Impact of implementing 5 potentially better respiratory practices on neonatal outcomes and costs

Developing a Respiratory Quality Improvement Program to Prevent and Treat Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit

Improvements in respiratory care have resulted in improved outcomes for preterm infants over the past three decades. To target the multifactorial nature of neonatal lung diseases, neonatal intensive care units (NICUs) should consider developing comprehensive respiratory quality improvement programs that address all drivers of neonatal respiratory disease. This article presents a potential framework for developing a quality improvement program to prevent bronchopulmonary dysplasia in the NICU. Drawing on available research and quality improvement reports, the authors discuss key components, measures, drivers, and interventions that should be considered when building a respiratory quality improvement program devoted to preventing and treating bronchopulmonary dysplasia.

Outcomes of multiple gestation births compared to singleton: analysis of multicenter KID database

Background

The available data regarding morbidity and mortality associated with multiple gestation births is conflicting and contradicting.

Objective

To compare morbidity, mortality, and length of stay (LOS) outcomes between multiple gestation (twin, triplet and higher-order) and singleton births.

Methods

Data from the national multicenter Kids’ Inpatient Database of the Healthcare Cost and Utilization Project from the years 2000, 2003, 2006, 2009, 2012, and 2016 were analyzed using a complex survey design using Statistical Analysis System (SAS) 9.4 (SAS Institute, Cary NC). Neonates with ICD9 and ICD10 codes indicating singletons, twins or triplets, and higher-order multiples were included. Mortality was compared between these groups after excluding transfer outs to avoid duplicate inclusion. To analyze LOS, we included inborn neonates and excluded transfers; who died inpatient and any neonates who appear to have been discharged less than 33 weeks PMA. The LOS was compared by gestational age groups.

Results

A total of 22,853,125 neonates were analyzed for mortality after applying inclusion-exclusion criteria; 2.96% were twins, and 0.13% were triplets or more. A total of 22,690,082 neonates were analyzed for LOS. Mean GA, expressed as mean (SD), for singleton, twins and triplets, were 38.30 (2.21), 36.39 (4.21), and 32.72 (4.14), respectively. The adjusted odds for mortality were similar for twin births compared to singleton (aOR: 1.004, 95% CI:0.960–1.051, p = 0.8521). The adjusted odds of mortality for triplet or higher-order gestation births were higher (aOR: 1.33, 95% CI: 1.128–1.575, p = 0.0008) when compared to the singleton births. Median LOS (days) was significantly longer in multiple gestation compared to singleton births overall (singletons: 1.59 [1.13, 2.19] vs. twins 3.29 [2.17, 9.59] vs. triplets or higher-order multiples 19.15 [8.80, 36.38], p < .0001), and this difference remained significant within each GA category.

Conclusion

Multiple gestation births have higher mortality and longer LOS when compared to singleton births. This population data from multiple centers across the country could be useful in counseling parents when caring for multiple gestation pregnancies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-021-00135-5.

The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review

Defining improvements in healthcare can be challenging due to the need to assess multiple outcomes and measures. In neonates, although progress in respiratory support has been a key factor in improving survival, the same degree of improvement has not been documented in certain outcomes, such as bronchopulmonary dysplasia. By exploring the evolution of neonatal respiratory care over the last 60 years, this review highlights not only the scientific advances that occurred with the application of invasive mechanical ventilation but also the weakness of the existing knowledge. The contributing role of non-invasive ventilation and less-invasive surfactant administration methods as well as of certain pharmacological therapies is also discussed. Moreover, we analyze the cost-benefit of neonatal care-respiratory support and present future challenges and perspectives.

Plasma Leak From the Circulation Contributes to Poor Outcomes for Preterm Infants: A Working Hypothesis

Preterm infants are at high risk of death and disability resulting from brain injury. Impaired cardiovascular function leading to poor cerebral oxygenation is a significant contributor to these adverse outcomes, but current therapeutic approaches have failed to improve outcome. We have re-examined existing evidence regarding hypovolemia and have concluded that in the preterm infant loss of plasma from the circulation results in hypovolemia; and that this is a significant driver of cardiovascular instability and thus poor cerebral oxygenation. High capillary permeability, altered hydrostatic and oncotic pressure gradients, and reduced lymphatic return all combine to increase net loss of plasma from the circulation at the capillary. Evidence is presented that early hypovolemia occurs in preterm infants, and that capillary permeability and pressure gradients all change in a way that promotes rapid plasma loss at the capillary. Impaired lymph flow, inflammation and some current treatment strategies may further exacerbate this plasma loss. A framework for testing this hypothesis is presented. Understanding these mechanisms opens the way to novel treatment strategies to support cardiovascular function and cerebral oxygenation, to replace current therapies, which have been shown not to change outcomes.

More than Just a Fad: Building and Maintaining a Small Baby Program

Survival rate for preterm infants has improved significantly in the last decade because of advancements in care provided by NICUs. Yet, a large proportion of extremely low birth weight (ELBW) infants continue to be at risk of being discharged home from NICUs with long-term co-morbidities. Several centers have introduced and described the concept of a focused program on the care of micro-preemies and demonstrated improved processes as well as outcomes utilizing a continuous improvement approach with adoption of standardized guidelines, checklists, and shared team values. The journey and effort that it takes to develop and sustain such a program have been described less. This article discusses the process of building a Small Baby Program using a change model framework, how the organization and staff bought into the concept, as well as the accomplishments and challenges experienced during the last 3 years as the program continues to evolve and grow.

A systematic review of reports of quality improvement for bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is the most common morbidity of preterm infants, and its incidence has not responded to research and intervention efforts to the same degree as other major morbidities associated with prematurity. The complexity of neonatal respiratory care as well as persistent inter-institutional variability in BPD rates suggest that BPD may be amenable to quality improvement (QI) efforts. We present a systematic review of QI for BPD in preterm infants. We identified 22 reports from single centers and seven from collaborative efforts published over the past two decades. In almost all of the reports, respiratory QI interventions successfully reduced BPD or other key respiratory measures, particularly for infants with birth weight over 1000 g. Several themes and lessons from existing reports may help inform future efforts in both research and QI to impact the burden of BPD.

Hippocampal epigenetic and insulin-like growth factor alterations in noninvasive versus invasive mechanical ventilation in preterm lambs

BACKGROUND

The brain of chronically ventilated preterm human infants is vulnerable to collateral damage during invasive mechanical ventilation (IMV). Damage is manifest, in part, by learning and memory impairments, which are hippocampal functions. A molecular regulator of hippocampal development is insulin-like growth factor 1 (IGF1). A gentler ventilation strategy is noninvasive respiratory support (NRS). We tested the hypotheses that NRS leads to greater levels of IGF1 messenger RNA (mRNA) variants and distinct epigenetic profile along the IGF1 gene locus in the hippocampus compared to IMV.

METHODS

Preterm lambs were managed by NRS or IMV for 3 or 21 days. Isolated hippocampi were analyzed for IGF1 mRNA levels and splice variants for promoter 1 (P1), P2, and IGF1A and 1B, DNA methylation in P1 region, and histone covalent modifications along the gene locus.

RESULTS

NRS had significantly greater levels of IGF1 P1 (predominant transcript), and 1A and 1B mRNA variants compared to IMV at 3 or 21 days. NRS also led to more DNA methylation and greater occupancy of activating mark H3K4 trimethylation (H3K4me³), repressive mark H3K27me³, and elongation mark H3K36me³ compared to IMV.

CONCLUSIONS

NRS leads to distinct IGF1 mRNA variant levels and epigenetic profile in the hippocampus compared to IMV.

IMPACT

Our study shows that 3 or 21 days of NRS of preterm lambs leads to distinct IGF1 mRNA variant levels and epigenetic profile in the hippocampus compared to IMV. Preterm infant studies suggest that NRS leads to better neurodevelopmental outcomes later in life versus IMV. Also, duration of IMV is directly related to hippocampal damage; however, molecular players remain unknown. NRS, as a gentler mode of respiratory management of preterm neonates, may reduce damage to the immature hippocampus through an epigenetic mechanism.

Introduction of a Quality Improvement Bundle Is Associated with Reduced Exposure to Mechanical Ventilation in Very Preterm Infants

INTRODUCTION

Exposure to mechanical ventilation (MV) is a risk factor for bronchopulmonary dysplasia (BPD) in very preterm infants (VPTIs). We assessed the impact of a quality improvement (QI) bundle in VPTIs (<32 week gestation) on exposure to MV.

METHODS

We introduced a QI bundle consisting of deferred cord clamping (DCC), nasal bubble continuous positive airway pressure (bCPAP) in the delivery room (DR), and minimally invasive surfactant therapy (MIST). We compared respiratory outcomes and neonatal morbidity in historical pre-QI (July-December 2017) and prospective post-QI (February-July 2019) cohorts (QICs) of VPTIs. We pre-specified an adjusted analysis to account for the effects of gestational age, sex, antenatal steroids, and any demographic data that significantly differed between cohorts.

RESULTS

The pre-QI and post-QICs included 87 and 98 VPTIs, respectively. The post-QIC had decreased rates of MV in the DR (adjusted odds ratio [aOR] 0.26, 95% confidence interval [CI] 0.09-0.71), in the first 72 h of life (aOR 0.27, 95% CI 0.11-0.62) and during admission (aOR 0.28, 95% CI 0.12-0.66). Rates of BPD, combined BPD/death, and BPD severity were similar. The post-QIC was less likely to be discharged with home oxygen (aOR 0.27, 95% CI 0.08-0.91). Necrotising enterocolitis grade ≥2 increased (aOR 19.01, 95% CI 1.93-188.6) in the post-QIC.

CONCLUSION

In this rapid-cycle QI study, implementation of a QI bundle consisting of DCC, early nasal bCPAP, and MIST in VPTIs was associated with reduced rates of MV in the DR, in the first 72 h of life and during admission, and reduced need for home oxygen.

A Quality Improvement Project to Standardize Surfactant Delivery in the Era of Noninvasive Ventilation

Introduction:

Continuous positive airway pressure (CPAP) and surfactant both improve outcomes for premature infants with respiratory distress syndrome. However, prolonged trials of CPAP, as well as observation periods after intubation, may delay the administration of surfactant. Late surfactant treatment likely increases the incidence of bronchopulmonary dysplasia, which leads to significant morbidity and healthcare utilization.

Methods:

We aimed to decrease time from meeting standard criteria (start of a continuous run of F_iO₂ > 40% or P_aCO₂ > 65 for >90 min) to intubation, and from intubation to surfactant administration, for infants <1,500 g or younger than 32 weeks gestation. Retrospective data collection from the electronic medical record assessed those process measures as the primary endpoints. Balancing measures were the adverse outcomes of asymmetric lung disease, the inappropriate position of the endotracheal tube, or pneumothorax on the first x-ray (within 24 h) after surfactant.

Results:

Mean time to intubation for infants 28–32 weeks gestation decreased from 321 to 81 minutes in response to a literature review for physicians and free-text orders for notification. Time to intubation for infants younger than 28 weeks gestation did not change. Administration of surfactant within 1 hour of intubation improved from 78% to 100% after a program for trainees and coordination with radiology. There were no adverse occurrences.

Conclusions:

Educational interventions and targeted process change can successfully implement standard criteria for intubation and surfactant administration for premature infants. Determination of an acceptable range of evidence-based practice is essential for the engagement of medical staff. Timely intubation and surfactant may decrease bronchopulmonary dysplasia.

Decreasing Chronic Lung Disease Associated with Bubble CPAP Technology: Experience at Five Years

Introduction:

Bubble continuous positive airway pressure (bCPAP) is associated with a decreased risk for chronic lung disease (CLD) in preterm neonates. This report examined the effectiveness of adopting bCPAP to reduce respiratory complications and medication usage in a community hospital NICU.

Methods:

The efficacy of bCPAP was assessed by retrospective examination and comparison of 45 neonates who received bCPAP and 87 neonates who received conventional ventilation only. Data on medication usage were also collected and analyzed.

Results:

After introduction of the bCPAP protocol, the median number of days on oxygen decreased in the bCPAP group compared with the conventional ventilation only group (median = 33 days, IQR = 7.5–66 vs median = 0, IQR = 0–0; P < 0.001). The exposure to conventional ventilation decreased in the bCPAP group compared with the conventional ventilation only group (median = 18 days, IQR = 5–42.5 vs median = 0, IQR = 0–7; P < 0.001). Postimplementation of bCPAP revealed decreases in CLD from 26 (30%) in the conventional ventilation only group to 2 (4%) in the bCPAP group (P = 0.002); there was also a significant decrease in the use of sedative medications in the bCPAP group compared with the conventional ventilation only group (mean = 5.20 doses, SD = 31.97 vs mean = 1.43, SD = 9.98; P < 0.001).

Conclusion:

The use of bCPAP results in significant decreases in the use of conventional ventilation, the risk for CLD, and the need for sedative medication.

Improving Respiratory Support Practices to Reduce Chronic Lung Disease in Premature Infants

Supplemental Digital Content is available in the text.

Introduction:

We implemented a bundle of respiratory care practices and optimized delivery of continuous positive airway pressure (CPAP) to reduce the incidence of chronic lung disease (CLD) among very low birth weight (VLBW) infants born before 33 weeks gestation.

Methods:

Our multidisciplinary task force utilized 6 plan-do-study-act cycles to test our interventions. The primary outcome was the quarterly percentage of infants diagnosed with CLD; other outcomes included the percentage of infants initially managed with CPAP, intubation <72 hours of age, use of a nasal cannula, and days of ventilation, oxygen, and/or CPAP. Process measures included compliance with each of the 5 components of the bundle; balancing measures included mortality and complications of prematurity.

Results:

Demographics were similar in the 55 infants born before and 76 infants born after the task force interventions, except for gestational age, which was lower before. CLD decreased by 55.5% (from 37.5% to 16.7%). Quarterly percentage of infants requiring intubation decreased from 87.5% to 40.8%. Quarterly average days of ventilation decreased from 11.2 to 6.1, and days of supplemental oxygen declined from 44.1 to 25.4, while the use of CPAP increased. There were no differences in adverse events including mortality, pneumothorax, use of postnatal steroids, or any retinopathy of prematurity. The incidence of patent ductus arteriosus declined from 60% to 33% (P < 0.01).

Conclusions:

We reduced the incidence of CLD among our very low birth weight infants born before 33 weeks gestation by over 50% without increasing any measured adverse outcomes. The incidence of patent ductus arteriosus declined.

Neuroprotective Care of Extremely Preterm Infants in the First 72 Hours After Birth

Birth at extremely low gestational ages presents a significant threat to infants' survival, health, development, and future well-being. After birth, a critical period of brain development must continue outside the womb. Neuro-supportive and neuroprotective family centered developmental care for and standardized care practices for extremely preterm infants have been shown to improve outcomes. Neuroprotective interventions must include a focus on the emotional connections of infants and their families. Being in skin-to-skin contact with the mother is the developmentally expected environment for all mammals and is especially important for supporting physiologic stability and neurodevelopment of preterm infants.

Exploring paediatric residents' perceptions of competency in neonatal intensive care

Assessment and stabilization of the newborn are expected competencies of trainees graduating from Canadian paediatrics residency training programs. There is limited evidence regarding the optimal approach to training, and whether such competencies are actually achieved by graduates. A national, cross-sectional survey was developed to explore paediatrics residents' self-reported experiences in performing neonatal procedures and resuscitation skills. Survey questions were constructed based on the review of the Royal College of Physicians and Surgeons of Canada objectives of training in paediatrics to include activities necessary in the assessment and stabilization of the newborn. The survey was distributed to residents across Canada. A total of 138 residents from 15 Canadian paediatrics residency training programs completed the survey. A minority of residents (17%) reported independently performing resuscitative skills (positive pressure ventilation, intubation and umbilical line insertion). Of all the different neonatal procedural skills, only lumbar puncture was reported as an activity that residents on average performed independently by senior years of training. Our study showed a direct relationship between the number of completed blocks of Neonatal Intensive Care Unit (NICU) and self-reported experiences in providing NICU resuscitation skills and procedures. We found an inverse relationship between the exposure to cross-cover calls and such experiences. Our study showed that a minority of paediatrics residents self-report evidence of competency in performing neonatal procedures and resuscitation skills. As residency programs are transitioning toward competence-based education, it is important to gain more insights with respect to strengths, deficiencies and opportunities for paediatrics residency training in terms of NICU experiences.

Evaluating the efficacy of Seattle-PAP for the respiratory support of premature neonates: study protocol for a randomized controlled trial

BACKGROUND

At birth, the majority of neonates born at <30 weeks of gestation require respiratory support to facilitate transition and ensure adequate gas exchange. Although the optimal approach to the initial respiratory management is uncertain, the American Academy of Pediatrics endorses noninvasive respiratory support with nasal continuous positive airway pressure (nCPAP) for premature neonates with respiratory insufficiency. Despite evidence for its use, nCPAP failure, requiring intubation and mechanical ventilation, is common. Recently, investigators have described a novel method to deliver bubble nCPAP, termed Seattle-PAP. While preclinical and pilot studies are encouraging regarding the potential value of Seattle-PAP, a large trial is needed to compare Seattle-PAP directly with the current standard of care for bubble nCPAP (Fisher & Paykel CPAP or FP-CPAP).

METHODS/DESIGN

We designed a multicenter, non-blinded, randomized controlled trial that will enroll 230 premature infants (22^0/7 to 29^6/7 weeks of gestation). Infants will be randomized to receive Seattle-PAP or FP-CPAP. The primary outcome is respiratory failure requiring intubation and mechanical ventilation. Secondary outcomes include measures of short- and long-term respiratory morbidity and cost-effectiveness.

DISCUSSION

This trial will assess whether Seattle-PAP is more efficacious and cost-effective than FP-CPAP in real-world practice among premature neonates.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03085329 . Registered on 21 March 2017.

Provider Perceptions of Bubble Continuous Positive Airway Pressure and Barriers to Implementation in a Level III Neonatal Unit in South India

BACKGROUND

Bubble continuous positive airway pressure (bCPAP) is a simple, safe, and cost-effective strategy to provide respiratory support to newborns with respiratory distress syndrome in resource-limited settings.

PURPOSE

To understand whether implementation of bCPAP, relative to other modes of respiratory support in the care of newborns with respiratory distress syndrome, increases positive attitudes about its potential for consistent and widespread use among providers in neonatal intensive care units (NICUs) of lower middle-income countries.

METHODS

Semistructured qualitative interviews with 14 healthcare providers, including 5 neonatal nurses, 2 respiratory therapists, 5 postgraduate trainees in pediatrics, and 2 attending physicians, were conducted at a level III NICU in south India where bCPAP had been in consistent use for 6 years. Interviews were transcribed and then coded and categorized using NVivo 10 Software (QSR International, Victoria, Australia).

FINDINGS

Categories that emerged from our data include (1) perceived indications, (2) learning curve, (3) perceived costs, (4) perceived shortages, and (5) barriers to use. Providers believed that bCPAP was easy to learn and that it helped empower neonatal nurses in decision-making process. Participants provided a nuanced perspective of cost-benefit associated with bCPAP and that it helped make optimal use of limited resources. Participants identified several barriers to the implementation of bCPAP.

IMPLICATIONS FOR PRACTICE

Providers of a level III NICU in a lower- to middle-income country viewed the use of bCPAP favorably. Addressing context-specific barriers will be important for the successful widespread implementation of bCPAP.

IMPLICATIONS FOR RESEARCH

Further research will need to focus on whether bCPAP can be safely implemented at level II NICUs.Video Abstract Available at https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx.

Resource utilization patterns using non-invasive ventilation in neonates with respiratory distress syndrome

OBJECTIVES

To describe the frequency of non-invasive ventilation (NIV) and endotracheal intubation use in neonates diagnosed with respiratory distress syndrome (RDS); to describe resources utilization (length of stay (LOS), charges, costs) among NIV and intubated RDS groups.

STUDY DESIGN

Retrospective study from the national Kid's Inpatient Database of the Healthcare Cost and Utilization Project, for the years 1997-2012. Propensity scoring and multivariate regression analysis used to describe differences.

RESULTS

A total of 595,254 out of 42,912,090 cases were identified with RDS. There was an increase in NIV use from 6% in 1997 to 17% in 2012. After matching, patients receiving NIV only were associated with shorter LOS: (95%CI) 25 (25.3,25.7) vs. 35 (34.2,34.9) days, decreased costs: ($/1k) 46.1 (45.5,46.8) vs. 65.0 (64.1,66.0), decreased charges: 130.3 (128.6,132.1) vs. 192.1 (189.5,194.6) compared to intubated neonates.

CONCLUSION

There was a three-fold increase in NIV use within the 15-year study period. NIV use was associated with decreased LOS, charges and costs compared to intubated patients.

Effects of underwater bubble CPAP on very-low-birth-weight preterm newborns in the delivery room and after transport to the neonatal intensive care unit

The development of less invasive ventilatory strategies in very-low-birth-weight (VLBW) preterm newborns has been a growing concern in recent decades. This study aimed to measure differences in the clinical progression of preterm newborns using two distinct periods in a university hospital: before and after using underwater bubble continuous positive airway pressure (ubCPAP). This is a retrospective study of VLBW preterm newborns with gestational ages less than or equal to 32 weeks admitted to the neonatal intensive care unit. The time series was divided into two groups: a pre-CPAP group ( n = 45) and a post-CPAP group ( n = 40). The post-CPAP group had fewer resuscitations, required fewer surfactant doses, spent fewer days on mechanical ventilation, and demonstrated less of a need for fraction of inspired oxygen > 30%. UbCPAP is an easy to use, minimally invasive, and effective ventilatory strategy for VLBW preterm newborns that can be used in environments with limited resources. Thus, adopting this simple strategy as part of a service organization and health policy can positively impact outcomes.

Preventing Continuous Positive Airway Pressure Failure: Evidence-Based and Physiologically Sound Practices from Delivery Room to the Neonatal Intensive Care Unit

Routine use of continuous positive airway pressure (CPAP) to support preterm infants with respiratory distress is an evidenced-based strategy to decrease incidence of bronchopulmonary dysplasia. However, rates of CPAP failure remain unacceptably high in very premature neonates, who are at high risk for developing bronchopulmonary dysplasia. Using the GRADE framework to assess the quality of available evidence, this article reviews strategies aimed at decreasing CPAP failure, starting with delivery room interventions and followed through to system-based efforts in the neonatal intensive care unit. Despite best efforts, some very premature neonates fail CPAP. Also reviewed are predictors of CPAP failure in this vulnerable population.

Quality improvement to reduce chronic lung disease rates in very-low birth weight infants: high compliance with a respiratory care bundle in a small NICU

OBJECTIVE

Reduce chronic lung disease by 10% among very-low birth weight infants by implementing a consistent respiratory care bundle.

STUDY DESIGN

Prospective quality improvement study of infants below 32 weeks gestation in a small neonatal intensive care unit. A respiratory care bundle to eliminate inter-provider variability and minimize use of mechanical ventilation was implemented. This included: defining delivery room management with use of continuous positive airway pressure/nasal intermittent positive pressure ventilation, uniform intubation/extubation criteria, and standardizing ventilation/post-extubation support.

RESULTS

A total of 107 very-low birth weight infants were included in this project. Compliance with the respiratory care bundle was >90%. Chronic lung disease rates at 36 weeks postmenstrual age fell from 43 to 12% (P = 0.0006), rates of combined chronic lung disease/death decreased from 50 to 20% (P = 0.002, OR = 0.25, 95% CI 0.1-0.6), rates of severe intraventricular hemorrhage decreased from 13 to 0% (P = 0.005), and surgical ligation of patent ductus arteriosus decreased from 35 to 3% (P < 0.0001).

CONCLUSION

High compliance with the respiratory care bundle was achieved and a 73% reduction in chronic lung disease rates in very-low birth weight infants occurred.

Using Quality Improvement Tools to Reduce Chronic Lung Disease

Rates of chronic lung disease (CLD) in very low birthweight infants have not decreased at the same pace as other neonatal morbidities over the past 20 years. Multifactorial causes of CLD make this common morbidity difficult to reduce, although there have been several successful quality improvement (QI) projects in individual neonatal intensive care units. QI projects have become a mainstay of neonatal care over the past decade, with an increasing number of publications devoted to this topic. A specific QI project for CLD must be based on best available evidence in the medical literature, expert recommendations, or based on work by previous QI initiatives.

Effects of delivery room quality improvement on premature infant outcomes

OBJECTIVE

Delivery room management interventions have been successfully implemented via collaborative quality improvement (QI) projects. However, it is unknown whether these successes translate to reductions in neonatal morbidity and mortality.

STUDY DESIGN

This was a prospective pre-post intervention study of three nonrandomized hospital groups within the California Perinatal Quality Care Collaborative. A collaborative QI model (Collaborative QI) was compared with a single-site QI model (NICU QI) and a non-participant population when implementing evidence-based delivery room practices. The intervention period was between June 2011 and May 2012. Infants born with gestational age between 22 weeks 0 days and 29 weeks 6 days and birth weight ⩽1500 g were included. Outcomes were mortality and select morbidities (bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and necrotizing enterocolitis (NEC)). Outcomes were compared between the baseline (January 2010 to May 2011) and post-intervention period (June 2012 to May 2013) within each comparison group.

RESULTS

Ninety-five hospitals were included with 4222 infants in the baseline period and 4186 infants in the post-intervention period. The Collaborative QI group had significantly reduced odds of developing BPD post-intervention (odds ratio (OR) 0.8, 95% confidence interval (CI) 0.65 to 0.99) or composite BPD-death (OR 0.83, 95% CI 0.69 to 1.00). In both the Collaborative QI and non-participants there were also reductions in IVH, severe IVH, composite severe IVH-death, severe ROP and composite severe ROP-death.

CONCLUSION

Hospitals dedicated to improving delivery room practices can impact neonatal outcomes.

The role and limitations of Cochrane reviews at the bedside: a systematic synopsis of five pediatric subspecialties

BACKGROUND

Cochrane meta-analyses provide the physician at the bedside with the most relevant, up-to-date clinical information. However, implementation of evidence-based medicine (EBM) at the bedside may be difficult for a variety of reasons. The aim of this study was to assess relevant issues and obstacles related to implementing EBM in pediatrics in real life at the bedside/cotside.

METHODS

We performed five systematic literature reviews of all published Cochrane reviews in neonatology (1996-2010), pediatric neurology (1996-2010), pediatric gastroenterology (1993-2012), pediatric cardiology (2001-2015), and complementary and alternative medicine (1996-2012; CAM) in children and neonates. In all five analyses, the main outcome variables were percentage of reviews concluding that a certain intervention provides a benefit, percentage of reviews concluding that a certain intervention should not be performed, and percentage of studies concluding that the current level of evidence is inconclusive.

RESULTS

In all five areas of pediatrics, a substantial number of Cochrane reviews yielded inconclusive data (neonatology: 46.6%; neuropediatrics: 26.8%; pediatric gastroenterology: 27.9%; pediatric cardiology: 42.9%; complementary and alternative medicine: 66.9%).

CONCLUSIONS

Our up-dated systematic synopsis reiterates the need for high-quality, sophisticated research to reduce the number of inconclusive meta-analyses in the field of pediatrics-most importantly in the field of complementary and alternative medicine (CAM), neonatology, and pediatric cardiology. The realization of high-quality, clinically driven research will in turn yield more systematic reviews with a clear conclusion (e. g., in favor or against a certain intervention, or treatment modality), thus, substantively decreasing the proportion of inconclusive reviews.

Quality improvement project: implementing guidelines supporting noninvasive respiratory management for premature infants

PURPOSE

Based on research evidence, the purpose was to implement noninvasive approaches in the initial respiratory stabilization of preterm infants.

DESIGN

Quality improvement project.

SAMPLE

One hundred fourteen infants admitted to the neonatal intensive care nursery (NICN) from January 1, 2012 to May 31, 2012 served as a historical control group. Ninety-four infants admitted from January 1, 2013 to May 31, 2013 served as the intervention group.

RESULTS

After implementation of the quality improvement initiative, there was a statistically significant increase in the rate of using continuous positive airway pressure (CPAP ) by 65.3 percent for initial respiratory stabilization of preterm infants.

Efficacy and safety of CPAP in low- and middle-income countries

We conducted a systematic review to evaluate the (1) feasibility and efficacy and (2) safety and cost effectiveness of continuous positive airway pressure (CPAP) therapy in low- and middle-income countries (LMIC). We searched the following electronic bibliographic databases-MEDLINE, Cochrane CENTRAL, CINAHL, EMBASE and WHOLIS-up to December 2014 and included all studies that enrolled neonates requiring CPAP therapy for any indication. We did not find any randomized trials from LMICs that have evaluated the efficacy of CPAP therapy. Pooled analysis of four observational studies showed 66% reduction in in-hospital mortality following CPAP in preterm neonates (odds ratio 0.34, 95% confidence interval (CI) 0.14 to 0.82). One study reported 50% reduction in the need for mechanical ventilation following the introduction of bubble CPAP (relative risk 0.5, 95% CI 0.37 to 0.66). The proportion of neonates who failed CPAP and required mechanical ventilation varied from 20 to 40% (eight studies). The incidence of air leaks varied from 0 to 7.2% (nine studies). One study reported a significant reduction in the cost of surfactant usage with the introduction of CPAP. Available evidence suggests that CPAP is a safe and effective mode of therapy in preterm neonates with respiratory distress in LMICs. It reduces the in-hospital mortality and the need for ventilation thereby minimizing the need for up-transfer to a referral hospital. But given the overall paucity of studies and the low quality evidence underscores the need for large high-quality studies on the safety, efficacy and cost effectiveness of CPAP therapy in these settings.

Non-invasive ventilation with bubble CPAP is feasible and improves respiratory physiology in hospitalised Malawian children with acute respiratory failure

BACKGROUND

In low-income countries and those with a high prevalence of HIV, respiratory failure is a common cause of death in children. However, the role of non-invasive ventilation with bubble continuous positive airway pressure (bCPAP) in these patients is not well established.

METHODS

A prospective observational study of bCPAP was undertaken between July and September 2012 in 77 Malawian children aged 1 week to 14 years with progressive acute respiratory failure despite oxygen and antimicrobial therapy.

RESULTS

Forty-one (53%) patients survived following bCPAP treatment, and an HIV-uninfected single-organ disease subgroup demonstrated bCPAP success in 14 of 17 (82%). Compared with children aged ≧60 months, infants of 0-2 months had a 93% lower odds of bCPAP failure (odds ratio 0·07, 95% confidence interval 0·004-1·02, P  =  0·05). Following commencement of bCPAP, respiratory physiology improved, the average respiratory rate decreased from 61 to 49 breaths/minute (P  =  0·0006), and mean oxygen saturation increased from 92·1% to 96·1% (P  =  0·02).

CONCLUSIONS

bCPAP was well accepted by caregivers and patients and can be feasibly implemented into a tertiary African hospital with high-risk patients and limited resources.

Early Bubble Continuous Positive Airway Pressure: Investigating Interprofessional Best Practices for the NICU Team

Premature neonates delivered <32 completed weeks gestation are unprepared to handle the physiologic demands of extrauterine life. Within the respiratory system, alveolar instability and collapse can cause decreased functional residual capacity, impaired oxygenation, and hypoxemia leading to respiratory distress syndrome. Supportive measures are indicated immediately after birth to establish physiologic stability including bubble continuous positive airway pressure (CPAP) or endotracheal intubation and mechanical ventilation. CPAP is a noninvasive, gentle mode of ventilation that can mitigate the effects of lung immaturity, but prolonged use can increase the risk for nasal breakdown. Strategies to mitigate this risk must be infused as best practices in the NICU environment. The purpose of this article is to propose an evidence-based best practice care bundle for the early initiation of CPAP in the delivery room and associated skin barrier protection strategies for premature neonates <32 weeks gestation and weighing <1,500 g.

Prenatal interventions to prevent bronchopulmonary dysplasia in animal models: a systematic review

OBJECTIVE

The objective of this study is to identify and systematically review in vivo animal studies on antenatal medical interventions to prevent bronchopulmonary dysplasia.

METHODS

An automated literature search was conducted using MEDLINE (Pubmed) and Embase including all studies using Medical Subject Headings (MeSH) and keywords following a step-by-step approach. All in vivo prenatal intervention studies in animal models mimicking key aspects of the pathophysiology of bronchopulmonary dysplasia were included. In view of relevance of the findings, an additional criterion was that outcomes at 48 h of life or beyond were available. The PRISMA statement concerning systemic reviews was applied and a quality checklist developed by the CAMARADES group was used.

RESULTS

In total, 518 abstracts were identified yet only eight studies were eligible for further analysis. Four studies involved administration of glucocorticoids, the other studies described therapy with epidermal growth factor, interleukin 1b, beta-naphthoflavone, or vitamin D. Outcomes were survival, pulmonary histology, lung function, and/or biochemical analysis.

CONCLUSIONS

Though many in vivo experimental studies in animal models for bronchopulmonary dysplasia have been done, only few have looked into the effect of prenatal interventions and measured outcomes after at least 48 h of life. Most involve the use of antenatal glucocorticoids, although still only four.

Small Baby Unit Improves Quality and Outcomes in Extremely Low Birth Weight Infants

OBJECTIVE

The survival rates for extremely low birth weight (ELBW) infants have improved, but many are discharged from the hospital with significant challenges. Our goal was to improve outcomes for this population by using a multidisciplinary team-based quality improvement approach.

METHODS

A unique program called the Small Baby Unit (SBU) was established in a children's hospital to care for the ELBW infant born at 28 weeks or less and weighing less than 1000 g at birth. These patients were cared for in a separate location from the main neonatal unit. A core multidisciplinary team that participates in ongoing educational and process-improvement collaboration provides care. Evidence-based guidelines and checklists standardized the approach.

RESULTS

Data from the 2 years before and 4 years after opening the SBU are included. There was a reduction in chronic lung disease from 47.5% to 35.4% (P = .097). The rate of hospital-acquired infection decreased from 39.3% to 19.4% (P < .001). Infants being discharged with growth restriction (combined weight and head circumference <10th percentile) decreased from 62.3% to 37.3% (P = .001). Reduced resource utilization was demonstrated as the mean number per patient of laboratory tests decreased from 224 to 82 (P < .001) and radiographs decreased from 45 to 22 (P < .001).

CONCLUSIONS

Care in a distinct unit by a consistent multidisciplinary SBU team using quality improvement methods improved outcomes in ELBW infants. Ongoing team engagement and development are required to sustain improved outcomes.

Economic Impact of Changes in Neonatal Intensive Care Unit Ventilation Strategies with the Advent of New Noninvasive Ventilation Techniques: A Review and Proposed Assessment Framework for High Flow Therapy as a Routine Respiratory Support Paradigm

Background: High flow therapy (HFT) has been demonstrated to be a safe and effective noninvasive respiratory support technique for the treatment of pre-term infants in neonatal intensive care. Objectives: Our objective was to develop a quantitative framework based on available evidence to estimate the economic impact of adoption of a HFT respiratory support strategy compared to current standard of care. Methods: Model parameters were derived from a recent study comparing respiratory modality utilization between five US-based neonatal intensive care units (NICUs) adopting a HFT strategy and a larger pool of NICUs in the Vermont-Oxford Network (VON), and from single center experience. We computed the total cost difference between the respiratory support strategies based on published cost data. Parameter uncertainty was tested in sensitivity analyses. Results: The constructed model projected expected cost savings of $2,317 for the HFT strategy for the base case. Results were sensitive to length of HFT use, length of CMV, cost of HFT, and length of nCPAP support. Conclusions: Adoption of a HFT strategy appears to be associated with meaningful savings in total NICU episode of care costs, primarily because of reductions in the time of conventional mechanical ventilation. Further research is warranted to substantiate these findings.

[Changes in the outcome for infants, with birth weight under 500 grams, at our department (First Department of Obstetrics and Gynecology, Semmelweis University, Budapest)]

INTRODUCTION

The mortality and morbidity of extremely low birth weight infants (birth weight below 1000 grams) are different from low birth weight and term infants. The Centers for Disease Control statistics from the year 2009 shows that the mortality of preterm infants with a birth weight less than 500 grams is 83.4% in the United States. In many cases, serious complications can be expected in survivals.

AIM

The aim of this retrospective study was to find prognostic factors which may improve the survival of the group of extremely low birth weight infants (<500 grams).

METHOD

Data of extremely low birth weight infants with less than 500 grams born at the 1st Department of Obstetrics and Gynecology, Semmelweis University between January 1, 2006 and June 1, 2012 were analysed, and mortality and morbidity of infants between January 1, 2006 and December 31, 2008 (period I) were compared those found between January 1, 2009 and June 1, 2012 (period II). Statistical analysis was performed with probe-t, -F and -Chi-square.

RESULTS

Survival rate of extremely low birth weight infants less than 500 grams in period 1 and II was 26.31% and 55.17%, respectively (p = 0.048), whereas the prevalence of complications were not significantly different between the period examined. The mean gestational age of survived infants (25.57 weeks) was higher than the gestational age of infants who did not survive (24.18 weeks) and the difference was statistically significant (p = 0.0045).

CONCLUSIONS

Education of the team of the Neonatal Intensive Care Unit, professional routine and technical conditions may improve the survival chance of preterm infants. The use of treatment protocols, conditions of the Neonatal Intensive Care Unit and steroid prophylaxis may improve the survival rate of extremely low birth weight infants.

Comparison of the effect of surfactant administration during nasal continuous positive airway pressure with that of nasal continuous positive airway pressure alone on complications of respiratory distress syndrome: a randomized controlled study

BACKGROUND

Studies on early surfactant administration during nasal continuous positive airway pressure (NCPAP) [intubate-surfactant-extubate (INSURE)] have used continuous positive airway pressure and INSURE in the first hours after birth, but in many centers patients are transported from far away hospitals, reaching the center at a later time. The aim of this study was to compare the effect of INSURE with only NCPAP in the management of respiratory distress syndrome (RDS) in an outborn hospital.

METHODS

This study was a controlled randomized clinical trial on 60 neonates who were transported to the neonatal intensive care unit of Boo-Ali Sina Hospital. Neonates born at 27(0)/7 to 34(6)/7 weeks of gestation, aged ≤12 hours, and diagnosed with RDS were placed on NCPAP and then randomly assigned to INSURE or NCPAP alone. The primary outcome was the need for intubation and mechanical ventilation on the basis of the criteria defined by us, and the secondary outcomes were neonatal mortality and other complications of RDS.

RESULTS

In 13 months, 60 eligible neonates were enrolled. Our participants in INSURE group received surfactant at the mean age of 5.1 hours. The relative risk of need for mechanical ventilation was 0.55 (95% confidence interval: 0.15-1.9, p = 0.53), and the rate of mortality or other complications of RDS was statistically similar between the two groups.

CONCLUSION

After the first few hours of life (mean age of 5.1 hours), the rate of mortality and chronic lung disease and the need for mechanical ventilation were not statistically different between patients receiving INSURE and those in receipt of NCPAP alone.

Impact of the systematic introduction of low-cost bubble nasal CPAP in a NICU of a developing country: a prospective pre- and post-intervention study

Background

The use of Nasal Continuous Positive Airway Pressure Ventilation (NCPAP) has begun to increase and is progressively replacing conventional mechanical ventilation (MV), becoming the cornerstone treatment for newborn respiratory distress syndrome (RDS). Howerver, NCPAP use in Lower-Middle Income Countries (LMICs) is poor. Moreover, bubble NCPAP (bNCPAP), for efficacy, cost effectiveness, and ease of use, should be the primary assistance technique employed in newborns with RDS.

Objective: To measure the impact on in-hospital newborn mortality of using a bNCPAP device as the first intervention on newborns requiring ventilatory assistance.

Methods

Design: Prospective pre-intervention and post-intervention study.

Setting: The largest Neonatal Intensive Care Unit (NICU) in Nicaragua.

Participants: In all, 230 (2006) and 383 (2008) patients were included.

Intervention: In May 2006, a strategy was introduced to promote the systematic use of bNCPAP to avoid intubation and MV in newborns requiring ventilatory assistance. Data regarding gestation, delivery, postnatal course, mortality, length of hospitalisation, and duration of ventilatory assistance were collected for infants assisted between May and December 2006, before the project began, and between May and December 2008, two years afterwards.

Outcome measures: The pre- vs post-intervention proportion of newborns who died in-hospital was the primary end point. Secondary endpoints included rate of intubation and duration of NICU stay.

Results

Significant differences were found in the rate of intubation (72 vs 39%; p < 0.0001) and the proportion of patients treated exclusively with bNCPAP (27% vs 61%; p <0.0001). Mortality rate was significantly reduced (40 vs 23%; p < 0.0001); however, an increase in the mean duration of NICU stay was observed (14.6 days in 2006 and 17.5 days in 2008, p = 0.0481).

The findings contribute to the evidence that NCPAP, particularly bNCPAP, is the first-line standard of care for efficacy, cost effectiveness, and ease of use in newborns with respiratory distress in LMICs.

Conclusions

This is the first extensive survey performed in a large NICU from a LMICs, proving the efficacy of the systematic use of a bNCPAP device in reducing newborn mortality. These findings are an incentive for considering bNCPAP as an elective strategy to treat newborns with respiratory insufficiency in LMICs.

A preterm pig model of lung immaturity and spontaneous infant respiratory distress syndrome

Respiratory distress syndrome (RDS) and bronchopulmonary dysplasia remain the leading causes of preterm infant morbidity, mortality, and lifelong disability. Research to improve outcomes requires translational large animal models for RDS. Preterm pigs delivered by caesarian section at gestation days (GD) 98, 100, 102, and 104 were provided 24 h of neonatal intensive care, monitoring (pulse oximetry, blood gases, serum biomarkers, radiography), and nutritional support, with or without intubation and mechanical ventilation (MV; pressure control ventilation with volume guarantee). Spontaneous development of RDS and mortality without MV are inversely related with GD at delivery and correspond with inadequacy of tidal volume and gas exchange. GD 98 and 100 pigs have consolidated lungs, immature alveolar architecture, and minimal surfactant protein-B expression, and MV is essential at GD 98. Although GD 102 pigs had some alveoli lined by pneumocytes and surfactant was released in response to MV, blood gases and radiography revealed limited recruitment 1-2 h after delivery, and mortality at 24 h was 66% (35/53) with supplemental oxygen provided by a mask and 69% (9/13) with bubble continuous positive airway pressure (8-9 cmH2O). The lungs at GD 104 had higher densities of thin-walled alveoli that secreted surfactant, and MV was not essential. Between GD 98 and 102, preterm pigs have ventilation inadequacies and risks of RDS that mimic those of preterm infants born during the saccular phase of lung development, are compatible with standards of neonatal intensive care, and are alternative to fetal nonhuman primates and lambs.

Staff and parents are discriminators for outcomes in neonatal intensive care units

AIM

We investigated the associations between staff work characteristics, parents' experiences and a number of medical outcome measures.

METHODS

This explorative multicentre study took place in the neonatal intensive care units (NICUs) of five German university hospitals between 2009 and 2011. We assessed staff work characteristics by surveying 126 NICU nurses and 57 physicians and asked 214 parents about their relationships with staff. The outcome variables of 230 premature infants with birth weights of less than 1500 g were collected over a period of 18 months. We used analysis of variance (ANOVA) and regression analyses for statistical purposes.

RESULTS

We found differences in outcome measures between the NICUs, particularly parameters of respiratory support, weight gain and length of stay. When we controlled for the NICUs' baseline factors, perceptions of the relationship between staff and parents (empathy, p < 0.001; conversation duration and frequency, p < 0.05; familiarity, p < 0.05) and staff work characteristics (workload, p < 0.05) were associated with at least one of these outcome measures.

CONCLUSION

Staff and parents were discriminators for neonatal outcomes through perceptions of work characteristics and the relationship between staff and parents, respectively. Respiratory support and nutrition measures were particularly sensitive. This research has prompted a nationwide, multicentre study of 66 NICUs.

High-frequency nasal ventilation for 21 d maintains gas exchange with lower respiratory pressures and promotes alveolarization in preterm lambs

BACKGROUND

Short-term high-frequency nasal ventilation (HFNV) of preterm neonates provides acceptable gas exchange compared to endotracheal intubation and intermittent mandatory ventilation (IMV). Whether long-term HFNV will provide acceptable gas exchange is unknown. We hypothesized that HFNV for up to 21 d would lead to acceptable gas exchange at lower inspired oxygen (O2) levels and airway pressures compared to intubation and IMV.

METHODS

Preterm lambs were exposed to antenatal steroids and treated with perinatal surfactant and postnatal caffeine. Lambs were intubated and resuscitated by IMV. At ~3 h of age, half of the lambs were switched to noninvasive HFNV. Support was for 3 or 21 d. By design, Pao2 and Paco2 were not different between groups.

RESULTS

At 3 d (n = 5) and 21 d (n = 4) of HFNV, fractional inspired O2 (FiO2), peak inspiratory pressure (PIP), mean airway, intratracheal, and positive end-expiratory pressures, oxygenation index, and alveolar-arterial gradient were significantly lower than matched periods of intubation and IMV. Pao2/FiO2 ratio was significantly higher at 3 and 21 d of HFNV compared to matched intubation and IMV. HFNV led to better alveolarization at 3 and 21 d.

CONCLUSION

Long-term HFNV provides acceptable gas exchange at lower inspired O2 levels and respiratory pressures compared to intubation and IMV.

That chorioamnionitis is a risk factor for bronchopulmonary dysplasia--the case against

Bronchopulmonary dysplasia (BPD) is the most frequent long term sequelae in infants born at less than 29 weeks of gestational age (GA) and histological chorioamnionitis (CA) is the most frequent condition associated with very preterm birth. Numerous studies have explored the association between BPD and CA with conflicting results. This inconsistency may be attributable to differences in populations, definitions, methods, and whether potential confounding factors such as GA, antenatal steroids, and post natal events were considered. A recent systematic review and meta-analysis shows some evidence of an association between BPD and CA; however, results adjusting for important confounders show more conservative measures of association. In addition, there was evidence of publication bias: when controlling for publication bias the results were more conservative and adjusted results were no longer significant. Recent large cohort studies not included in the systematic review do not support the belief that CA is associated with an increased risk of BPD. Despite a large body of evidence, CA cannot be definitively considered a risk factor for BPD.

Improving delivery room management for very preterm infants

BACKGROUND AND OBJECTIVES

Events in the delivery room significantly impact the outcomes of preterm infants. We developed evidence-based guidelines to prevent heat loss, reduce exposure to supplemental oxygen, and increase use of noninvasive respiratory support to improve the care and outcomes of infants with birth weight ≤1250 g at our institution.

METHODS

The guidelines were implemented through multidisciplinary conferences, routine use of a checklist, appointment of a dedicated resuscitation nurse, and frequent feedback to clinicians. This cohort study compares a historical group (n = 80) to a prospective group (n = 80, after guidelines were implemented). Primary outcome was axillary temperature at admission to the intensive care nursery. Secondary outcomes measured adherence to the guidelines and changes in clinically relevant patient outcomes.

RESULTS

Baseline characteristics of the groups were similar. After introduction of the guidelines, average admission temperatures increased (36.4°C vs 36.7°C, P < .001) and the proportion of infants admitted with moderate/severe hypothermia fell (14% vs 1%, P = .003). Infants were exposed to less oxygen during the first 10 minutes (P < .001), with similar oxygen saturations. Although more patients were tried on continuous positive airway pressure (40% vs 61%, P = .007), the intubation rate was not significantly different (64% vs 54%, P = .20). Median durations of invasive ventilation and hospitalization decreased after the quality initiative (5 vs 1 days [P = .008] and 80 vs 60 days [P = .02], respectively).

CONCLUSIONS

We have demonstrated significantly improved quality of delivery room care for very preterm infants after introduction of evidence-based delivery room guidelines. Multidisciplinary involvement and continuous education and reinforcement of the guidelines permitted sustained change.

Systematic Cochrane reviews in neonatology: a critical appraisal

BACKGROUND

There is a lack of up-to-date, systematic reviews that critically assess the role and potential limitations of evidence-based medicine (EBM) and systematic reviews in neonatology.

METHODS

We performed a systematic literature review of all Cochrane reviews published between 1996 and 2010 by the Cochrane Neonatal Review Group (CNRG). Main outcome parameter: assessment of the percentage of reviews that concluded that a certain intervention provides a benefit, the percentage of reviews that concluded that no benefit was seen, and the percentage of studies that concluded that the current level of evidence is inconclusive.

RESULTS

In total, 262 reviews were assessed, most of which included exclusively preterm infants (146/262). The majority of reviews assessed pharmacological interventions (145/262); other important fields included nutritional (46/262), and ventilatory issues (27/262). In 42/262 reviews, a clear recommendation in favor of a specific intervention was given, whereas 98/262 reviews concluded that certain interventions should not be performed. However, the largest proportion of reviews was inconclusive (122/262) and did not issue specific recommendations. The proportion of inconclusive reviews increased from 30% (1996-2000), to 50% (2001-2005), and finally to 58% for the years 2006-2010. Common reasons for inconclusive reviews were the small number of patients (105), insufficient data (94), insufficient methodological quality (87), and heterogeneity of studies (69).

CONCLUSION

There is an ongoing need for high-quality research in order to reduce the proportion of inconclusive meta-analyses in the field of neonatology. Funding and research agencies will play a vital role in selecting the most appropriate research programs.

Impact of changes in perinatal care on neonatal respiratory outcome and survival of preterm newborns: an overview of 15 years

Survival and outcomes for preterm infants with respiratory distress syndrome (RDS) have improved over the past 30 years. We conducted a study to assess the changes in perinatal care and delivery room management and their impact on respiratory outcome of very low birth weight newborns, over the last 15 years. A comparison between two epochs was performed, the periods before and after 2005, when early nasal continuous positive airway pressure (NCPAP) and Intubation-SURfactant-Extubation (INSURE) were introduced in our center. Three hundred ninety-five clinical records were assessed, 198 (50.1%) females, gestational age 29.1 weeks (22–36), and birth weight 1130 g (360–1498). RDS was diagnosed in 247 (62.5%) newborns and exogenous surfactant was administered to 217 (54.9%). Thirty-three (8.4%) developed bronchopulmonary dysplasia (BPD), and 92 (23%) were deceased. With the introduction of early NCPAP and INSURE, there was a decrease on the endotracheal intubation need and invasive ventilation (P < 0.0001), oxygen therapy (P = 0.002), and mortality (P < 0.0001). The multivariate model revealed a nonsignificant reduction in BPD between the two epochs (OR = 0.86; 95% CI 0.074–9.95; P = 0.9). The changes in perinatal care over the last 15 years were associated to an improvement of respiratory outcome and survival, despite a nonsignificant decrease in BPD rate.