Non-invasive versus invasive respiratory support in preterm infants

Respiratory insufficiency is almost ubiquitous in infants born preterm, with its incidence increasing with lower gestational age. A wide range of respiratory support management strategies are available for these infants, separable into non-invasive and invasive forms of respiratory support. Here we review the history and evolution of respiratory care for the preterm infant and then examine evidence that has emerged to support a non-invasive approach to respiratory management where able. Continuous positive airway pressure (CPAP) is the non-invasive respiratory support mode currently with the most evidence for benefit. CPAP can be delivered safely and effectively and can commence in the delivery room. Particularly in early life, time spent on non-invasive respiratory support, avoiding intubation and mechanical ventilation, affords benefit for the preterm infant by virtue of a lessening of lung injury and hence a reduction in incidence of bronchopulmonary dysplasia. In recent years, enthusiasm for application of non-invasive support has been further bolstered by new techniques for administration of exogenous surfactant. Methods of less invasive surfactant delivery, in particular with a thin catheter, have allowed neonatologists to administer surfactant without resort to endotracheal intubation. The benefits of this approach appear to be sustained, even in those infants subsequently requiring mechanical ventilation. This cements the notion that any reduction in exposure to mechanical ventilation leads to alleviation of injury to the vulnerable preterm lung, with a long-lasting effect. Despite the clear advantages of non-invasive respiratory support, there will continue to be a role for intubation and mechanical ventilation in some preterm infants, particularly for those born <25 weeks' gestation. It is currently unclear what role early non-invasive support has in this special population, with more studies required.

Determining reference data for overnight oximetry in neonates: A pilot study

OBJECTIVE

To determine the variability of overnight oximetry parameters in a group of normal, healthy term infants; to enable the calculation of the number of subjects required to produce reliable reference ranges for neonatal overnight oximetry.

METHODS

A convenience sample of normal, healthy term neonates was recruited. Each had overnight oximetry using the Masimo SET Radical oximeter (data downloaded using Profox software). The report included the number of oxygen desaturation events (an absolute decrease in SpO₂ of 4 or more), and the duration of oxygen saturations <90%.

RESULTS

21 babies were recruited with data available from 19. 32% were female; 68% born by vaginal delivery; 37% fully breast feeding, 53% bottle and 11% by a combination of both. The mean (SD) GA was 39.2 (0.79) weeks, the mean (SD) BW was 3477 (240) grams. The median (IQR) post-natal age at the time the oximetry recording started was 31 (28-41) hours; four babies were <24 h old. All babies had some desaturation events ranging from 4 to 36 times per hour. On average babies spent 3.0% (SD 2.3) of the time with an SpO₂ < 90% (range 0.12-7.94).

CONCLUSIONS

In a cohort of healthy term neonates, as assessed by overnight oximetry, the mean SpO₂ was 97% (SD 1, range 95-99). All neonates had a number of oxygen desaturation events ranging from 4 to 36 per hour. The mean proportion of time spent with oxygen saturations below 90% was around 3%.

A novel case of neonatal acute respiratory distress syndrome with SARS-CoV-2 infection: potential perinatal transmission

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is the first pandemic of the 21st century. SARS-CoV-2 infection is mainly transmitted via droplets. Although some cases of perinatal transmission have been reported, it is unclear whether these infections occurred via transplacental or transcervical routes or via environmental exposure. Herein, we present the case of a newborn who died with neonatal acute respiratory distress syndrome exhibiting severe pulmonary involvement. The baby was born to a COVID-19 PCR (+) mother by C-section and was found to be COVID-19 PCR (+) from a nasopharyngeal swab sample tested within 24 hours of birth due to the suspected transplacental transmission of SARS-CoV-2 from the mother to the fetus.

Severe haemophilia A in a preterm girl with Turner syndrome: case report - a diagnostic and therapeutic challenge for a paediatrician (Part 2)

BACKGROUND

Haemophilia A is an X-linked genetic condition which manifests itself mainly in male children in the first 2 years of life, during gross motor skill development. This disorder is rare in females. The clinical manifestation of severe haemophilia in preterm infants poses a great challenge to the therapeutic team. As extreme prematurity is linked to an increased risk of central nervous system or gastrointestinal bleeding, a well-informed and balanced treatment from the first days of life is crucial to prevent long-term damage. Haemophilia is most commonly caused by inheriting defective genes, and can also be linked to skewed X inactivation and Turner syndrome. The coincidental occurrence of haemophilia A and Turner syndrome is extremely rare, with only isolated cases described to date. Hence, a multidisciplinary approach is needed.

CASE PRESENTATION

The authors report on a preterm girl (gestational age 28 weeks) diagnosed with haemophilia and Turner syndrome. The first manifestation of haemophilia was prolonged bleeding from injection sites on the second day of life. Indeterminate aPTT and factor VIII level < 1% confirmed the diagnosis of haemophilia A. Dysmorphic features which did not match the typical clinical picture of haemophilia, the female sex, and a negative paternal family history led to the diagnosis of Turner syndrome. While in hospital, the girl received multiple doses of recombinant factor VIII in response to prolonged bleedings from the injection sites and from a nodule on the girl's head, and before and after retinal laser photocoagulation. No central nervous system or abdominal cavity bleeding was observed. The substitutive therapy was complicated by the development of factor VIII inhibitor (anti-factor VIII (FVIII) antibodies). Treatment was continued with recombinant factor VIIa. This article aims at demonstrating the complexity of the diagnostics and treatment of a preterm child with two genetic disorders.

CONCLUSIONS

Haemophilia should always be considered in the differential diagnosis of prolonged bleeding, even in patients with a negative family history. In the case of coinciding atypical phenotypic features, further diagnostics for another genetic disease are recommended. Infant care should follow current care standards, while considering certain individual features.

Neonatal mortality associated with perinatal asphyxia: a population-based study in a middle-income country

Background

It is challenging to decrease neonatal mortality in middle-income countries, where perinatal asphyxia is an important cause of death. This study aims to analyze the annual trend of neonatal mortality with perinatal asphyxia according to gestational age in São Paulo State, Brazil, during a 10-year period and to verify demographic, maternal and neonatal characteristics associated with these deaths.

Methods

Population-based study of neonatal deaths associated with perinatal asphyxia from 0 to 27 days in São Paulo State, Brazil, from 2004 to 2013. Perinatal asphyxia was considered as associated to death if intrauterine hypoxia, birth asphyxia or neonatal aspiration of meconium were noted in any line of the Death Certificate according to ICD-10. Poisson Regression was applied to analyze the annual trend of neonatal mortality rate according to gestational age. Kaplan-Meier curve was used to assess age at death during the 10-year study period. Hazard ratio of death during the neonatal period according to gestational age was analyzed by Cox regression adjusted by year of birth and selected epidemiological factors.

Results

Among 74,002 infant deaths in São Paulo State, 6648 (9%) neonatal deaths with perinatal asphyxia were studied. Neonatal mortality rate with perinatal asphyxia fell from 1.38‰ in 2004 to 0.95‰ in 2013 (p = 0.002). Reduction started in 2008 for neonates with 32–41 weeks, in 2009 for 28–31 weeks, and in 2011 for 22–27 weeks. Median time until 50% of deaths occurred was 25.3 h (95%CI: 24.0; 27.2). Variables independently associated with higher risk of death were < 7 prenatal visits, 1st minute Apgar score 0–3, and death at the same place of birth. Cesarean delivery compared to vaginal was protective against death with perinatal asphyxia for infants at 28–36 weeks.

Conclusions

There was an expressive reduction in neonatal mortality rates associated with perinatal asphyxia during this 10-year period in São Paulo State, Brazil. Variables associated with these deaths highlight the need of public health policies to improve quality of regionalized perinatal care.

Annual trend of neonatal mortality and its underlying causes: population-based study - São Paulo State, Brazil, 2004-2013

BACKGROUND

Population-based studies analyzing neonatal deaths in middle-income countries may contribute to design interventions to achieve the Sustainable Development Goals, established by United Nations. This study goal is to analyze the annual trend of neonatal mortality in São Paulo State, Brazil, over a 10-year period and its underlying causes and to identify maternal and neonatal characteristics at birth associated with neonatal mortality.

METHOD

A population-based study of births and deaths from 0 to 27 days between 2004 and 2013 in São Paulo State, Brazil, was performed. The annual trend of neonatal mortality rate according to gestational age was analyzed by Poisson or by Negative Binomial Regression models. Basic causes of neonatal death were classified according to ICD-10. Association of maternal demographic variables (block 1), prenatal and delivery care variables (block 2), and neonatal characteristics at birth (block 3) with neonatal mortality was evaluated by Poisson regression analysis adjusted by year of birth.

RESULTS

Among 6,056,883 live births in São Paulo State during the study period, 48,309 died from 0 to 27 days (neonatal mortality rate: 8.0/1,000 live births). For the whole group and for infants with gestational age 22-27, 28-31, 32-36, 37-41 and ≥ 42 weeks, reduction of neonatal mortality rate was, respectively, 18 %, 15 %, 38 %, 53 %, 31 %, and 58 %. Median time until 50 % of deaths occurred was 3 days. Main basic causes of death were respiratory disorders (25 %), malformations (20 %), infections (17 %), and perinatal asphyxia (7 %). Variables independently associated with neonatal deaths were maternal schooling, prenatal care, parity, newborn sex, 1st minute Apgar, and malformations. Cesarean delivery, compared to vaginal, was protective against neonatal mortality for infants at 22-31 weeks, but it was a risk factor for those with 32-41 weeks.

CONCLUSIONS

Despite the significant decrease in neonatal mortality rate over the 10-year period in São Paulo State, improved access to qualified health care is needed in order to avoid preventable neonatal deaths and increase survival of infants that need more complex levels of assistance.

Severe haemophilia a in a preterm girl with turner syndrome - a case report from the prenatal period to early infancy (part I)

BACKGROUND

Bleedings are more frequent in the population of preterm children than among those born at term, much less in older children. The reasons for such bleedings in preterms include plasma factor deficiencies, immaturity of small vessels in the germinal matrix region, prenatal hypoxia or sepsis. They affect the brain tissue, the gastrointestinal tract and the respiratory system, or are manifested by prolonged bleedings from injection sites. Haemophilia is a rare cause of haemorrhages in the neonatal period, and in the female population it is even seen as an extremely rare disorder. Its aetiology in girls is diverse: inheriting defective genes from their parents, skewed X inactivation or a single X chromosome.

CASE PRESENTATION

The article presents a case of a preterm girl born in the 28th week of pregnancy, who was diagnosed with severe haemophilia A stemming from the absence of the X chromosome. The girl's father is healthy, but her mother's brother suffers from haemophilia. On the second day of the child's life, a prolonged bleeding from the injection site was observed. A coagulation profile revealed prolonged APTT which pointed to haemophilia A diagnosis. Moreover, a marked clinical dysmorphy, female sex and a negative family history on the father's side led the treating team to extend the diagnostic procedures to encompass karyotype evaluation. The girl was diagnosed with Turner syndrome. No bleeding to the central nervous system was observed during her hospital stay.

CONCLUSIONS

Preterm children belong to the risk group of bleeding into the central nervous system or haemorrhages in the course of sepsis. Rare causes of such bleedings should also be borne in mind, including haemophilia. The initial symptoms of haemophilia in preterm children occur in the first days of their lives, which is connected with a number of invasive procedures required in that period. Genetic conditions may coexist with one another. Arriving at one diagnosis does not mean one should abandon further diagnostic procedures in cases where additional atypical symptoms are present which do not match the clinical image of a primary disease.

Prognostic role of acute kidney injury on long-term outcome in infants with hypoxic-ischemic encephalopathy

BACKGROUND

The objective of this study was to evaluate the prognostic role of postnatal acute kidney injury (AKI) on neurodevelopmental outcome in infants with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia (TH).

METHODS

This is a prospective observational study including all neonates with HIE receiving TH between 2009 and 2016 at a single center. AKI was classified according to the Kidney Disease: Improving Global Outcomes definition modified for neonatal age. Child development was assessed using the Griffiths Mental Development Scales (GMDS). Study outcome was defined as unfavorable outcome (including death or disability according to GMDS) or favorable otherwise, at 12 and 24 months.

RESULTS

One-hundred and one neonates (median gestational age 39 weeks) were included. AKI was diagnosed in 10 neonates (10%). Seven patients died within the first year, 35 patients had disability at 12 months, and 45 patients at 24 months. AKI was associated with increased likelihood of unfavorable outcome at 24 months (100% vs. 59% in neonates without AKI; p = 0.01). AKI showed good positive predictive value (1.00, 95% CI 0.71-1.00) and specificity (1.00, 95% CI 0.88-1.00), but poor negative predictive value (0.41, 95% CI 0.30-0.52) and sensitivity (0.19, 95% CI 0.11-0.32) at 24 months.

CONCLUSIONS

AKI might be a reliable indicator of death or long-term disability in infants with HIE receiving TH, but the absence of AKI does not guarantee a favorable long-term outcome.

Tracheal suctioning of meconium at birth for non-vigorous infants: a systematic review and meta-analysis

CONTEXT

The International Liaison Committee on Resuscitation sought to review the initial management of non-vigorous newborns delivered through meconium stained amniotic fluid (MSAF).

OBJECTIVE

To complete a systematic review and meta-analysis comparing endotracheal intubation and suctioning to immediate resuscitation without intubation for non-vigorous infants born at ≥34 weeks gestation delivered through MSAF.

DATA SOURCES

Medline, EMBASE, the Cochrane Database of Systematic Reviews, and other registries were searched from 1966 to November 7, 2019.

STUDY SELECTION

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

DATA EXTRACTION

Reviewers extracted data, appraised risk of bias, and assessed Grading of Recommendations Assessment, Development and Evaluation certainty of evidence for each outcome.

RESULTS

Four randomized controlled trials (RCTs) included 581 patients and one observational study included 231 patients. No significant differences were observed between the group treated with tracheal suctioning compared with immediate resuscitation for survival at discharge (4 RCTs; risk ratio [RR] = 1.01; 95 % CI, 0.96-1.06; p = 0.69; observational study; no deaths), hypoxic ischemic encephalopathy and meconium aspiration syndrome.

LIMITATIONS

The certainty of evidence was low for survival at discharge and very low for all other outcomes.

CONCLUSIONS

For non-vigorous newborns delivered through MSAF, there is insufficient evidence to suggest routine immediate direct laryngoscopy with tracheal suctioning.

PROSPERO

CRD42019122778.

CLINICAL TRIALS REGISTRATION

PROSPERO; CRD42019122778.

Neuronal vulnerability to fetal hypoxia-reoxygenation injury and motor deficit development relies on regional brain tetrahydrobiopterin levels

Hypertonia is pathognomonic of cerebral palsy (CP), often caused by brain injury before birth. To understand the early driving events of hypertonia, we utilized magnetic resonance imaging (MRI) assessment of early critical brain injury in rabbit fetuses (79% term) that will predict hypertonia after birth following antenatal hypoxia-ischemia. We examined if individual variations in the tetrahydrobiopterin cofactor in the parts of the brain controlling motor function could indicate a role in specific damage to motor regions and disruption of circuit integration as an underlying mechanism for acquiring motor disorders, which has not been considered before. The rabbit model mimicked acute placental insufficiency and used uterine ischemia at a premature gestation. MRI during the time of hypoxia-ischemia was used to differentiate which individual fetal brains would become hypertonic. Four brain regions collected immediately after hypoxia-ischemia or 48 h later were analyzed in a blinded fashion. Age-matched sham-operated animals were used as controls. Changes in the reactive nitrogen species and gene expression of the tetrahydrobiopterin biosynthetic enzymes in brain regions were also studied. We found that a combination of low tetrahydrobiopterin content in the cortex, basal ganglia, cerebellum, and thalamus brain regions, but not a unique low threshold of tetrahydrobiopterin, contributed etiologically to hypertonia. The biggest contribution was from the thalamus. Evidence for increased reactive nitrogen species was found in the cortex. By 48 h, tetrahydrobiopterin and gene expression levels in the different parts of the brain were not different between MRI stratified hypertonia and non-hypertonia groups. Sepiapterin treatment given to pregnant dams immediately after hypoxia-ischemia ameliorated hypertonia and death. We conclude that a developmental tetrahydrobiopterin variation is necessary with fetal hypoxia-ischemia and is critical for disrupting normal motor circuits that develop into hypertonia. The possible mechanistic pathway involves reactive nitrogen species.

[Hypertrophic cardiomyopathy in preterm newborn with kidney transplanted mother]

Hypertrophic cardiomyopathy in the newborn is a rare entity with heterogeneous etiology. Transient forms have been described in children of mothers with gestational diabetes and in preterm infants exposed both to prenatal and postnatal corticosteroids. We report a case of a preterm infant son of a mother who received renal transplant in whom hypertrophic cardiomyopathy was detected. He had been prenatally exposed to corticosteroids and tacrolimus that received the mother as immunosuppressive therapy. Both drugs cross the placental barrier and, on reaching the fetus, could have favored its development. Hypertrophic cardiomyopathy may be an uncommon side effect of treatment with tacrolimus in adults and children and it is reversible upon withdrawal. To our knowledge, it is the first published case of transient hypertrophic cardiomyopathy after fetal exposure to both corticosteroids and tacrolimus in the son of a renal transplanted mother.

Netherton syndrome: A neonatal case with respiratory insufficiency

Netherton syndrome (NS) is a rare, autosomal recessive disease characterized with congenital ichthyosiform erythroderma, hair abnormality and atopic manifestations. This syndrome is caused by recessive mutation in the SPINK5 gene. Disease manifestations vary considerably among NS individuals. We report a newborn presented with severe respiratory insufficiency, hypothermia and erythroderma, was diagnosed as having NS and confirmed with molecular genetic testing.

Prevalence of respiratory pathogens during two consecutive respiratory syncytial virus seasons at a tertiary medical care center

AIM

To determine the etiological profiles of lower respiratory tract infection (LRI) in neonates during respiratory syncytial virus(RSV) season, and to define the clinical features of RSV-related infection and others.

METHODS

The retrospective study included newborn infants who were hospitalized for LRI during the two consecutive RSV seasons, and then tested for possible etiological agent by multiplex real-time polymerase chain reaction. All relevant data were reviewed, and the clinical characteristics of RSV-related infection were compared to those of others.

RESULTS

Of 224 patients, 160 (71 %) were positive for at least one potentially causative agent. Of them, 65 % had RSV, and 15 % had more than on ecausative agent (co-infection). The RSV group had more the findings of respiratory distress (p< 0.01), abnormal chest radiography (p< 0.01), need for intensive care (p< 0.01), and duration of oxygen requirement (p< 0.01) but less fever on admission and duration of antibiotic use (for both, p< 0.01), and no longer hospital stay. Need of intensive care nursery was more common in patients with co-infection than others (25 % vs. 6.5 %, p< 0.01).

CONCLUSIONS

This study highlighted that RSV was the most frequent agent in neonates hospitalized for LRI during the season, with a more severe clinical course than other detected pathogens. The disease severity of RSV infection may have seemed to be increased by the presence of coinfection and abnormal chest radiography.

[Phenotype study of SCN2A gene related epilepsy]

Objective: To summarize the phenotype of epileptic children with SCN2A mutations. Methods: Epileptic patients who were treated in the Pediatric Department of Peking University First Hospital from September 2006 to October 2017 and detected with SCN2A mutations by targeted next-generation sequencing were enrolled. Clinical manifestations of all patients were analyzed retrospectively. Results: A total of 21 patients (16 boys and 5 girls) with SCN2A mutations were collected. Twenty-one SCN2A mutations were identified. Ten patients had mutations inherited from one of their parents and 11 patients had de novo mutations. The age of epilepsy onset was from 2 days to 2 years and 6 months: six patients with seizure onset in neonates (29%) , six patients with seizure onset between 1 month and 3 months of age (29%), three patients with seizure onset between 4 months and 6 months of age, two patients with seizure onset between 7 months and one year of age, and four patients with seizure onset beyond one year of age. Multiple seizure types were observed. The focal seizure was the most common seizure type which was observed in 18 patients (86%) . Spasm seizure was observed in 6 patients (29%) . Other seizure types were rare. In 19 patients, seizures manifested in clusters (90%) . In 3 patients, seizures manifested fever-sensitive. Nine of ten patients with inherited SCN2A mutations had normal development. However, all patients with de novo SCN2A mutations had mild or severer development delay. In 21 patients with SCN2A mutations, five were diagnosed with benign familial infantile epilepsy, 3 with benign familial neonatal-infantile epilepsy, 3 with Ohtahara syndrome, 3 with West syndrome, 2 with encephalopathy with early infantile onset epilepsy, one with febrile seizures plus, one with Dravet syndrome, one with encephalopathy with childhood-onset epilepsy, one with autism with epilepsy and one with intellectual disability with epilepsy. Conclusions: The clinical features of patients with SCN2A mutations include that main seizure onset is the neonate and early infancy, and the main seizure type is the focal seizure, manifested in clusters. The large spectrum of SCN2A-related epilepsy, which not only includes epilepsy with a comparatively favorable prognosis, but also epileptic encephalopathy. De novo mutations often lead to severe phenotype with development delay.

Neurodevelopmental outcomes of the late preterm infant

Late preterm infants (born at 34^0/7-36^6/7 weeks gestation) have been found to have increased morbidity and mortality compared to full term infants. Research has also been done to explore longer-term neurodevelopmental outcomes. This review details neurodevelopmental outcomes from birth to adulthood for late preterm infants. Outcome studies indicate that they are at increased risk of developmental disability, school failure, behavior problems, social and medical disabilities, and death. Many questions still remain regarding late preterm infant neurodevelopmental outcomes and future research should be done into this topic. Given the high prevalence of late preterm births, even small differences in abilities, special education, and length of education may have broader consequences.

Rigid endoscope-assisted orotracheal intubation for vallecular cyst surgery in neonates and young infants

OBJECTIVES

To investigate the outcomes of rigid endoscope-assisted orotracheal intubation (REI) in neonates and young infants with difficult airway conditions as an alternative intubation technique when more specific airway instruments are not available in most developing countries, and to evaluate the safety and advantages of this method.

METHODS

Neonatal and young infantile patients undergoing vallecular cyst surgery with a Cormack-Lehane Grade 3 or 4 glottic view between June 2013 and June 2015 were studied. Fifteen patients were intubated using rigid endoscopic assistance. Fifteen other patients who were intubated using the conventional technique were selected from the previous consecutive cases and used as a matched control group.

RESULTS

REI was successfully performed in all 15 patients in one intubation attempt. The anesthetic preparation duration for the REI group was 6 min (interquartile range 5-7 min), which was shorter than the anesthetic preparation duration for patients intubated using the conventional technique (15 min [interquartile range 10-20 min], p < 0.001). The time required for intubation with a rigid endoscope was 66.5 s (interquartile range 58-74 s). No volume reduction of cysts or tracheotomies was needed in the REI group, and no cysts were ruptured nor did laryngeal mucosa damage occur with this technique. Among patients of conventional group, one required a tracheotomy, and four required cyst volume reduction by needle aspiration. No residual lesions or recurrence were observed during one year of postoperative follow-up in the REI group, and two recurrences were observed in the conventional group.

CONCLUSION

REI, which used common pieces of equipment in an otolaryngology operating room, may be a safe and feasible alternative for intubation in neonatal and young infantile patients with vallecular cysts or other difficult airway conditions.

A quality improvement initiative to reduce central line infection in neonates using checklists

Central line associated blood stream infections (CLABSI) are the most common complication of central catheters in neonates. These infections increase length of hospital stay, hospital costs and impact on mortality and morbidities. We performed a quasi-experimental study, over 24 months, utilising a pre-post design to determine the impact checklists had on central line infections. We introduced checklists for insertion, daily maintenance and procedural access based on the existing clinical guideline. Infections and compliance were monitored and reported back to the unit each month. We utilised the interrupted time series analysis to evaluate the impact of introduction of the checklists. Over the 24 months, 318 infants were included with a total of 509 central lines inserted. In the post intervention phase, definite CLABSI rates declined by 41%, from 13.8 definite CLABSIs per 1000 central-line days to 7.8 definite CLABSIs per 1000 central-line days. There was significant change in the mean levels in the post intervention phase (coefficient crude -0.01015; 95% CI -0.01980-0.00051, p value 0.039). Checklist compliance for insertion was 70%, and daily maintenance compliance overall mean was 66%.

CONCLUSION

Our quality improvement initiative using checklists, supported with education and feedback, significantly reduced CLABSI in our neonatal unit. What is Known: • Central line associated blood stream infection (CLABSI) continue to cause mortality and morbidity in the neonatal population. • Bundles of intervention use quality improvement methodology to reduce CLABSI and checklists can assist with the introduction of these. What is New: • Checklists assist with reducing central line infection. • To ensure the success of checklists, robust education, leadership and continuous feedback are vital.

Performances of low level hospital health caregivers after a neonatal resuscitation course

Background

High fidelity simulation has been executed to allow the evaluation of technical and non-technical skills of health caregivers. Our objective was to assess technical and non-technical performances of low level hospitals health caregivers who attended a Neonatal Resuscitation course using high fidelity simulation in a standard-setting scenario.

Methods

Twenty-three volunteers were asked to manage a simple scenario (infant with secondary apnea) after the course. Technical and non-technical skills were assessed by using previously published scores. Performances were assessed during the scenario and after 2 months by filmed video recordings.

Results

Sixteen (69.5%) participants failed to pass the minimum required technical score. Staff experience and participation in previous courses were associated to higher score in technical and non-technical skills, while working in level I or II hospitals did not affect the scores. Previous experience in neonatal resuscitation requiring positive pressure ventilation was associated to better non-technical performance. Technical and non-technical scores were significantly correlated (r = 0.67, p = 0.0005). Delayed and direct evaluation of technical skills provided the same scores.

Conclusions

A neonatal resuscitation course, performed by using a high fidelity simulation manikin, had a limited impact on technical and non-technical skills of participants working in low level hospitals. Training programs should be tailored to the participants’ professional background and to the more relevant sessions.

A randomised controlled trial of flow driver and bubble continuous positive airway pressure in preterm infants in a resource-limited setting

OBJECTIVES

The variable-flow flow driver (FD; EME) and continuous-flow bubble (Fisher-Paykel) continuous positive airway pressure (CPAP) systems are widely used. As these differ in cost and technical requirements, determining comparative efficacy is important particularly where resources are limited.

DESIGN

We performed a randomised, controlled, equivalence trial of CPAP systems. We specified the margin of equivalence as 2 days. We analysed binary variables by logistical regression adjusted for gestation, and log transformed continuous variables by multiple linear regression adjusted for gestation, sex and antenatal steroids.

SETTING

A neonatal unit with no blood gas analyser or surfactant availability and limited X-ray and laboratory facilities

PATIENTS

Neonates <37 weeks of gestation.

INTERVENTIONS

We provided CPAP at delivery followed by randomisation to FD or bubble (B).

OUTCOMES

Primary outcome included total days receiving CPAP; secondary outcomes included days receiving CPAP, supplemental oxygen, ventilation, death, pneumothorax and nasal excoriation.

RESULTS

We randomised 125 infants (B 66, FD 59). Differences in infant outcomes on B and FD were not statistically significant. The median (range) for CPAP days for survivors was B 0.8 (0.04 to 17.5), FD 0.5 (0.04 to 5.3). B:FD (95% CI) ratios were CPAP days 1.3 (0.9 to 2.1), CPAP plus supplementary oxygen days 1.2 (0.7 to 1.9). B:FD (95% CI) ORs were death 2.3 (0.2 to 28), ventilation 2.1 (0.5 to 9), nasal excoriation 1.2 (0.2 to 8) and pneumothorax 2.4 (0.2 to 26).

CONCLUSIONS

In a resource-limited setting we found B CPAP equivalent to FD CPAP in the total number of days receiving CPAP within a margin of 2 days.

TRIAL REGISTRATION NUMBER

ISRCTN22578364.

Intracranial dynamics in pre-term infants and neonates: implications for physiotherapists

The control of cerebral circulation and intracranial dynamics differs markedly in the pre-term and full term neonate from that in the adult. Immaturity can combine with several clinical conditions and iatrogenic factors to predispose the neonate to cerebral lesions, which may subsequently increase morbidity. As physiotherapists play an increasingly important role in neonatology, it is important to appreciate the immaturity of the nervous system and to recognise the risk factors for such conditions as peri-intraventricular haemorrhage and periventricular leucomalacia. This paper describes intracranial dynamics in the pre-term and full term infant and illustrates how these factors may interact with clinical conditions to cause cerebral lesions. Studies which examine the effect of respiratory physiotherapy on intracranial dynamics are reviewed and suggestions made for further research.

Umbilical cord blood lead levels and neonatal behaviour

Negative correlations have been found between cord blood lead levels and scores on the Brazelton Neonatal Behaviour Assessment in 30 otherwise healthy newborns. Items in the Habituation, Orientation and Regulation of state clusters, particularly those items related to self-regulatory, self-quieting and auditory habituation, showed lower scores (worse performance) in those newborns with higher cord blood lead levels. These disturbances are potentially important since this type of behavior may interfere with the normal process of adaptation to their environment, leading to a less than optimal bonding between newborns and their carers.

[Colonization by Candida in a neonatal intensive care unit]

BACKGROUND

Candida infections have increased in the last few decades. Previous colonization is the most important risk factor for the development of fungemia. Understanding local epidemiology is necessary in order to select the optimal anti-fungal treatment. The purpose of this study was to establish colonization by Candida in patients, staff and medical devices in a neonatal intensive care unit.

METHODS

A prospective cohort study was conducted. Cultures were obtained from different anatomic sites, from medical devices and from the hands of healthcare staff at admission and every 7 days until discharge of the unit. Identification and susceptibility tests to amphotericin B, fluconazole, itraconazole, voriconazole and caspofungin were performed.

RESULTS

Out of 98 patients, 24 % were already colonized at admission, 15 % became colonized during their stay at the hospital. Out of 738 samples obtained from devices, 2 % were positive. Out of 89 cultures obtained from hands, 55 % were positive. A total of 124 Candida strains were retrieved; Candida parapsilosis was the most common species (59 %), followed by Candida albicans (26 %). Resistance to itraconazole was only found in 13 %.

CONCLUSIONS

Colonization in neonatal intensive care-admitted patients was 40 %, and it was a common event in the hands of the healthcare staff. Candida parapsilosis was the predominant species. Resistance was found only to itraconazole.