Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birthweight infants?

BACKGROUND

Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85-95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3-0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence.

METHODS

An international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks' gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months' and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity).

DISCUSSION

The use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18-24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice.

TRIAL REGISTRATION

The trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.

CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study

BACKGROUND AND OBJECTIVES

Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV.

METHODS

We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference.

RESULTS

A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01).

CONCLUSIONS

CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.

Variations in Site-Specific Costs for Infants Born Extremely Preterm in Canadian Neonatal Intensive Care Units

OBJECTIVE

To quantify site-specific costs and their association with survival without major morbidity (SWMM) in Canada for neonates <28 weeks of gestation admitted to large tertiary neonatal intensive care units.

METHODS

We conducted a retrospective analysis of infants born at <28 weeks of gestation and admitted to Canadian Neonatal Network sites from 2010 through 2021. Sites that cared for at least 50 eligible infants by gestational age in weeks over the study period were included. Using a validated costing algorithm that assessed physician, nursing, respiratory therapy, diagnostic imaging, transfusions, procedural, medication, and certain indirect costs, we calculated site and resource-specific costs in 2017 Canadian dollars (CAD) and evaluated their relationship with SWMM.

RESULTS

Seven sites with 8180 (range 841-1605) eligible neonates with a mean (SD) gestation of 25.4 [1.3] weeks were included. Survival to discharge or transfer was 85.3% with a mean (SD) length of stay of 75 (46) days. The mean (SD) total and daily costs per neonate varied between $94 992 ($60 283) and $174 438 ($130 501) CAD and $1833 ($916) to $2307 ($1281) CAD, respectively. Between sites, there was no relationship between costs and SWMM.

CONCLUSIONS

There was marked variation in costs and SWMM between sites in Canada with universal health care. The lack of concordance between both outcomes and costs among sites may provide possibilities for outcomes improvement and cost containment.

Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures were Equivalent?

Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures. KEY POINTS: · Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV.. · In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures.. · We call for future research on noninvasive support modes to account for mean airway pressures..

Peri-extubation settings in preterm neonates: a systematic review and meta-analysis

OBJECTIVE

To systematically review: 1) peri-extubation settings; and 2) association between peri-extubation settings and outcomes in preterm neonates.

STUDY DESIGN

In this systematic review, studies were eligible if they reported patient-data on peri-extubation settings (objective 1) and/or evaluated peri-extubation levels in relation to clinical outcomes (objective 2). Data were meta-analyzed when appropriate using random-effects model.

RESULTS

Of 9681 titles, 376 full-texts were reviewed and 101 included. The pooled means of peri-extubation settings were summarized. For objective 2, three experimental studies were identified comparing post-extubation CPAP levels. Meta-analyses revealed lower odds for treatment failure [pooled OR 0.46 (95% CI 0.27-0.76); 3 studies, 255 participants] but not for re-intubation [pooled OR 0.66 (0.22-1.97); 3 studies, 255 participants] with higher vs. lower CPAP.

CONCLUSIONS

Summary of peri-extubation settings may guide clinicians in their own practices. Higher CPAP levels may reduce extubation failure, but more data on peri-extubation settings that optimize outcomes are needed.

The Impact of Infant Sex on Multiple Courses versus a Single Course of Antenatal Corticosteroids: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

 Animal literature has suggested that the impact of antenatal corticosteroids (ACS) may vary by infant sex. Our objective was to assess the impact of infant sex on the use of multiple courses versus a single course of ACS and perinatal outcomes.

STUDY DESIGN

 We conducted a secondary analysis of the Multiple Courses of Antenatal Corticosteroids for Preterm Birth trial, which randomly allocated pregnant people to multiple courses versus a single course of ACS. Our primary outcome was a composite of perinatal mortality or clinically significant neonatal morbidity (including neonatal death, stillbirth, severe respiratory distress syndrome, intraventricular hemorrhage [grade III or IV], cystic periventricular leukomalacia, and necrotizing enterocolitis [stage II or III]). Secondary outcomes included individual components of the primary outcome as well as anthropometric measures. Baseline characteristics were compared between participants who received multiple courses versus a single course of ACS. An interaction between exposure to ACS and infant sex was assessed for significance and multivariable regression analyses were conducted with adjustment for predefined covariates, when feasible.

RESULTS

 Data on 2,300 infants were analyzed. The interaction term between treatment status (multiple courses vs. a single course of ACS) and infant sex was not significant for the primary outcome (p = 0.86), nor for any of the secondary outcomes (p > 0.05).

CONCLUSION

 Infant sex did not modify the association between exposure to ACS and perinatal outcomes including perinatal mortality or neonatal morbidity or anthropometric outcomes. However, animal literature indicates that sex-specific differences after exposure to ACS may emerge over time and thus investigating long-term sex-specific outcomes warrants further attention.

KEY POINTS

· We explored the impact of infant sex on perinatal outcomes after multiple versus a single course of ACS.. · Infant sex was not a significant effect modifier of ACS exposure and perinatal outcomes.. · Animal literature indicates that sex-specific differences after ACS exposure may emerge over time.. · Further investigation of long-term sex-specific outcomes is warranted..

High continuous positive airway pressures versus non-invasive positive pressure ventilation in preterm neonates: protocol for a multicentre pilot randomised controlled trial

INTRODUCTION

Low pressure nasal continuous positive airway pressure (nCPAP) has long been the mainstay of non-invasive respiratory support for preterm neonates, at a constant distending pressure of 5-8 cmH2O. When traditional nCPAP pressures are insufficient, other modes including nasal intermittent positive pressure ventilation (NIPPV) are used. In recent years, high nCPAP pressures (≥9 cmH2O) have also emerged as an alternative. However, the comparative benefits and risks of these modalities remain unknown.

METHODS AND ANALYSIS

In this multicentre pilot randomised controlled trial, infants <29 weeks' gestational age (GA) who either: (A) fail treatment with traditional nCPAP or (B) being extubated from invasive mechanical ventilation with mean airway pressure ≥10 cmH2O, will be randomised to receive either high nCPAP (positive end-expiratory pressure 9-15 cmH2O) or NIPPV (target mean Paw 9-15 cmH2O). Primary outcome is feasibility of the conduct of a larger, definitive trial as assessed by rates of recruitment and protocol violations. The main secondary outcome is failure of assigned treatment within 7 days postrandomisation. Multiple other clinical outcomes including bronchopulmonary dysplasia will be ascertained. All randomised participants will be analysed using intention to treat. Baseline and demographic variables as well as outcomes will be summarised and compared using univariate analyses, and a p<0.05 will be considered significant.

ETHICS AND DISSEMINATION

The trial has been approved by the respective research ethics boards at each institution (McMaster Children's Hospital: Hamilton integrated REB approval #2113; Royal Alexandra Hospital: Health Research Ethics Board approval ID Pro00090244; Westmead Hospital: Human Research Ethics Committee approval ID 2022/ETH01343). Written, informed consent will be obtained from all parents/guardians prior to study enrolment. The findings of this pilot study will be disseminated via presentations at national and international conferences and via publication in a peer-reviewed journal. Social media platforms including Twitter will also be used to generate awareness.

TRIAL REGISTRATION NUMBER

NCT03512158.

Comparison of High CPAP versus NIPPV in Preterm Neonates: A Retrospective Cohort Study

OBJECTIVE

The aim of this study was to compare outcomes following receipt of high continuous positive airway pressure (CPAP) versus nasal intermittent positive pressure ventilation (NIPPV) in extremely preterm neonates.

STUDY DESIGN

We retrospectively compared outcomes of preterm neonates (22-28 weeks' gestation) following their first episode of either high CPAP (≥ 9 cm H₂O) or NIPPV. Primary outcome was failure of high CPAP or NIPPV within 7 days, as determined by either need for intubation or use of an alternate noninvasive mode.

RESULTS

During the 3-year study period, 53 infants received high CPAP, while 119 patients received NIPPV. There were no differences in the primary outcome (adjusted odds ratio 1.21; 95% confidence interval 0.49-3.01). The use of alternate mode of noninvasive support was higher with the use of high CPAP but no other outcome differences were noted.

CONCLUSION

Based on this cohort, there was no difference in incidence of failure between high CPAP and NIPPV, although infants receiving high CPAP were more likely to require an alternate mode of noninvasive support.

KEY POINTS

· Use of high CPAP pressures (defined as ≥9 cm H2O) is gradually increasing during care of preterm neonates.. · Limited data exists regarding its efficacy and safety.. · This study compares high CPAP with NIPPV, and demonstrates comparable short-term clinical outcomes..

Timing of Systemic Steroids and Neurodevelopmental Outcomes in Infants < 29 Weeks Gestation

Objective: To determine the association between postnatal age (PNA) at first administration of systemic postnatal steroids (sPNS) for bronchopulmonary dysplasia (BPD) and mortality or significant neurodevelopmental impairment (sNDI) at 18−24 months corrected age (CA) in infants < 29 weeks’ gestation. Methods: Data from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases were used to conduct this retrospective cohort study. Infants exposed to sPNS for BPD after the 1st week of age were included and categorized into 8 groups based on the postnatal week of the exposure. The primary outcome was a composite of mortality or sNDI. A multivariable logistic regression model adjusting for potential confounders was used to determine the association between the sPNS and ND outcomes. Results: Of the 10,448 eligible infants, follow-up data were available for 6200 (59.3%) infants. The proportion of infants at first sPNS administration was: 8%, 17.5%, 23.1%, 18.7%, 12.6%, 8.3%, 5.8%, and 6% in the 2nd, 3rd, 4th, 5th, 6th, 7th, 8−9th, and ≥10th week of PNA respectively. No significant association between the timing of sPNS administration and the composite outcome of mortality or sNDI was observed. The odds of sNDI and Bayley-III motor composite < 70 increased by 1.5% (95% CI 0.4, 2.9%) and 2.6% (95% CI 0.9, 4.4%), respectively, with each one-week delay in the age of initiation of sPNS. Conclusions: No significant association was observed between the composite outcome of mortality or sNDI and PNA of sPNS. Among survivors, each week’s delay in initiation of sPNS may increase the odds of sNDI and motor delay.

Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

OBJECTIVE

 This study aimed to evaluate whether the initial pressure level on high continuous positive airway pressure (CPAP; ≥9 cm H2O), in relation to preextubation mean airway pressure (Paw), influences short-term clinical outcomes in preterm neonates.

STUDY DESIGN

 In this retrospective cohort study, preterm neonates <29 weeks' gestational age (GA) extubated from mean Paw ≥9 cm H2O and to high CPAP (≥9 cm H2O) were classified into "higher level CPAP" (2-3 cm H2O higher than preextubation Paw) and "equivalent CPAP" (-1 to +1 cm H2O in relation to preextubation Paw). Only the first eligible extubation per infant was analyzed. The primary outcome was failure within ≤7 days of extubation, defined as any one or more of (1) need for reintubation, (2) escalation to an alternate noninvasive respiratory support mode, or (3) use of CPAP >preextubation Paw + 3 cm H2O. Secondary outcomes included individual components of the primary outcome, along with other clinical and safety outcomes.

RESULTS

 Over a 10-year period (Jan 2011-Dec 2020), 175 infants were extubated from mean Paw >9 cm H2O to high CPAP pressures. Twenty-seven patients (median GA = 24.7, [interquartile range (IQR)]: (24.0-26.4) weeks and chronological age = 31, IQR: [21-40] days) were classified into the "higher level CPAP" group while 148 infants (median GA = 25.4, IQR: [24.6-26.6] weeks and chronological age = 26, IQR: [10-39] days) comprised the "equivalent CPAP" group. There was no difference in the primary outcome (44 vs. 51%; p = 0.51), including postadjustment for confounders (adjusted OR [aOR] = 0.47 [95% confidence interval (CI): 0.17-1.29; p = 0.14]). However, reintubation risk within 7 days was lower with higher level CPAP (7 vs. 37%; p < 0.01), including postadjustment (aOR = 0.07; 95% CI: 0.02-0.35; p < 0.01).

CONCLUSION

 In this cohort, use of initial distending CPAP pressures 2 to 3 cm H2O higher than preextubation Paw did not alter the primary outcome of failure but did lower the risk of reintubation. The latter is an interesting hypothesis-generating finding that requires further confirmation.

KEY POINTS

· Use of high CPAP pressures (≥9 cm H2O) is gradually increasing in the care of preterm neonates.. · This study compares higher level versus equivalent CPAP in relation to preextubation Paw.. · The findings demonstrate no difference in failure as defined with use of higher level CPAP pressures..

Clinical burden associated with therapies for cardio-pulmonary critical decompensation in preterm neonates across Canadian neonatal intensive care units

The aim of this retrospective cohort study was to study the clinical burden associated with cardio-pulmonary critical decompensations (CPCDs) in preterm neonates and factors associated with mortality. Through the Canadian Neonatal Network (30 tertiary NICUs, 2010-2017), we identified infants < 32-week gestational age with CPCDs, defined by "significant exposure" to cardiotropes and/or inhaled nitric oxide (iNO): (1) either therapy for ≥ 3 consecutive days, (2) both for ≥ 2 consecutive days, or (3) any exposure within 2 days of death. Early CPCDs (≤ 3 days of age) and late CPCDs (> 3 days) were examined separately. Outcomes included CPCD-incidence, mortality, and inter-site variability using standardized ratios (observed/adjusted expected rate) and network funnel plots. Mixed-effects analysis was used to quantify unit-level variability in mortality. Overall, 10% of admissions experienced CPCDs (n = 2915). Late CPCDs decreased by ~ 5%/year, while early CPCDs were unchanged during the study period. Incidence and CPCD-associated mortality varied between sites, for both early (0.6-7.5% and 0-100%, respectively) and late CPCDs (2.5-15% and 14-83%, respectively), all p < 0.01. Units' late-CPCD incidence and mortality demonstrated an inverse relationship (slope =  -2.5, p < 0.01). Mixed-effects analysis demonstrated clustering effect, with 6.4% and 8.6% of variability in mortality after early and late CPCDs respectively being site-related, unexplained by available patient-level characteristics or unit volume. Mortality was higher with combined exposure than with only-cardiotropes or only-iNO (41.3%, 24.8%, 21.5%, respectively; p < 0.01).

CONCLUSIONS

Clustering effects exist in CPCD-associated mortality among Canadian NICUs, with higher incidence units showing lower mortality. These data may aid network-level benchmarking, patient-level risk stratification, parental counseling, and further research and quality improvement work.

WHAT IS KNOWN

• Preterm neonates remain at high risk of acute and chronic complications; the most critically unwell require therapies such as cardiotropic drugs and inhaled nitric oxide. • Infants requiring these therapies are known to be at high risk for adverse neonatal outcomes and for mortality.

WHAT IS NEW

• This study helps illuminate the national burden of acute cardio-pulmonary critical decompensation (CPCD), defined as the need for cardiotropic drugs or inhaled nitric oxide, and highlights the high risk of morbidity and mortality associated with this disease state. • Significant nationwide variability exists in both CPCD incidence and associated mortality; a clustering effect was observed with higher incidence sites showing lower CPCD-associated mortality.

Nasal Intermittent Positive Pressure Ventilation versus Continuous Positive Airway Pressure and Apnea of Prematurity: A Systematic Review and Meta-Analysis

OBJECTIVE

The study aimed to systematically review and analyze the impact of nasal intermittent positive pressure ventilation (NIPPV) versus continuous positive airway pressure (CPAP) on apnea of prematurity (AOP) in preterm neonates.

STUDY DESIGN

In this systematic review and meta-analysis, experimental studies enrolling preterm infants comparing NIPPV (synchronized, nonsynchronized, and bi-level) and CPAP (all types) were searched in multiple databases and screened for the assessment of AOP. Primary outcome was AOP frequency per hour (as defined by authors of included studies).

RESULTS

Out of 4,980 articles identified, 18 studies were included with eight studies contributing to the primary outcome. All studies had a high risk of bias, with significant heterogeneity in definition and measurement of AOP. There was no difference in AOPs per hour between NIPPV versus CPAP (weighted mean difference = -0.19; 95% confidence interval [CI]: -0.76 to 0.37; eight studies, 456 patients). However, in a post hoc analysis evaluating the presence of any AOP (over varying time periods), the pooled odds ratio (OR) was lower with NIPPV (OR: 0.46; 95% CI: 0.32-0.67; 10 studies, 872 patients).

CONCLUSION

NIPPV was not associated with decrease in AOP frequency, although demonstrated lower odds of developing any AOP. However, definite recommendations cannot be made based on the quality of the published evidence.

KEY POINTS

· AOP is a common clinical complication related to preterm birth.. · NIPPV is often used to mitigate AOP and complications.. · Relative impact of NIPPV and CPAP on AOP remains unclear..

Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants

BACKGROUND

Preterm infants are at risk of lung atelectasis due to various anatomical and physiological immaturities, placing them at high risk of respiratory failure and associated harms. Nasal continuous positive airway pressure (CPAP) is a positive pressure applied to the airways via the nares. It helps prevent atelectasis and supports adequate gas exchange in spontaneously breathing infants. Nasal CPAP is used in the care of preterm infants around the world. Despite its common use, the appropriate pressure levels to apply during nasal CPAP use remain uncertain.

OBJECTIVES

To assess the effects of 'low' (≤ 5 cm H₂O) versus 'moderate-high' (> 5 cm H₂O) initial nasal CPAP pressure levels in preterm infants receiving CPAP either: 1) for initial respiratory support after birth and neonatal resuscitation or 2) following mechanical ventilation and endotracheal extubation.

SEARCH METHODS

We ran a comprehensive search on 6 November 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials.

SELECTION CRITERIA

We included RCTs, quasi-RCTs, cluster-RCTs and cross-over RCTs randomizing preterm infants of gestational age < 37 weeks or birth weight < 2500 grams within the first 28 days of life to different nasal CPAP levels.

DATA COLLECTION AND ANALYSIS

We used the standard methods of Cochrane Neonatal to collect and analyze data. We used the GRADE approach to assess the certainty of the evidence for the prespecified primary outcomes.

MAIN RESULTS

Eleven trials met inclusion criteria of the review. Four trials were parallel-group RCTs reporting our prespecified primary or secondary outcomes. Two trials randomized 316 infants to low versus moderate-high nasal CPAP for initial respiratory support, and two trials randomized 117 infants to low versus moderate-high nasal CPAP following endotracheal extubation. The remaining seven studies were cross-over trials reporting short-term physiological outcomes. The most common potential sources of bias were absent or unclear blinding of personnel and assessors and uncertain selective reporting. Nasal CPAP for initial respiratory support after birth and neonatal resuscitation None of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months. The remaining five outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.56 to 1.85; 1 trial, 271 participants); mortality by hospital discharge (RR 1.04, 95% CI 0.51 to 2.12; 1 trial, 271 participants); BPD at 28 days of age (RR 1.10, 95% CI 0.56 to 2.17; 1 trial, 271 participants); BPD at 36 weeks' PMA (RR 0.80, 95% CI 0.25 to 2.57; 1 trial, 271 participants), and treatment failure or need for mechanical ventilation (RR 1.00, 95% CI 0.63 to 1.57; 1 trial, 271 participants). We assessed the certainty of the evidence as very low for all five outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. Nasal CPAP following mechanical ventilation and endotracheal extubation One of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. On the basis of these data, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcome of treatment failure or need for mechanical ventilation (RR 1.52, 95% CI 0.92 to 2.50; 2 trials, 117 participants; I² = 17%; risk difference 0.15, 95% CI -0.02 to 0.32; number needed to treat for an additional beneficial outcome 7, 95% CI -50 to 3). We assessed the certainty of the evidence as very low due to risk of bias, inconsistency across the studies, and imprecise effect estimates. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months or BPD at 28 days of age. The remaining three outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants); mortality by hospital discharge (RR 2.94, 95% CI 0.12 to 70.30; 1 trial, 93 participants), and BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants). We assessed the certainty of the evidence as very low for all three outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates.  AUTHORS' CONCLUSIONS: There are insufficient data from randomized trials to guide nasal CPAP level selection in preterm infants, whether provided as initial respiratory support or following extubation from invasive mechanical ventilation. We are uncertain as to whether low or moderate-high nasal CPAP levels improve morbidity and mortality in preterm infants. Well-designed trials evaluating this important aspect of a commonly used neonatal therapy are needed.

Necrotizing enterocolitis and mortality after transfusion of ABO non-identical blood

BACKGROUND

The relationship between ABO non-identical transfusion and the outcomes of necrotizing enterocolitis (NEC), and all-cause mortality in very-low birth weight (VLBW) neonates receiving red blood cell transfusion is unknown.

STUDY DESIGN AND METHODS

A retrospective multicenter cohort study was conducted in VLBW neonates in neonatal intensive care units between 2004 and 2016. VLBW (≤1500 grams) neonates were followed until discharge or in-hospital death. The primary exposure was ABO group. Secondary exposures included platelet count, plasma transfusions, and maternal ABO group. Outcome measures were NEC (defined as Bell stage ≥ 2) and all-cause mortality. Time-dependent Cox regression models with competing risks were used to investigate factors associated with NEC and mortality.

RESULTS

Thousand and sixteen neonates were included with 10.8% developing NEC (n = 110) and 14.1% mortality (n = 143). Platelet count (hazard ratio [HR] = 0.995; 95% confidence interval [CI]: 0.922-0.998) and number of plasma transfusions (HR = 2.908; 95% CI:1.265-6.682) were associated with NEC, while ABO group (non-O vs. O) was not (HR = 0.761; 95% CI: 0.393-1.471). Higher all-cause mortality occurred in neonates without NEC who were non-O compared with O (HR = 17.5; 95% CI: 1.784-171.692), but not in neonates with NEC (HR = 1.112; 95% CI: 0.142-8.841). Plasma transfusion was associated with increased mortality in both groups.

DISCUSSION

ABO non-identical transfusion was not associated with NEC or mortality in neonates with NEC. It was associated with increased mortality in neonates without NEC. As many neonatal intensive care units transfuse only O group blood as routine practice, future trials are needed to investigate the association between this practice and neonatal mortality.

50 Poractant alfa versus bovine lipid extract surfactant for respiratory distress syndrome in preterm infants: A prospective comparative effectiveness cohort study

Primary Subject area

Neonatal-Perinatal Medicine

Background

There is a paucity of comparative effectiveness data for bovine lipid extract surfactant (BLES) and poractant alfa (Curosurf).

Objectives

To compare duration of respiratory support and short-term outcomes in very preterm infants treated with bovine lipid extract surfactant and poractant alfa.

Design/Methods

We performed a prospective, multicentre, comparative effectiveness study. Thirteen Canadian level III neonatal intensive care units (NICUs) provided bovine lipid extract surfactant to infants born &lt;32 weeks’ gestational age (GA) for a set period of time in the year 2019 (3 to 9 months), then changed to poractant alfa for the remainder of the year. The primary outcome was total duration of respiratory support (invasive and non-invasive). We utilized the Canadian Neonatal Network database for all study data.

Results

A total of 968 eligible infants (530 infants &lt; 28 weeks’ GA and 438 infants 280-316weeks’ GA) were included, of which 494 received bovine lipid extract surfactant and 474 received poractant alfa. In unadjusted analysis, no difference was observed in total duration of any respiratory support (median 38 vs. 40.5 days). After adjusting for baseline characteristics and accounting for cluster effects, infants treated with poractant alfa spent a median of 4.16 fewer days on respiratory support (95% CI 0.05, 8.28 days). This reduction was observed in the subgroup of infants 280-316 weeks’ GA, but not in those &lt; 28 weeks’ GA, and was explained by their shorter time on non-invasive respiratory support. No differences were observed in the need to re-dose surfactant, hospital mortality, bronchopulmonary dysplasia, or length of stay in NICU.

Conclusion

Administration of poractant alfa was associated with shorter median duration of respiratory support compared to bovine lipid extract surfactant in preterm neonates &lt; 32 weeks’ GA.

Duration of and trends in respiratory support among extremely preterm infants

OBJECTIVE

To evaluate annual trends in the administration and duration of respiratory support among preterm infants.

DESIGN

Retrospective cohort study.

SETTING

Tertiary neonatal intensive care units in the Canadian Neonatal Network.

PATIENTS

8881 extremely preterm infants born from 2010 to 2017 treated with endotracheal and/or non-invasive positive pressure support (PPS).

MAIN OUTCOME MEASURES

Competing risks methods were used to investigate the outcomes of mortality and time to first successful extubation, definitive extubation, weaning off PPS, and weaning PPS and/or low-flow oxygen, according to gestational age (GA). Cox proportional hazards and regression models were fitted to evaluate the trend in duration of respiratory support, survival and surfactant treatment over the study period.

RESULTS

The percentages of infants who died or were weaned from respiratory support were presented graphically over time by GA. Advancing GA was associated with ordinally earlier weaning from respiratory support. Year over year, infants born at 23 weeks were initially and definitively weaned from endotracheal and all PPS earlier (HR 1.06, 95% CI 1.01 to 1.11, for all outcomes), while survival simultaneously increased (OR 1.11, 95% CI 1.03 to 1.18). Infants born at 26 and 27 weeks remained on non-invasive PPS longer (HR 0.97, 95% CI 0.95 to 0.98 and HR 0.97, 95% CI 0.95 to 0.99, respectively). Early surfactant treatment declined among infants born at 24-27 weeks GA.

CONCLUSIONS

Infants at the borderline of viability have experienced improved survival and earlier weaning from all forms of PPS, while those born at 26 and 27 weeks are spending more time on PPS in recent years. GA-based estimates of the duration of respiratory support and survival may assist in counselling, benchmarking, quality improvement and resource planning.

Experiences, Knowledge, and Preferences of Canadian Parents Regarding Preterm Mode of Birth

OBJECTIVES

To describe Canadian parents' experiences with mode of birth for preterm singleton pregnancies; knowledge about maternal and infant risks of the different modes of preterm birth, particularly breech birth; and communication preferences with respect to mode of birth.

METHODS

We conducted an online survey of Canadian parents who had experienced the preterm birth of a live-born infant between 2010 and 2019. Data were collected from August to September 2019. The sample size was calculated as requiring 96 participants.

RESULTS

Of the 153 respondents, 152 were mothers. Respondents were approximately evenly split between those who had experienced an extremely preterm birth (<28 wk), a very preterm birth (28-31 wk), or a moderate-to-late preterm birth (32-36 wk). Most parents reported that mode of birth was discussed before the birth (61.7%, 73.3% and 77.3% for extremely, very, and moderate-to-late preterm births, respectively). The minority of parents reported being given a choice about mode of birth (20.8%, 23.0%, and 36.4% for extremely, very, and moderate-to-late preterm births, respectively). The use of written material during discussion on mode of birth was rare (2.1%, 3.3% and 6.8% for extremely, very, and moderate-to-late preterm births, respectively). Of women who had a cesarean delivery, 39.6% (36/91) were unaware of the maternal risks. Many parents expressed preference for both oral and written communication during counselling on mode of birth (62.6%).

CONCLUSION

Few Canadian parents reported receiving a choice about mode of preterm birth, being aware of associated risks, or receiving written information. There is an urgent need to develop tools that provide information for parents facing preterm birth.

Pulse oximetry screening for critical congenital heart defects in Ontario, Canada: a cost-effectiveness analysis

OBJECTIVE

Previously conducted cost-effectiveness analyses of pulse oximetry screening (POS) for critical congenital heart defects (CCHDs) have shown it to be a cost-effective endeavour, but the geographical setting of Ontario in relation to its vast yet sparsely populated regions presents unique challenges. The objective of this study was to estimate the cost-effectiveness of POS for CCHD in Ontario, Canada.

METHODS

A cost-effectiveness analysis, comparing POS to no POS, was conducted from the Ontario healthcare payer perspective using a Markov model. The base case was defined as a well-appearing newborn at 24 h of age. Outcome measures, including quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios (ICER) [ΔCost/ΔQALMs], were calculated over a lifetime horizon. All outcomes were discounted at 1.5% per year. Cost-effectiveness was assessed using an a priori ICER threshold of CAD$4166.67 per QALM (equivalent to CAD$50,000 per quality-adjusted life year). Deterministic and probabilistic sensitivity analyses were conducted to assess parameter uncertainty.

RESULTS

Implementation of POS is expected to lead to timely diagnosis of 51 CCHD cases annually. The incremental cost of performing POS was estimated to be $27.27 per screened individual, with a gain of 0.02455 QALMs. This yielded an ICER of CAD$1110.79 per QALM, well below the pre-determined threshold. The probabilistic sensitivity analysis estimated a 92.3% chance of routine implementation of POS being cost-effective.

CONCLUSION

Routine implementation of POS for CCHD in Ontario is expected to be cost-effective.

Assessing the clinical significance of echocardiograms in determining treatment of patent ductus arteriosus in neonates

BACKGROUND

To evaluate the utility of echocardiogram (ECHO) in detection and treatment of patent ductus arteriosus (PDA) and hemodynamically significant PDA (hsPDA) in preterm neonates.

METHODS

This was a retrospective case-control study of all preterm infants born or admitted to the level III Neonatal Intensive Care Unit in McMaster Children's Hospital from January 2009 to January 2013. These cases were further classified into the following sub-groups: group A) hsPDA confirmed on ECHO; and the control, group B) PDA (but not hemodynamically significant) confirmed on ECHO. Patients without an ECHO were excluded from all analyses. The primary outcome was incidence of treatment for PDA.

RESULTS

PDA treatment was administered in 83.3% and 11.2% of patients in groups A and B respectively (P < 0.05). Among patients with a hsPDA within group A, 17% did not receive treatment, while 11% of patients with non-hemodynamically significant PDA received treatment for the PDA. Within the cohort of patients who received treatment for a hsPDA, gestational age below 35 weeks as well as murmurs heard on auscultation were both found to be predictors of treatment.

CONCLUSION

While the ECHO remains the gold standard for detecting pathological PDA, there is evidence that other traditional clinical measures continue to guide clinical practice and treatment decisions. Further research is required to gain an understanding of how clinical measures and ECHO may be used in conjunction to optimize resource utilization.

Bubble versus other continuous positive airway pressure forms: a systematic review and meta-analysis

BACKGROUND

Use of bubble continuous positive airway pressure (CPAP) has generated considerable interest in neonatal care, but its comparative effectiveness compared with other forms of CPAP, especially in developed countries, remains unclear.

OBJECTIVE

To systematically review and meta-analyse short-term clinical outcomes among preterm infants treated with bubble CPAP vs all other forms of CPAP.

METHODS

Prospective experimental studies published from 1995 onward until October 2018 comparing bubble versus other CPAP forms in preterm neonates <37 weeks' gestational age were included after a systematic review of multiple databases using pre-specified search criteria.

RESULTS

A total of 978 articles were identified, of which 19 articles were included in meta-analyses. Of these, 5 had a high risk of bias, 8 had unclear risk and 6 had low risk. The risk of the primary outcome (CPAP failure within 7 days) was lower with bubble CPAP (0.75; 95% CI 0.57 to 0.98; 12 studies, 1194 subjects, I²=21%). Among secondary outcomes, only nasal injury was higher with use of bubble CPAP (risk ratio (RR) 2.04, 95% CI 1.33 to 3.14; 9 studies, 983 subjects; I²=42%) whereas no differences in mortality (RR 0.82, 95% CI 0.47 to 1.92; 9 studies, 1212 subjects, I²=20%) or bronchopulmonary dysplasia (BPD) (RR 0.8, 95% CI 0.53 to 1.21; 8 studies, 816 subjects, I²=0%) were noted.

CONCLUSION

Bubble CPAP may lead to lower incidence of CPAP failure compared with other CPAP forms. However, it does not appear to translate to improvement in mortality or BPD and potential for nasal injury warrants close monitoring during clinical application.

TRIAL REGISTRATION NUMBER

CRD42019120411.

Efficiency of budesonide delivery via a mesh nebulizer in an in-vitro neonatal ventilator model

OBJECTIVE

To determine the delivery efficiency of budesonide aerosol via a mesh nebulizer in a neonatal ventilator model.

DESIGN/METHOD

In an in-vitro ventilated neonatal model, budesonide suspension was administered using a mesh nebulizer. A collection filter was placed distal to the endotracheal tube and budesonide captured by the filter was measured using UV spectroscopy. The ventilator was, in turn, either on high frequency or conventional ventilation mode and the nebulizer was placed either proximal (close to the endotracheal tube) or distal (between the wet side of humidifier and the inspiratory circuit). Each combination (nebulizer position and ventilation mode) to assess budesonide delivery was tested five times.

RESULTS

Overall delivery of budesonide to the distal end of the endotracheal tube a small percentage of the total dose administered. The deposition with conventional ventilation was 2.12% (±1.06) and 1.26% (±0.27), with proximal and distal placement of the nebulizer, respectively. With high-frequency ventilation, the deposition percentages were 1.82% (±0.82) and 1.69% (±0.23), with proximal and distal nebulizer placement, respectively.

CONCLUSION

Only a small percentage of administered budesonide is delivered to the distal endotracheal tube, irrespective of ventilation mode, and nebulizer placement.

A call for a streamlined ethics review process for multijurisdictional, child health research studies

To be time and resource efficient in neonatal research and to answer clinically relevant questions with validity and generalizability, large numbers of infants from multiple hospitals need to be included. Multijurisdictional research in Canada is currently fraught with research ethics review process hurdles that lead to delays, administrative costs, and possibly termination of projects. We describe our experience applying for ethics review to 13 sites in 7 provinces for a project comparing two standard of care therapies for preterm born infants with respiratory distress syndrome. We welcome the current opportunity created by the Institute of Human Development Child and Youth Health and the Institute for Genetics, to collaboratively identify practical solutions that would benefit Canadian researchers, Research Ethics Boards, and children and families.

High continuous positive airway pressure in neonates: A physiological study

OBJECTIVE

We sought to evaluate physiological cardiorespiratory implications of high pressures (>8 cmH₂ O) on continuous positive airway pressure (CPAP) in preterm neonates.

METHODS

Fifteen preterm neonates at postmenstrual age ≥32 weeks on CPAP 5 cmH₂ O were enrolled. Pressures were increased by 2 cmH ₂ O increments until 13 cmH ₂ O. At each increment, cardiac output, electrical diaphragmatic (Edi) activity, and clinical cardiorespiratory parameters were measured. Predefined cut-off values for changes in cardiorespiratory parameters were used as termination criteria. Data, presented as mean (SD), were compared using repeated measures analysis of variance.

RESULTS

The mean GA, age at study, and weight of subjects were 27.4 (2.6) weeks, 58.5 (35.5) days, and 2.3 (0.6) kg, respectively. The median (IQR) time at each CPAP increment was 10 (5, 20) min. Cardiac output (mL/kg/min) at 5, 7, 9, 11, and 13 cmH ₂ O were not different at 295 (75), 290 (66), 281 (69), 286 (73), and 292 (58), respectively (P = 0.99). Edi values demonstrated a trend towards decline at 9 cmH ₂ O before rising again. No other cardiorespiratory parameter was different across CPAP levels; no subject met termination criteria.

CONCLUSION

High CPAP levels were well tolerated for short durations. Further physiological and clinical research is required on safety/efficacy in neonates with more severe lung disease, as well as its impact over longer durations.

Incidence, risk factors, and outcomes of pulmonary hypertension in preterm infants with bronchopulmonary dysplasia

Objectives

To determine the incidence and risk factors for pulmonary hypertension (PH) in preterm infants with moderate to severe bronchopulmonary dysplasia (BPD) and to compare short-term outcomes.

Methods

Preterm infants <32 weeks gestation born August 2013 through July 2015 with moderate to severe BPD at 36 weeks postmenstrual age were categorized into BPD-PH (exposure) and BPD-noPH (control) groups.

Results

Of 92 infants with BPD, 87 had echocardiographic assessment, of whom 24 (28%) had PH. On multiple logistic regression after adjustment for gestational age and sex, no significant risk factors for PH were identified based on data from this cohort. There were no differences in resource utilization or clinical outcomes including survival to discharge.

Conclusion

Approximately one out of four patients with moderate to severe BPD were identified as having PH. No significant risk factors for PH were identified. No differences in outcomes were identified for those with and without PH.

Sustained quality improvement in outcomes of preterm neonates with a gestational age less than 29 weeks: results from the Evidence-based Practice for Improving Quality Phase 3 1

Quality improvement initiatives in neonatology have yielded positive results; however, few programs have demonstrated sustainability. We evaluated an ongoing, national quality improvement initiative (Evidence-based Practice for Improving Quality Phase 3 (EPIQ-3)) on outcomes of preterm neonates with a gestational age (GA) of 22⁰-28⁶ weeks (i.e., from 22 weeks and 0 days of gestation to 28 weeks and 6 days of gestation). Data from 7459 neonates admitted to 25 Canadian centers between 2013 and 2017 were studied. Trends in mortality and major morbidities were evaluated. The number of neonates with a GA of 22⁰-23⁶ weeks increased from 90 in 2013 to 139 in 2017 without a significant change in any other GA categories. In the entire cohort, the odds of composite outcome of mortality or any major morbidity (adjusted odds ratio (AOR) 0.72, 95% confidence interval (CI) 0.61-0.84) and of necrotizing enterocolitis (AOR 0.66, 95% CI 0.49-0.89) were lower in 2017 than in 2013. When calculated per year, the odds of composite outcome (AOR 0.93, 95% CI 0.89-0.97) and odds of necrotizing enterocolitis (AOR 0.89, 95% CI 0.82-0.96) decreased significantly. Among the subgroup of neonates with a GA of 26⁰-28⁶ weeks, the odds of composite outcome (AOR 0.63, 95% CI 0.51-0.79), necrotizing enterocolitis (AOR 0.44, 95% CI 0.26-0.73), and nosocomial infection (AOR 0.64, 95% CI 0.49-0.84) were reduced. The collaborative, multidisciplinary, nationwide EPIQ-3 program improved outcomes of preterm neonates, and the improvement was sustainable over 5 years.

Neonatal respiratory outcomes in pregnancy induced hypertension: introducing a novel index

Objective: To evaluate short-term respiratory outcomes, mortality and bronchopulmonary dysplasia (BPD) in preterm infants born to mothers with and without pregnancy induced hypertension (PIH).Methods: Exposed infants <33 weeks' gestation were matched to controls in a 1:2 ratio, based on gestation, sex and antenatal steroid exposure in this retrospective cohort study. Primary outcomes were a novel cumulative respiratory index (cRI) (product of mean airway pressure-hours and FiO₂-hours while on invasive ventilation during first 72 hours), mortality and BPD.Results: Seventy-nine exposed infants were matched with 158 controls. cRI was higher in exposed infants (median 1854; IQR 186-13,901) versus controls (median 1359; IQR 210-11,302) but not statistically significant (p = .63). On conditional regression analysis, PIH did not predict cRI (adjusted β = 0.96; 95% CI = 0.79-1.17; p = .712). No association between PIH and mortality (unadjusted odds ratio [OR] = 3.14; 95% CI = 0.76-13.0; p=.11) was identified. PIH was significantly associated with BPD on univariate analysis (OR = 2.29; 95% CI = 1.02-5.17; p=.046), but not after adjustment (aOR = 1.26; 95% CI = 0.38-4.19; p=.7).Conclusions: PIH was not associated with cRI, mortality or BPD in this study. Further validation of cRI and exploration of its relationship with PIH as well as neonatal outcomes is warranted.

Impact of antenatal corticosteroids in preterm neonates based on maternal body mass index

OBJECTIVE

Impact of antenatal corticosteroid (ACS) in context of maternal body mass index (BMI) as it relates to neonatal outcomes remains unclear. We sought to evaluate effects of ACS on clinical outcomes of preterm infants based on maternal BMI.

METHODS

We performed a retrospective cohort study among neonates 23-33 weeks' GA at a tertiary neonatal intensive care unit from 2011 to 2015. Outcomes of neonates exposed to any ACS and pre-pregnancy maternal BMI ≥ 25 (N = 491) were compared with maternal BMI < 25 (N = 484). A priori planned subgroup analyses based on ACS exposure (partial ACS; complete ACS ≤ 7 days prior to delivery (PTD); and complete ACS > 7 days PTD) were conducted. Primary outcome was composite of mortality or any of moderate/severe bronchopulmonary dysplasia, severe neurologic injury, severe retinopathy of prematurity, necrotizing enterocolitis stage, or primary bloodstream infection.

RESULTS

Preterm neonates with maternal BMI ≥ 25 (exposed to any ACS) were not at increased risk of composite outcome vs. BMI < 25 (adjusted odd ratio (aOR) 1.03, 95% confidence interval (CI) 0.84-1.48), nor any individual neonatal morbidities. Similar findings were noted in subgroup analyses by type of ACS exposure.

CONCLUSION

Impact of ACS on neonatal outcomes do not appear to be influenced by maternal BMI based on data from this cohort. However, further research is required to definitively elucidate the impact of BMI on ACS with regards to pharmacokinetics and neonatal outcomes.

Severe Neurodevelopmental Impairment in Neonates Born Preterm: Impact of Varying Definitions in a Canadian Cohort

OBJECTIVE

To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort.

STUDY DESIGN

Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23-28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months' corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI.

RESULTS

The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37-5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, employment status, antenatal corticosteroid treatment, and gestational age were not associated consistently with severe NDI. Although maternal substance use, sex, score of neonatal acute physiology >20, late-onset sepsis, bronchopulmonary dysplasia, and brain injury were consistently associated with severe NDI irrespective of definition, the strength of the associations varied.

CONCLUSIONS

The definition of severe NDI significantly influences the incidence and the associations between risk factors and severe NDI. A standardized definition would facilitate site comparisons and scientific communication.

COST-EFFECTIVENESS OF PULSE OXIMETRY SCREENING FOR CRITICAL CONGENITAL HEART DEFECTS IN ONTARIO

BACKGROUND

Critical congenital heart defects (CCHDs) are a leading cause of morbidity and mortality in newborns, and late diagnosis is associated with mortality and worse outcomes. Many jurisdictions in the USA and elsewhere have implemented routine pulse oximetry screening (POS) for CCHD, which the Canadian Paediatric Society has recently endorsed. Cost-effective analyses in USA and Europe support this approach, but the geographical setting of Ontario in relation to its vast yet sparsely populated regions presents unique challenges with regard to POS implementation.

OBJECTIVES

To estimate the cost-effectiveness of POS for CCHD in the context of its implementation in Ontario, Canada.

DESIGN/METHODS

A cost-effectiveness analysis using a Markov model was conducted inputting values derived from an extensive review of literature, and using relevant local databases. The base-case was a 24-hour clinically stable infant born in Ontario. The model employed the healthcare payer (ministry of health) perspective and a life-time horizon. A number of mutually exclusive health states were created, representative of the natural course of CCHDs. The strategies compared were routine pulse oximetry screening versus no screening. Outcome measures, all discounted 1.5%, were quality-adjusted life months (QALMs), lifetime costs, and incremental cost-effectiveness ratios. An a priori threshold of CAD$4,166.67 per QALM (equivalent to CAD$50,000 per quality adjusted life year) was used. Probabilistic sensitivity analysis was conducted using multiple simulations of the model within expected range of variables included in the model.

RESULTS

The incremental cost of performing POS was estimated to be $27.27 per individual, with a gain of 0.02455 QALMs (Table 1). This yielded an incremental cost-effectiveness ratio (ICER), [Δ Cost / Δ QALMs] of CAD$1,110.79, well below the pre-determined threshold for cost-effectiveness. A probabilistic sensitivity analysis estimated a 93% chance of routine implementation of POS of being cost-effective, with majority of simulated ICERs lying below the threshold of acceptability (Figure 1).

CONCLUSION

Routine implementation of POS for CCHD is expected to be cost-effective with a high degree of certainty. Further validation of this model may be conducted following implementation to confirm these findings based on local population data.

IMPACT OF HIGH LEVELS OF CONTINUOUS POSITIVE AIRWAY PRESSURE ON CARDIAC OUTPUT IN PRETERM NEONATES: A PROSPECTIVE PHYSIOLOGICAL STUDY

BACKGROUND

Many NICUs employ high (>8 cmH2O) positive end-expiratory pressures (PEEP) on nasal continuous positive airway pressure (NCPAP) to prevent intubation and associated ventilator-induced lung injury, despite limited safety/efficacy data.

OBJECTIVES

This study sought to evaluate the physiological impact of high NCPAP PEEP.

DESIGN/METHODS

Fifteen preterm neonates at postmenstrual age ≥32 weeks (without congenital anomalies or acute intercurrent illness) on NCPAP PEEP of 5 cmH2O were enrolled. PEEP was increased by 2 cmH2O increments until 13 cmH2O. At each increment, following 5 minutes washout, cardiac output (aortic velocity-time integral x heart rate) and cardiorespiratory parameters including blood pressure, heart rate, respiratory rate were measured over 10 minutes. Predefined cut-off values for changes in cardiorespiratory parameters were used as termination criteria. Data are presented as mean (SD), and were compared using one-way ANOVA.

RESULTS

The mean GA, age at study, and weight of subjects were 27.4 (2.6) weeks, 58.5 (35.5) days, and 2.3 (0.6) kg, respectively. Cardiac output (mL/kg/min) at PEEPs of 5, 7, 9, 11, and 13 cmH2O were not different at 295 (75), 290 (66), 281 (69), 286 (73), and 292 (58), respectively (P=0.986), as shown in Figure 1a. Importantly there were also no differences in either aortic velocity-time integral or heart rate over these PEEP ranges (Figures 1b and 1c). There were no significant differences in cardiorespiratory parameters; no subjects met cut-off criteria. Data collection was terminated in 2 subjects after PEEP 9 cmH2O due to lung over-distension subjectively noted on echocardiogram.

CONCLUSION

High levels of NCPAP PEEP were well tolerated for short durations. Further physiological and clinical research is required on safety/efficacy in neonates with more severe lung disease, as well as its impact over longer durations.

Neurodevelopmental Outcomes of Infants Born at <29 Weeks of Gestation Admitted to Canadian Neonatal Intensive Care Units Based on Location of Birth

OBJECTIVE

To compare mortality and neurodevelopmental outcomes of outborn and inborn preterm infants born at <29 weeks of gestation admitted to Canadian neonatal intensive care units (NICUs).

STUDY DESIGN

Data were obtained from the Canadian Neonatal Network and Canadian Neonatal Follow-up Network databases for infants born at <29 weeks of gestation admitted to NICUs from April 2009 to September 2011. Rates of death, severe neurodevelopmental impairment (NDI), and overall NDI were compared between outborn and inborn infants at 18-21 months of age, corrected for prematurity.

RESULTS

Of 2951 eligible infants, 473 (16%) were outborn. Mean birth weight (940 ± 278 g vs 897 + 237 g), rates of treatment with antenatal steroids (53.9% vs 92.9%), birth weight small for gestational age (5.3% vs 9.4%), and maternal college education (43.7% vs 53.9%) differed between outborn and inborn infants, respectively (all P values <.01). The median Score for Neonatal Acute Physiology-II (P = .01) and Apgar score at 5 minutes (P < .01) were higher in inborn infants. Severe brain injury was more common among outborn infants (25.3% vs 14.7%, P < .01). Outborn infants had higher odds of death or severe NDI (aOR 1.7, 95% CI 1.3-2.2), death or overall NDI (aOR 1.6, 95% CI 1.2-2.2), death (aOR 2.1, 95% CI 1.5-3.0), and cerebral palsy (aOR 1.9, 95% CI 1.1-3.3).

CONCLUSIONS

The composite outcomes of death or neurodevelopmental impairment were significantly higher in outborn compared with inborn infants admitted to Canadian NICUs. Adverse outcomes were mainly attributed to increased mortality and cerebral palsy in outborn neonates.

Pregnancy-induced hypertension and neonatal outcomes: a systematic review and meta-analysis

OBJECTIVE

Pregnancy-induced hypertension (PIH) is associated with preterm delivery but its independent impact on neonatal outcomes remains unclear. We sought to systematically review and meta-analyze clinical outcomes of preterm infants <37 weeks' gestation born to mothers with and without PIH.

STUDY DESIGN

Medline, Embase, PsychINFO and CINAHL were searched from January 2000 to October 2016. Studies with low-moderate risk of bias reporting neonatal outcomes based on PIH as primary exposure variable were included. Data were extracted independently by two co-authors.

RESULTS

PIH was associated with lower mortality (3 studies; adjusted odds ratio (aOR) 0.65; 95% confidence interval (CI) 0.54 to 0.79), lower severe retinopathy of prematurity (ROP) (2 studies; aOR 0.83; 0.72 to 0.96) and lower severe brain injury (2 studies; unadjusted OR (uOR) 0.57; 0.49 to 0.66). No association between PIH and short-term respiratory outcomes, bronchopulmonary dysplasia (BPD) or necrotizing enterocolitis (NEC) was identified. In subgroup analysis among infants <29 weeks' gestation, BPD odds were higher (3 studies; aOR 1.15; 1.06 to 1.26), whereas mortality lower (2 studies; aOR 0.73; 0.69 to 0.77). In subgroup analysis limited to severe PIH, odds of mortality (3 studies; uOR 2.36; 1.07 to 5.22) and invasive ventilation (3 studies; uOR 3.26; 1.11 to 9.61) were higher. In subgroup analysis limited to preeclampsia, odds of BPD (3 studies; uOR 1.21; 95% CI:1.03 to 1.43) and NEC were higher (3 studies; uOR 2.79; 95% CI:1.57 to 4.96).

CONCLUSION

PIH was associated with reduced odds of mortality and ROP (all infants), but higher odds for BPD (<29 weeks' gestation). The paradoxical reduction in mortality may be due to survival bias and deserves further exploration in future studies.

What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses

Background

Given the controversy around mode of delivery, our objective was to assess the evidence regarding the safest mode of delivery for actively resuscitated extremely preterm cephalic/non-cephalic twin pairs before 28 weeks of gestation.

Methods

We searched Cochrane CENTRAL, MEDLINE, EMBASE and http://clinicaltrials.gov from January 1994 to January 2017. Two reviewers independently screened titles, abstracts and full text articles, extracted data and assessed risk of bias. We included randomized controlled trials and observational studies. Our primary outcome was a composite of neonatal death (<28 days of life) and severe brain injury in survivors (intraventricular hemorrhage grade ≥ 3 or periventricular leukomalacia). We performed random-effects meta-analyses, generating odds ratios with 95% confidence intervals for the first and second twin separately, and for both twins together. We assessed the risk of bias using a modified Newcastle Ottawa Scale (NOS) for observational studies and used Grading of Recommendations Assessment, Development and Evaluation approach (GRADE).

Results

Our search generated 2695 articles, and after duplicate removal, we screened 2051 titles and abstracts, selecting 113 articles for full-text review. We contacted 36 authors, and ultimately, three observational studies met our inclusion criteria. In cephalic/non-cephalic twin pairs delivered by caesarean section compared to vaginal birth at 24⁺⁰–27⁺⁶ weeks the odds ratio for our composite outcome of neonatal death and severe brain injury for the cephalic first twin was 0.35 (95% CI 0.00–92.61, two studies, I² = 76%), 1.69 for the non-cephalic second twin (95% CI 0.04–72.81, two studies, I² = 55%) and 0.83 for both twins (95% CI 0.05–13.43, two studies, I² = 56%). According to the modified Newcastle Ottawa Scale we assessed individual study quality as being at high risk of bias and according to GRADE the overall evidence for our primary outcomes was very low.

Conclusion

Our systematic review on the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs found very limited existing evidence, without significant differences in neonatal death and severe brain injury by mode of delivery.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1554-7) contains supplementary material, which is available to authorized users.

Head Growth Trajectory and Neurodevelopmental Outcomes in Preterm Neonates

OBJECTIVES

To evaluate the association between head growth (HG) during neonatal and postdischarge periods and neurodevelopmental outcomes of preterm neonates of <29 weeks gestational age.

METHODS

We conducted a retrospective cohort study of infants <29 weeks gestational
age admitted between 2009 and 2011 to participating Canadian Neonatal Network
units and followed by Canadian Neonatal Follow-Up Network clinics. Differences in head circumference (ΔHC) z score were calculated for 3 time periods, which include admission to discharge, discharge to follow-up at 16-36 months, and admission to follow-up. These were categorized in 1 reference group (ΔHC z score between -1 and +1) and 4 study groups (ΔHC z score of <-2, between -2 to -1, +1 to +2, and >+2). Neurodevelopmental outcomes were compared with the reference group.

RESULTS

1973 infants met the inclusion criteria. Poor HG occurred frequently during the NICU admission (ΔHC z score <-2 in 24% infants versus 2% infants post-discharge) with a period of "catch-up" growth postdischarge. Significant neurodevelopmental impairment was higher in infants with the poorest HG from admission to follow-up (adjusted odds ratio 2.18, 95% confidence interval 1.50-3.15), specifically cognitive and motor delays. Infants with poor initial HG and catch-up postdischarge have a lower adjusted odds ratio of significant neurodevelopmental impairment (0.35, 95% CI 0.16-0.74). Infants with poor HG received a longer duration of parenteral nutrition and mechanical ventilation and had poor weight gain.

CONCLUSIONS

Poor HG during the neonatal and postdischarge periods was associated with motor and cognitive delays at 16 to 36 months.

Bronchopulmonary dysplasia and pulmonary hypertension: a meta-analysis

OBJECTIVE

Pulmonary hypertension (PH) is a complication of bronchopulmonary dysplasia (BPD) but the true impact of PH in patients with BPD remains unclear. We sought to systematically review and meta-analyze incidence of PH in BPD and compare clinical outcomes of BPD patients with PH to those without PH in preterm infants.

STUDY DESIGN

Medline, Embase, PsychINFO and CINAHL were searched from January 2000 through December 2015. Cohort, case-control and randomized studies were included. Case-reports, case-series and letters to editors and studies with high risk of bias were excluded. Study design, inclusion/exclusion criteria, diagnostic criteria for BPD and PH and outcomes were extracted independently by two co-authors.

RESULTS

The pooled incidence of PH in patients with BPD (any severity) was 17% (95% confidence interval (CI) 12 to 21; 7 studies) and 24% (95% CI 17 to 30; 9 studies) in moderate-severe BPD. Patients with BPD have higher unadjusted odds of developing PH compared to those without BPD (odds ratio (OR) 3.00; 95% CI 1.18 to 7.66; 4 studies). Patients with BPD and PH were at higher odds of mortality (OR 5.29; 95% CI 2.07 to 13.56; 3 studies) compared with BPD without PH, but there was no significant difference in duration of initial hospitalization, duration of supplemental oxygen requirement or need for home oxygen. No studies included in this review reported on long-term pulmonary or neurodevelopmental outcomes.

CONCLUSIONS

PH occurs in one out of 4 to 5 preterm neonates with BPD. Patients with BPD and PH may have higher odds of mortality; however, there is urgent need for high quality studies that control for confounders and provide data on long-term outcomes.

Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units

AIM

To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs).

METHODS

A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice.

RESULTS

In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes.

CONCLUSION

There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.

Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units

AIM

To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs).

METHODS

A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice.

RESULTS

In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes.

CONCLUSION

There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.

Use of high noninvasive respiratory support pressures in preterm neonates: a single-center experience

PURPOSE

To describe the incidence, indications and clinical outcomes following high pressures on noninvasive respiratory support (NRS) in preterm neonates.

STUDY DESIGN

Retrospective cohort study of all neonates with BW <1.500 g admitted from July 2012 to June 2014 and placed on high noninvasive respiratory support (NRS), defined as mean airway pressure ≥10 cm H₂O for at least 12 continuous hours using nasal continuous positive airway pressure (NCPAP) and/or nasal high-frequency ventilation (NIHFV). Clinical and physiological outcomes following high NRS were ascertained. Median (IQR) and percentages were used to describe continuous and categorical data, respectively.

RESULTS

There were 131 instances of high NRS use in 70 of 315 eligible infants. Most common indication was post-extubation, observed in 37% (49/131) of high NRS instances. Intubation was avoided in 71% (93/131) of instances in the first 7 days following high NRS initiation. There were no physiological perturbations in heart rate, blood pressure or oxygen requirement. Furthermore, there were no instances of lung hyperinflation, pneumothoraces or spontaneous intestinal perforation following high NRS.

CONCLUSION

The use of high NRS pressure was followed by avoidance of intubation in the majority of cases without adverse effects. Further research on high NRS use including its indications, clinical outcomes and safety profile is warranted.

Introduction of microsystems in a level 3 neonatal intensive care unit-an interprofessional approach

Background

Growth of neonatal intensive care units in number and size has raised questions towards ability to maintain continuity and quality of care. Structural organization of intensive care units is known as a key element for maintaining the quality of care of these fragile patients. The reconstruction of megaunits of intensive care to smaller care units within a single operational service might help with provision of safe and effective care.

Methods/Design

The clinical team and patient distribution lay out, admission and discharge criteria and interdisciplinary round model was reorganized to follow the microstructure philosophy. A working group met weekly to formulate the implementation planning, to review the adaptation and adjustment process and to ascertain the quality of implementation following the initiation of the microsystem model.

Discussion

In depth examination of microsystem model of care in this study, provides systematic evaluation of this model on variable aspects of health care. The individual projects of this trial can be source of solid evidence for guidance of future decisions on optimized model of care for the critically ill newborns.

Trial registration

ClinicalTrial.gov, NCT02912780. Retrospectively registered on 22 September 2016.

Non-invasive high-frequency ventilation versus bi-phasic continuous positive airway pressure (BP-CPAP) following CPAP failure in infants <1250 g: a pilot randomized controlled trial

OBJECTIVE

Non-invasive high-frequency ventilation (NIHFV), a relatively new modality, is gaining popularity despite limited data. We sought to evaluate the effectiveness of NIHFV versus bi-phasic continuous positive airway pressure (BP-CPAP) in preterm infants failing CPAP.

STUDY DESIGN

Infants with BW<1250 g on CPAP were randomly assigned to NIHFV or BP-CPAP if they met pre-determined criteria for CPAP failure. Infants were eligible for randomization after 72 h age and until 2000 g. Guidelines for adjustment of settings and criteria for failure of assigned mode were implemented. The primary aim was to assess feasibility of a larger trial. In addition, failure of assigned non-invasive respiratory support (NRS) mode, invasive mechanical ventilation (MV) 72 h and 7 days post-randomization, and bronchopulmonary dysplasia (BPD) were assessed.

RESULTS

Thirty-nine infants were randomized to NIHFV (N=16) or BP-CPAP (N=23). There were no significant differences in mean (s.d.) postmenstrual age (28.6 (1.5) versus 29.0 (2.3) weeks, P=0.47), mean (s.d.) weight at randomization (965.0 (227.0) versus 958.1 (310.4) g, P=0.94) or other baseline demographics between the groups. Failure of assigned NRS mode was lower with NIHFV (37.5 versus 65.2%, P=0.09), although not statistically significant. There were no differences in rates of invasive MV 72 h and 7 days post-randomization or BPD.

CONCLUSION

NIHFV was not superior to BP-CPAP in this pilot study. Effectiveness of NIHFV needs to be proven in larger multi-center, appropriately powered trials before widespread implementation.