whether these changes were sustainable. Multivariate logistic regression was used to evaluate the impact of the new protocol on the primary outcome, adjusted for possible confounders. RESULTS Overall prevalence of ECC dropped from 13 to 1% (P < 0.01), with a 98% relative risk reduction for infants needing transitional support on a resuscitation table (adjusted OR 0.02, P < 0.001). Mean cord clamping time increased by 43% (p < 0.001). Although fewer infants were placed directly on mothers' chest (n = 43 [42%] vs n = 69 [75.0%], P < 0.001), there were no significant differences in needs for immediate transitional care or transfers to Neonatal Intensive Care Unit. A pattern of improvement was seen already before the intervention, especially after mandatory educational sessions and cross-professional simulation training. CONCLUSIONS A new delivery-room protocol involving mobile resuscitation equipment successfully eliminated early cord clamping in assisted vaginal deliveries of term and near-term infants. A systematic approach, like the Model for Improvement, seemed crucial for both achieving and sustaining the desired results. TRIAL REGISTRATION The study was approved as a service evaluation as defined by the Regional Committee for Medical and Health Research Ethics ( 2018/1755/REK midt ).
Collapse
Affiliation(s)
- Elisabeth Sæther
- Department of Obstetrics and Gynecology, Møre and Romsdal Hospital Trust, Åsehaugen 5, N-6017, Ålesund, Norway.
| | | | - Christer Jensen
- Department of Medicine and Healthcare, Møre and Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway.,Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Ålesund, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Helse Møre and Romsdal Hospital Trust, Ålesund, Norway
| | - Beate Horsberg Eriksen
- Department of Pediatrics, Møre and Romsdal Hospital Trust, Ålesund Hospital, Ålesund, Norway
| |
Collapse
|
50
|
Polglase GR, Schmölzer GM, Roberts CT, Blank DA, Badurdeen S, Crossley KJ, Miller SL, Stojanovska V, Galinsky R, Kluckow M, Gill AW, Hooper SB. Cardiopulmonary Resuscitation of Asystolic Newborn Lambs Prior to Umbilical Cord Clamping; the Timing of Cord Clamping Matters! Front Physiol 2020; 11:902. [PMID: 32848852 PMCID: PMC7406709 DOI: 10.3389/fphys.2020.00902] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/06/2020] [Indexed: 12/14/2022] Open
Abstract
Background: Current guidelines recommend immediate umbilical cord clamping (UCC) for newborns requiring chest compressions (CCs). Physiological-based cord clamping (PBCC), defined as delaying UCC until after lung aeration, has advantages over immediate UCC in mildly asphyxiated newborns, but its efficacy in asystolic newborns requiring CC is unknown. The aim of this study was to compare the cardiovascular response to CCs given prior to or after UCC in asystolic near-term lambs. Methods: Umbilical, carotid, pulmonary, and femoral arterial flows and pressures as well as systemic and cerebral oxygenation were measured in near-term sheep fetuses [139 ± 2 (SD) days gestation]. Fetal asphyxia was induced until asystole ensued, whereupon lambs received ventilation and CC before (PBCC; n = 16) or after (n = 12) UCC. Epinephrine was administered 1 min after ventilation onset and in 3-min intervals thereafter. The PBCC group was further separated into UCC at either 1 min (PBCC1, n = 8) or 10 min (PBCC10, n = 8) after return of spontaneous circulation (ROSC). Lambs were maintained for a further 30 min after ROSC. Results: The duration of CCs received and number of epinephrine doses required to obtain ROSC were similar between groups. After ROSC, we found no physiological benefits if UCC was delayed for 1 min compared to immediate cord clamping (ICC). However, if UCC was delayed for 10 min after ROSC, we found significant reductions in post-asphyxial rebound hypertension, cerebral blood flow, and cerebral oxygenation. The prevention of the post-asphyxial rebound hypertension in the PBCC10 group occurred due to the contribution of the placental circulation to a low peripheral resistance. As a result, left and right ventricular outputs continued to perfuse the placenta and were evidenced by reduced mean pulmonary blood flow, persistence of right-to-left shunting across the ductus arteriosus, and persistence of umbilical arterial and venous blood flows. Conclusion: It is possible to obtain ROSC after CC while the umbilical cord remains intact. There were no adverse effects of PBCC compared to ICC; however, the physiological changes observed after ROSC in the ICC and early PBCC groups may result in additional cerebral injury. Prolonging UCC after ROSC may provide significant physiological benefits that may reduce the risk of harm to the cerebral circulation.
Collapse
Affiliation(s)
- Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Calum T Roberts
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Douglas A Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Shiraz Badurdeen
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Suzanne L Miller
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Vanesa Stojanovska
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Robert Galinsky
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Andrew W Gill
- Centre for Neonatal Research and Education, The University of Western Australia, Subiaco, WA, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| |
Collapse
|