Do Sustained Lung Inflations during Neonatal Resuscitation Affect Cerebral Blood Volume in Preterm Infants? A Randomized Controlled Pilot Study

Effect of the change of mechanical ventilation mode on cerebral oxygen saturation level in neonates

BACKGROUND

This study aimed to apply near-infrared spectroscopy (NIRS) to monitor cerebral oxygen saturation (SrO2) level in neonates before and after the change of mechanical ventilation mode, and thus, the effects of the change of mechanical ventilator mode on SrO2 level in neonates were assessed.

METHODS

This trial was designed as an observational study .A total of 70 neonates who were admitted to the Department of Neonatology of Beijing Luhe Hospital Affiliated to Capital Medical University (Beijing, China) between September 2019 and October 2021 and required respiratory support were included. The variations of SrO2 level before and after the change of mechanical ventilation mode, including changing from Synchronized intermittent mandatory ventilation (SIMV) to noninvasive ventilation (NIV, group 1), and from NIV to oxygen inhalation (group 2), were monitored by Enginmed EGOS-600 A. The changes of SrO2 level at 30 min before and 1 h after the change of ventilation mode were compared between the two groups.

RESULTS

The SrO2 level in the group 1 30 min before, as well as 10 min, 30 min, and 1 h after the change of ventilation mode was 62.54 ± 3.36%, 65.43 ± 3.98%, 64.38 ± 4.23%, and 64.63 ± 3.71%, respectively. The SrO2 level at all the points after the change of ventilation mode increased compared with 30 min before the change (P < 0.05). The SrO2 level in the group 2 at each time point was 62.67 ± 4.69%, 64.61 ± 5.00%, 64.04 ± 4.48%, and 64.55 ± 4.32%, respectively. Compared with 30 min before ventilator weaning, the SrO2 level at all the points after ventilator weaning increased (P < 0.05). Peak inspiratory pressure (PIP) excluding Nasal Continuous Positive Airway Pressure (NCPAP)) in group 1 was lower than that before extubation, and the difference was statistically significant (P = 0) (Table 7).

CONCLUSIONS

SrO2 level showed an increasing trend after the change of ventilation mode, and the increase of SrO2 level at 10 min after the change of ventilation mode was the most prominent. From SIMV to NIV, increased SrO2 levels may be associated with decreased PIP.

Interventions to Reduce Severe Brain Injury Risk in Preterm Neonates: A Systematic Review and Meta-analysis

Importance

Interventions to reduce severe brain injury risk are the prime focus in neonatal clinical trials.

Objective

To evaluate multiple perinatal interventions across clinical settings for reducing the risk of severe intraventricular hemorrhage (sIVH) and cystic periventricular leukomalacia (cPVL) in preterm neonates.

Data Sources

MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception until September 8, 2022, using prespecified search terms and no language restrictions.

Study Selection

Randomized clinical trials (RCTs) that evaluated perinatal interventions, chosen a priori, and reported 1 or more outcomes (sIVH, cPVL, and severe brain injury) were included.

Data Extraction and Synthesis

Two co-authors independently extracted the data, assessed the quality of the trials, and evaluated the certainty of the evidence using the Cochrane GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Fixed-effects pairwise meta-analysis was used for data synthesis.

Main Outcomes and Measures

The 3 prespecified outcomes were sIVH, cPVL, and severe brain injury.

Results

A total of 221 RCTs that assessed 44 perinatal interventions (6 antenatal, 6 delivery room, and 32 neonatal) were included. Meta-analysis showed with moderate certainty that antenatal corticosteroids were associated with small reduction in sIVH risk (risk ratio [RR], 0.54 [95% CI, 0.35-0.82]; absolute risk difference [ARD], -1% [95% CI, -2% to 0%]; number needed to treat [NNT], 80 [95% CI, 48-232]), whereas indomethacin prophylaxis was associated with moderate reduction in sIVH risk (RR, 0.64 [95% CI, 0.52-0.79]; ARD, -5% [95% CI, -8% to -3%]; NNT, 20 [95% CI, 13-39]). Similarly, the meta-analysis showed with low certainty that volume-targeted ventilation was associated with large reduction in risk of sIVH (RR, 0.51 [95% CI, 0.36-0.72]; ARD, -9% [95% CI, -13% to -5%]; NNT, 11 [95% CI, 7-23]). Additionally, early erythropoiesis-stimulating agents (RR, 0.68 [95% CI, 0.57-0.83]; ARD, -3% [95% CI, -4% to -1%]; NNT, 34 [95% CI, 22-67]) and prophylactic ethamsylate (RR, 0.68 [95% CI, 0.48-0.97]; ARD, -4% [95% CI, -7% to 0%]; NNT, 26 [95% CI, 13-372]) were associated with moderate reduction in sIVH risk (low certainty). The meta-analysis also showed with low certainty that compared with delayed cord clamping, umbilical cord milking was associated with a moderate increase in sIVH risk (RR, 1.82 [95% CI, 1.03-3.21]; ARD, 3% [95% CI, 0%-6%]; NNT, -30 [95% CI, -368 to -16]).

Conclusions and Relevance

Results of this study suggest that a few interventions, including antenatal corticosteroids and indomethacin prophylaxis, were associated with reduction in sIVH risk (moderate certainty), and volume-targeted ventilation, early erythropoiesis-stimulating agents, and prophylactic ethamsylate were associated with reduction in sIVH risk (low certainty) in preterm neonates. However, clinicians should carefully consider all of the critical factors that may affect applicability in these interventions, including certainty of the evidence, before applying them to clinical practice.

Aeration strategy at birth does not impact carotid haemodynamics in preterm lambs

BACKGROUND

The impact of different respiratory strategies at birth on the preterm lung is well understood; however, concerns have been raised that lung recruitment may impede cerebral haemodynamics. This study aims to examine the effect of three different ventilation strategies on carotid blood flow, carotid artery oxygen content and carotid oxygen delivery.

METHODS

124-127-day gestation apnoeic intubated preterm lambs studied as part of a larger programme primarily assessing lung injury were randomised to positive pressure ventilation with positive end-expiratory pressure (PEEP) 8 cmH2O (No-RM; n = 12), sustained inflation (SI; n = 15) or dynamic PEEP strategy (DynPEEP; maximum PEEP 14 or 20 cmH2O, n = 41) at birth, followed by 90 min of standardised ventilation. Haemodynamic data were continuously recorded, with intermittent arterial blood gas analysis.

RESULTS

Overall carotid blood flow measures were comparable between strategies. Except for mean carotid blood flow that was significantly lower for the SI group compared to the No-RM and DynPEEP groups over the first 3 min (p < 0.0001, mixed effects model). Carotid oxygen content and oxygen delivery were similar between strategies. Maximum PEEP level did not alter cerebral haemodynamic measures.

CONCLUSIONS

Although there were some short-term variations in cerebral haemodynamics between different PEEP strategies and SI, these were not sustained.

IMPACT

Different pressure strategies to facilitate lung aeration at birth in preterm infants have been proposed. There is minimal information on the effect of lung recruitment on cerebral haemodynamics. This is the first study that compares the effect of sustained lung inflation and dynamic and static positive end-expiratory pressure on cerebral haemodynamics. We found that the different ventilation strategies did not alter carotid blood flow, carotid oxygen content or carotid oxygen delivery. This preclinical study provides some reassurance that respiratory strategies designed to focus on lung aeration at birth may not impact cerebral haemodynamics in preterm neonates.

Cerebral oxygenation immediately after birth and long-term outcome in preterm neonates-a retrospective analysis

BACKGROUND

Prematurity is associated with increased risk for morbidity and mortality. Aim of this study was to evaluate whether cerebral oxygenation during fetal-to-neonatal transition period was associated with long-term outcome in very preterm neonates.

METHODS

Preterm neonates ≤ 32 weeks of gestation and/or ≤ 1500 g with measurements of cerebral regional oxygen saturation (crSO₂) and cerebral fractional tissue oxygen extraction (cFTOE) within the first 15 min after birth were analysed retrospectively. Arterial oxygen saturation (SpO₂) and heart rate (HR) were measured with pulse oximetry. Long-term outcome was assessed at two years using "Bayley Scales of Infant Development" (BSID-II/III). Included preterm neonates were stratified into two groups: adverse outcome group (BSID-III ≤ 70 or testing not possible due to severe cognitive impairment or mortality) or favorable outcome group (BSID-III > 70). As the association between gestational age and long-term outcome is well known, correction for gestational age might disguise the potential association between crSO₂ and neurodevelopmental impairment. Therefore, due to an explorative approach the two groups were compared without correction for gestational age.

RESULTS

Forty-two preterm neonates were included: adverse outcome group n = 13; favorable outcome group n = 29. Median(IQR) gestational age and birth weight were 24.8 weeks (24.2-29.8) and 760 g (670-1054) in adverse outcome group and 30.6 weeks (28.1-32.0) (p = 0.009*) and 1250 g (972-1390) (p = 0.001*) in the favorable outcome group, respectively. crSO₂ was lower (significant in 10 out of 14 min) and cFTOE higher in adverse outcome group. There were no difference in SpO₂, HR and fraction of inspired oxygen (FiO₂), except for FiO₂ in minute 11, with higher FiO₂ in the adverse outcome group.

CONCLUSION

Preterm neonates with adverse outcome had beside lower gestational age also a lower crSO₂ during immediate fetal-to-neonatal transition when compared to preterm neonates with age appropriate outcome. Lower gestational age in the adverse outcome group would suggest beside lower crSO₂ also lower SpO₂ and HR in this group, which were however similar in both groups.

Cardiac output and regional-cerebral-oxygen-saturation in preterm neonates during immediate postnatal transition: An observational study

AIM

To examine potential correlations between cardiac output (CO) with cerebral-regional-oxygen-saturation (crSO₂ ) and cerebral-fractional-tissue-oxygen-extraction (cFTOE) during immediate foetal-to-neonatal transition in term and preterm neonates with and without respiratory support.

METHODS

Post hoc analyses of secondary outcome parameters of prospective observational studies were performed. We included neonates with cerebral near-infrared-spectroscopy (NIRS) monitoring and an oscillometric blood pressure measurement at minute 15 after birth. Heart rate (HR) and arterial oxygen saturation (SpO₂ ) were monitored. CO was calculated with Liljestrand and Zander formula and correlated with crSO₂ and cFTOE.

RESULTS

Seventy-nine preterm neonates and 207 term neonates with NIRS measurements and calculated CO were included. In 59 preterm neonates (mean gestational age (GA): 29.4 ± 3.7 weeks) with respiratory support, CO correlated significantly positively with crSO₂ and significantly negatively with cFTOE. In 20 preterm neonates (GA 34.9 ± 1.3 weeks) without respiratory support and in 207 term neonates with and without respiratory support, CO correlated neither with crSO₂ nor with cFTOE.

CONCLUSION

In compromised preterm neonates with lower gestational age and in need of respiratory support, CO was associated with crSO₂ and cFTOE, whereas in stable preterm neonates with higher gestational age as well as in term neonates with and without respiratory support, no associations were observed.

Near-infrared spectroscopy in the medical management of infants

Near-infrared spectroscopy (NIRS) is a technology that is easy to use and can provide helpful information about organ oxygenation and perfusion by measuring regional tissue oxygen saturation (rSO2) with near-infrared light. The sensors can be placed in different anatomical locations to monitor rSO2 levels in several organs. While NIRS is not without limitations, this equipment is now becoming increasingly integrated into modern healthcare practice with the goal of achieving better outcomes for patients. It can be particularly applicable in the monitoring of pediatric patients because of their size, and especially so in infant patients. Infants are ideal for NIRS monitoring as nearly all of their vital organs lie near the skin surface which near-infrared light penetrates through. In addition, infants are a difficult population to evaluate with traditional invasive monitoring techniques that normally rely on the use of larger catheters and maintaining vascular access. Pediatric clinicians can observe rSO2 values in order to gain insight about tissue perfusion, oxygenation, and the metabolic status of their patients. In this way, NIRS can be used in a non-invasive manner to either continuously or periodically check rSO2. Because of these attributes and capabilities, NIRS can be used in various pediatric inpatient settings and on a variety of patients who require monitoring. The primary objective of this review is to provide pediatric clinicians with a general understanding of how NIRS works, to discuss how it currently is being studied and employed, and how NIRS could be increasingly used in the near future, all with a focus on infant management.

Fetal to neonatal transition: what additional information can be provided by cerebral near infrared spectroscopy?

This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by NIRS during fetal to neonatal transition. Cerebral NIRS(cNIRS) offers the possibility of non-invasive, continuous, and objective brain monitoring in addition to the recommended routine monitoring. During the last decade, with growing interest in early and sensitive brain monitoring, many research groups worldwide have been working with cNIRS and verified the feasibility of cNIRS monitoring immediately after birth. Cerebral hypoxia during fetal to neonatal transition, defined as cerebral oxygenation values below10th percentile, seems to have an impact on neurological outcomes. Feasibility to guide clinical support using cNIRS to reduce the burden of cerebral hypoxia has been shown. It is well known that in some cases cerebral oxygenation follows different patterns than SpO2. Cerebral oxygenation does not only depend on systemic oxygenation, hemoglobin content and cerebral blood flow, but also on cardiocirculatory condition, ventilation, and metabolic parameters. Hence, measurement of cerebral oxygenation may uncover problems not detectable by standard monitoring. Therefore, applying NIRS can provide caregivers a more complete clinical overview, especially in critically ill neonates. In this review, we aim to describe the additional information which can be provided by cNIRS during fetal to neonatal transition. IMPACT: This narrative review focuses on the clinical use and relevance of cerebral oxygenation measured by near infrared spectroscopy (NIRS) during fetal to neonatal transition. During the last decade, interest on brain monitoring is growing continuously as the measurement of cerebral oxygenation may uncover problems which are not detectable by routine monitoring. Therefore, it will be crucial to have additional information to get a complete overview, especially in critically ill neonates in need of medical and respiratory support. In this review, we offer additional information which can be provided by cerebral NIRS during fetal to neonatal transition.

Correlation between arterial blood pressures and regional cerebral oxygen saturation in preterm neonates during postnatal transition-an observational study

OBJECTIVE

To assess whether blood pressure (systolic (SABP), diastolic (DABP), and mean arterial blood pressure (MABP) and cerebral-regional-oxygen-saturation (crSO2) and cerebral-fractional-tissue-oxygen-extraction (cFTOE) are associated after immediate fetal-to-neonatal transition in preterm neonates with and without respiratory support.

STUDY DESIGN

Post-hoc analyses of secondary outcome parameters of prospective observational studies were performed. We included moderate and late preterm neonates with and without respiratory support with cerebral NIRS monitoring (INVOS 5100c) and an oscillometric blood pressure measurement at minute 15 after birth. Heart rate (HR) and arterial oxygen saturation (SpO2) were monitored routinely. Blood pressure values were correlated with crSO2 and cFTOE.

RESULTS

47 preterm neonates with NIRS measurements and blood pressure measurement during immediate transition after birth were included. Twenty-five preterm neonates (gestational age: 34.4±1.6 weeks) received respiratory support. In these neonates crSO2 correlated significantly positively with systolic blood pressure (SABP; r = 0.46, p = 0.021), diastolic blood pressure (DABP; r = 0.51, p = 0.009) and, mean arterial pressure (MABP; r = 0.48, p = 0.015). cFTOE correlated significantly negatively with SABP (r = -0.44, p = 0.027), DABP (r = -0.49, p = 0.013) and mean MABP (r = -0.44, p = 0.029). Twenty-two preterm neonates (gestational age: 34.5 ± 1.5 weeks) did not receive respiratory support. In those neonates, neither crSO2 nor cFTOE correlated with blood pressure.

CONCLUSION

In compromised moderate and late preterm neonates with respiratory support, both, crSO2 and cFTOE correlated with blood pressure. These findings suggest that passive pressure-dependent cerebral perfusion was present in preterm neonates with respiratory support, indicating an impaired cerebral autoregulation in those compromised preterm neonates.

Does physiological-based cord clamping improve cerebral tissue oxygenation and perfusion in healthy term neonates? - A randomized controlled trial

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.

Sustained Inflation During Chest Compression: A New Technique of Pediatric Cardiopulmonary Resuscitation That Improves Recovery and Survival in a Pediatric Porcine Model

Background

Chest compression (CC) during sustained inflations (CC+SI) compared with CC with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation in asphyxiated pediatric piglets will reduce time to return of spontaneous circulation (ROSC).

Methods and Results

Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure <25 mm Hg with bradycardia. After cardiac arrest, piglets were randomized to CC+SI (n=12) or CCaV (n=12) or sham (n=8). Sham‐operated animals had no asphyxia. Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded. There were no differences in baseline parameters or the duration and degree of asphyxiation. Median (interquartile range) Time to ROSC was 248 (41–346) seconds compared with 720 (167–720) seconds in the CC+SI group and CCaV group, respectively (P=0.0292). There was a 100% higher rate of ROSC in the CC+SI group versus CCaV group, with 10 (83%) versus 5 (42%) achieving ROSC (P=0.089), respectively. Piglets in the CC+SI and CCaV groups received intravenous epinephrine boluses to achieve ROSC (8/12 versus 10/12 P=0.639). There was a significantly higher minute ventilation in the CC+SI group, which was secondary to a 5‐fold increase in the number of inflations per minute and a 1.5‐fold increase in tidal volume.

Conclusions

CC+SI reduced time to ROSC and improved survival compared with using CCaV. CC+SI allowed passive ventilation of the lung while providing chest compressions. This technique warrants further studies to examine the potential to improve outcomes in pediatric patients with cardiac arrest.

Registration

URL: https://www.preclinicaltrials.eu; Unique identifier: PCTE0000152.

Impact of bradycardia and hypoxemia on oxygenation in preterm infants requiring respiratory support at birth

AIM OF THE STUDY

Analysis of the impact of bradycardia and hypoxemia on the course of cerebral and peripheral oxygenation parameters in preterm infants in need for respiratory support during foetal-to-neonatal transition.

METHODS

The first 15 min after birth of 150 preterm neonates in need for respiratory support born at the Division of Neonatology, Graz (Austria) were analyzed. Infants were divided into different groups according to duration of bradycardia exposure (no Bradycardia, brief bradycardia <2 min, and prolonged bradycardia ≥2 min) and to systemic oxygen saturation (SpO₂) value at 5 min of life (<80% or ≥80%). Analysis was performed considering the degree of bradycardia alone (step 1) and in association with the presence of hypoxemia (step 2).

RESULTS

In step 1, courses of SpO₂ differed significantly between bradycardia groups (p = 0.002), while courses of cerebral regional oxygen saturation (crStO₂) and cerebral fractional tissue oxygen extraction (cFTOE) were not influenced (p = 0.382 and p = 0.878). In step 2, the additional presence of hypoxemia had a significant impact on the courses of SpO₂ (p < 0.001), crStO₂ (p < 0.001) and cFTOE (p = 0.045).

CONCLUSION

Our study shows that the degree of bradycardia has a significant impact on the course of SpO₂ only, but when associated with the additional presence of hypoxemia a significant impact on cerebral oxygenation parameters was seen (crStO₂, cFTOE). Furthermore, the additional presence of hypoxemia has a significant impact on FiO₂ delivered. Our study emphasizes the importance of HR and SpO₂ during neonatal resuscitation, underlining the relevance of hypoxemia during the early transitional phase.

Sustained Lung Inflations During Neonatal Resuscitation at Birth: A Meta-analysis

CONTEXT

The International Liaison Committee on Resuscitation prioritized review of sustained inflation (SI) of the lung at birth.

OBJECTIVE

To complete a systematic review and meta-analysis comparing strategies using 1 or more SI ≥1 second with intermittent inflations <1 second for newborns at birth.

DATA SOURCES

Medline, Embase, and Evidence-Based Medicine Reviews were searched from January 1, 1946, to July 20, 2020.

STUDY SELECTION

Studies were selected by pairs of independent reviewers in 2 stages.

DATA EXTRACTION

Reviewers extracted data, appraised risk of bias, and assessed certainty of evidence for each outcome.

RESULTS

Ten trials enrolling 1502 preterm newborns were included. Five studies included newborns who did not receive assisted ventilation at the outset. There were no differences between SI and control groups for death before discharge or key morbidities. For death within the first 2 days, comparing SI with the controls, risk ratio was 2.42 (95% confidence interval = 1.15-5.09). In subgroup analysis of preterm infants ≤28 + 0 weeks' gestation, for death before discharge, risk ratio was 1.38 (95% confidence interval = 1.00-1.91). Together, these findings suggest the potential for harm of SI.

LIMITATIONS

The certainty of evidence was very low for death in the delivery room and low for all other outcomes.

CONCLUSIONS

In this systematic review, we did not find benefit in using 1 or more SI >5 seconds for preterm infants at birth. SI(s) may increase death before discharge among the subgroup born ≤28 + 0 weeks' gestation. There is insufficient evidence to determine the likely effect of SI(s) on other key morbidities.

2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Sustained inflation: The lung recruitment maneuvers for neonates

Establishing effective respiration is vital in the transition from fetal to neonatal life. Respiratory support mainly facilitates and creates functional residual capacity and maintains adequate gas exchange. Sustained inflation (SI) delivers prolonged inflation and rapidly creates and establishes the functional residual capacity. The use of SI in preterm infants in the delivery room is still controversial. The optimum settings of SI remain unknown. Animal studies and clinical reports have demonstrated the advantages and disadvantages of SI. In this article, the current literature was reviewed to examine the efficacy of SI in infants.

Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.

Sustained Inflation vs Standard Resuscitation for Preterm Infants: A Systematic Review and Meta-analysis

IMPORTANCE

Most preterm infants require respiratory support to establish lung aeration after birth. Intermittent positive pressure ventilation and continuous positive airway pressure are standard therapies. An initial sustained inflation (inflation time >5 seconds) is a widely practiced alternative strategy.

OBJECTIVE

To conduct a systematic review and meta-analysis of sustained inflation vs intermittent positive pressure ventilation and continuous positive airway pressure for the prevention of hospital mortality and morbidity for preterm infants.

DATA SOURCES

MEDLINE (through PubMed), Embase, the Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials were searched through June 24, 2019.

STUDY SELECTION

Randomized clinical trials of preterm infants born at less than 37 weeks' gestation that compared sustained inflation (inflation time >5 seconds) vs standard resuscitation with either intermittent positive pressure ventilation or continuous positive airway pressure were included. Studies including other cointerventions were excluded.

DATA EXTRACTION AND SYNTHESIS

Two reviewers assessed the risk of bias of included studies. Meta-analysis of pooled outcome data used a fixed-effects model specific to rarer events. Subgroups were based on gestational age and study design (rescue vs prophylactic sustained inflation).

MAIN OUTCOMES AND MEASURES

Death before hospital discharge.

RESULTS

Nine studies recruiting 1406 infants met inclusion criteria. Death before hospital discharge occurred in 85 of 736 infants (11.5%) treated with sustained inflation and 62 of 670 infants (9.3%) who received standard therapy for a risk difference of 3.6% (95% CI, -0.7% to 7.9%). Although analysis of the primary outcome identified important heterogeneity based on gestational age subgroups, the 95% CI for the risk difference included 0 for each individual gestational age subgroup. There was no difference in the primary outcome between subgroups based on study design. Sustained inflation was associated with increased risk of death in the first 2 days after birth (risk difference, 3.1%; 95% CI, 0.9%-5.3%). No differences in the risk of other secondary outcomes were identified. The quality-of-evidence assessment was low owing to risk of bias and imprecision.

CONCLUSIONS AND RELEVANCE

There was no difference in the risk of the primary outcome of death before hospital discharge, and there was no evidence of efficacy for sustained inflation to prevent secondary outcomes. These findings do not support the routine use of sustained inflation for preterm infants after birth.

Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes

BACKGROUND

At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable gas exchange. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs.

OBJECTIVES

To assess the benefits and harms of an initial sustained lung inflation (SLI) (> 1 second duration) versus standard inflations (≤ 1 second) in newborn infants receiving resuscitation with intermittent PPV.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3), MEDLINE via PubMed (1966 to 1 April 2019), Embase (1980 to 1 April 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 1 April 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean standard deviation (SD), and weighted mean difference (WMD) for continuous data. We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

Ten trials enrolling 1467 infants met our inclusion criteria. Investigators in nine trials (1458 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review: mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40 (I² not applicable); typical RD 0.00, 95% CI -0.02 to 0.02; I² = 0%; 5 studies, 479 participants); and mortality during hospitalisation (typical RR 1.09, 95% CI 0.83 to 1.43; I² = 42%; typical RD 0.01, 95% CI -0.02 to 0.04; I² = 24%; 9 studies, 1458 participants). The quality of the evidence was low for death in the delivery room because of limitations in study design and imprecision of estimates (only one death was recorded across studies). For death before discharge the quality was moderate: with longer follow-up there were more deaths (n = 143) but limitations in study design remained. Among secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; I² = 95%; 5 studies, 524 participants; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study at high risk of bias: when this study was removed from the analysis, the size of the effect was reduced (MD -1.71 days, 95% CI -3.04 to -0.39; I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. risk of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.91, 95% CI 0.79 to 1.04; I² = 65%; 5 studies, 811 participants); risk of surfactant administration during hospital admission (typical RR 0.99, 95% CI 0.91 to 1.08; I² = 0%; 9 studies, 1458 participants); risk of chronic lung disease (typical RR 0.99, 95% CI 0.83 to 1.18; I² = 0%; 4 studies, 735 participants); pneumothorax (typical RR 0.89, 95% CI 0.57 to 1.40; I² = 34%; 8 studies, 1377 infants); or risk of patent ductus arteriosus requiring pharmacological treatment (typical RR 0.99, 95% CI 0.87 to 1.12; I² = 48%; 7 studies, 1127 infants). The quality of evidence for these secondary outcomes was moderate (limitations in study design ‒ GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates ‒ GRADE). We could not perform any meta-analysis in the comparison of the use of initial sustained inflation versus standard inflations in newborns receiving resuscitation with chest compressions because we identified only one trial for inclusion (a pilot study of nine preterm infants).

AUTHORS' CONCLUSIONS

Our meta-analysis of nine studies shows that sustained lung inflation without chest compression was not better than intermittent ventilation for reducing mortality in the delivery room (low-quality evidence ‒ GRADE) or during hospitalisation (moderate-quality evidence ‒ GRADE), which were the primary outcomes of this review. However, the single largest study, which was well conducted and had the greatest number of enrolled infants, was stopped early for higher mortality rate in the sustained inflation group. When considering secondary outcomes, such as rate of intubation, rate or duration of respiratory support, or bronchopulmonary dysplasia, we found no benefit of sustained inflation over intermittent ventilation (moderate-quality evidence ‒ GRADE). Duration of mechanical ventilation was shortened in the SLI group (low-quality evidence ‒ GRADE); this result should be interpreted cautiously, however, as it might have been influenced by study characteristics other than the intervention. There is no evidence to support the use of sustained inflation based on evidence from our review.

[Application of sustained lung inflation in preterm infants with a gestational age of <34 weeks: a Meta analysis]

OBJECTIVE

To systematically review the effect of sustained lung inflation (SLI) in preterm infants with a gestational age of <34 weeks.

METHODS

PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, China Biology Medicine disc, Chinese Journal Full-text Database, and Weipu Database were searched for randomized controlled trials (RCTs) on the application of SLI versus noninvasive positive pressure ventilation alone in preterm infants. Revman 5.3 was used to perform a Meta analysis for the RCTs which met the inclusion criteria.

RESULTS

A total of 9 RCTs were included, with 1 432 preterm infants in total (with a gestational age of 23-33.7 weeks). The Meta analysis showed that compared with the control group, the SLI group had a significantly lower proportion of the infants who needed mechanical ventilation within 72 hours (51.9% vs 56.9%, RR=0.91, P=0.04, 95%CI: 0.83-0.99). There were no significant differences between the two groups in the mortality rate, rate of use of pulmonary surfactant, and incidence rates of related complications (bronchopulmonary dysplasia, pneumothorax, and grade III-IV intracranial hemorrhage) (P>0.05).

CONCLUSIONS

SLI can reduce the use of mechanical ventilation in preterm infants with a gestational age of <34 weeks and does not increase the risk of other complications.

Improving Newborn Respiratory Outcomes With a Sustained Inflation: A Systematic Narrative Review of Factors Regulating Outcome in Animal and Clinical Studies

Respiratory support is critically important for survival of newborns who fail to breathe spontaneously at birth. Although there is no internationally accepted definition of a sustained inflation (SI), it has commonly been defined as a positive pressure inflation designed to establish functional residual capacity and applied over a longer time period than normally used in standard respiratory support (SRS). Outcomes vary distinctly between studies and to date there has been no comprehensive investigation of differences in SI approach and study outcome in both pre-clinical and clinical studies. A systematic literature search was performed and, after screening, identified 17 animal studies and 17 clinical studies evaluating use of a SI in newborns compared to SRS during neonatal resuscitation. Study demographics including gestational age, SI parameters (length, repetitions, pressure, method of delivery) and study outcomes were compared. Animal studies provide mechanistic understanding of a SI on the physiology underpinning the cardiorespiratory transition at birth. In clinical studies, there is considerable difference in study quality, delivery of SIs (number, pressure, length) and timing of primary outcome evaluation which limits direct comparison between studies. The largest difference is method of delivery, where the role of a SI has been observed in intubated animals, as the inflation pressure is directly applied to the lung, bypassing the obstructed upper airway in an apnoeic state. This highlights a potential limitation in clinical use of a SI applied non-invasively. Further research is required to identify if a SI may have greater benefits in subpopulations of newborns.

Effect of Intrauterine Growth Restriction on Cerebral Regional Oxygen Saturation in Preterm and Term Neonates during Immediate Postnatal Transition

BACKGROUND

Intrauterine growth restriction (IUGR) is associated with adverse perinatal outcome. Affected fetuses commonly display typical blood flow redistribution towards the brain ("brain sparing"). Accordingly, increased cerebral oxygen saturation has been observed in IUGR neonates within the first days of life.

AIM

The aim of our study was to assess cerebral oxygenation behavior during immediate neonatal transition in IUGR infants.

METHODS

This is a retrospective single-center observational cohort study. Cerebral regional oxygen saturation (crSO2) was measured with near-infrared spectroscopy in neonates during the first 15 min after birth. Neonates with IUGR (IUGR group) were matched for gestational age (±1 week) and gender with neonates that were appropriate for gestational age (AGA). The AGA:IUGR matching ratio was 3:1. Arterial oxygen saturation (SpO2), heart rate (HR), crSO2, and cerebral fractional tissue oxygen extraction (cFTOE) were compared between the groups.

RESULTS

Between August 2010 and October 2017, 45 neonates with IUGR were identified and matched to 135 AGA neonates. Mean gestational age was 33.1 ± 3.0 weeks in the IUGR group and 33.5 ± 2.7 weeks in the AGA group. Mean birth weight was 1,559 ± 582 g in the IUGR group and 2,051 ± 679 g in the AGA group. There was a significant group difference in crSO2 beginning at 5 min and continuing for the rest of the observation time with higher crSO2 values in the IUGR group (main effect group: p = 0.011; interaction time × group: p = 0.039). In cFTOE, a significant difference could be observed at 5-9 and 11-13 min with lower rates of oxygen extraction in the IUGR group (main effect group: p = 0.025; interaction time × group: p = 0.463). Concerning SpO2 and HR, there was no significant difference between the IUGR and the AGA neonates.

CONCLUSION

Neonates of the IUGR group did show significantly higher crSO2 values and significantly lower cFTOE values already during immediate neonatal transition compared to the AGA group.

Effect of Sustained Inflations vs Intermittent Positive Pressure Ventilation on Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants: The SAIL Randomized Clinical Trial

IMPORTANCE

Preterm infants must establish regular respirations at delivery. Sustained inflations may establish lung volume faster than short inflations.

OBJECTIVE

To determine whether a ventilation strategy including sustained inflations, compared with standard intermittent positive pressure ventilation, reduces bronchopulmonary dysplasia (BPD) or death at 36 weeks' postmenstrual age without harm in extremely preterm infants.

DESIGN, SETTING, AND PARTICIPANTS

Unmasked, randomized clinical trial (August 2014 to September 2017, with follow-up to February 15, 2018) conducted in 18 neonatal intensive care units in 9 countries. Preterm infants 23 to 26 weeks' gestational age requiring resuscitation with inadequate respiratory effort or bradycardia were enrolled. Planned enrollment was 600 infants. The trial was stopped after enrolling 426 infants, following a prespecified review of adverse outcomes.

INTERVENTIONS

The experimental intervention was up to 2 sustained inflations at maximal peak pressure of 25 cm H2O for 15 seconds using a T-piece and mask (n = 215); standard resuscitation was intermittent positive pressure ventilation (n = 211).

MAIN OUTCOME AND MEASURES

The primary outcome was the rate of BPD or death at 36 weeks' postmenstrual age. There were 27 prespecified secondary efficacy outcomes and 7 safety outcomes, including death at less than 48 hours.

RESULTS

Among 460 infants randomized (mean [SD] gestational age, 25.30 [0.97] weeks; 50.2% female), 426 infants (92.6%) completed the trial. In the sustained inflation group, 137 infants (63.7%) died or survived with BPD vs 125 infants (59.2%) in the standard resuscitation group (adjusted risk difference [aRD], 4.7% [95% CI, -3.8% to 13.1%]; P = .29). Death at less than 48 hours of age occurred in 16 infants (7.4%) in the sustained inflation group vs 3 infants (1.4%) in the standard resuscitation group (aRD, 5.6% [95% CI, 2.1% to 9.1%]; P = .002). Blinded adjudication detected an imbalance of rates of early death possibly attributable to resuscitation (sustained inflation: 11/16; standard resuscitation: 1/3). Of 27 secondary efficacy outcomes assessed by 36 weeks' postmenstrual age, 26 showed no significant difference between groups.

CONCLUSIONS AND RELEVANCE

Among extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks' postmenstrual age. These findings do not support the use of ventilation with sustained inflations among extremely preterm infants, although early termination of the trial limits definitive conclusions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02139800.

Oxygen Saturation Targeting During Delivery Room Stabilization: What Does This Mean for Regional Cerebral Oxygenation?

Objective: To investigate if preterm neonates with arterial oxygen saturation (SpO₂)<80% at 5 min after birth show different regional cerebral tissue oxygen saturation (rcStO₂), compared to infants reaching the target. Methods: Retrospective analysis of four prospective observational studies. Preterm neonates needing respiratory support during delivery room stabilization were included. Regional cerebral tissue oxygen saturation was measured with near-infrared spectroscopy (NIRS) during the first 15 min after birth along with SpO₂ and heart rate (HR). Neonates were divided into two groups: those with a 5-min SpO₂ ≥ 80% ("≥80% group") and those with a 5-min SpO₂ < 80% ("<80% group"). Groups were compared regarding rcStO₂, SpO₂, and HR. Furthermore, we analyzed whether a 5-min SpO₂ < 80% was associated with a rcStO₂ below the 10th percentile at the same time point. Results: 146 neonates were included, with 68 (47%) in the "≥80% group" and 78 (53%) in the "<80% group." Neonates in the " <80% group" had a significantly lower rcStO₂ (p < 0.001). Furthermore, 80.3% of neonates in the " <80% group" and 23.4% in the "≥80% group" had rcStO₂ values below the 10th percentile at 5 min (p < 0.001). HR was significantly lower at minute 3 and 4 in the " <80% group" (p < 0.002). Conclusion: Preterm infants needing respiratory support, who do not reach the SpO₂ target of 80% at 5 min after birth, show significantly diminished rcStO₂ values compared to neonates reaching the target.

Neuroinflammation in preterm babies and autism spectrum disorders

Genetic anomalies have a role in autism spectrum disorders (ASD). Each genetic factor is responsible for a small fraction of cases. Environment factors, like preterm delivery, have an important role in ASD. Preterm infants have a 10-fold higher risk of developing ASD. Preterm birth is often associated with maternal/fetal inflammation, leading to a fetal/neonatal inflammatory syndrome. There are demonstrated experimental links between fetal inflammation and the later development of behavioral symptoms consistent with ASD. Preterm infants have deficits in connectivity. Most ASD genes encode synaptic proteins, suggesting that ASD are connectivity pathologies. Microglia are essential for normal synaptogenesis. Microglia are diverted from homeostatic functions towards inflammatory phenotypes during perinatal inflammation, impairing synaptogenesis. Preterm infants with ASD have a different phenotype from term born peers. Our original hypothesis is that exposure to inflammation in preterm infants, combined with at risk genetic background, deregulates brain development leading to ASD.

Tactile stimulation during neonatal transition and its effect on vital parameters in neonates during neonatal transition

AIM

This study analysed tactile stimulation during neonatal transition and resuscitation in preterm and term neonates born by Caesarean delivery. It examined the frequency, location and body region, duration and possible effects of stimulation on heart rate and arterial oxygen saturation (SpO₂ ).

METHODS

Two independent investigators analysed video recordings of tactile stimulation on term and preterm neonates during neonatal transition from January 2012 to December 2014. They were recorded during a prospective observational study and randomised controlled trial at a tertiary centre, the Medical University of Graz, Austria. SpO₂ and heart rate were continuously recorded. Data on the frequency, body region and duration of stimulation were collected. To investigate the possible effects of stimulation, SpO₂ and heart rate were compared before and after stimulation.

RESULTS

Term infants received tactile stimulation more than once, and it tended to start later, last longer and be applied in more locations than in preterm infants. Only preterm infants showed a significant increase in SpO₂ after stimulation and heart rates did not show any significant changes in either group.

CONCLUSION

Tactile stimulation was applied in different ways to preterm and term infants during neonatal transition and SpO₂ showed a significant increase in preterm infants.

Applications of near infrared spectroscopy in the neonate

PURPOSE OF REVIEW

There has been a significant increase in the utilization of NIRS in neonatal care over the last few years, with some centers now routinely utilizing this monitoring technique for direct intervention at the bedside. In this review, we provide a summary of the most up-to-date evidence on near infrared spectroscopy utilization, with particular emphasis on measurement of cerebral oxygenation in preterm infants.

RECENT FINDINGS

There have been significant advances in the technology, leading to an increase in the number of available devices and in the use of this monitoring tool to reduce cerebral injury in preterm infants. The role of NIRS in assessing cerebral autoregulation in preterm and term infants, in evaluating somatic oxygenation, and in the management of newborns with hypoxic ischaemic encephalopathy is discussed.

SUMMARY

Two recent pilot randomized controlled trials highlight the potential of cerebral oxygenation monitoring to direct management in the delivery room and the neonatal intensive care unit. However, we urge caution against routine use and await the results of further studies in this area before considering this type of monitoring as standard of care.

Cerebral Blood Volume During Neonatal Transition in Term and Preterm Infants With and Without Respiratory Support

Background: Recently, we demonstrated that in healthy newborn infants cerebral blood volume (CBV) was decreasing continuously after birth. We hypothesized that this was due to the increase in oxygen delivery to the brain during neonatal transition. Thus delayed cerebral oxygen delivery in infants in need for respiratory support (RS) during postnatal stabilization might influence changes in CBV. Objective: Aim of the study was to evaluate transitional changes in CBV immediately after birth in term and preterm infants with and without need of RS. Methods: We performed a post-hoc analysis of data collected as primary and secondary outcome parameters in prospective observational studies and randomized controlled trials at the Medical University of Graz (Austria). NIRS measurements by using "NIRO 200-NX" (Hamamatsu, Japan) were carried out over the first 15 min after birth in term and preterm infants delivered by cesarean section with and without requirement for RS. Results: In 204 neonates, we observed a significant decrease in CBV within the first 15 min after birth (p < 0.001) with a trend toward smaller ΔCBV in neonates receiving RS (p = 0.097) compared to neonates without RS. Differences of ΔCBV between groups reached statistically significance (p < 0.05) at minutes 2, 6, and 7, and showed a trend (p < 0.1) at minutes 3, 4, and 5. After adjusting for gestational age, these differences became smaller and failed to reach significance. Conclusions: We observed a significant decrease of CBV in term and preterm infants with and without RS. Interestingly, ΔCBV was smaller in the first 7 min in neonates with RS reaching statistically significance (p < 0.05) at minutes 2, 6, and 7. This study cannot differentiate, whether RS itself or the condition leading to requirement for RS is responsible for the observed CBV behavior.

Sustained inflations versus UK standard inflations during initial resuscitation of prematurely born infants in the delivery room: a study protocol for a randomised controlled trial

BACKGROUND

Many infants born at less than 34 weeks of gestational age will require resuscitation in the delivery suite. Yet, different resuscitation techniques are specified in different national guidelines, likely reflecting a limited evidence base. One difference is the length of mechanical inflation initially delivered to infants either via a facemask or endotracheal tube. Some guidelines specify short inflations delivered at rates of 40-60/min, others recommend initial inflations lasting 2-3 s or sustained inflations lasting for ≥ 5 s for initial resuscitation. Research has shown that tidal volumes > 2.2 mL/kg (the anatomical dead space) are seldom generated unless the infant's respiratory effort coincides with an inflation (active inflation). When inflations lasting 1-3 s were used, the time to the first active inflation was inversely proportional to the inflation time. This trial investigates whether a sustained inflation or repeated shorter inflations is more effective in stimulating the first active inflation.

METHODS

This non-blinded, randomised controlled trial performed at a single tertiary neonatal unit is recruiting 40 infants born at < 34 weeks of gestational age. A 15-s sustained inflation is being compared to five repeated inflations of 2-3 s during the resuscitation at delivery. A respiratory function monitor is used to record airway pressure, flow, expiratory tidal volume and end tidal carbon dioxide (ETCO₂) levels. The study is performed as emergency research without prior consent and was approved by the NHS London-Riverside Research Ethics Committee. The primary outcome is the minute volume in the first minute of resuscitation with secondary outcomes of the time to the first active inflation and ETCO₂ level during the first minute of recorded resuscitation.

DISCUSSION

This is the first study to compare a sustained inflation to the current UK practice of five initial inflations of 2-3 s.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02967562 . Registered on 15 November 2016.

Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes

BACKGROUND

At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable effective breathing. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs.

OBJECTIVES

To assess the efficacy of an initial sustained (> 1 second duration) lung inflation versus standard inflations (≤ 1 second) in newly born infants receiving resuscitation with intermittent PPV.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1), MEDLINE via PubMed (1966 to 17 February 2017), Embase (1980 to 17 February 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 17 February 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and weighted mean difference (WMD) for continuous data. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

MAIN RESULTS

Eight trials enrolling 941 infants met our inclusion criteria. Investigators in seven trials (932 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review - mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40; participants = 479; studies = 5; I² not applicable) and mortality during hospitalisation (typical RR 1.01, 95% CI 0.67 to 1.51; participants = 932; studies = 7; I² = 19%); the quality of the evidence was low for death in the delivery room (limitations in study design and imprecision of estimates) and was moderate for death before discharge (limitations in study design of most included trials). Amongst secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; participants = 524; studies = 5; I² = 95%; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study: When this study was removed from the analysis, the effect was largely reduced (MD -1.71 days, 95% CI -3.04 to -0.39, I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. rate of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.93, 95% CI 0.79 to 1.09; participants = 811; studies = 5; I² = 0%); need for surfactant administration during hospital admission (typical RR 0.97, 95% CI 0.86 to 1.10; participants = 932; studies = 7; I² = 0%); rate of chronic lung disease (typical RR 0.95, 95% CI 0.74 to 1.22; participants = 683; studies = 5; I² = 47%); pneumothorax (typical RR 1.44, 95% CI 0.76 to 2.72; studies = 6, 851 infants; I² = 26%); or rate of patent ductus arteriosus requiring pharmacological treatment (typical RR 1.08, 95% CI 0.90 to 1.30; studies = 6, 745 infants; I² = 36%). The quality of evidence for these secondary outcomes was moderate (limitations in study design of most included trials - GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates - GRADE).

AUTHORS' CONCLUSIONS

Sustained inflation was not better than intermittent ventilation for reducing mortality in the delivery room and during hospitalisation. The number of events across trials was limited, so differences cannot be excluded. When considering secondary outcomes, such as need for intubation, need for or duration of respiratory support, or bronchopulmonary dysplasia, we found no evidence of relevant benefit for sustained inflation over intermittent ventilation. The duration of mechanical ventilation was shortened in the SLI group. This result should be interpreted cautiously, as it can be influenced by study characteristics other than the intervention. Future RCTs should aim to enrol infants who are at higher risk of morbidity and mortality, should stratify participants by gestational age, and should provide more detailed monitoring of the procedure, including measurements of lung volume and presence of apnoea before or during the SLI.

Lung-protective ventilatory strategies in intubated preterm neonates with RDS

This article provides a narrative review of lung-protective ventilatory strategies (LPVS) in intubated preterm infants with RDS. A description of strategies is followed by results on short-and long-term respiratory and neurodevelopmental outcomes. Strategies will include patient-triggered or synchronized ventilation, volume targeted ventilation, the technique of intubation, surfactant administration and rapid extubation to NCPAP (INSURE), the open lung concept, strategies of high-frequency ventilation, and permissive hypercapnia. Based on this review single recommendations on optimal LPVS cannot be made. Combinations of several strategies, individually applied, most probably minimize or avoid potential serious respiratory and cerebral complications like bronchopulmonary dysplasia and cerebral palsy.

Cerebral Tissue Oxygenation during Immediate Neonatal Transition and Resuscitation

This article provides a review of cerebral tissue oxygenation during immediate transition after birth in human neonates. Recommended routine monitoring, especially if resuscitation is needed, during this period includes arterial oxygen saturation and heart rate measured by pulse oximetry and electrocardiogram. However, there is increasing interest to monitor in addition with near-infrared spectroscopy (NIRS) the oxygenation of the brain. There is a different pattern of increase between cerebral tissue oxygenation and arterial oxygen saturation during the immediate transition, with cerebral tissue oxygenation reaching a plateau faster than arterial oxygen saturation. Differences can be explained, since cerebral tissue oxygenation is not only affected by arterial oxygen saturation but also by cerebral blood flow, hemoglobin content, and cerebral oxygen consumption. Normal values have already been established for different devices, gestational ages, and modes of delivery in neonates without any medical support. Cerebral hypoxia during immediate transition might cause brain damage. In preterm neonates with cerebral hemorrhage evolving in the first week after birth, the cerebral tissue oxygenation is already lower in the first minutes after birth compared to preterm neonates without cerebral hemorrhage. Using cerebral NIRS in combination with intervention guidelines has been shown to reduce the burden of cerebral hypoxia in preterm neonates. Cerebral tissue oxygenation during immediate transition seems to have an impact on outcome, whereby NIRS monitoring is feasible and has the advantage of continuous, non-invasive recording. The impact of NIRS monitoring and interventions on short- and long-term outcomes still need to be evaluated.

Peripheral Intravenous Access in Preterm Neonates during Postnatal Stabilization: Feasibility and Safety

BACKGROUND

Current European Guideline for resuscitation recommends a centrally positioned umbilical venous catheter as the best option for administering necessary drugs. Especially in preterm infants, a frequently used alternative is the peripheral venous catheter.

METHODS

Two randomized controlled studies were conducted at the Division of Neonatology, Medical University of Graz. During neonatal resuscitation, a standardized protocol was filled out by an uninvolved observer including time points after birth of all attempts of venous puncture, time point of successful venous puncture, and total number of needed attempts. Arterial oxygen saturation (SpO₂) and heart rate (HR) were measured using pulse oximetry at the right hand/wrist. In each neonate, either NIRO 200NX (Hamamatsu, Japan) or INVOS 5100C (Covidien-Medtronic, USA) were used to measure cerebral tissue oxygenation index (cTOI) and cerebral regional oxygen saturation (crSO₂), respectively. SpO₂, HR, and cTOI/crSO₂ during and 1 min before and after successful venous punctures were analyzed.

RESULTS

70 protocols were reviewed. Data of 61 preterm neonates were analyzed. Mean gestational age was 31.5 ± 2.2 weeks, and the mean birth weight was 1,527 ± 541 g. In median, it needed one attempt [interquartile range (IQR) 1-2] to establish a peripheral venous catheter. In median, intravenous (IV) catheterization was successfully established 5 (IQR 4-9) min after birth. SpO₂ and cTOI/crSO₂ rose significantly following the percentiles during the first 10 min after the birth. HR did not change significantly.

CONCLUSION

Peripheral IV catheterization during postnatal stabilization of preterm infants is feasible and successful in most of the cases at first attempt.

Sustained Lung Inflation: Physiology and Practice

Lung aeration is the most critical task newborns must accomplish after birth. Almost all extremely preterm infants require respiratory support during this process, but the best method to promote lung aeration in preterm infants is unknown. The current standard practice is intermittent positive pressure ventilation with positive end-expiratory pressure. Sustained inflation is a promising alternative strategy for lung liquid clearance and aeration. Here we review the physiologic rationale for sustained inflation and the available clinical evidence for sustained inflation in preterm infants.

Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room

Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization.