2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Delivery Room Lung Ultrasound-Feasibility, Normal Patterns, and Predictive Value for Respiratory Support in Term and Near-Term Neonates: A Monocentric Study

AIM

our study aimed to characterize the lung ultrasound (LUS) patterns noted immediately after delivery in term and near-term neonates, and to investigate whether the LUS scores or patterns observed at that point could anticipate the need for respiratory support in the sample of patients studied.

MATERIALS AND METHODS

We performed two ultrasound examinations: one in the delivery room and the second at one hour of age. The anterior and lateral regions of both lungs were examined. We assessed the correlation between the LUS scores or patterns and the gestational age, umbilical arterial blood gases, the need for respiratory support (CPAP or mechanical ventilation), the presence of respiratory distress, and the need for the administration of oxygen.

RESULTS

LUS scores were significantly higher in the delivery room examination (8.05 ± 1.95) than at 1 h of age (6.4 ± 1.75) (p < 0.001). There were also statistically significant differences between the LUS patterns observed in different lung regions between the delivery room exam and the exam performed at 1 h of age (p values between 0.001 and 0.017). There were also differences noted regarding the LUS patterns between different lung regions at the exam in the delivery room (the right anterior region LUS patterns were significantly worse than the right lateral LUS patterns (p < 0.004), left anterior LUS patterns (p < 0.001), and left lateral LUS patterns (p < 0.001)). A statistically significant correlation was found between LUS scores and the gestational age of the patients (r = 0.568, p < 0.001-delivery room; r = 4.0443, p < 0.001-one hour of age). There were statistically significant associations between LUS scores, patterns at delivery (p < 0.001) and 1 h of age (p < 0.001), and the need for respiratory support (CPAP or mechanical ventilation).

CONCLUSIONS

LUS in the delivery room offers important information regarding lung fluid elimination and aeration of the lungs, and early LUS features are significantly associated with the risk of respiratory distress and the need for respiratory support.

A randomised controlled trial comparing umbilical cord milking to delayed cord clamping at birth in preterm infants 28-36 weeks gestational age

Delayed cord clamping (DCC) is an established practice in perinatology with multiple benefits. However, in instances where the implementation of DCC is not viable, it needs alternatives, especially during caesarean deliveries. A non-inferiority randomized, non-blinded, trial was conducted at a tertiary care referral unit in South India among the preterm newborns (28-36 weeks) randomized to DCC as opposed to intact-umbilical cord milking (UCM). The primary objective was to compare the mean haemoglobin values between the two groups, and the secondary outcome was to compare death and/or major IVH (> Grade II). Of the 132 eligible newborn infants, 99 were randomized to two study groups. Of the 59 and 40 randomised to UCM and DCC, 54 and 36 received the allocated intervention respectively. Preterm infants who underwent UCM had significantly higher haemoglobin (19.97 ± 1.44) as compared to DCC group (18.62 ± 0.98) p-0.0001. The rates of mortality and/or major IVH were comparable between the two groups.

CONCLUSION

UCM may be a feasible alternative to DCC especially in settings where the latter is not achievable, without increasing the risk of adverse effects to the preterm infants, this finding needing further confirmation with larger sample.

TRIAL REGISTRATION

CTRI (Clinical Trial Registry-India) registration number: CTRI/2020/04/024566 (registered prospectively on 13/04/2020).

WHAT IS KNOWN

• Delayed cord clamping (DCC) is recommended as a standard of care for all the stable term and preterm newborn babies at birth.

WHAT IS NEW

• Intact umbilical cord milking may be a reasonable choice of cord management when DCC is unsuccessful, without increasing adverse effects for the new born.

Effect of Delayed Cord Clamping on Breastfeeding Behaviors During the First Breastfeed: A Randomized Controlled Study

Objective: Delayed cord clamping (DCC) may increase the success of breastfeeding by improving neurological and cardiovascular function in neonates. In this study, we investigated the impact of DCC on breastfeeding behaviors, neonatal activity status, and maternal satisfaction during the first breastfeeding. Methods: This randomized controlled study was conducted in a tertiary hospital in Turkey with 100 term infants delivered by elective cesarean section with spinal anesthesia. The participants were randomly assigned to the early cord clamping (ECC) group or DCC group. The Infant Breastfeeding Assessment Tool (IBFAT) was used to assess infant alertness, breastfeeding behaviors, and maternal satisfaction with breastfeeding within the first 2 hours of life. Results: Scores on the IBFAT were significantly higher in the DCC group compared with the ECC group (p = 0.02). Maternal satisfaction with breastfeeding did not differ between the groups (p = 0.3). Infant alertness tended to be better in the DCC group, but the difference was not statistically significant (p = 0.08). Conclusion: The results of this study indicated that DCC was associated with more favorable breastfeeding behaviors compared with ECC.

Neonatal Resuscitation: Peculiarities and Challenges

N/a.

Quantitative Lung Ultrasonography to Guide Surfactant Therapy in Neonates Born Late Preterm and Later

Importance

Surfactant administration may be needed in late preterm through full-term neonates, but the pathophysiology of their respiratory failure can be different from that of early preterm neonates. The lung ultrasonography score (LUS) is accurate to guide surfactant replacement in early preterm neonates, but to our knowledge, it has not yet been studied in the late preterm through full-term neonatal population.

Objective

To assess whether LUS is equally accurate to predict surfactant need in late preterm through full-term neonates as in early preterm neonates.

Design, Setting, and Participants

This prospective, international, multicenter diagnostic study was performed between December 2022 and November 2023 in tertiary academic neonatal intensive care units in France, Italy, Spain, and the US. Late preterm through full-term neonates (≥34 weeks' gestation) with respiratory failure early after birth were enrolled.

Exposure

Point-of-care lung ultrasonography to calculate the neonatal LUS (range, 0-18, with higher scores indicating worse aeration), which was registered in dedicated research databases and unavailable for clinical decision-making.

Main Outcomes and Measures

The main outcomes were the area under the curve (AUC) in receiver operating characteristic analysis and derived accuracy variables, considering LUS as a replacement for other tests (ie, highest global accuracy) and as a triage test (ie, highest sensitivity). Sample size was calculated to assess noninferiority of LUS to predict surfactant need in the study population compared with neonates born more prematurely. Correlations of LUS with the ratio of hemoglobin oxygen saturation as measured by pulse oximetry (SpO2) to fraction of inspired oxygen (FiO2) and with the oxygen saturation index (OSI) were assessed.

Results

A total of 157 neonates (96 [61.1%] male) were enrolled and underwent lung ultrasonography at a median of 3 hours (IQR, 2-7 hours) of life; 32 (20.4%) needed surfactant administration (pretest probability, 20%). The AUC was 0.87 (95% CI, 0.81-0.92). The highest global accuracy and sensitivity were reached for LUS values higher than 8 or 4 or lower, respectively. Subgroup analysis gave similar diagnostic accuracy in neonates born late preterm (AUC, 0.89; 95% CI, 0.81-0.97; n = 111) and early term and later (AUC, 0.84; 95% CI, 0.73-0.96; n = 46). After adjusting for gestational age, LUS was significantly correlated with SpO2:FiO2 (adjusted β, -10.4; 95% CI, -14.0 to -6.7; P < .001) and OSI (adjusted β, 0.2; 95% CI, 0.1-0.3; P < .001).

Conclusions and Relevance

In this diagnostic study of late preterm through full-term neonates with respiratory failure early after birth, LUS accuracy to predict surfactant need was not inferior to that observed in earlier preterm neonates. An LUS higher than 8 was associated with highest global accuracy (replacement test), suggesting that it can be used to guide surfactant administration. An LUS value of 4 or lower was associated with the highest sensitivity (triage test), suggesting it is unlikely for this population to need surfactant.

Updated Clinical Practice Guidelines in Resuscitation and the Management of Respiratory Distress Syndrome in Extremely Preterm Infants during Two Epochs in Romania: Impact on Outcomes

BACKGROUND

Adequate perinatal management is essential in caring for extremely preterm (EP) infants. We aimed to evaluate and compare the impact of different protocols on short-term outcomes.

METHODS

A retrospective study was conducted on EP infants in a Romanian perinatal tertiary center during 2008-2012 and 2018-2022.

RESULTS

Data on 270 EP infants (121 in period I, 149 in period II) were analyzed collectively and stratified into two subgroups by gestational age. Initial FiO2 administration (100% vs. 40%% p < 0.001), lung recruitment at birth (19.0% vs. 55.7% p < 0.001), early rescue surfactant administration (34.7% vs. 65.8%; p < 0.001), and the mechanical ventilation rate (98.3% vs. 58.4%; p < 0.001) were significantly improved during period II. Survival rates of EP infants significantly improved from 41.3% to 72.5%, particularly in the 26-28 weeks subgroup (63.8% to 83%). Compared to period I, the overall frequency of severe IVH decreased in period II from 30.6% to 14.1%; also, BPD rates were lower (36.6% vs. 23.4%; p = 0.045) in the 26-28 weeks subgroup. Despite improvements, there were no significant differences in the frequencies of NEC, sepsis, PVL, ROP, or PDA.

CONCLUSIONS

Implementing evidence-based clinical guidelines can improve short-term outcomes.

[Interpretation of 2023 American Heart Association and American Academy of Pediatrics focused update on neonatal resuscitation guidelines]

In November 2023, the American Heart Association and the American Academy of Pediatrics jointly released key updates to the neonatal resuscitation guidelines based on new clinical evidence. This update serves as an important supplement to the "Neonatal resuscitation: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care". The aim of this paper is to outline the key updates and provide guidance on umbilical cord management and the selection of positive pressure ventilation equipment and its additional interfaces in neonatal resuscitation.