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Kunisaki SM, Desiraju S, Yang MJ, Lakshminrusimha S, Yoder BA. Ventilator strategies in congenital diaphragmatic hernia. Semin Pediatr Surg 2024; 33:151439. [PMID: 38986241 DOI: 10.1016/j.sempedsurg.2024.151439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
This review focuses on contemporary mechanical ventilator practices used in the initial management of neonates born with congenital diaphragmatic hernia (CDH). Both conventional and non-conventional ventilation modes in CDH are reviewed. Special emphasis is placed on the rationale for gentle ventilation and the current evidence-based clinical practice guidelines that are recommended for supporting these fragile infants. The interplay between CDH lung hypoplasia and other key cardiopulmonary elements of the disease, namely a reduced pulmonary vascular bed, abnormal pulmonary vascular remodeling, and left ventricular hypoplasia, are discussed. Finally, we provide insights into future avenues for mechanical ventilator research in CDH.
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins Medicine, USA.
| | - Suneetha Desiraju
- Division of Neonatology, Johns Hopkins Children's Center, Johns Hopkins Medicine, USA
| | - Michelle J Yang
- Division of Neonatology, Primary Children's Medical Center, University of Utah Health, USA
| | - Satyan Lakshminrusimha
- Division of Neonatal-Perinatal Medicine, UC Davis Children's Hospital, University of California at Davis Health, USA
| | - Bradley A Yoder
- Division of Neonatology, Primary Children's Medical Center, University of Utah Health, USA
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2
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Renik-Jankowska W, Buczyńska A, Sidorkiewicz I, Kosiński P, Zbucka-Krętowska M. Exploring new perspectives on congenital diaphragmatic hernia: A comprehensive review. Biochim Biophys Acta Mol Basis Dis 2024; 1870:167105. [PMID: 38428682 DOI: 10.1016/j.bbadis.2024.167105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
Congenital diaphragmatic hernia (CDH) represents a developmental anomaly that profoundly impacts the embryonic development of both the respiratory and cardiovascular systems. Understanding the influences of developmental defects, their origins, and clinical consequences is of paramount importance for further research and the advancement of therapeutic strategies for this condition. In recent years, groundbreaking studies in the fields of metabolomics and genomics have significantly expanded our knowledge regarding the pathogenic mechanisms of CDH. These investigations introduce novel diagnostic and therapeutic avenues. CDH implies a scarcity of available information within this domain. Consequently, a comprehensive literature review has been undertaken to synthesize existing data, providing invaluable insights into this rare disease. Improved comprehension of the molecular underpinnings of CDH has the potential to refine diagnostic precision and therapeutic interventions, thus potentially enhancing clinical outcomes for CDH patients. The identification of potential biomarkers assumes paramount significance for early disease detection and risk assessment in CDH, facilitating prompt recognition and the implementation of appropriate interventions. The process of translating research findings into clinical practice is significantly facilitated by an exhaustive literature review. It serves as a pivotal step, enabling the integration of novel, more effective diagnostic and therapeutic modalities into the management of CDH patients.
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Affiliation(s)
- Weronika Renik-Jankowska
- Department of Gynecological Endocrinology and Adolescent Gynecology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland.
| | - Angelika Buczyńska
- Clinical Research Centre, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland.
| | - Iwona Sidorkiewicz
- Clinical Research Support Centre, Medical University of Bialystok, ul. M. Skłodowskiej-Curie 24a, 15-276 Bialystok, Poland.
| | - Przemysław Kosiński
- Department of Obstetrics, Perinatology, and Gynecology, Medical University of Warsaw, Żwirki i Wigury 63A, 02-091 Warszawa, Poland.
| | - Monika Zbucka-Krętowska
- Department of Gynecological Endocrinology and Adolescent Gynecology, Medical University of Bialystok, M. Sklodowskiej-Curie 24a, 15-276 Bialystok, Poland
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3
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Wild KT, Rintoul N, Hedrick HL, Heimall L, Soorikian L, Foglia EE, Ades AM, Herrick HM. Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia: Lessons Learned through Video Review. Fetal Diagn Ther 2024:000538536. [PMID: 38531327 DOI: 10.1159/000538536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Delivery room (DR) interventions for infants with congenital diaphragmatic hernia (CDH) are not well described. This study sought to describe timing and order of DR interventions and identify system factors impacting CDH DR resuscitations using a human factors framework. METHODS Single center observational study of video recorded CDH DR resuscitations documenting timing and order of interventions. The team used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify system factors impacting DR resuscitations and time to invasive ventilation. RESULTS We analyzed 31 video recorded CDH resuscitations. We observed variability in timing and order of resuscitation tasks. The 'Internal Environment' and 'Tasks' components of the SEIPS model were prominent factors affecting resuscitation efficiency; significant room and bed spatial constraints exist, and nurses have a significant task burden. Additionally, endotracheal tube preparation was a prominent barrier to timely invasive ventilation. CONCLUSION Video review revealed variation in event timing and order during CDH resuscitations. Standardization of room set-up, equipment, and event order and reallocation of tasks facilitate more efficient intubation and ventilation, representing targets for CDH DR improvement initiatives. This work emphasizes the utility of rigorous human factors review to identify areas for improvement during DR resuscitation.
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Alikhani VS, Thies-Lagergren L, Svedenkrans J, Elfvin A, Bolk J, Andersson O. Stabilisation and resuscitation with intact cord circulation is feasible using a wide variety of approaches; a scoping review. Acta Paediatr 2023; 112:2468-2477. [PMID: 37767916 DOI: 10.1111/apa.16985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023]
Abstract
AIM This scoping review identified studies on approaches to intact cord resuscitation and/or stabilisation (ICR/S) for neonates delivered by Caesarean section (C-section). METHODS A systematic literature search was carried out using the PubMed, Web of Science, Scopus, Cochrane and CINAHL databases to identify papers published in English from inception to 14 November 2022. RESULTS We assessed 2613 studies and included 18 from 10 countries, covering 1-125 C-sections: the United States, the United Kingdom, Australia, India, Italy, China, France, The Netherlands, New Zealand and Taiwan. The papers were published from 2014 to 2023, and the majority were randomised controlled trials and observational studies. Different platforms, equipment and staff positions in relation to the operating table were described. Options for resuscitation and stabilisation included different bedding and trolley approaches, and maintaining aseptic conditions was mainly addressed by the neonatal team scrubbing in. Hypothermia was prevented by using warm surfaces, polythene bags and radiant heaters. Equipment was kept easily accessible by mounting it on a trolley or a separate mobile pole. CONCLUSION We could not reach definitive conclusions on the optimal method for performing ICR/S during a C-section, due to study variations. However, a number of equipment and management options appeared to be feasible approaches.
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Affiliation(s)
- Vesta Seyed Alikhani
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Jenny Svedenkrans
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Lund University, Lund, Sweden
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Elfvin
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jenny Bolk
- Division of Clinical Epidemiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
- Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Ola Andersson
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Lund University, Lund, Sweden
- Department of Neonatology, Skåne University Hospital, Malmö, Sweden
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Lyle ANJ, Shaikh H, Oslin E, Gray MM, Weiss EM. Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review. JAMA Netw Open 2023; 6:e2348882. [PMID: 38127349 PMCID: PMC10739112 DOI: 10.1001/jamanetworkopen.2023.48882] [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] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology. Objective To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting. Evidence Review A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus. Findings Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented. Conclusions and Relevance These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.
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Affiliation(s)
- Allison N J Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Henna Shaikh
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
| | - Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
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Johng S, Fraga MV, Patel N, Kipfmueller F, Bhattacharya A, Bhombal S. Unique Cardiopulmonary Interactions in Congenital Diaphragmatic Hernia: Physiology and Therapeutic Implications. Neoreviews 2023; 24:e720-e732. [PMID: 37907403 DOI: 10.1542/neo.24-11-e720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Congenital diaphragmatic hernia (CDH) results in abdominal contents entering the thoracic cavity, affecting both cardiac and pulmonary development. Maldevelopment of the pulmonary vasculature occurs within both the ipsilateral lung and the contralateral lung. The resultant bilateral pulmonary hypoplasia and associated pulmonary hypertension are important components of the pathophysiology of this disease that affect outcomes. Despite prenatal referral to specialized high-volume centers, advanced ventilation strategies, pulmonary hypertension management, and the option of extracorporeal membrane oxygenation, overall CDH mortality remains between 25% and 30%. With increasing recognition that cardiac dysfunction plays a large role in morbidity and mortality in patients with CDH, it becomes imperative to understand the different clinical phenotypes, thus allowing for individual patient-directed therapies. Further research into therapeutic interventions that address the cardiopulmonary interactions in patients with CDH may lead to improved morbidity and mortality outcomes.
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Affiliation(s)
- Sandy Johng
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Maria V Fraga
- Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, PA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
| | | | - Shazia Bhombal
- Department of Pediatrics, Emory University/Children's Healthcare of Atlanta, Atlanta, GA
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7
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Horn-Oudshoorn EJJ, Blekherov AM, van den Bosch GE, Simons SHP, Knol R, Te Pas A, Reiss IKM, DeKoninck PLJ. Sedation Prior to Intubation at Birth in Infants with Congenital Diaphragmatic Hernia: An International Survey on Current Practices. Neonatology 2023; 120:434-440. [PMID: 37279703 PMCID: PMC10614521 DOI: 10.1159/000530573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 03/27/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION Infants with congenital diaphragmatic hernia (CDH) are commonly intubated immediately after birth. Consensus on whether to provide sedation prior to intubation in the delivery room is lacking, although avoidance of stress is especially important in this population with high risk of pulmonary hypertension. We aimed at obtaining an overview of local pharmacological interventions and at providing guidance on delivery room management. METHODS An electronic survey was sent to international clinicians in referral centres for prenatal and postnatally diagnosed infants with CDH. This survey addressed demographic information, use of sedation and/or muscle relaxant prior to intubation, and use of pain scales in the delivery room. RESULTS We received 93 relevant responses from 59 centres. Most centres were from Europe (n = 33, 56%), followed by North America (n = 16, 27%), Asia (n = 6, 10%), Australia (n = 2, 3%), and South America (n = 2, 3%). A total of 19% (11/59) of the centres routinely provided sedation prior to intubation in the delivery room, with midazolam and fentanyl being most often used. Methods of administration varied for all medications provided. Only 5 of 11 centres using sedation reported an adequate sedative effect prior to intubation. Muscle relaxants prior to intubation were used in 12% (7/59) of the centres, although not always in combination with sedation. CONCLUSION This international survey shows a substantial variation in sedation practices in the delivery room and scarce use of both sedative agents and muscle relaxants prior to intubation of CDH infants. We provide guidance on developing protocols for pre-intubation medication in this population.
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Affiliation(s)
- Emily J J Horn-Oudshoorn
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands,
| | - Alisa M Blekherov
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Gerbrich E van den Bosch
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sinno H P Simons
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ronny Knol
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Arjan Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Neonatal and Paediatric Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Philip L J DeKoninck
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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8
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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.
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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.
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Chakkarapani AA, Roehr CC, Hooper SB, Te Pas AB, Gupta S. Transitional circulation and hemodynamic monitoring in newborn infants. Pediatr Res 2023:10.1038/s41390-022-02427-8. [PMID: 36593283 DOI: 10.1038/s41390-022-02427-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/14/2022] [Accepted: 11/21/2022] [Indexed: 01/03/2023]
Abstract
Transitional circulation is normally transient after birth but can vary markedly between infants. It is actually in a state of transition between fetal (in utero) and neonatal (postnatal) circulation. In the absence of definitive clinical trials, information from applied physiological studies can be used to facilitate clinical decision making in the presence of hemodynamic compromise. This review summarizes the peculiar physiological features of the circulation as it transitions from one phenotype into another in term and preterm infants. The common causes of hemodynamic compromise during transition, intact umbilical cord resuscitation, and advanced hemodynamic monitoring are discussed. IMPACT: Transitional circulation can vary markedly between infants. There are alterations in preload, contractility, and afterload during the transition of circulation after birth in term and preterm infants. Hemodynamic monitoring tools and technology during neonatal transition and utilization of bedside echocardiography during the neonatal transition are increasingly recognized. Understanding the cardiovascular physiology of transition can help clinicians in making better decisions while managing infants with hemodynamic compromise. The objective assessment of cardio-respiratory transition and understanding of physiology in normal and disease states have the potential of improving short- and long-term health outcomes.
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Affiliation(s)
| | - Charles C Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
- Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, UK
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Stuart B Hooper
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Neonatology, Willem Alexander Children's Hospital, Leiden University Medical Center Leiden, Leiden, The Netherlands
| | - Samir Gupta
- Division of Neonatology, Sidra Medicine, Doha, Qatar.
- Durham University, Durham, UK.
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10
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Pala C, Blake SM. One Size Does Not Fit All: Congenital Diaphragmatic Hernia Management in Neonates. Neonatal Netw 2023; 42:45-51. [PMID: 36631262 DOI: 10.1891/nn-2021-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2022] [Indexed: 01/13/2023]
Abstract
Congenital diaphragmatic hernia (CDH) results from abnormal development of the diaphragm during fetal life, allowing abdominal organs to herniate through the defect into the thorax. Stunted lung growth is associated with pulmonary hypoplasia and pulmonary hypertension, which are the primary sources of morbidity and mortality for this population. Despite strides in neonatal and surgical care, the management of neonates with CDH remains challenging. Optimal treatment strategies are still largely unknown. Many centers utilize gentle ventilation, permissive hypercapnia, and pulmonary hypertension treatment inclusive of nitric oxide, sildenafil, or epoprostenol, delayed surgical repair, and extracorporeal membrane oxygenation (ECMO). Evidence-based guidelines are needed to enhance CDH care practices and better outcomes. The successful management of CDH is a collaborative team effort from the prenatal to the postnatal period and beyond.
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11
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Ali N, Sawyer T. Special consideration in neonatal resuscitation. Semin Perinatol 2022; 46:151626. [PMID: 35738945 DOI: 10.1016/j.semperi.2022.151626] [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: 10/18/2022]
Abstract
Delivery room resuscitation of neonates is performed according to evidence-based neonatal resuscitation guidelines. Neonatal resuscitation guidelines focus on the resuscitation of newborns suffering from perinatal asphyxia. Special considerations are needed when resuscitating newborns in locations other than the delivery room and for newborns with congenital anomalies. In this review, we examine the resuscitation of newborns at home and in the emergency department and highlight special considerations for resuscitating newborns with specific congenital anomalies. In addition, we explore the resuscitation of neonates in the neonatal intensive care unit and discuss the potential use of pediatric advanced life support guidelines. Finally, we highlight the importance of simulation to prepare teams for neonatal resuscitations. This review aims to prepare healthcare professionals in all disciplines caring for neonates at risk for requiring resuscitation under special circumstances.
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Affiliation(s)
- Noorjahan Ali
- Department of Pediatrics Division of Perinatal-Neonatal Medicine UT Southwestern of Dallas Children's Medical Center of Dallas Texas, USA.
| | - Taylor Sawyer
- Department of Pediatrics Division of Neonatology, University of Washington School of Medicine Seattle Washington, USA
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12
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De Bie FR, Avitabile CM, Joyeux L, Hedrick HL, Russo FM, Basurto D, Deprest J, Rintoul NE. Neonatal and fetal therapy of congenital diaphragmatic hernia-related pulmonary hypertension. Arch Dis Child Fetal Neonatal Ed 2022; 107:458-466. [PMID: 34952853 DOI: 10.1136/archdischild-2021-322617] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/06/2021] [Indexed: 01/01/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a complex malformation characterised by a triad of pulmonary hypoplasia, pulmonary hypertension (PH) and cardiac ventricular dysfunction. Much of the mortality and morbidity in CDH is largely accounted for by PH, especially when persistent beyond the neonatal period and refractory to available treatment. Gentle ventilation, haemodynamic optimisation and pulmonary vasodilation constitute the foundations of neonatal treatment of CDH-related PH (CDH-PH). Moreover, early prenatal diagnosis, the ability to assess severity and the developmental nature of the condition generate the perfect rationale for fetal therapy. Shortcomings of currently available clinical therapies in combination with increased understanding of CDH pathophysiology have spurred experimental drug trials, exploring new therapeutic mechanisms to tackle CDH-PH. We herein discuss clinically available neonatal and fetal therapies specifically targeting CDH-PH and review the most promising experimental treatments and future research avenues.
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Affiliation(s)
- Felix R De Bie
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA .,My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Catherine M Avitabile
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luc Joyeux
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Holly L Hedrick
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francesca M Russo
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium.,Department of Obstetrics and Gynaecology, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - David Basurto
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium
| | - Jan Deprest
- My FetUZ, Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium, Katholieke Universiteit Leuven, Leuven, Flanders, Belgium.,Department of Obstetrics and Gynecology, Division Woman and Child, Fetal Medicine Unit, KU Leuven University Hospitals Leuven, Leuven, Flanders, Belgium
| | - Natalie E Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Division of Neonatal Intensive Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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13
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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.
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14
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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.
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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
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15
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Zani A, Chung WK, Deprest J, Harting MT, Jancelewicz T, Kunisaki SM, Patel N, Antounians L, Puligandla PS, Keijzer R. Congenital diaphragmatic hernia. Nat Rev Dis Primers 2022; 8:37. [PMID: 35650272 DOI: 10.1038/s41572-022-00362-w] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 11/09/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is a rare birth defect characterized by incomplete closure of the diaphragm and herniation of fetal abdominal organs into the chest that results in pulmonary hypoplasia, postnatal pulmonary hypertension owing to vascular remodelling and cardiac dysfunction. The high mortality and morbidity rates associated with CDH are directly related to the severity of cardiopulmonary pathophysiology. Although the aetiology remains unknown, CDH has a polygenic origin in approximately one-third of cases. CDH is typically diagnosed with antenatal ultrasonography, which also aids in risk stratification, alongside fetal MRI and echocardiography. At specialized centres, prenatal management includes fetal endoscopic tracheal occlusion, which is a surgical intervention aimed at promoting lung growth in utero. Postnatal management focuses on cardiopulmonary stabilization and, in severe cases, can involve extracorporeal life support. Clinical practice guidelines continue to evolve owing to the rapidly changing landscape of therapeutic options, which include pulmonary hypertension management, ventilation strategies and surgical approaches. Survivors often have long-term, multisystem morbidities, including pulmonary dysfunction, gastroesophageal reflux, musculoskeletal deformities and neurodevelopmental impairment. Emerging research focuses on small RNA species as biomarkers of severity and regenerative medicine approaches to improve fetal lung development.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. .,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Wendy K Chung
- Department of Paediatrics, Columbia University, New York, NY, USA
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child and Clinical Department of Obstetrics and Gynaecology, University Hospitals, KU Leuven, Leuven, Belgium.,Institute for Women's Health, UCL, London, UK
| | - Matthew T Harting
- Department of Paediatric Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA.,The Comprehensive Center for CDH Care, Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shaun M Kunisaki
- Division of General Paediatric Surgery, Johns Hopkins Children's Center, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, UK
| | - Lina Antounians
- Division of General and Thoracic Surgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology Program, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Pramod S Puligandla
- Department of Paediatric Surgery, Harvey E. Beardmore Division of Paediatric Surgery, Montreal Children's Hospital of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Richard Keijzer
- Department of Surgery, Division of Paediatric Surgery, Paediatrics & Child Health, Physiology & Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
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16
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Abstract
PURPOSE OF REVIEW For over a decade, the International Liaison Committee on Resuscitation has recommended delayed cord clamping (DCC), but implementation has been variable due to lack of consensus on details of technique and concerns for risks in certain patient populations. This review summarizes recent literature on the benefits and risks of DCC in term and preterm infants and examines alternative approaches such as physiologic-based cord clamping or intact cord resuscitation (ICR) and umbilical cord milking (UCM). RECENT FINDINGS DCC improves hemoglobin/hematocrit among term infants and may promote improved neurodevelopment. In preterms, DCC improves survival compared to early cord clamping; however, UCM has been associated with severe intraventricular hemorrhage in extremely preterm infants. Infants of COVID-19 positive mothers, growth-restricted babies, multiples, and some infants with cardiopulmonary anomalies can also benefit from DCC. Large randomized trials of ICR will clarify safety and benefits in nonvigorous neonates. These have the potential to dramatically change the sequence of events during neonatal resuscitation. SUMMARY Umbilical cord management has moved beyond simple time-based comparisons to nuances of technique and application in vulnerable sub-populations. Ongoing research highlights the importance of an individualized approach that recognizes the physiologic equilibrium when ventilation is established before cord clamping.
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Affiliation(s)
| | - Susan Niermeyer
- University of Colorado School of Medicine, Colorado School of Public Health, Aurora, Colorado, USA
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17
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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.
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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
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18
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Patel N, Massolo AC, Kraemer US, Kipfmueller F. The heart in congenital diaphragmatic hernia: Knowns, unknowns, and future priorities. Front Pediatr 2022; 10:890422. [PMID: 36052357 PMCID: PMC9424541 DOI: 10.3389/fped.2022.890422] [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: 03/05/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
There is growing recognition that the heart is a key contributor to the pathophysiology of congenital diaphragmatic hernia (CDH), in conjunction with developmental abnormalities of the lung and pulmonary vasculature. Investigations to date have demonstrated altered fetal cardiac morphology, notably relative hypoplasia of the fetal left heart, as well as early postnatal right and left ventricular dysfunction which appears to be independently associated with adverse outcomes. However, many more unknowns remain, not least an understanding of the genetic and cellular basis for cardiac dysplasia and dysfunction in CDH, the relationship between fetal, postnatal and long-term cardiac function, and the impact on other parts of the body especially the developing brain. Consensus on how to measure and classify cardiac function and pulmonary hypertension in CDH is also required, potentially using both non-invasive imaging and biomarkers. This may allow routine assessment of the relative contribution of cardiac dysfunction to individual patient pathophysiological phenotype and enable better, individualized therapeutic strategies incorporating targeted use of fetal therapies, cardiac pharmacotherapies, and extra-corporeal membrane oxygenation (ECMO). Collaborative, multi-model approaches are now required to explore these unknowns and fully appreciate the role of the heart in CDH.
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Affiliation(s)
- Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow, United Kingdom
| | | | - Ulrike S Kraemer
- Intensive Care Unit, Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, Bonn, Germany
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19
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Abstract
Keeping the umbilical cord intact after delivery facilitates transition from fetal to neonatal circulation and allows a placental transfusion of a considerable amount of blood. A delay of at least 3 minutes improves neurodevelopmental outcomes in term infants. Although regarded as common sense and practiced by many midwives, implementation of delayed cord clamping into practice has been unduly slow, partly because of beliefs regarding theoretic risks of jaundice and lack of understanding regarding the long-term benefits. This article provides arguments for delaying cord clamping for a minimum of 3 minutes.
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Affiliation(s)
- Ola Andersson
- Department of Clinical Sciences, Lund, Pediatrics, Lund University, SE-221 85 Lund, Sweden; Department of Neonatology, Skåne University Hospital, Jan Waldenströms gata 47, Malmö SE-214 28, Sweden.
| | - Judith S Mercer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA; University of Rhode Island, Kingston, RI, USA
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20
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Katheria A, Lee HC, Knol R, Irvine L, Thomas S. A review of different resuscitation platforms during delayed cord clamping. J Perinatol 2021; 41:1540-1548. [PMID: 33850283 PMCID: PMC8042840 DOI: 10.1038/s41372-021-01052-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/10/2021] [Accepted: 03/29/2021] [Indexed: 12/02/2022]
Abstract
There is a large body of evidence demonstrating that delaying clamping of the umbilical cord provides benefits for term and preterm infants. These benefits include reductions in mortality in preterm infants and improved developmental scores at 4 years of age in term infants. However, non-breathing or non-vigorous infants at birth are excluded due to the perceived need for immediate resuscitation. Recent studies have demonstrated early physiological benefits in both human and animal models if resuscitation is performed with an intact cord, but this is still an active area of research. Given the large number of ongoing and planned trials, we have brought together an international group that have been intimately involved in the development or use of resuscitation equipment designed to be used while the cord is still intact. In this review, we will present the benefits and limitations of devices that have been developed or are in use. Published trials or ongoing studies using their respective devices will also be reviewed.
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Affiliation(s)
- Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital, San Diego, CA, USA.
| | - Henry C Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Ronny Knol
- Department of Pediatrics, Erasmus Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Leigh Irvine
- Foothills Medical Centre, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Sumesh Thomas
- Foothills Medical Centre, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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21
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Efficacy of Intact Cord Resuscitation Compared to Immediate Cord Clamping on Cardiorespiratory Adaptation at Birth in Infants with Isolated Congenital Diaphragmatic Hernia (CHIC). CHILDREN-BASEL 2021; 8:children8050339. [PMID: 33925985 PMCID: PMC8146982 DOI: 10.3390/children8050339] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/26/2022]
Abstract
Resuscitation at birth of infants with Congenital Diaphragmatic Hernia (CDH) remains highly challenging because of severe failure of cardiorespiratory adaptation at birth. Usually, the umbilical cord is clamped immediately after birth. Delaying cord clamping while the resuscitation maneuvers are started may: (1) facilitate blood transfer from placenta to baby to augment circulatory blood volume; (2) avoid loss of venous return and decrease in left ventricle filling caused by immediate cord clamping; (3) prevent initial hypoxemia because of sustained uteroplacental gas exchange after birth when the cord is intact. The aim of this trial is to evaluate the efficacy of intact cord resuscitation compared to immediate cord clamping on cardiorespiratory adaptation at birth in infants with isolated CDH. The Congenital Hernia Intact Cord (CHIC) trial is a prospective multicenter open-label randomized controlled trial in two balanced parallel groups. Participants are randomized either immediate cord clamping (the cord will be clamped within the first 15 s after birth) or to intact cord resuscitation group (umbilical cord will be kept intact during the first part of the resuscitation). The primary end-point is the number of infants with APGAR score <4 at 1 min or <7 at 5 min. One hundred eighty participants are expected for this trial. To our knowledge, CHIC is the first study randomized controlled trial evaluating intact cord resuscitation on newborn infant with congenital diaphragmatic hernia. Better cardiorespiratory adaptation is expected when the resuscitation maneuvers are started while the cord is still connected to the placenta.
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22
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DeKoninck PLJ, Horn-Oudshoorn EJJ, Knol R, Crossley KJ, Reiss IKM. Knowledge Gaps in the Fetal to Neonatal Transition of Infants With a Congenital Diaphragmatic Hernia. Front Pediatr 2021; 9:784810. [PMID: 34970518 PMCID: PMC8712749 DOI: 10.3389/fped.2021.784810] [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: 09/28/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Clinical research for infants born with a congenital diaphragmatic hernia (CDH) has until recently mainly focused on advances in prenatal and postnatal treatment. However, during the early perinatal transition period there are major physiological adaptations. For most infants these changes will happen uneventfully, but for CDH infants this marks the beginning of serious respiratory complications. In recent years, there is emerging evidence that the clinical management during the perinatal stabilization period in the delivery room may influence postnatal outcomes. Herein, we discuss major knowledge gaps and novel concepts that aim to optimize fetal to neonatal transition for infants with CDH. One such novel and interesting approach is performing resuscitation with an intact umbilical cord, the efficacy of this procedure is currently being investigated in several clinical trials. Furthermore, close evaluation of neonatal physiological parameters in the first 24 h of life might provide early clues concerning the severity of lung hypoplasia and the risk of adverse outcomes. We will provide an overview of trending concepts and discuss potential areas for future research.
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Affiliation(s)
- Philip L J DeKoninck
- Department of Obstetrics and Gynecology, Division Fetal Medicine, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Emily J J Horn-Oudshoorn
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Ronny Knol
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC University Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
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23
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Williams E, Greenough A. Respiratory Support of Infants With Congenital Diaphragmatic Hernia. Front Pediatr 2021; 9:808317. [PMID: 35004552 PMCID: PMC8740288 DOI: 10.3389/fped.2021.808317] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/01/2021] [Indexed: 12/23/2022] Open
Abstract
Optimisation of respiratory support of infants with congenital diaphragmatic hernia (CDH) is critical. Infants with CDH often have severe lung hypoplasia and abnormal development of their pulmonary vasculature, leading to ventilation perfusion mismatch. It is vital that lung protective ventilation strategies are employed during both initial stabilisation and post-surgical repair to avoid ventilator induced lung damage and oxygen toxicity to prevent further impairment to an already diminished gas-exchanging environment. There is a lack of robust evidence for the routine use of surfactant therapy during initial resuscitation of infants with CDH and thus administration cannot be recommended outside clinical trials. Additionally, inhaled nitric oxide has been shown to have no benefit in reducing the mortality rates of infants with CDH. Other therapeutic agents which beneficially act on pulmonary hypertension are currently being assessed in infants with CDH in randomised multicentre trials. The role of novel ventilatory modalities such as closed loop automated oxygen control, liquid ventilation and heliox therapy may offer promise for infants with CDH, but the benefits need to be determined in appropriately designed clinical trials.
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Affiliation(s)
- Emma Williams
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, United Kingdom.,National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' National Health Service (NHS) Foundation Trust and King's College London, London, United Kingdom
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24
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Shetty S, Arattu Thodika FMS, Greenough A. Managing respiratory complications in infants and newborns with congenital diaphragmatic hernia. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1865915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Anne Greenough
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, UK
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, UK
- Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, UK
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25
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Guttmann K, Martin A, Chaudhary A, Cole J, Foglia EE. Resuscitation before cord clamping: the maternal experience. Arch Dis Child Fetal Neonatal Ed 2020; 105:569-570. [PMID: 31806665 PMCID: PMC10014131 DOI: 10.1136/archdischild-2019-318190] [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] [Accepted: 11/15/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Katherine Guttmann
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ashley Martin
- Center for Outcomes Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aasma Chaudhary
- Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Joanna Cole
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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26
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Horn-Oudshoorn EJJ, Knol R, Te Pas AB, Hooper SB, Cochius-den Otter SCM, Wijnen RMH, Schaible T, Reiss IKM, DeKoninck PLJ. Perinatal stabilisation of infants born with congenital diaphragmatic hernia: a review of current concepts. Arch Dis Child Fetal Neonatal Ed 2020; 105:449-454. [PMID: 32170029 PMCID: PMC7363792 DOI: 10.1136/archdischild-2019-318606] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 11/04/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is associated with high mortality rates and significant pulmonary morbidity, mainly due to disrupted lung development related to herniation of abdominal organs into the chest. Pulmonary hypertension is a major contributor to both mortality and morbidity, however, treatment modalities are limited. Novel prenatal and postnatal interventions, such as fetal surgery and medical treatments, are currently under investigation. Until now, the perinatal stabilisation period immediately after birth has been relatively overlooked, although optimising support in these early stages may be vital in improving outcomes. Moreover, physiological parameters obtained from the perinatal stabilisation period could serve as early predictors of adverse outcomes, thereby facilitating both prevention and early treatment of these conditions. In this review, we focus on the perinatal stabilisation period by discussing the current delivery room guidelines in infants born with CDH, the physiological changes occurring during the fetal-to-neonatal transition in CDH, novel delivery room strategies and early predictors of adverse outcomes. The combination of improvements in the perinatal stabilisation period and early prediction of adverse outcomes may mitigate the need for specific postnatal management strategies.
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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
| | - 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
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - René M H Wijnen
- Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, 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 .,Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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27
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Blank DA, Crossley KJ, Kashyap AJ, Hodges RJ, DeKoninck PLJ, McGillick EV, Rodgers KA, Te Pas AB, Hooper SB, Polglase GR. Physiologic-Based Cord Clamping Maintains Core Temperature vs. Immediate Cord Clamping in Near-Term Lambs. Front Pediatr 2020; 8:584983. [PMID: 33194919 PMCID: PMC7644840 DOI: 10.3389/fped.2020.584983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/16/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Physiologic-based cord clamping (PBCC) involves deferring umbilical cord clamping until after lung aeration. It is unclear if infant is at risk of becoming hypothermic during PBCC. Objectives: To test if PBCC would maintain core temperature more effectively than immediate cord clamping (ICC). Design: At 0.93 gestation, fetal lambs were surgically exteriorized and instrumented from pregnant ewes under general anesthesia. Prior to the start of the experiment, lambs were thoroughly dried, placed on hot water bottles, and core temperature was continuously monitored using a rectal thermometer. PBCC lambs (n = 21), received intermittent positive pressure ventilation (iPPV) for ≥5 min prior to umbilical cord clamping. In ICC lambs (n = 23), iPPV commenced within 60 s after umbilical cord clamping. iPPV was provided with heated/humidified gas. Lambs were moved under a radiant warmer after umbilical cord clamping. Additional warmth was provided using a plastic overlay, hairdryer, and extra water bottles, as needed. Two-way mixed and repeated measures one-way ANOVAs were used to compare temperature changes between and within a single group, respectively, over time. Results: Basal fetal parameters including core temperature were similar between groups. ICC lambs had a significant reduction in temperature compared to PBCC lambs (p < 0.001), evident by 1 min (p = 0.002). ICC lambs decreased temperature by 0.51°C (± 0.42) and 0.79°C (± 0.55) at 5 and 10 min respectively (p < 0.001). In PBCC lambs, temperature did not significantly change before or after umbilical cord clamping (p = 0.4 and p = 0.3, respectively). Conclusions: PBCC stabilized core temperature at delivery better than ICC in term lambs. Hypothermia may not be a significant risk during PBCC.
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Affiliation(s)
- Douglas A Blank
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Aidan J Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Ryan J Hodges
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.,Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Karyn A Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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