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Ikels AK, Herting E, Stichtenoth G. Higher awakening threshold of preterm infants in prone position may be a risk factor for SIDS. Acta Paediatr 2024; 113:1562-1568. [PMID: 38469704 DOI: 10.1111/apa.17194] [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: 10/23/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024]
Abstract
AIM The supine sleeping position in the prevention of sudden infant death syndrome in preterm infants is poorly understood. We aimed to investigate the effect of sleep posture on cardiorespiratory parameters and movement patterns in preterm infants close to discharge. METHODS This observational study included neonates born in 2022 at the University Hospital Schleswig-Holstein, Lübeck, Germany. Motion sensor data, heart rate, respiratory rate and oxygen saturation were recorded for infants with postconceptional age 35-37 weeks during sleep in the prone and supine positions. RESULTS We recorded data from 50 infants, born at 31 (24-35) weeks of gestation (mean(range)), aged 5.2 ± 3.7 weeks (mean ± SD), of whom 48% were female. Five typical movement patterns were identified. In the prone position, the percentage of calm, regular breathing was higher and active movement was less frequent when compared to the supine position. The percentage of calm irregular breathing, number of apnoeas, bradycardias, desaturations and vital sign changes were not influenced by position. CONCLUSION The prone position seems to be associated with a higher arousal threshold. The supine position appears advantageous for escape from life-threatening situations such as sudden infant death syndrome.
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Affiliation(s)
| | - Egbert Herting
- Department of Paediatrics, University of Lübeck, Lubeck, Germany
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2
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Patterson H, Eady J, Sommerfield A, Sommerfield D, Hauser N, von Ungern-Sternberg BS. Patient positioning and its impact on perioperative outcomes in children: A narrative review. Paediatr Anaesth 2024; 34:507-518. [PMID: 38546348 DOI: 10.1111/pan.14883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 05/12/2024]
Abstract
Patient positioning interacts with a number of body systems and can impact clinically important perioperative outcomes. In this educational review, we present the available evidence on the impact that patient positioning can have in the pediatric perioperative setting. A literature search was conducted using search terms that focused on pediatric perioperative outcomes prioritized by contemporary research in this area. Several key themes were identified: the effects of positioning on respiratory outcomes, cardiovascular outcomes, enteral function, patient and carer-centered outcomes, and soft issue injuries. We encountered considerable heterogeneity in research in this area. There may be a role for lateral positioning to reduce respiratory adverse outcomes, head elevation for intubation and improved oxygenation, and upright positioning to reduce peri-procedural anxiety.
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Affiliation(s)
- Heather Patterson
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Jonathan Eady
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Department of Anaesthesia, Antrim Area Hospital, Northern Health and Social Care Trust, Antrim, UK
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
- Institute for Paediatric Perioperative Excellence, The University of Western Australia, Perth, Westren Australia, Australia
- Perioperative Care Program, Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Perth, Western Australia, Australia
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3
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Loi B, Regiroli G, Foligno S, Centorrino R, Yousef N, Vedovelli L, De Luca D. Respiratory and haemodynamic effects of 6h-pronation in neonates recovering from respiratory distress syndrome, or affected by acute respiratory distress syndrome or evolving bronchopulmonary dysplasia: a prospective, physiological, crossover, controlled cohort study. EClinicalMedicine 2023; 55:101791. [PMID: 36712892 PMCID: PMC9874350 DOI: 10.1016/j.eclinm.2022.101791] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pronation ameliorates oxygenation in adults with acute respiratory distress syndrome (ARDS); the effect in neonates with ARDS or other types of respiratory failure is unknown. We aimed to verify if pronation has similar respiratory and haemodynamic effects in three common types of neonatal respiratory failure. METHODS Prospective, physiologic, crossover, quasi-randomised, controlled cohort study performed in a tertiary academic neonatal intensive care unit. We enrolled neonates with: 1) recovering respiratory distress syndrome (RDS, mild restrictive pattern); 2) neonatal ARDS (NARDS, severe restrictive pattern); or 3) evolving bronchopulmonary dysplasia (BPD), that is chronic pulmonary insufficiency of prematurity (mixed restrictive/obstructive pattern). Neonates with other lung disorders, malformations or haemodynamic impairment were excluded. Patients were started prone or supine and then shifted to the alternate position for 6h; measurements were performed after 30' of "wash out" from the positioning and at the end of 6h period. Primary outcomes were respiratory (PtcCO2, modified ventilatory index, PtcO2/FiO2, SpO2/FiO2, oxygenation index, ultrasound-assessed lung aeration) and haemodynamic (perfusion index, heart rate, arterial pressure, cardiac output) parameters. FINDINGS Between May 1st, 2019, and May 31st, 2021, 161 participants were enrolled in this study, and included in the final analysis. Pronation improved gas exchange and lung aeration (p always <0.01) and these effects were overturned in the alternate position, except for lung aeration in NARDS where the improvement persisted. The effects were greater in patients recovering from RDS than in those with evolving BPD than in those with NARDS, in this order (p always <0.01). Pronation produced a net recruitment as lung ultrasound score decreased in patients shifted from supine (16.9 (standard deviation: 5.8)) to prone (14.1 (standard deviation: 3.3), p < 0.01) and this reduction correlated with oxygenation improvement. Haemodynamic parameters remained within normal ranges. INTERPRETATION 6h-pronation can be used to improve gas exchange and lung aeration in neonates with recovering RDS, evolving BPD or NARDS without relevant haemodynamic effects. FUNDING None.
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Affiliation(s)
- Barbara Loi
- Division of Paediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Giulia Regiroli
- Division of Paediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
| | - Silvia Foligno
- Division of Paediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
| | - Roberta Centorrino
- Division of Paediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
| | - Nadya Yousef
- Division of Paediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
| | - Luca Vedovelli
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padova, Padova, Italy
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, Paris Saclay University Hospitals, APHP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
- Corresponding author. Service de Pédiatrie et Réanimation Néonatale, Hôpital “A. Béclère”- APHP Université Paris Saclay, 157 rue de la Porte de Trivaux, 92140 Clamart (Paris-IDF), France.
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4
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Richmond CM, Ring F, Richmond L, Rossouw E, Ballard E, Birch P. 'Propped and prone' positioning reduces respiratory events in spontaneously breathing preterm infants: A randomised triple crossover study. J Paediatr Child Health 2023; 59:81-88. [PMID: 36314399 PMCID: PMC10092656 DOI: 10.1111/jpc.16241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/02/2022] [Accepted: 09/26/2022] [Indexed: 11/07/2022]
Abstract
AIM We compared effects of infant positioning and feed-rate interventions on respiratory events and oximetry parameters in spontaneously breathing preterm infants born <32 weeks gestation managed in a neonatal unit. METHODS A randomised triple crossover design was employed. n = 68 infants underwent three test conditions A: control (supine/flat, gravity bolus feeds), B: position intervention (propped/prone) and C: feed-rate intervention (continuous pump feeds) in randomised sequence over three consecutive days. Primary outcomes were number of events (apnoea, bradycardia and desaturation) and percentage time SpO2 < 80% over 24 h. The secondary outcome was percentage time SpO2 ≥ 88%. Treatment effects were estimated using linear mixed-effects models. RESULTS Propped/prone positioning significantly reduced events and improved percentage time SpO2 < 80% and ≥88% compared to both other conditions (all P < 0.001). Outcomes for the feed-rate intervention were not significantly different to control. CONCLUSIONS Alternative infant positioning should be considered in preterm infants managed in the neonatal unit.
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Affiliation(s)
- Christopher M Richmond
- Newborn Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Genetic Health Queensland, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Gold Coast, Queensland, Australia
| | - Fabian Ring
- Newborn Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Lacey Richmond
- Newborn Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,School of Nursing & Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
| | - Erika Rossouw
- Newborn Care Unit, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Emma Ballard
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia.,School of Nursing Midwifery and Social Work, University of Queensland, Brisbane, Queensland, Australia
| | - Pita Birch
- Department of Neonatology, Mater Mother's Hospitals, South Brisbane, Queensland, Australia
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5
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Castro ES, Bacil LF, Almeida FDLD, Andreazza MG, Alves RA, Valderramas SR. Premature newborn positionings and physiologic parameters – a randomized clinical study. FISIOTERAPIA EM MOVIMENTO 2023. [DOI: 10.1590/fm.2023.36102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Abstract Introduction Multiple studies have shown the effects of prone (PP), supine (SP) and kangaroo (KP) positions on clinical and physiological outcomes in preterm newborns, but none compared these three types of positioning between them. Objective To investigate the influence of these positionings on heart rate, respiratory rate, peripheral oxygen saturation (SpO2) and alertness status in clinically stable preterm newborns (NBs) admitted to a neonatal intensive care unit. Methods In a randomized clinical trial, clinically stable NBs with gestational ages from 30 to 37 weeks who were breathing spontaneously were allocated in three positioning groups: PP, SP and KP. Heart rate, breathing frequency, SpO2 and alertness status were evaluated immediately before and after 30 minutes of positioning. Results In all, 66 NBs were assessed (corrected age: 35.48 ± 1.94 weeks; weight: 1840.14 ± 361.09 g), (PP: n = 22; SP: n = 23; KP: n = 21). NBs in the PP group showed a significant improvement in peripheral SpO2 (97.18 ± 2.16 vs 95.47 ± 2.93 vs 95.57 ± 2.95, p = 0.03) compared with the SP and KP groups. Conclusion In clinically stable preterm NBs, the PP was associated with better peripheral oxygen saturation than the SP or KP. In addition, there was a reduction in heart rate within prone position group and in the KP group there was an increase in the number of NBs in the deep sleep classification.
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Yang L, Bao Z, Zhang L, Lei X, Zhang L. Position management on pulmonary function and bronchopulmonary dysplasia in premature infants: study protocol for a randomised controlled trial. BMJ Open 2022; 12:e062291. [PMID: 36521889 PMCID: PMC9756205 DOI: 10.1136/bmjopen-2022-062291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Bronchopulmonary dysplasia (BPD) is a common disease caused by various factors and mechanisms in premature infants. Owing to lung hypoplasia and the lack of alveolar surfactants in premature infants, oxygen therapy is often needed to maintain adequate breathing. Nevertheless, prolonged oxygen therapy can easily induce BPD, and there is currently no effective treatment. Therefore, the prevention of BPD in premature infants during hospitalisation is essential. Studies have revealed that the prone position can effectively improve the oxygenation of premature infants. However, a few studies have reported whether prone positioning can improve lung function and reduce BPD incidence. This trial will determine whether the prone position, compared with the supine position, can reduce BPD incidence and improve lung function in preterm infants. METHODS AND ANALYSIS This study protocol is for a single-centre, single-blind, randomised controlled trial of the prone position in premature infants. Following daily feeding, premature infants will be placed in the lateral position for 30 min; then they will be turned to the supine position (control group) or prone position (intervention group) for 2 hours each in the morning and afternoon. Moreover, infants in both groups will be placed in the supine or lateral position alternately according to their medical needs for the remaining time. The study begins when the premature infants are stable within 5 days after admission and ends when they are discharged from the hospital or at 36 weeks postmenstrual age. The primary outcome is the survival rate without BPD. The secondary outcomes include lung function parameters and lung oxygen saturation. ETHICS AND DISSEMINATION This trial is approved by the ethics committee of the Affiliated Hospital of Southwest Medical University, (ref approval no.KY2021186). The results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ChiCTR2100049847.
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Affiliation(s)
- Liu Yang
- School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Zhengrong Bao
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Lianyu Zhang
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Clinical Nursing Research Institute, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xiaoping Lei
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Perinatology, Southwest Medical University, Luzhou, Sichuan, China
| | - Lingping Zhang
- Department of Pediatrics, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Department of Neonatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
- Clinical Nursing Research Institute, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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7
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Lee J, Parikka V, Lehtonen L, Soukka H. Parent-infant skin-to-skin contact reduces the electrical activity of the diaphragm and stabilizes respiratory function in preterm infants. Pediatr Res 2022; 91:1163-1167. [PMID: 34088986 PMCID: PMC8176875 DOI: 10.1038/s41390-021-01607-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/19/2021] [Accepted: 05/24/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND The physiological benefit of parent-infant skin-to-skin contact (SSC) is uncertain for preterm infants with ventilatory support. We aimed to investigate whether SSC stabilizes the respiration compared to incubator care in mechanically ventilated preterm infants. METHODS The prospective observational study was performed in Turku University Hospital, Finland. Preterm infants were eligible if they were born before 36 weeks gestation and received respiratory support with either invasive or non-invasive neurally adjusted ventilatory assist (NAVA). SSC was applied as soon as possible after birth. Respiratory variables were collected from the ventilator log data, and SSC episodes were compared with matched control periods during incubator care. RESULTS A total of 167 episodes of SSC were recorded from 17 preterm infants: 138 episodes during invasive NAVA and 29 episodes during non-invasive NAVA. During invasive NAVA, peak electrical activity of the diaphragm (Edi), minimum Edi, respiratory rate, time on backup ventilation, peak inspiratory pressure, and mean airway pressure were significantly lower in SSC than in incubator care. During non-invasive NAVA, peak Edi, minimum Edi, time on backup ventilation, and peak inspiratory pressure were significantly lower in SSC than in incubator care. CONCLUSIONS SSC stabilized and improved the respiratory physiology in mechanically ventilated preterm infants. IMPACT Skin-to-skin contact reduced work of breathing compared to incubator care in mechanically ventilated preterm infants. Skin-to-skin contact reduced the need for backup ventilation during neurally adjusted ventilatory assist in preterm infants. Skin-to-skin contact among ventilated preterm infants was not only safe but also stabilized and improved their respiratory physiology.
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Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Inha University Hospital, Incheon, Republic of Korea. .,Department of Pediatrics, Inha University College of Medicine, Incheon, Republic of Korea.
| | - Vilhelmiina Parikka
- grid.410552.70000 0004 0628 215XDepartment of Pediatrics, Turku University Hospital, Turku, Finland ,grid.1374.10000 0001 2097 1371Department of Pediatrics, University of Turku, Turku, Finland
| | - Liisa Lehtonen
- grid.410552.70000 0004 0628 215XDepartment of Pediatrics, Turku University Hospital, Turku, Finland ,grid.1374.10000 0001 2097 1371Department of Pediatrics, University of Turku, Turku, Finland
| | - Hanna Soukka
- grid.410552.70000 0004 0628 215XDepartment of Pediatrics, Turku University Hospital, Turku, Finland ,grid.1374.10000 0001 2097 1371Department of Pediatrics, University of Turku, Turku, Finland
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8
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Jani PR, Lowe K, Perdomo A, Wakefield L, Hinder M, Galea C, Goyen TA, Halliday R, Waters KA, Badawi N, Tracy M. Cerebral Oxygenation and Perfusion when Positioning Preterm Infants: Clinical Implications. J Pediatr 2021; 235:75-82.e1. [PMID: 33857466 DOI: 10.1016/j.jpeds.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 04/04/2021] [Accepted: 04/05/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate cerebral tissue oxygenation (cTOI) and cerebral perfusion in preterm infants in supine vs prone positions. STUDY DESIGN Sixty preterm infants, born before 32 weeks of gestation, were enrolled; 30 had bronchopulmonary dysplasia (BPD, defined as the need for respiratory support and/or supplemental oxygen at 36 weeks of postmenstrual age). Cerebral perfusion, cTOI, and polysomnography were measured in both the supine and prone position with the initial position being randomized. Infants with a major intraventricular hemorrhage or major congenital abnormality were excluded. RESULTS Cerebral perfusion was unaffected by position or BPD status. In the BPD group, the mean cTOI was higher in the prone position compared with the supine position by a difference of 3.27% (P = .03; 95% CI 6.28-0.25) with no difference seen in the no-BPD group. For the BPD group, the burden of cerebral hypoxemia (cumulative time spent with cTOI <55%) was significantly lower in the prone position (23%) compared with the supine position (29%) (P < .001). In those without BPD, position had no effect on cTOI. CONCLUSIONS In preterm infants with BPD, the prone position improved cerebral oxygenation and reduced cerebral hypoxemia. These findings may have implications for positioning practices. Further research will establish the impact of position on short- and long-term developmental outcomes.
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Affiliation(s)
- Pranav R Jani
- Westmead Hospital, Westmead, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia.
| | - Krista Lowe
- Westmead Hospital, Westmead, New South Wales, Australia
| | - Aldo Perdomo
- Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Murray Hinder
- Westmead Hospital, Westmead, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
| | - Claire Galea
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia; The Cerebral Palsy Alliance, Allambie Heights, New South Wales, Australia
| | | | - Robert Halliday
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Karen Ann Waters
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Nadia Badawi
- University of Sydney, Sydney, New South Wales, Australia; The Children's Hospital at Westmead, Westmead, New South Wales, Australia; The Cerebral Palsy Alliance, Allambie Heights, New South Wales, Australia
| | - Mark Tracy
- Westmead Hospital, Westmead, New South Wales, Australia; University of Sydney, Sydney, New South Wales, Australia
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Goodstein MH, Stewart DL, Keels EL, Moon RY. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021; 148:peds.2021-052045. [PMID: 34155134 DOI: 10.1542/peds.2021-052045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (ie, weight <2500 g) and 10% were born preterm (ie, gestational age of <37 weeks). Ten to fifteen percent of infants (approximately 500 000 annually), including low birth weight and preterm infants and others with congenital anomalies, perinatally acquired infections, and other diseases, require admission to a NICU. Every year, approximately 3600 infants in the United States die of sudden unexpected infant death (SUID), including sudden infant death syndrome (SIDS), unknown and undetermined causes, and accidental suffocation and strangulation in an unsafe sleep environment. Preterm and low birth weight infants are 2 to 3 times more likely than healthy term infants to die suddenly and unexpectedly. Thus, it is important that health care professionals prepare families to maintain their infant in a safe home sleep environment as per recommendations of the American Academy of Pediatrics. Medical needs of the NICU infant often require practices such as nonsupine positioning, which should be transitioned as soon as medically possible and well before hospital discharge to sleep practices that are safe and appropriate for the home environment. This clinical report outlines the establishment of appropriate NICU protocols for the timely transition of these infants to a safe home sleep environment. The rationale for these recommendations is discussed in the accompanying technical report "Transition to a Safe Home Sleep Environment for the NICU Patient," included in this issue of Pediatrics.
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Affiliation(s)
- Michael H Goodstein
- Division of Newborn Services, WellSpan Health, York, Pennsylvania .,Department of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Dan L Stewart
- Department of Pediatrics, Norton Children's and School of Medicine, University of Louisville, Louisville, Kentucky
| | - Erin L Keels
- National Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois.,Neonatal Advanced Practice, Nationwide Children's Hospital, Columbus, Ohio
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10
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Goodstein MH, Stewart DL, Keels EL, Moon RY. Transition to a Safe Home Sleep Environment for the NICU Patient. Pediatrics 2021; 148:peds.2021-052046. [PMID: 34155135 DOI: 10.1542/peds.2021-052046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Of the nearly 3.8 million infants born in the United States in 2018, 8.3% had low birth weight (<2500 g [5.5 lb]) and 10% were born preterm (gestational age of <37 completed weeks). Many of these infants and others with congenital anomalies, perinatally acquired infections, and other disease require admission to a NICU. In the past decade, admission rates to NICUs have been increasing; it is estimated that between 10% and 15% of infants will spend time in a NICU, representing approximately 500 000 neonates annually. Approximately 3600 infants die annually in the United States from sleep-related deaths, including sudden infant death syndrome International Classification of Diseases, 10th Revision (R95), ill-defined deaths (R99), and accidental suffocation and strangulation in bed (W75). Preterm and low birth weight infants are particularly vulnerable, with an incidence of death 2 to 3 times greater than healthy term infants. Thus, it is important for health care professionals to prepare families to maintain their infant in a safe sleep environment, as per the recommendations of the American Academy of Pediatrics. However, infants in the NICU setting commonly require care that is inconsistent with infant sleep safety recommendations. The conflicting needs of the NICU infant with the necessity to provide a safe sleep environment before hospital discharge can create confusion for providers and distress for families. This technical report is intended to assist in the establishment of appropriate NICU protocols to achieve a consistent approach to transitioning NICU infants to a safe sleep environment as soon as medically possible, well before hospital discharge.
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Affiliation(s)
- Michael H Goodstein
- Division of Newborn Services, WellSpan Health, York, Pennsylvania .,Department of Pediatrics, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania
| | - Dan L Stewart
- Department of Pediatrics, Norton Children's and School of Medicine, University of Louisville, Louisville, Kentucky
| | - Erin L Keels
- National Association of Neonatal Nurse Practitioners, National Association of Neonatal Nurses, Chicago, Illinois.,Neonatal Advanced Practice, Nationwide Children's Hospital, Columbus, Ohio
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11
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Kato Y, Takemoto A, Oumi C, Hisaichi T, Shimaji Y, Takaoka M, Moriyama H, Hirata K, Wada K. Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist. Early Hum Dev 2021; 157:105379. [PMID: 33962362 DOI: 10.1016/j.earlhumdev.2021.105379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC) reduces neonatal mortality and morbidity and is widely implemented in the neonatal intensive care unit. However, changes in respiratory effort during SSC in ventilated preterm infants remain unclear. AIMS To evaluate the effect of SSC on electrical activity of the diaphragm (Edi) and vital signs in premature infants who are intubated and under neurally adjusted ventilatory assist ventilation. STUDY DESIGN We performed an observational cross-over study. Data were measured in three periods: before (pre-SSC period), during (SSC period), and after (post-SSC period) SSC. Stable 30-min data in each period were extracted. SUBJECTS Thirty-four SSC procedures were performed in 14 preterm infants with a median gestational age of 25.3 weeks (interquartile range, 24, 26.4) and a birth weight of 659 g (566, 694). The median postnatal age was 41 days (31, 53) at the study with a median postmenstrual age of 31.3 weeks (30.4, 32.5). OUTCOME MEASURES Median values of Edi peak, Edi minimum, respiratory rate, SpO2, and heart rate were measured in each condition. The Kruskal-Wallis test with Bonferroni multiple comparisons was used to compare each parameter in each period. RESULTS Median Edi peak and Edi minimum values were significantly lower during SSC compared with pre- and post-SSC, without any change in respiratory rate, SpO2, or heart rate. CONCLUSIONS Respiratory efforts as evaluated by Edi are significantly reduced during SSC in ventilated preterm infants.
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Affiliation(s)
- Yuta Kato
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Ayumi Takemoto
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Chiyo Oumi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Tomomi Hisaichi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Yuki Shimaji
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Misa Takaoka
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Hiroko Moriyama
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
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Miller-Barmak A, Riskin A, Hochwald O, Haddad J, Dinur G, Vortman R, Kugelman A, Borenstein-Levin L. Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support. J Pediatr 2020; 226:123-128. [PMID: 32615194 DOI: 10.1016/j.jpeds.2020.06.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO2) histograms. STUDY DESIGN Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO2 ranges. RESULTS The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO2 ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO2 >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]). CONCLUSIONS Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO2 histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO2 ranges.
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Affiliation(s)
- Adi Miller-Barmak
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Arieh Riskin
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Julie Haddad
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rita Vortman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Shepherd KL, Yiallourou SR, Odoi A, Yeomans E, Willis S, Horne RSC, Wong FY. When does prone sleeping improve cardiorespiratory status in preterm infants in the NICU? Sleep 2019; 43:5587709. [DOI: 10.1093/sleep/zsz256] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/06/2019] [Indexed: 12/22/2022] Open
Abstract
Abstract
Study Objectives
Preterm infants undergoing intensive care are often placed prone to improve respiratory function. Current clinical guidelines recommend preterm infants are slept supine from 32 weeks’ postmenstrual age, regardless of gestational age at birth. However, respiratory function is also related to gestational and chronological ages and is affected by sleep state. We aimed to identify the optimal timing for adopting the supine sleeping position in preterm infants, using a longitudinal design assessing the effects of sleep position and state on cardiorespiratory stability.
Methods
Twenty-three extremely (24–28 weeks’ gestation) and 33 very preterm (29–34 weeks’ gestation) infants were studied weekly from birth until discharge, in both prone and supine positions, in quiet and active sleep determined by behavioral scoring. Bradycardia (heart rate ≤100 bpm), desaturation (oxygen saturation ≤80%), and apnea (pause in respiratory rate ≥10 s) episodes were analyzed.
Results
Prone positioning in extremely preterm infants reduced the frequency of bradycardias and desaturations and duration of desaturations. In very preterm infants, prone positioning only reduced the frequency of desaturations. The position-related effects were not related to postmenstrual age. Quiet sleep in both preterm groups was associated with fewer bradycardias and desaturations, and also reduced durations of bradycardia and desaturations in the very preterm group.
Conclusions
Cardiorespiratory stability is improved by the prone sleep position, predominantly in extremely preterm infants, and the improvements are not dependent on postmenstrual age. In very preterm infants, quiet sleep has a more marked effect than the prone position. This evidence should be considered in individualizing management of preterm infant positioning.
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Affiliation(s)
- Kelsee L Shepherd
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Australia
| | - Stephanie R Yiallourou
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Australia
- Pre-Clinical Disease and Prevention, Baker Heart and Diabetes Institute, Melbourne Australia
| | - Alexsandria Odoi
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Australia
| | - Emma Yeomans
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
| | - Stacey Willis
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
| | - Rosemary S C Horne
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Australia
| | - Flora Y Wong
- The Ritchie Centre, Hudson Institute of Medical Research and Department of Paediatrics, Monash University, Melbourne, Australia
- Monash Newborn, Monash Children’s Hospital, Melbourne, Australia
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Havranek T, Shatzkin E, Chuang M, Xie X, Kim M, Rosen O. Respiratory outcomes after neonatal prone versus supine positioning following scheduled cesarean delivery: a randomized trial. J Matern Fetal Neonatal Med 2019; 34:2938-2944. [PMID: 31564177 DOI: 10.1080/14767058.2019.1674805] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Prone positioning is a common practice after vaginal birth promoting skin to skin contact and has been associated with improved oxygenation in mechanically ventilated neonates in the recent analysis. Neonates of women not in labor delivered via C-section are at increased risk of respiratory distress; it is unclear whether vigorous neonates without a need of resuscitation would benefit from prone positioning immediately after birth. OBJECTIVE To determine whether prone positioning of vigorous term neonates for the first 5 min after scheduled cesarean delivery will decrease the incidence of respiratory distress and therapeutic interventions, characterized by the frequency and duration of respiratory support (RS). DESIGN/METHODS In a single center, randomized parallel clinical trial, vigorous term neonates delivered via scheduled cesarean delivery were positioned prone or supine and their heart rate, oxygen saturation and signs of respiratory distress were recorded at 1-min intervals for the first 5 min. Infants not reaching target oxygen saturations suggested by the neonatal resuscitation guidelines received RS via Neopuff in supine position; respiratory support was discontinued once oxygen saturation targets were met and infant was free of respiratory symptoms. Primary outcomes measured were frequency and duration of RS, secondary outcomes were admission to the NICU for respiratory distress, length of stay, heart rate and oxygen saturation during the initial 5 min of life. RESULTS Two hundred twenty-five neonates in prone and 231 in supine position completed the study out of 500 randomized subjects. Frequency of RS (31 versus 30%, p = .93), mean RS duration (4.08 versus 4.39 min; p = .71), frequency of admission to the NICU (5% in both groups; p = .95) and mean length of stay (0.14 versus 0.28 days; p = .42) were similar between the prone and supine groups. The supine cohort had higher initial oxygen saturation (p = .02) as well as heart rate (p = .004). CONCLUSIONS Prone or supine positioning of term neonates after scheduled cesarean delivery resulted in comparable respiratory outcomes including the need for resuscitation in the first minutes of life.
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Affiliation(s)
- Tomas Havranek
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - Ellen Shatzkin
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
| | - Meleen Chuang
- Department of OB/GYN Women's Health/Montefiore, Bronx, NY, USA
| | - Xianhong Xie
- Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mimi Kim
- Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Orna Rosen
- Department of Pediatrics, Albert Einstein College of Medicine, Montefiore, Bronx, NY, USA
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15
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Spengler D, Loewe E, Krause MF. Supine vs. Prone Position With Turn of the Head Does Not Affect Cerebral Perfusion and Oxygenation in Stable Preterm Infants ≤32 Weeks Gestational Age. Front Physiol 2018; 9:1664. [PMID: 30524314 PMCID: PMC6262027 DOI: 10.3389/fphys.2018.01664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 11/05/2018] [Indexed: 11/17/2022] Open
Abstract
Intraventricular hemorrhage (IVH) is a frequent major damage to the brain of premature babies ≤32 weeks gestational age, and its incidence (20–25%) has not significantly changed lately. Because of the intrinsic fragility of germinal matrix blood vessels, IVH occurs following disruption of subependymal mono-layer arteries and is generally attributed to ischemia-reperfusion alterations or venous congestion, which may be caused by turn of the head. Therefore, supine position with the head in a midline position is considered a standard position for preterm infants during their first days of life. We asked whether a change in body position (supine vs. prone) linked with a turn of the head by 90° in the prone position would change blood flow velocities and resistance indices in major cerebral arteries and veins of stable premature babies at two different time points (t0, day of life 2, vs. t1, day 9). Moreover, we assessed cerebral tissue oxygenation (cStO2) by near-infrared spectroscopy and determined correlations for changes in velocities and oxygenation. Twenty one premature infants [gestational age 30 (26–32) weeks] with sufficiently stable gas exchange and circulation were screened by ultrasonography and near-infrared spectroscopy. Peak systolic and end-diastolic blood flow velocities in the anterior cerebral arteries (29 ± 6 m/s vs. 28 ± 7 peak flow at t0, 36 ± 8 vs. 35 ± 7 at t1), the basilar artery, the right and the left internal carotid artery, and the great cerebral vein Galen (4.0 ± 0.8 m/s vs. 4.1 ± 1.0 maximum flow at t0, 4.4 ± 0.8 vs. 4.4 ± 1.0 at t1) did not show significant differences following change of body and head position. Also, there were no differences in cStO2 (83 ± 7% vs. 84 ± 7 at t0, 76 ± 10 vs. 77 ± 11 at t1) and in vital signs such as heart rate and blood pressure. We conclude that change in body position with turn of the head in the prone position does not elicit significant alterations in cerebral blood flow velocities or in oxygenation of cerebral tissues. Maturational changes in arterial flow velocities and cStO2 are not correlated. For this subgroup of premature infants at low risk of IVH our data do not support the concept of exclusive preterm infant care in supine position.
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Affiliation(s)
- Dietmar Spengler
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Elisa Loewe
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Martin F Krause
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
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Effects of Cycled Lighting Versus Continuous Near Darkness on Physiological Stability and Motor Activity Level in Preterm Infants. Adv Neonatal Care 2017; 17:282-291. [PMID: 27984231 DOI: 10.1097/anc.0000000000000372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Preterm infants generally spend weeks in the neonatal intensive care unit where light intensity can fluctuate as well as be high, leading to physiological instability and increased motor activity in these infants. To date, 2 lighting control methods have been studied: cycled lighting and continuous near darkness. The most appropriate method of lighting is still unknown due to ambivalent results from the studies that have assessed these 2 interventions. OBJECTIVE To compare the effects of cycled lighting versus continuous near darkness on physiological stability and motor activity level in preterm infants born between 28 and 32 weeks of gestation. METHODS A randomized clinical trial was conducted to compare physiological stability and motor activity level in preterm infants assigned to cycled lighting or continuous near darkness. Thirty-eight participants were recruited and randomly assigned to one of the lighting conditions for 24 hours. Physiological stability was measured using the Stability of the Cardiorespiratory System in Premature Infants (SCRIP) score, the means, and the coefficient of variation of each physiological parameter measured. The level of motor activity was measured with an accelerometer. RESULTS There were no significant differences between the 2 groups with regard to physiological stability measured by the SCRIP score, means, and coefficient of variation as well as motor activity level. Participants in both groups were physiologically stable and their motor activity level was comparable. IMPLICATIONS FOR PRACTICE AND RESEARCH Neither cycled lighting nor continuous near darkness negatively impacted infant's physiologic stability and motor activity level. Further research is required to identify the most appropriate lighting control method for preterm infants born between 28 and 32 weeks of gestation.
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17
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Ballout RA, Foster JP, Kahale LA, Badr L. Body positioning for spontaneously breathing preterm infants with apnoea. Cochrane Database Syst Rev 2017; 1:CD004951. [PMID: 28067942 PMCID: PMC6464155 DOI: 10.1002/14651858.cd004951.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It has been proposed that body positioning in preterm infants, as compared with other, more invasive measures, may be an effective method of reducing clinically significant apnoea. OBJECTIVES To determine effects of body positioning on cardiorespiratory parameters in spontaneously breathing preterm infants with clinically significant apnoea.Subgroup analyses examined effects of body positioning of spontaneously breathing preterm infants with apnoea from the following subgroups.• Gestational age < 28 weeks or birth weight less than 1000 grams.• Apnoea managed with methylxanthines.• Frequent apnoea (> 10 events/d).• Type of apnoea measured (central vs mixed vs obstructive) SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG) to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10), MEDLINE via PubMed (1966 to 14 November 2016), Embase (1980 to 14 November 2016) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2016 November 14). We also searched clinical trials databases and conference proceedings for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled clinical trials with parallel, factorial or cross-over design comparing the impact of different body positions on apnoea in spontaneously breathing preterm infants were eligible for our review. DATA COLLECTION AND ANALYSIS We assessed trial quality, data extraction and synthesis of data using standard methods of the CNRG. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence. MAIN RESULTS The search conducted in November 2016 identified no new studies. Five studies (N = 114) were eligible for inclusion. None of the individual studies nor meta-analyses showed a reduction in apnoea, bradycardia, oxygen desaturation or oxygen saturation with body positioning (supine vs prone; prone vs right lateral; prone vs left lateral; right lateral vs left lateral; prone horizontal vs prone head elevated; right lateral horizontal vs right lateral head elevated, left lateral horizontal vs left lateral head elevated). AUTHORS' CONCLUSIONS We found insufficient evidence to determine effects of body positioning on apnoea, bradycardia and oxygen saturation in preterm infants. No new studies have been conducted since the original review was published. Large, multi-centre studies are warranted to provide conclusive evidence, but it may be plausible to conclude that positioning of spontaneously breathing preterm infants has no effect on their cardiorespiratory parameters.
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Affiliation(s)
- Rami A Ballout
- American University of BeirutFaculty of MedicineRiad‐El‐Solh Beirut 1107 2020P.O. Box: 11‐0236BeirutLebanon
| | - Jann P Foster
- Western Sydney UniversitySchool of Nursing and MidwiferyPenrith DCAustralia
- University of SydneySydney Nursing School/Central Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologySydneyAustralia
- Ingham Research InstituteLiverpoolNSWAustralia
| | - Lara A Kahale
- American University of BeirutFaculty of MedicineRiad‐El‐Solh Beirut 1107 2020P.O. Box: 11‐0236BeirutLebanon
| | - Lina Badr
- Azusa Pacific UniversityAzusa, CaliforniaUSA
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Trachsel D, Svendsen J, Erb T, von Ungern-Sternberg B. Effects of anaesthesia on paediatric lung function. Br J Anaesth 2016; 117:151-63. [DOI: 10.1093/bja/aew173] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Geyer JE, Smith PK, Kair LR. Safe sleep for pediatric inpatients. J SPEC PEDIATR NURS 2016; 21:119-30. [PMID: 27221207 DOI: 10.1111/jspn.12146] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE To improve sleep environment safety for inpatient infants. DESIGN AND METHODS This quality improvement project involved assessment of sleep environment safety for inpatient infants before and after a bundled intervention of staff education and introduction of swaddle sacks and bedside storage bins. RESULTS The proportion of infant cribs without loose objects in them increased (32-72%, p = .025), and safe sleep positioning remained stable (82% vs. 95%, p = .183). PRACTICE IMPLICATIONS Staff education, swaddle sleep sacks, and bedside storage containers were associated with improved sleep safety among pediatric inpatients at our institution and may help at other institutions.
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Affiliation(s)
- Janet E Geyer
- Nursing Practice Leader with the Department of Nursing, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Penny K Smith
- Nurse Clinician Specialist with the Department of Nursing, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Laura R Kair
- Clinical Assistant Professor of Pediatrics, Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
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McMullen SL, Wu YW, Austin-Ketch T, Carey MG. Transitioning the premature infant from nonsupine to supine position prior to hospital discharge. Neonatal Netw 2016; 33:194-8. [PMID: 24985111 DOI: 10.1891/0730-0832.33.4.194] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to document the clinical practice of transitioning the hospitalized premature infant to the supine position and determine if hospital policy influenced practice. DESIGN This study was a retrospective medical chart review. SAMPLE The charts were reviewed from two urban hospitals that had Level III NICUs in upstate New York. MAIN OUTCOME VARIABLE The outcome variable was to determine clinical practice of transitioning premature infants to the supine position. RESULTS The percentage of premature infants who were transitioned to the supine position at least 24 hours prior to hospital discharge varied, but the postmenstrual age at transition did not vary. The hospital with a policy transitioned premature infants to the supine position one week prior to discharge as compared with two days in the hospital without a policy. Despite national recommendations, no infants were transitioned into the supine position by 32 weeks postmenstrual age.
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Semi-Prone Position Can Influence Variability in Respiratory Rate of Premature Infants Using Nasal CPAP. J Pediatr Nurs 2016; 31:e167-74. [PMID: 26614613 DOI: 10.1016/j.pedn.2015.10.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/05/2015] [Accepted: 10/20/2015] [Indexed: 11/22/2022]
Abstract
UNLABELLED To determine the effect of positions (supine, lateral, semiprone) on the physiological parameters (HR, RR, SpO2) of premature infants receiving NCPAP who were non-oxygen-dependent and non-BPD, and to identify significant clinical changes associated with these variables. METHODS A crossover study design with three different positions in the assigned sequence (supine-supine, supine-lateral and supine-semiprone) was used, and each position was maintained for 1h. The subjects' vital signs were recorded 30 min after initiation of each position and measured for 30 min. RESULTS Forty-seven infants with a median GA of 28.6 weeks (range 26-35) were studied, and their median BW was 1210g (range 776-2920). Overall, position-related effects showed significant difference in the variability in RR (OR=0.68; CI 0.51-0.89), with the variability in RR being significantly lower in the semiprone position. The lateral position was associated with increased RR (B=2.9; p=0.02). Previous use of ventilator (PUV) was associated with increased HR, whereas BW and GA were negatively associated with higher HR. Cesarean birth, use of surfactant and PUV were associated with lower SpO2, whereas BW and GA were correlated with higher SpO2. GA was identified as a protective factor, while PUV was a risk factor for the variability in both HR and SpO2. CONCLUSIONS Premature infants receiving NCPAP sleeping in the semiprone position may have more stable RR, while the lateral position did not improve RR. Thus, the semiprone and supine positions may be considered preferable when positioning the monitored premature infants with NCPAP.
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van der Burg PS, de Jongh FH, Miedema M, Frerichs I, van Kaam AH. The effect of prolonged lateral positioning during routine care on regional lung volume changes in preterm infants. Pediatr Pulmonol 2016; 51:280-5. [PMID: 26291607 DOI: 10.1002/ppul.23254] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/04/2015] [Accepted: 07/03/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION During routine nursing care, preterm infants are often placed in lateral position for several hours, but the effect of this procedure on regional lung volume and ventilation is unknown. In our study we examined this effect during 3 hrs of lateral positioning in stable preterm infants. METHODS Preterm infants on non-invasive respiratory support were eligible for the study. Infants were placed in supine position and subsequently transferred to right or left lateral position, according to their individual routine nursing schedule. Changes in end-expiratory lung volume (EELV), tidal volume (VT ) and ventilation distribution were recorded using electrical impedance tomography (EIT), starting 10 min before and up to 180 min after the positional change. Additionally, oxygen requirement, transcutaneous oxygen saturation and respiratory rate were recorded. RESULTS 15 infants were included (GA 28.9 ± 2.0 wk, BW 1167 ± 290 g). EELV increased significantly after changing to lateral position, stabilizing at a median value of 40.8 (IQR 29.0-99.3) AU/kg at 30 min. This increase could almost be exclusively attributed to the non-dependent lung regions. Tidal volume, oxygenation, and respiratory rate remained stable. Changing to the right, but not the left, lateral position resulted in a rapid but transient shift in ventilation to the dependent lung regions. After 180 min there were no differences in ventilation distribution between lateral and supine positioning. CONCLUSION This study shows that lateral position up to 3 hours, as part of normal nursing care of preterm infants, has no adverse effects on lung volumes and its regional distribution.
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Affiliation(s)
- Pauline S van der Burg
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Martijn Miedema
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Inez Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Germany
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
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Rubini A. The Effects of Prone with Respect to Supine Position on Stress Relaxation, Respiratory Mechanics, and the Work of Breathing Measured by the End-Inflation Occlusion Method in the Rat. Lung 2015; 194:53-9. [PMID: 26585574 DOI: 10.1007/s00408-015-9827-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The working hypothesis is that the prone position with respect to supine may change the geometric configuration of the lungs inside the chest wall, thus their reciprocal mechanical interactions, leading to possible effects on stress relaxation phenomena and respiratory mechanics. METHOD The effects of changing body posture from supine to prone on respiratory system mechanics, particularly on stress relaxation, were investigated in the rat by the end-inflation occlusion method. RESULTS In the prone with respect to supine position, an increment of the frictional resistance of the airway (from 0.13 ± 0.01 to 0.19 ± 0.02 cm H2O/l sec(-1), p < 0.05) and a decrement of the stress relaxation-linked pressure dissipation (from 0.51 ± 0.05 to 0.45 ± 0.05 cm H2O/l sec(-1), p < 0.01) were found. Respiratory system elastance and total resistive pressure dissipation did not change significantly. Accordingly, a significant increase of the frictional "ohmic" mechanical inspiratory work of breathing and a decrease of the visco-elastic work of inspiration were demonstrated, while no significant changes occurred for the total mechanical work of breathing and its total resistive and elastic components. CONCLUSION It is concluded that postural changes affect the visco-elastic characteristics of the respiratory system and the related stress relaxation phenomena by influencing the disposition and relation of the lungs inside the chest wall and their relative geometrical configuration, and the interaction phenomena of the constitutive parenchymal structures, i.e., elastin and collagen fibers. Since the prone position resulted in no serious or disadvantageous respiratory system mechanical derangement, it is suggested it may be usefully applied in nursing or for therapeutic goals.
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Affiliation(s)
- Alessandro Rubini
- Physiology Section, Department of Biomedical Sciences, University of Padova, Via Marzolo 3, 35100, Padua, Italy.
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Arakaki VDSNM, Oliveira AMD, Bogossian T, Almeida VSD, Silva GDD, Ferreira HC. Importance of physiotherapy/nursing multidisciplinary integration about update newborn position in the neonatal intensive care unit. FISIOTERAPIA EM MOVIMENTO 2015. [DOI: 10.1590/0103-5150.028.003.ao02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
AbstractIntroduction The high-risk newborns may require long periods of hospitalization until they reach clinical stability for hospital discharge. Avoiding babies to be in only one body position may be an effective way to cause respiratory and neuro-psycho-motor benefits, comfort and preventing pressure ulcers.Objectives This study investigated the impact of physiotherapy/nursing integration in update on body positioning of the newborn in the Neonatal Intensive Care Unit.Methods A questionnaire was administered to nurses and nursing technicians of the neonatal unit of Maternity School of UFRJ and nurses of the Advanced Course in Neonatal Nursing from the same institution. Two classes were taught by the physical therapist of the sector and the questions answered before and after these lessons. It was also a brief characterization of professional participants of the study. We used the Student's t test to compare the correct answers before (PRE) and after (POST) the classes, considering p < 0.05.Results There was a significant increase in the degree of knowledge of nurses and nursing technicians when compared the responses before (nurses: 68.8%; technicians: 70.1%) and after classes (nurses: 78.4 %; technicians: 88.9%). The nurses were less than five years of graduated (45%) and little time of professional experience in neonatology (60%). Forty-seven percent of technicians had less than five years of training and 82% had less than 10 years of experience.Conclusion The use of training by the nursing staff was significant, showing the importance of multidisciplinary approach and the integration of knowledge in the search for a humanized and effective care.
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Brunherotti MAA, Martinez FE. [Influence of body position on the displacement of nasal prongs in preterm newborns receiving continuous positive airway pressure]. REVISTA PAULISTA DE PEDIATRIA 2015; 33:281-6. [PMID: 26116326 PMCID: PMC4620954 DOI: 10.1016/j.rpped.2015.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 01/14/2015] [Accepted: 01/18/2015] [Indexed: 11/27/2022]
Abstract
Objective: To evaluate the influence of body position on the displacement of nasal
prongs in preterm infants. Methods: This prospective, randomized, crossover study enrolled infants born at a mean
gestational age of 29.7±2 weeks, birth weight of 1353±280g and
2.9±2.2 days of life, submitted to continuous positive airway
pressure by nasal prongs. The main outcome was the number of times that the
nasal prongs were displaced following infant positioning in the following
body positions: prone, right lateral, left lateral, and supine, according to
a pre-established random order. Moreover, cardiorespiratory variables
(respiratory rate, heart rate, and oxygen saturation) were evaluated for
each body position. Data for each position were collected every 10 min, over
a period of 60 min. An occurrence was defined when the nasal prongs were
displaced from the nostrils after 3 min in the desired position, requiring
intervention of the examiner. Results: Among the 16 studied infants, the occurrence of nasal prong displacement was
only observed in the prone position (9 infants - 56.2%) and in the left
lateral position (2 infants - 12.5%). The number of times that the prongs
were displaced was 11 in the prone position (7 within the first 10min) and 2
in the left lateral position (1 within the first 10min). No clinically
significant changes were observed in the cardiorespiratory variables. Conclusions: Maintenance of the nasal prongs to provide adequate noninvasive respiratory
support was harder in the prone position.
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Changes in lung volume and ventilation following transition from invasive to noninvasive respiratory support and prone positioning in preterm infants. Pediatr Res 2015; 77:484-8. [PMID: 25518010 DOI: 10.1038/pr.2014.201] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 09/20/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND To minimize secondary lung injury, ventilated preterm infants are extubated as soon as possible. To maximize extubation success, they are often placed in prone position. The effect of extubation and subsequent prone positioning on lung volumes is currently unknown. METHODS Changes in end-expiratory lung volume (ΔEELV), tidal volume (VT), and ventilation distribution were monitored during transition from endotracheal to nasal continuous positive airway pressure and following prone positioning using electrical impedance tomography. In addition, the continuous distending pressure (CDP) and oxygen need (FiO₂) were recorded. RESULTS Twenty preterm infants (GA 28.7 ± 1.7 wk) were included. Following extubation, the CDP decreased from 7.9 ± 0.5 to 6.0 ± 0.2 cmH₂O, while the FiO₂ remained stable. Both ΔEELV and VT increased significantly (P < 0.05) after extubation, without changing ventilation distribution. Prone positioning resulted in a further increase in ΔEELV (P < 0.01) and a decrease in respiratory rate. VT remained stable but its distribution clearly shifted toward the ventral lung regions. CONCLUSION Infants who are transitioned from invasive to noninvasive respiratory support are able to maintain their EELV and increase their VT. Prone positioning increases EELV and shifts tidal ventilation to the ventral lung regions. The latter suggests that infants should preferably be placed in prone position after extubation.
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Soukka H, Grönroos L, Leppäsalo J, Lehtonen L. The effects of skin-to-skin care on the diaphragmatic electrical activity in preterm infants. Early Hum Dev 2014; 90:531-4. [PMID: 24819407 DOI: 10.1016/j.earlhumdev.2014.04.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 03/17/2014] [Accepted: 04/14/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC) is widely used in neonatal intensive care units due to its positive effects on infant physiology and parent-infant interaction. AIMS We investigated the safety and the effect of SSC on the diaphragm electrical activity (EAdi) in premature infants recovering from respiratory distress syndrome treated on noninvasive neurally adjusted respiratory assist. STUDY DESIGN An observational cross-over study design was used. The infants were evaluated during SSC and in both prone and supine positions before and after SSC during a 9-hour study period. The EAdi was measured via miniaturized sensors incorporated into a feeding tube. SUBJECTS Seventeen premature infants with a mean age of 20d (range, 2-43d) were studied. Their mean birth weight was 900g (490-1845g) and mean gestational age at birth 28wk (25-32wk). OUTCOME MEASURES Under each condition, EAdi peak (representing tidal, neural inspiratory effort) and EAdi minimum (representing neural expiratory activity) were numerically quantified. Oxygen saturation, heart rate, and apnea were recorded. RESULTS The mean EAdi minimum values were lower during SSC and prone position. In addition, a tendency towards lower EAdi peak values was found during SSC. There were no differences in the occurrence of apnea between the study phases. CONCLUSIONS SSC is safe and it is not associated with increased neural activity of the diaphragm. On the contrary, low EAdi minimum values were registered reflecting more complete diaphragmatic de-activation between respiratory cycles.
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Affiliation(s)
- Hanna Soukka
- Department of Pediatrics, Turku University Hospital, Finland.
| | | | - Juha Leppäsalo
- Department of Pediatrics, Turku University Hospital, Finland
| | - Liisa Lehtonen
- Department of Pediatrics, Turku University Hospital, Finland
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Saiki T, Milner AD, Hannam S, Rafferty GF, Peacock JL, Greenough A. Sleeping position and responses to a carbon dioxide challenge in convalescent prematurely born infants studied post-term. Arch Dis Child Fetal Neonatal Ed 2014; 99:F215-8. [PMID: 24473750 DOI: 10.1136/archdischild-2013-305586] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To test the hypothesis that the ventilatory response to a carbon dioxide (CO2) challenge would be lower in the prone compared to the supine position in prematurely born infants studied post-term. To determine whether there were postural-related differences in respiratory drive, respiratory muscle strength, thoracoabdominal synchrony and/or lung volume. DESIGN Prospective cohort study. SETTING Tertiary neonatal unit. PATIENTS Eighteen infants (median gestational age 31 (range 22-32) weeks) were studied at a median of 5 (range 2-11) weeks post-term. INTERVENTIONS The ventilatory responses to three added carbon dioxide (CO2) levels (0% baseline, 2% and 4%) were assessed in the prone and supine positions. MAIN OUTCOME MEASURES The airway pressure change after the first 100 ms of an occluded inspiration (P0.1) (respiratory drive) and the maximum inspiratory pressure during crying with an occluded airway (Pimax) (respiratory muscle strength) were measured. The P0.1/Pimax ratio at each CO2 level and slope of the P0.1/Pimax response were calculated. RESULTS The mean P0.1 (p<0.05) and P0.1/Pimax (p<0.05) were higher and the functional residual capacity (p=0.031) lower in the supine compared to the prone position. The mean P0.1 and P0.1/Pimax increased independently of position as the percentage CO2 increased (p<0.001). There was no tendency for the differences in P0.1 and P0.1/Pimax between the prone and supine position to vary by CO2 level. CONCLUSIONS Convalescent, prematurely born infants studied post-term have a reduced respiratory drive, but not a lower ventilatory response to a CO2 challenge, in the prone compared to the supine position.
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Affiliation(s)
- Tolulope Saiki
- Division of Asthma, Allergy & Lung Biology, MRC-Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, , London, UK
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Gouna G, Rakza T, Kuissi E, Pennaforte T, Mur S, Storme L. Positioning effects on lung function and breathing pattern in premature newborns. J Pediatr 2013; 162:1133-7, 1137.e1. [PMID: 23312684 DOI: 10.1016/j.jpeds.2012.11.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 10/22/2012] [Accepted: 11/08/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare breathing patterns and lung function in the supine, lateral, and prone positions in oxygen-dependent preterm infants. STUDY DESIGN Respiratory function in preterm infants receiving nasal continous positive airway pressure therapy for mild respiratory failure was evaluated by respiratory inductive plethysmography. Infants were randomized to supine, left lateral, and prone positions for 3 hours. A nest provided a semiflexed posture for the infants placed in the left lateral position, similar to the in utero position. Tidal volume (Vt), phase angle between abdominal and thoracic movements, rib cage contribution to Vt, and dynamic elevation of end-expiratory lung volume were measured. RESULTS Fraction of inspired O2 was similar in the 3 positions for 19 infants (mean gestational age, 27±2 weeks; mean birth weight, 950±150 g; mean postnatal age, 17±5 days). However, arterial O2 saturation and Vt were higher in the left lateral and prone positions than in the supine position (P<.05). The phase angle between abdominal and thoracic movements was lower and rib cage contribution to Vt was higher in the left lateral and prone positions than in the supine position (P<.05). Dynamic elevation of end-expiratory lung volume was greater in the supine position than in the left lateral and prone positions (P<.05). CONCLUSION In oxygen-dependent preterm infants, both the left lateral and prone positions improve lung function by optimizing breathing strategy. In the neonatal intensive care unit, the left lateral position can be used as an alternative to the prone position for mild respiratory failure.
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Affiliation(s)
- Georgette Gouna
- Department of Perinatology, Jeanne de Flandre Hospital, University Hospital of Lille, and EA4489 Perinatal Environment and Growth, School of Medicine, Université Lille 2, Lille, France
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Gillies D, Wells D, Bhandari AP. Positioning for acute respiratory distress in hospitalised infants and children. Cochrane Database Syst Rev 2012; 2012:CD003645. [PMID: 22786486 PMCID: PMC7144689 DOI: 10.1002/14651858.cd003645.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Because of the association of prone positioning with sudden infant death syndrome (SIDS) it is recommended that young infants be placed on their backs (supine). However, the prone position may be a non-invasive way of increasing oxygenation in participants with acute respiratory distress. Because of substantial differences in respiratory mechanics between adults and children and the risk of SIDS in young infants, a specific review of positioning for infants and young children with acute respiratory distress is warranted. OBJECTIVES To compare the effects of different body positions in hospitalised infants and children with acute respiratory distress. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 3), which contains the Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to April week 1, 2012), EMBASE (2004 to April 2012) and CINAHL (2004 to April 2012). SELECTION CRITERIA Randomised controlled trials (RCTs) or pseudo-RCTs comparing two or more positions in the management of infants and children hospitalised with acute respiratory distress. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each study. We resolved differences by consensus or referral to a third review author. We analysed bivariate outcomes using an odds ratio and 95% confidence interval (CI). We analysed continuous outcomes using a mean difference and 95% CI. We used a fixed-effect model unless heterogeneity was significant, in which case we used a random-effects model. MAIN RESULTS We extracted data from 53 studies. We included 24 studies with a total of 581 participants. Three studies used a parallel-group, randomised design which compared prone and supine positions only. The remaining 21 studies used a randomised cross-over design. These studies compared prone, supine, lateral, elevated and flat positions.Prone positioning was significantly more beneficial than supine positioning in terms of oxygen saturation (mean difference (MD) 1.97%, 95% CI 1.18 to 2.77), arterial oxygen (MD 6.24 mm Hg, 95% confidence interval (CI) 2.20 to 10.28), episodes of hypoxaemia (MD -3.46, 95% CI -4.60 to -2.33) and thoracoabdominal synchrony (MD -30.76, 95% CI -41.39 to -20.14). No adverse effects were identified. There were no statistically significant differences between any other positions.As the majority of studies did not describe how possible biases were addressed, the potential for bias in these findings is unclear. AUTHORS' CONCLUSIONS The prone position was significantly superior to the supine position in terms of oxygenation. However, as most participants were ventilated preterm infants, the benefits of prone positioning may be most relevant to these infants. In addition, although placing infants and children in the prone position may improve respiratory function, the association of SIDS with prone positioning means that infants should only be placed in this position while under continuous cardiorespiratory monitoring.
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Affiliation(s)
- Donna Gillies
- Western Sydney and Nepean Blue Mountains Mental Health Service, Parramatta, Australia.
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Abstract
BACKGROUND It has been proposed that the use of body positioning may be a more effective way to reduce clinically significant apnoea than the use of more invasive measures. OBJECTIVES To determine the effect of body positioning on cardiorespiratory functioning in spontaneously breathing preterm infants with clinically significant apnoea. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1988 to March 2011) and CINAHL (1988 to March 2011), abstracts of conference proceedings and citations of published articles. SELECTION CRITERIA All studies in which infants or their sequence of body positioning was randomised or quasi-randomised. We included cross-over studies. DATA COLLECTION AND ANALYSIS We performed assessment of trial quality, data extraction and synthesis of data using standard methods of the Cochrane Neonatal Review Group. MAIN RESULTS Five studies (N = 114) were eligible for inclusion. None of the individual studies or the meta-analyses showed a reduction in apnoea, bradycardia, oxygen desaturation or oxygen saturation with body positioning (supine versus prone; prone versus right lateral; prone versus left lateral; right lateral versus left lateral; prone horizontal versus prone head elevated; right lateral horizontal versus right lateral head elevated and left lateral horizontal versus left lateral head elevated). AUTHORS' CONCLUSIONS There is insufficient evidence to determine the role of body positioning on apnoea, bradycardia, oxygen desaturation and oxygen saturation. Large randomised controlled trials are needed to determine the effect of body positioning on cardiorespiratory function in spontaneously breathing preterm infants.
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Affiliation(s)
- Sandie L Bredemeyer
- Perinatal Nursing, Centre for Nursing & Midwifery Research, RPA Women and Babies, School of Nursing, University of Sydney,Sydney, Australia.
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Lanza FDC, Barcellos PG, Dal Corso S. Benefícios do decúbito ventral associado ao CPAP em recém-nascidos prematuros. FISIOTERAPIA E PESQUISA 2012. [DOI: 10.1590/s1809-29502012000200008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
O objetivo deste estudo foi avaliar os benefícios nas variáveis clínicas do decúbito ventral (DV) associado a pressão positiva contínua nas vias aéreas (CPAP), em recém-nascido pré-termo (RNPT). Foi feito um estudo transversal em RNPT com utilização do CPAP internados na unidade de terapia intensiva (UTI). As frequências cardíaca (FC) e respiratória (FR), SpO2, quantificação do desconforto respiratório pelo boletim de Silverman e Andersen (BSA: quanto maior o valor, pior o desconforto respiratório) foram avaliados em cinco fases. Na fase I foram avaliadas a FC, FR, SpO2 e BSA em decúbito supino. Nas fases II, III, IV e V foram coletadas as mesmas variáveis da fase I após 5, 15, 30 e 60 min, respectivamente. O RNPT foi posicionado em DV logo após a fase I. Foi realizada análise de variância repetida para comparação entre todas as variáveis estudadas nas cinco fases, e utilizado-se teste de Bonferroni para análise post hoc. Foi considerada significância estatística quando p<0,05. No estudo, foram incluídos 13 RNPT, com média idade gestacional 33±1,5 semanas, sendo 7 do gênero masculino. Não houve alteração significante na FC, FR e SpO2, entre todas as fases. Houve redução no BSA nas fases III e IV quando comparadas à fase I: fase 1, 4,6±1,6 vs. fase III, 2,4±0,5 (p=0,02); fase I, 4,6±1,6 vs. fase IV, 2,4±0,5 (p=0,002). Concluiu-se, então, então que DV reduz o desconforto respiratório em RNPT quando associado ao CPAP, quando permanecem por, pelo menos, 15 min, sem alteração na FC, FR e SpO2.
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Malagoli RDC, Santos FFA, Oliveira EA, Bouzada MCF. Influência da posição prona na oxigenação, frequência respiratória e na força muscular nos recém-nascidos pré-termo em desmame da ventilação mecânica. REVISTA PAULISTA DE PEDIATRIA 2012. [DOI: 10.1590/s0103-05822012000200015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVO: Verificar a influência do posicionamento do recém-nascido prematuro sobre a força da musculatura respiratória, oxigenação e frequência respiratória. MÉTODOS: Estudo transversal com amostra pareada de recém-nascidos com idade gestacional inferior a 34 semanas, intubados, em processo final de desmame de ventilação mecânica. Foram excluídos aqueles com malformações, síndromes genéticas, doenças neuromusculares, traqueostomizados e em pós-operatório de cirurgias abdominais ou torácicas. As medidas de pressão inspiratória máxima foram aferidas utilizando-se manovacuômetro digital; a frequência respiratória através da observação das incursões respiratórias das crianças em um minuto e a saturação de oxigênio por oxímetro, nas posturas prona e supino. Os testes estatísticos aplicados foram Kruskal-Wallis, o teste t de Student e o coeficiente de correlação de Pearson, sendo significante p<0,05. RESULTADOS: Foram estudadas 45 crianças com síndrome do desconforto respiratório. A idade gestacional média foi de 30,4 semanas e o peso médio ao nascer de 1522g. Os valores de saturação de oxigênio foram mais elevados (p<0,001) e os de pressão inspiratória máxima mais baixos (p<0,001) na posição prona. Os valores de frequência respiratória foram semelhantes nas duas posições estudadas (p=0,072). CONCLUSÕES: Observaram-se menores valores de pressão inspiratória além de aumento da saturação de oxigênio na posição prona quando comparada à supino. Em relação à frequência respiratória, não foi observada variação entre as posturas prona e supino.
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Saiki T, Hannam S, Rafferty GF, Milner AD, Greenough A. Ventilatory response to added dead space and position in preterm infants at high risk age for SIDS. Pediatr Pulmonol 2011; 46:239-45. [PMID: 24081885 DOI: 10.1002/ppul.21358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 08/03/2010] [Accepted: 08/03/2010] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The vulnerability of prematurely born infants to sudden infant death syndrome (SIDS) in the prone position might be explained by a reduced ability to respond to a stress, such as hypercarbia, in that position; our objective, therefore, was to further explore the influence of position on the response to a stress. WORKING HYPOTHESIS The ability of prematurely born infants to respond to added dead space in the prone compared to the supine position would be impaired at the high risk age for SIDS. PATIENTS Twenty infants, median gestational age of 30 (range 24-32) weeks were studied at a median postmenstrual age (PMA) of 45 weeks. In addition, comparisons were made to the results of 25 infants studied at 36 weeks PMA. METHODOLOGY Infants were studied supine and prone. Breath by breath minute volume was measured at baseline and after a dead space was incorporated into the breathing circuit; the time constant of the response was calculated. The pressure generated in the first 100 msec of an occlusion (P0.1 ), the maximum inspiratory pressure during an airway occlusion and functional residual capacity (FRC) were also measured in both positions. RESULTS The median time constant was longer (38 (range 15-85) vs. 26 (range 2-40) sec (P = 0.002)). P0.1 lower (P = 0.003) and FRC higher (P = 0.031) in the prone compared to the supine position. In the prone position, the time constant correlated with PMA (P = 0.047), that is, the rate of response to added dead space was significantly damped with increasing postnatal age up to the critical age for SIDS. CONCLUSIONS The dampened rate of response to added dead space in the prone compared to the supine position lends support to the hypothesis that a poorer response to a stress may contribute to prematurely born infants increased risk of SIDS in the prone position.
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Affiliation(s)
- Tolulope Saiki
- Division of Asthma, Allergy and Lung Biology, MRC-Asthma Centre, King's College London, London, United Kingdom
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Elder DE, Campbell AJ, Larsen PD, Galletly D. Respiratory variability in preterm and term infants: Effect of sleep state, position and age. Respir Physiol Neurobiol 2011; 175:234-8. [DOI: 10.1016/j.resp.2010.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 11/18/2010] [Accepted: 11/19/2010] [Indexed: 10/18/2022]
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McMullen SL, Lipke B, LeMura C. Sudden infant death syndrome prevention: a model program for NICUs. Neonatal Netw 2009; 28:7-12. [PMID: 19176302 DOI: 10.1891/0730-0832.28.1.7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Health care providers' opinions can influence how parents place their infant to sleep. Neonatal nurses can improve how they teach and model safe infant sleep practices to parents. To increase neonatal nurses' knowledge, a sudden infant death syndrome (SIDS) prevention program was implemented. Program components included a computerized teaching tool, a crib card, sleep sacks, and discharge instructions. Initial program evaluation showed that 98 percent of infants slept supine and 93 percent slept in sleep sacks in open cribs. However, nurses continued to swaddle some infants with blankets to improve thermoregulation. To increase nursing compliance in modeling safe infant sleep practices, Halo SleepSack Swaddles were provided for nurses to use in place of a blanket to regulate infant temperature. Recent data show that 100 percent of infants in open cribs are now sleeping supine wearing a Halo Swaddle or a traditional Halo SleepSack. This model program can easily be replicated to enhance neonatal nurses' knowledge about SIDS prevention.
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Affiliation(s)
- Sherri L McMullen
- St. Joseph's Hospital Health Center, 301 Prospect Avenue, Syracuse, NY 13203, USA.
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Rao H, Saiki T, Landolfo F, Smith APR, Hannam S, Rafferty GF, Milner AD, Greenough A. Position and ventilatory response to added dead space in prematurely born infants. Pediatr Pulmonol 2009; 44:387-91. [PMID: 19283763 DOI: 10.1002/ppul.21021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Prematurely born infants are at increased risk of sudden infant death syndrome (SIDS) if slept prone. WORKING HYPOTHESIS Prematurely born infants would have an impaired response to an added dead space and lower respiratory muscle strength in the prone compared to the supine position. STUDY DESIGN Prospective study. PATIENT-SUBJECT SELECTION: Twenty-five infants, median gestational age of 30 (range 26-32) weeks. METHODOLOGY The infants were studied supine and prone at a median of 36 weeks postmenstrual age. Breath by breath minute volume was measured at baseline and after a dead space was incorporated into the breathing circuit; the time constant of the response was calculated. The maximum inspiratory occlusion pressure generated (MIOP) and the pressure generated over the first 100 msec (P(0.1)) during airway occlusion were assessed. RESULTS The median time constant was longer (26 (range 8-106) sec vs. 22 (range 6-92) sec (P = 0.045)) and the median MIOP (P = 0.001) and P(0.1) (P = 0.003) were lower in the prone compared to the supine position. CONCLUSION Prematurely born infants have a dampened response to tube breathing and reduced respiratory muscle strength in the prone compared to the supine position, which may contribute to their increased vulnerability to SIDS in the prone position.
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Affiliation(s)
- Harish Rao
- King's College London, MRC-Asthma Centre, Division of Asthma, Allergy and Lung Biology, London, UK
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Picheansathian W, Woragidpoonpol P, Baosoung C. Positioning of Preterm Infants for Optimal Physiological Development: a systematic review. ACTA ACUST UNITED AC 2009. [DOI: 10.11124/jbisrir-2009-188] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Picheansathian W, Woragidpoonpol P, Baosoung C. Positioning of Preterm Infants for Optimal Physiological Development: a systematic review. ACTA ACUST UNITED AC 2009; 7:224-259. [PMID: 27820087 DOI: 10.11124/01938924-200907070-00001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
EXECUTIVE SUMMARY Positioning of preterm infants is a basic task of neonatal nursing care. A variety of outcomes are affected by different body positioning of preterm infants. This review evaluates the clinical evidence of the effects of positioning of preterm infants with regard to physiological outcomes and sleep states. OBJECTIVES To conduct a systematic review to determine the best available evidence related to the positioning of preterm infants. The specific review questions addressed were: the physiological outcomes affected by different positioning, and the best position for promoting sleep. CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW This review considered all studies that included infants born before 37 weeks of gestational age in any hospital setting. Outcomes included measures for physiologic effects and sleep state. The review primarily considered any randomized clinical trails (RCTs) that explored different positions in preterm infant but also included quasi-experimental designs. SEARCH STRATEGY FOR IDENTIFICATION OF STUDIES The search sought to find published and unpublished studies. The database search included: Pubmed, CINAHL, ProQuest, EMBASE, Science Direct, and Dissertation Abstracts International. Studies were additionally identified from reference lists of all studies retrieved. ASSESSMENT AND DATA EXTRACTION All studies were checked for methodological quality by two reviewers and data was extracted using tools developed by the Joanna Briggs Institute. DATA ANALYSIS The study results were pooled in statistical meta-analysis using Review Manager Software and summarized in narrative form where statistical pooling was not appropriate or possible. RESULTS Thirty two studies were included in the review. The results of this review support the prone position in preterm infants for improvement of arterial oxygen saturation, improved lung and chest wall synchrony of respiratory improvements, decreased incidence of apnea in infants with a clinical history of apnea, promoted sleep, and decreased gastroesophageal reflux. However, the prone position increased postural abnormalities, orthopaedic abnormalities of the feet, and delayed developmental musculature. The combined use of a postural support roll and a postural nappy while very preterm infants are nursed, improved hip and shoulder posture up to term postmenstrual age. The change in body position from horizontal to head-up tilt in very immature and unstable infants may affect the cerebral homodynamic. The management of position per se may not be sufficient for assisting preterm neonates to cope with the painful procedure. Furthermore, preterm infants are susceptible to oxygen desaturation in car seats and carrying slings. CONCLUSION Prone positioning was shown to have many advantages for prematurely born infants. But the longer, deep sleep period and fewer awakenings associated with a prone position would support higher vulnerability for preterm infants to sudden infant death syndrome (SIDS). Therefore, all preterm infants placed in the prone position should have continuous cardio-respiratory and oxygen saturation monitoring. Preterm infants should be placed in a properly supported position to ensure functional support of all parts of the body as well as ensuring physical safety. In addition, preterm infants should not be left unattended in car safety seats and carrying slings.
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Landolfo F, Saiki T, Peacock J, Hannam S, Rafferty GF, Greenough A. Hering-Breuer reflex, lung volume and position in prematurely born infants. Pediatr Pulmonol 2008; 43:767-71. [PMID: 18618620 DOI: 10.1002/ppul.20855] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To investigate the effect of position on the strength of the Hering-Breuer reflex in prematurely born infants and determine whether any differences seen were related to differences in lung or tidal volume between positions. WORKING HYPOTHESIS Position related differences in the strength of the Hering-Breuer reflex relate to differences in lung or tidal volume. STUDY DESIGN Prospective observational study. PATIENT/SUBJECT SELECTION: Eighteen infants, median gestational age 30 (range 25-32) weeks were studied. METHODOLOGY Infants were examined in the supine and prone position, each position was maintained for 2 hr. At the end of each 2-hr period, the strength of the Hering-Breuer reflex was assessed by determining the prolongation of expiration following an end inspiratory occlusion. In addition, tidal volume and functional residual capacity (FRC) were assessed in each position. RESULTS The strength of the Hering-Breuer reflex was greater (P = 0.01) and the mean FRC was higher (P < 0.0001) in the prone compared to the supine position. The position related differences in the strength of the reflex correlated significantly with position related differences in FRC (P = 0.05). CONCLUSIONS The Hering-Breuer reflex is stronger in the prone compared to the supine position. Our results suggest this is explained by position related differences in lung volume.
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Affiliation(s)
- Francesca Landolfo
- King's College London, MRC Asthma Centre, Division of Asthma, Allergy and Lung Biology, Brunel University, London, UK
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Goberman AM, Johnson S, Cannizzaro MS, Robb MP. The effect of positioning on infant cries: implications for sudden infant death syndrome. Int J Pediatr Otorhinolaryngol 2008; 72:153-65. [PMID: 17996952 DOI: 10.1016/j.ijporl.2007.09.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 09/25/2007] [Accepted: 09/28/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE A definitive cause for sudden infant death syndrome (SIDS) has not yet been identified, but some theories point to laryngeal or respiratory causes, in addition to theories of reduced arousal or reduced autonomic response. The occurrence of SIDS has dropped since the movement to place newborns to sleep in the supine position; however, some research has found a respiratory disadvantage for infants in this position. The current paper studied acoustic characteristics of infant pain cries to determine the potential differences related to prone versus supine positioning. METHODS Fifty-one newborn infant cries were recorded during and following a blood draw screening procedure, with infants placed either in the supine or prone position. All infants were healthy, full-term infants. Complete crying episodes were audio-recorded, and results were based on compositional analysis and long-time average spectrum analysis across each crying episode. RESULTS Spectral analysis revealed acoustic differences related to infant positioning, and acoustic analysis also revealed that there were no respiratory differences between supine-positioned and prone-positioned infants. Overall, the acoustic differences suggest decreased arousal and/or a decreased response to pain for healthy infants recorded in the prone position. CONCLUSIONS As decreased arousal and prone positioning have been seen as possible causative factors for SIDS, the current results are seen as a successful step in evaluating the possibility of using acoustic analysis of infant cries as a means of evaluating SIDS risk for healthy infants.
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Affiliation(s)
- Alexander M Goberman
- Department of Communication Disorders, Bowling Green State University, 200 Health Center Building, Bowling Green, OH 43403-0149, United States.
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Di Fiore JM, Hibbs AM, Zadell AE, Merrill JD, Eichenwald EC, Puri AR, Mayock DE, Courtney SE, Ballard RA, Martin RJ. The effect of inhaled nitric oxide on pulmonary function in preterm infants. J Perinatol 2007; 27:766-71. [PMID: 17805339 DOI: 10.1038/sj.jp.7211830] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Bronchopulmonary dysplasia (BPD) in preterm infants is associated with impaired alveolar growth, inflammation and airway hyperreactivity. In animal models of BPD, inhaled nitric oxide (NO) improves alveolar growth and inhibits airway smooth muscle proliferation. This study was designed to assess the effect of inhaled NO on resistance and compliance in ventilated preterm infants with evolving BPD. STUDY DESIGN Expiratory resistance and compliance of the respiratory system were measured in 71 ventilated preterm infants, < or = 32 weeks gestation, randomized to NO (n=34) versus placebo (n=37) for > or = 24 days at 7 to 21 days of life. RESULT At baseline expiratory resistance (231+/-71 versus 215+/-76 cm H(2)O l(-1) s(-1)) and compliance (0.49+/-0.14 versus 0.53+/-0.13 ml cm H(2)O(-1) kg(-1)) were comparable between placebo and NO groups, respectively. There was no effect of NO on expiratory resistance or compliance at 1 h, 1 week or 2 weeks of study gas administration. CONCLUSION NO had no short- or medium-term effect on expiratory resistance or compliance in ventilated preterm infants.
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Affiliation(s)
- J M Di Fiore
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH, USA.
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Kassim Z, Donaldson N, Khetriwal B, Rao H, Sylvester K, Rafferty GF, Hannam S, Greenough A. Sleeping position, oxygen saturation and lung volume in convalescent, prematurely born infants. Arch Dis Child Fetal Neonatal Ed 2007; 92:F347-50. [PMID: 17012305 PMCID: PMC2675354 DOI: 10.1136/adc.2006.094078] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine whether the effects of sleeping position on lung volume and oxygenation are influenced by postmenstrual age (PMA) and oxygen dependency in convalescent prematurely born infants. DESIGN Prospective study. SETTING Tertiary neonatal unit. PATIENTS 41 infants (21 oxygen dependent), median gestational age 28 weeks (range 24-31 weeks) and birth weight 1120 g (range 556-1780 g). INTERVENTION Infants were studied both supine and prone at two-weekly intervals from 32 weeks' PMA until discharge. Each posture was maintained for 1 h. MAIN OUTCOME MEASURES Pulse oximeter oxygen saturation (Spo(2)) was monitored continuously, and at the end of each hourly period functional residual capacity (FRC) was measured. RESULTS Overall, lung volumes were higher in the prone position throughout the study period; there was no significant effect of PMA on lung volumes. Overall, Spo(2) was higher in the prone position (p = 0.02), and the effect was significant in the oxygen-dependent infants (p = 0.03) (mean difference in Spo(2) between prone and supine was 1.02%, 95% CI 0.11% to 1.92%), but not in the non-oxygen-dependent infants. There was no significant influence of PMA on Spo(2). CONCLUSION In the present study, prone sleeping did not improve oxygenation in prematurely born infants, 32 weeks' PMA or older and with no ongoing respiratory problems. However, the infants were monitored in each position for an hour, thus it is recommended that oxygen saturation should continue to be monitored after 32 weeks' PMA to be certain that longer periods of supine sleeping are not associated with loss of lung volume and hypoxaemia.
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Affiliation(s)
- Zainab Kassim
- Children Nationwide Regional Neonatal Intensive Care Centre, 4th floor, Golden Jubilee Wing, King's College Hospital, London SE5 9PJ, UK
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Greenough A. How has research in the past 5 years changed my clinical practice. Arch Dis Child Fetal Neonatal Ed 2007; 92:F404-7. [PMID: 17712188 PMCID: PMC2675370 DOI: 10.1136/adc.2006.107540] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2007] [Indexed: 11/04/2022]
Abstract
This article discusses how research in the past 5 years into management strategies influencing respiratory outcomes has changed (or not changed) the author's clinical practice. Changes include using inhaled nitric oxide but no longer systemic pulmonary vasodilators in term born infants with pulmonary hypertension. Use of postnatal steroids is now restricted to systemic administration in infants with severe respiratory failure and who are ventilator dependent beyond 2 weeks of age. Infants with bronchopulmonary dysplasia, unless they have pulmonary hypertension, are maintained at oxygen saturation levels of 90-92% rather than >/=95%. Supine sleeping is instituted in prematurely born infants without contraindications several weeks prior to neonatal discharge to reinforce to parents the importance of supine sleeping their baby at home. Further research is required to identify the optimal respiratory support strategy, particularly for very immature infants.
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Affiliation(s)
- Anne Greenough
- Deparment of Child Health, 4th Floor Golden Jubilee Wing, King's College Hospital, London SE5 9RS, UK.
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Abstract
Perspective on the paper by Kassim et al (see page 347)
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Affiliation(s)
- Christian F Poets
- Department of Neonatology, University Hospital Tübingen, Calwerstr 7, 72076 Tübingen, Germany.
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Rao H, May C, Hannam S, Rafferty GF, Greenough A. Survey of sleeping position recommendations for prematurely born infants on neonatal intensive care unit discharge. Eur J Pediatr 2007; 166:809-11. [PMID: 17103188 DOI: 10.1007/s00431-006-0325-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 09/27/2006] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Prematurely born infants are at an increased risk of sudden infant death syndrome (SIDS), particularly when sleeping prone. Parents are strongly influenced in their choice of sleeping position for their infant by practitioners. The aim of this study was to determine the neonatal units' recommendations regarding the sleeping position for premature infants prior to and after discharge and ascertain whether there had been changes from those recorded in a survey performed in 2001-2002. MATERIALS AND METHODS A questionnaire survey was sent to all 229 neonatal units in the United Kingdom; 80% responded. RESULTS AND DISCUSSION The majority (83%) of units utilized the supine sleep position for infants at least 1-2 weeks prior to discharge, but after discharge, only 38% of the units actively discouraged prone sleeping and 17% additionally recommended side sleeping. Compared to the previous survey, significantly more units started infants with supine sleeping 1-2 weeks prior to discharge (p < 0.0001) and fewer recommended side sleeping after discharge (p = 0.0015). However, disappointingly, less actively discouraged prone sleeping after discharge (p = 0.0001). CONCLUSION Recommendations regarding sleeping position for prematurely born infants after neonatal discharge by some practitioners remain inappropriate. Evidence-based guidelines are required as these would hopefully inform all neonatal units' recommendations.
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Affiliation(s)
- Harish Rao
- Division of Asthma, Allergy and Lung Biology, King's College London, MRC-Asthma Centre, Denmark Hill, UK
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Regli A, Habre W, Saudan S, Mamie C, Erb TO, von Ungern-Sternberg BS. Impact of Trendelenburg positioning on functional residual capacity and ventilation homogeneity in anaesthetised children. Anaesthesia 2007; 62:451-5. [PMID: 17448055 DOI: 10.1111/j.1365-2044.2007.05030.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Trendelenburg positioning, a head-down tilt, is routinely used in anaesthesia when inserting a central venous catheter to increase the calibre of the jugular or subclavian veins and to prevent an air embolism. We investigated the impact of Trendelenburg positioning on functional residual capacity and ventilation homogeneity as well as the potential reversibility of these changes by repositioning and/or a recruitment manoeuvre in children with congenital heart disease. Functional residual capacity and ventilation homogeneity were assessed in 20 anaesthetised children between the ages of 3 months and 8 years who required central venous catheterisation before undergoing cardiac surgery. Functional residual capacity was measured (1) in the supine position, (2) in the Trendelenburg position, (3) after repositioning supine and (4) after a recruitment manoeuvre to total lung capacity which was performed by manually elevating the airway pressure to 40 cmH(2)O for ten consecutive breaths. Adopting the Trendelenburg position led to a significant decrease in functional residual capacity (median [range]- 12 (6-21)%) and increase in lung clearance index (12 (2-19)%). Baseline values were not reached after repositioning supine in any patient until after a standardised recruitment manoeuvre was performed.
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Affiliation(s)
- A Regli
- Department of Anaesthesia, Pharmacology and Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
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Aris C, Stevens TP, Lemura C, Lipke B, McMullen S, Côté-Arsenault D, Consenstein L. NICU nurses' knowledge and discharge teaching related to infant sleep position and risk of SIDS. Adv Neonatal Care 2006; 6:281-94. [PMID: 17045948 DOI: 10.1016/j.adnc.2006.06.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Infants requiring neonatal intensive care are often placed prone during their acute illness. After hospital discharge the American Academy of Pediatrics (AAP) recommends supine sleep position to reduce the risk of Sudden Infant Death Syndrome (SIDS). Little is known about nursing knowledge and practice regarding best sleep positions for infants as they transition from neonatal intensive care to home. OBJECTIVE To explore and describe neonatal intensive care unit (NICU) nurses' knowledge and practice in the NICU, and to determine the content of parent instruction regarding infant sleep position at discharge. STUDY DESIGN This survey was conducted in 2 phases. In Phase I, a questionnaire was designed and completed by 157 neonatal nurses currently practicing in Level III and IV NICUs in the state of New York. After content analysis of responses and item revisions, a panel of experts reviewed questionnaire items. Phase II involved completion of the final questionnaire by 95 NICU nurses in 4 additional hospitals. The combined results of Phase I and II are reported. RESULTS Of 514 questionnaires distributed, 252 (49%) were completed and analyzed. During NICU hospitalization, nurse respondents identified prone position as the best general sleep position for preterm infants (65%) followed by either prone or side-lying (12%). The nurses' assessment of the infants' readiness for supine sleep position at the time of NICU discharge varied. Most nurses responded that preterm infants were ready to sleep supine anytime (29%), close to discharge (13%), when maintaining their body temperature in an open crib (25%), between 34 to 36 weeks postmenstrual age (PMA) (15%), after 37 weeks PMA (13%), and when the infant's respiratory status was stable (6%). Typical sleep positions chosen for full-term infants in the NICU were supine (40%), side or supine (30%), all positions (18%), side (8%), prone or side (3%), and prone (1%). Frequently cited reasons to place full-term infants to sleep prone were: reflux (45%), upper airway anomalies (40%), respiratory distress (29%), inconsolability (29%), and to promote development (17%). At NICU discharge, 52% of nurses instructed parents to place their infants in the supine position for sleep. The most common nonsupine sleep positions recommended by nurses at discharge were either supine or side (38%), and exclusive side positioning (9%). CONCLUSIONS Nearly 95% of respondents identified a nonsupine sleep position as optimal for hospitalized preterm infants. Further, only 52% of neonatal nurses routinely provide discharge instructions that promote supine sleep positions at home. This study suggests that nursing self-reports of discharge teaching practices are inconsistent, and in some cases in direct conflict with the national "Back to Sleep" recommendations, which emphasize that the supine position is the safest position for healthy full-term and preterm infants after hospital discharge.
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Affiliation(s)
- Christine Aris
- St. Joseph's Hospital Health Center, Syracuse, NY 13203, USA.
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Belghazi K, Tourneux P, Elabbassi EB, Ghyselen L, Delanaud S, Libert JP. Effect of posture on the thermal efficiency of a plastic bag wrapping in neonate: assessment using a thermal "sweating" mannequin. Med Phys 2006; 33:637-44. [PMID: 16878567 DOI: 10.1118/1.2163248] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
To assess the various heat exchanges with the environment a multisegment, anthropometric, thermal mannequin representing a neonate with a birth weight of 900 g has been designed. The mannequin simulates not only dry heat loss (radiative+conductive+convective body heat exchanges) but also the evaporative skin water loss which can be encountered in low-birth-weight neonates. The model was placed in the supine or prone position in a closed incubator (air temperature, 33 C; relative air humidity, 50%; air velocity below 0.1 m s(-1)). Experiments were performed with the mannequin either naked or wrapped in a flexible, plastic bag (with the head exposed) used to prevent excessive body water loss at delivery and during the following hours About 30% of the model's total surface was wetted with water. Our results demonstrated that body position does not modify dry and evaporative heat losses, whatever the experimental conditions. The plastic bag acts rapidly and reduces total heat loss by 30% to 34%, primarily through a reduction in evaporative water loss (between 5.4 and 6.7 g kg(-1) h(-1)). When the bag is present, the uncovered surface of the head accounts for about 50% of the total heat loss. This simple and inexpensive solution can be used to prevent thermal stress and dehydration in very small premature neonates.
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Affiliation(s)
- Khalid Belghazi
- DMAG EA 3901-INERIS, Faculté de Médecine, Université de Picardie Jules Verne, 3 rue des louvels, F-80036 Amiens cédex 1, France.
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Levy J, Habib RH, Liptsen E, Singh R, Kahn D, Steele AM, Courtney SE. Prone versus supine positioning in the well preterm infant: effects on work of breathing and breathing patterns. Pediatr Pulmonol 2006; 41:754-8. [PMID: 16779849 DOI: 10.1002/ppul.20435] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Premature infants with respiratory distress oxygenate better and have improved breathing synchrony when they are nursed in the prone position. We investigated whether work of breathing (WOB) is decreased in the prone position in healthy premature infants nearing discharge from the neonatal intensive care unit. Nineteen convalescing premature infants in room air were studied in both supine and prone position. Positioning order was randomized. Mean birth weight was 1358 +/- 332 (SD) g, gestational age 29.7 +/- 2.1 weeks, weight at study 1757 +/- 248 g, and age at study 33.6 +/- 1.4 days. Calibrated respiratory inductance plethysmography (RIP) was used to measure tidal volume; an esophageal catheter estimated pleural pressure. Inspiratory, elastic, and resistive WOB were calculated and were unaffected by prone versus supine positioning (P = 0.46, 0.36, and 0.87, respectively). Similarly, respiratory rate, tidal volume, minute ventilation, and lung compliance did not differ between positions. These data suggest that sleep position recommendations for healthy premature infants discharged home without oxygen should be no different than for term infants.
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Affiliation(s)
- Jennifer Levy
- Department of Pediatrics, Schneider Children's Hospital, North Shore Long Island Jewish Health System, New Hyde Park, New York 11040, USA
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