Intratracheal budesonide mixed with surfactant to increase survival free of bronchopulmonary dysplasia in extremely preterm infants: statistical analysis plan for the international, multicenter, randomized PLUSS trial

BACKGROUND

Bronchopulmonary dysplasia (BPD), an inflammatory-mediated chronic lung disease, is common in extremely preterm infants born before 28 weeks' gestation and is associated with an increased risk of adverse neurodevelopmental and respiratory outcomes in childhood. Effective and safe prophylactic therapies for BPD are urgently required. Systemic corticosteroids reduce rates of BPD in the short term but are associated with poorer neurodevelopmental outcomes if given to ventilated infants in the first week after birth. Intratracheal administration of corticosteroid admixed with exogenous surfactant could overcome these concerns by minimizing systemic sequelae. Several small, randomized trials have found intratracheal budesonide in a surfactant vehicle to be a promising therapy to increase survival free of BPD. The primary objective of the PLUSS trial is to determine whether intratracheal budesonide mixed with surfactant increases survival free of bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) in extremely preterm infants born before 28 weeks' gestation.

METHODS

An international, multicenter, double-blinded, randomized trial of intratracheal budesonide (a corticosteroid) mixed with surfactant for extremely preterm infants to increase survival free of BPD at 36 weeks' postmenstrual age (PMA; primary outcome). Extremely preterm infants aged < 48 h after birth are eligible if (1) they are mechanically ventilated, or (2) they are receiving non-invasive respiratory support and there is a clinical decision to treat with surfactant. The intervention is budesonide (0.25 mg/kg) mixed with poractant alfa (200 mg/kg first intervention, 100 mg/kg if second intervention), administered intratracheally via an endotracheal tube or thin catheter. The comparator is poractant alfa alone (at the same doses). Secondary outcomes include the components of the primary outcome (death, BPD prior to or at 36 weeks' PMA), and potential systemic side effects of corticosteroids. Longer-term outcomes will be published separately, and include cost-effectiveness, early childhood health until 2 years of age, and neurodevelopmental outcomes at 2 years of age (corrected for prematurity).

STATISTICAL ANALYSIS PLAN

A sample size of 1038 infants (519 in each group) is required to provide 90% power to detect a relative increase in survival free of BPD of 20% (an absolute increase of 10%), from the anticipated event rate of 50% in the control arm to 60% in the intervention (budesonide) arm, alpha error 0.05. To allow for up to 2% of study withdrawals or losses to follow-up, PLUSS aimed to enroll a total of 1060 infants (530 in each arm). The binary primary outcome will be reported as the number and percentage of infants who were alive without BPD at 36 weeks' PMA for each randomization group. To estimate the difference in risk (with 95% CI), between the treatment and control arms, binary regression (a generalized linear multivariable model with an identity link function and binomial distribution) will be used. Along with the primary outcome, the individual components of the primary outcome (death, and physiological BPD at 36 weeks' PMA), will be reported by randomization group and, again, binary regression will be used to estimate the risk difference between the two treatment groups for survival and physiological BPD at 36 weeks' PMA.

Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis

AIM

To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation.

METHODS

Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines.

RESULTS

DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient.

CONCLUSIONS

DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Two-Year Outcomes After Minimally Invasive Surfactant Therapy in Preterm Infants: Follow-Up of the OPTIMIST-A Randomized Clinical Trial

Importance

The long-term effects of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome remain to be definitively clarified.

Objective

To examine the effect of MIST on death or neurodevelopmental disability (NDD) at 2 years' corrected age.

Design, Setting, and Participants

Follow-up study of a randomized clinical trial with blinding of clinicians and outcome assessors conducted in 33 tertiary-level neonatal intensive care units in 11 countries. The trial included 486 infants with a gestational age of 25 to 28 weeks supported with continuous positive airway pressure (CPAP). Collection of follow-up data at 2 years' corrected age was completed on December 9, 2022.

Interventions

Infants assigned to MIST (n = 242) received exogenous surfactant (200 mg/kg poractant alfa) via a thin catheter; those assigned to the control group (n = 244) received sham treatment.

Main Outcomes and Measures

The key secondary outcome of death or moderate to severe NDD was assessed at 2 years' corrected age. Other secondary outcomes included components of this composite outcome, as well as hospitalizations for respiratory illness and parent-reported wheezing or breathing difficulty in the first 2 years.

Results

Among the 486 infants randomized, 453 had follow-up data available (median gestation, 27.3 weeks; 228 females [50.3%]); data on the key secondary outcome were available in 434 infants. Death or NDD occurred in 78 infants (36.3%) in the MIST group and 79 (36.1%) in the control group (risk difference, 0% [95% CI, -7.6% to 7.7%]; relative risk [RR], 1.0 [95% CI, 0.81-1.24]); components of this outcome did not differ significantly between groups. Secondary respiratory outcomes favored the MIST group. Hospitalization with respiratory illness occurred in 49 infants (25.1%) in the MIST group vs 78 (38.2%) in the control group (RR, 0.66 [95% CI, 0.54-0.81]) and parent-reported wheezing or breathing difficulty in 73 (40.6%) vs 104 (53.6%), respectively (RR, 0.76 [95% CI, 0.63-0.90]).

Conclusions and Relevance

In this follow-up study of a randomized clinical trial of preterm infants with respiratory distress syndrome supported with CPAP, MIST compared with sham treatment did not reduce the incidence of death or NDD by 2 years of age. However, infants who received MIST had lower rates of adverse respiratory outcomes during their first 2 years of life.

Trial Registration

anzctr.org.au Identifier: ACTRN12611000916943.

Intratracheal budesonide mixed with surfactant to increase survival free of bronchopulmonary dysplasia in extremely preterm infants: study protocol for the international, multicenter, randomized PLUSS trial

BACKGROUND

Bronchopulmonary dysplasia (BPD), an inflammatory-mediated chronic lung disease, is common in extremely preterm infants born before 28 weeks' gestation and is associated with an increased risk of adverse neurodevelopmental and respiratory outcomes in childhood. Effective and safe prophylactic therapies for BPD are urgently required. Systemic corticosteroids reduce rates of BPD in the short-term but are associated with poorer neurodevelopmental outcomes if given to ventilated infants in the first week after birth. Intratracheal administration of corticosteroid admixed with exogenous surfactant could overcome these concerns by minimizing systemic sequelae. Several small, randomized trials have found intratracheal budesonide in a surfactant vehicle to be a promising therapy to increase survival free of BPD.

METHODS

An international, multicenter, double-blinded, randomized trial of intratracheal budesonide (a corticosteroid) mixed with surfactant for extremely preterm infants to increase survival free of BPD at 36 weeks' postmenstrual age (PMA; primary outcome). Extremely preterm infants aged < 48 h after birth are eligible if: (1) they are mechanically ventilated, or (2) they are receiving non-invasive respiratory support and there is a clinical decision to treat with surfactant. The intervention is budesonide (0.25 mg/kg) mixed with poractant alfa (200 mg/kg first intervention, 100 mg/kg if second intervention), administered intratracheally via an endotracheal tube or thin catheter. The comparator is poractant alfa alone (at the same doses). Secondary outcomes include the components of the primary outcome (death, BPD prior to or at 36 weeks' PMA), potential systemic side effects of corticosteroids, cost-effectiveness, early childhood health until 2 years of age, and neurodevelopmental outcomes at 2 years of age (corrected for prematurity).

DISCUSSION

Combining budesonide with surfactant for intratracheal administration is a simple intervention that may reduce BPD in extremely preterm infants and translate into health benefits in later childhood. The PLUSS 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 regardless of their initial mode of respiratory support. Should intratracheal budesonide mixed with surfactant increase survival free of BPD, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au ), ACTRN12617000322336. First registered on 28th February 2017.

Trientine tetrahydrochloride versus penicillamine for maintenance therapy in Wilson disease (CHELATE): a randomised, open-label, non-inferiority, phase 3 trial

BACKGROUND

Wilson disease is an inherited disorder of copper transport. Whereas penicillamine is used therapeutically to re-establish copper balance, trientine is indicated for patients with penicillamine intolerance. We aimed to compare penicillamine with trientine tetrahydrochloride (TETA4) for maintenance therapy in patients with Wilson disease.

METHODS

We conducted a randomised, open-label, non-inferiority, phase 3 trial at 15 health-care centres across nine countries (patients were recruited from 13 of these health-care centres across Brazil, Europe, and the USA). We enrolled patients aged 18-75 years with stable Wilson disease who were treated for at least 1 year with penicillamine. Patients entered a 12-week period to determine stability through clinical assessment by site investigators and predefined thresholds for serum non-caeruloplasmin-bound copper (NCC; by an exchangeable copper assay; 25-150 μg/L), 24 h urinary copper excretion (100-900 μg/24 h), and alanine aminotransferase (ALT; <2 × upper limit of normal). Stable patients were randomly assigned (1:1) to continue receiving the maintenance twice daily dose of oral penicillamine or switched mg-for-mg to oral TETA4 centrally with a web-based system using minimisation. The primary endpoint, assessed 24 weeks after randomisation, was NCC by speciation assay. The non-inferiority margin of mean difference in NCC by speciation assay was -50 μg/L, as estimated by a general linear model for repeated visits, adjusted for baseline values. Further data on safety and efficacy were collected during a 24-week extension period. Data were analysed using an intention-to-treat approach. Safety was assessed in all patients who received at least one dose of study treatment. This study is registered with ClinicalTrials.gov, NCT03539952 (active, not recruiting).

FINDINGS

Between June 4, 2018, and March 10, 2020, 77 patients were screened. 53 patients were randomly assigned (27 to the penicillamine group and 26 to the TETA4 group). After 24 weeks, the mean difference in serum NCC by speciation assay between the penicillamine group and TETA4 group was -9·1 μg/L (95% CI -24·2 to 6·1), with the lower limit of the 95% CI within the defined non-inferiority margin. At 24 weeks, urinary copper excretion was lower with TETA4 than with penicillamine (mean difference 237·5 μg/24 h (99% CI 115·6 to 359·4). At 48 weeks, TETA4 remained non-inferior to penicillamine in terms of NCC by speciation assay (mean difference NCC -15·5 μg/L [95% CI -34·5 to 3·6]). Urinary copper excretion at 48 weeks remained in the expected range for well treated patients in both study groups, and the mean difference (124·8 μg/24 h [99% CI -37·6 to 287·1]) was not significantly different. At 24 weeks and 48 weeks, masked clinical adjudication of stability assessed by three independent clinicians confirmed clinical stability (100%) of all participants, in agreement with the stability seen with the NCC by speciation assay. There were no notable changes in either the Clinical Global Impression of Change or Unified Wilson Disease Rating Scale (neurological assessment) from baseline (pre-randomisation) at weeks 24 and 48. The mean change in serum total copper from baseline to 24 weeks was 17·6 μg/L (99% CI -9·5 to 44·7) with penicillamine and -6·3 μg/L (-34·7 to 22·1) with TETA4, and the mean change in serum total caeruloplasmin from baseline to 24 weeks was 1·8 mg/L (-19·2 to 22·8) with penicillamine and -2·2 mg/L (-6·1 to 1·7) with TETA4. All liver enzymes were similar at 24 weeks and 48 weeks, with the exception of elevated ALT concentration at 48 weeks for patients in the TETA4 group. Penicillamine was associated with three post-randomisation serious adverse events (leukopenia, cholangiocarcinoma, and hepatocellular cancer); none were reported for TETA4. The most common treatment-emergent adverse events were headache for penicillamine (five [19%] of 27 patients vs two [8%] of 26) and abdominal pain for TETA4 (one [4%] vs four [15%]); all treatment-emergent adverse events resolved and were mild to moderate. One patient developed a rash with TETA4 that resolved on discontinuation of therapy.

INTERPRETATION

The efficacy of TETA4 as oral maintenance therapy was non-inferior to penicillamine and well tolerated in adults with Wilson disease.

FUNDING

Orphalan.

Nasal High-Flow Therapy during Neonatal Endotracheal Intubation

BACKGROUND

Neonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt.

METHODS

We performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant.

RESULTS

The primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3).

CONCLUSIONS

Among infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.).

Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome: The OPTIMIST-A Randomized Clinical Trial

IMPORTANCE

The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain.

OBJECTIVE

To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020.

INTERVENTIONS

Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met.

MAIN OUTCOMES AND MEASURES

The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately.

RESULTS

Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group.

CONCLUSIONS AND RELEVANCE

Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000916943.

The addition of fetal scalp blood lactate measurement as an adjunct to cardiotocography to reduce caesarean sections during labour: The Flamingo randomised controlled trial

BACKGROUND

Fetal scalp blood sampling for lactate measurement (FBSLM) is sometimes used to assist in identification of the need for expedited birth in the presence of an abnormal cardiotocograph (CTG). However, there is no randomised controlled trial evidence to support this.

AIM

To determine whether adding FBSLM reduces the risk of birth by emergency caesarean section in labours complicated by an abnormal CTG, compared with CTG without FBS.

MATERIAL AND METHODS

Labouring women at a tertiary maternity hospital in Melbourne, Australia with a singleton, cephalic presentation, at ≥37 weeks gestation with an abnormal CTG pattern were randomised to the intervention (n = 61), with intermittent FBSLM in addition to CTG monitoring, or control (CTG without FBS, n = 62). The primary outcome was rate of birth by caesarean section. Secondary outcomes included overall operative birth and fetal and neonatal safety endpoints.

TRIAL REGISTRATION

ACTRN12611000172909.

RESULTS

The smaller than anticipated sample was unable to demonstrate an effect from adding FBSLM to CTG monitoring on birth by caesarean section vs monitoring by CTG without FBS (25/61 and 28/62 respectively, P = 0.64, risk ratio 0.91, 95% confidence intervals 0.60-1.36). One newborn infant in the CTG group met the criteria for the composite neonatal outcome of death or serious outcome, neonatal encephalopathy, five-minute Apgar score < 4, neonatal resuscitation, admission to neonatal intensive care unit for 96 h or more.

CONCLUSION

We were unable to provide robust evidence of the effectiveness of FBSLM to improve the specificity of the CTG in the assessment of fetal wellbeing.

Lung ultrasound during newborn resuscitation predicts the need for surfactant therapy in very- and extremely preterm infants

INTRODUCTION

Early identification of infants requiring surfactant therapy improves outcomes. We evaluated the accuracy of delivery room lung ultrasound (LUS) to predict surfactant therapy in very- and extremely preterm infants.

METHODS

Infants born at <32^0/7 weeks were prospectively enrolled at 2 centres. LUS videos of both sides of the chest were obtained 5-10 min, 11-20 min, and 1-3 h after birth. Clinicians were masked to the results of the LUS assessment and surfactant therapy was provided according to local guidelines. LUS videos were graded blinded to clinical data. Presence of unilateral type 1 ('whiteout') LUS or worse was considered test positive. Receiver Operating Characteristic (ROC) analysis compared the accuracy of LUS and an FiO₂ threshold of 0.3 to predict subsequent surfactant therapy.

RESULTS

Fifty-two infants with a median age of 27^6/7 weeks (IQR 26^0/7-28^6/7) were studied. Thirty infants (58%) received surfactant. Area under the ROC curve (AUC) for LUS at 5-10 min, 11-20 min and 1-3 h was 0.78 (95% CI, 0.66-0.90), 0.76 (95% CI, 0.65-0.88) and 0.86 (95% CI, 0.75-0.97) respectively, outperforming FiO₂ at the 5-10 min timepoint (AUC 0.45, 95% CI 0.29-0.62, p = 0.001). At 11-20 min, LUS had a specificity of 95% (95% CI 77-100%) and sensitivity of 59% (95% CI, 39-77%) to predict surfactant therapy. All infants born at 23-27^6/7 weeks with LUS test positive received surfactant. Twenty-six infants (50%) had worsening of LUS grades on serial assessment.

CONCLUSIONS

LUS in the delivery room and accurately predicts surfactant therapy in infants <32^0/7 weeks.

Outcomes after Introduction of Minimally Invasive Surfactant Therapy in Two Australian Tertiary Neonatal Units

OBJECTIVE

To assess the procedural and clinical outcomes associated with the introduction of minimally invasive surfactant therapy (MIST) into standard care at 2 tertiary Australian neonatal intensive care units.

STUDY DESIGN

A prospective audit was designed before the introduction of MIST in 2018, with data collected over a period of 18 months. Procedural data were completed by the clinical team performing MIST, including clinical observations, medication use, and adverse events. The audit team collected demographic data and subsequent clinical outcomes from medical records.

RESULTS

There were 135 MIST procedures recorded in 122 infants. For the included infants, the median gestation was 30^2/7 weeks (IQR, 27^6/7 to 32^2/7 weeks) and birth weight was 1439 g (IQR, 982-1958 g). During the MIST procedure, desaturation to a peripheral oxygen saturation of <80% was common, occurring in 75.2% of procedures. Other adverse events included need for positive pressure ventilation (10.6%) and bradycardia <100 beats per minute (13.3%). The use of atropine premedication was associated with a significantly lower incidence of bradycardia: 8.6% vs 52.9% (P < .01). Senior clinicians demonstrated higher rates of procedural success. The majority of infants (63.9%) treated with MIST did not require subsequent intubation and mechanical ventilation.

CONCLUSIONS

MIST can be successfully introduced in neonatal units with limited experience of this technique. The use of atropine premedication decreases the incidence of bradycardia during the procedure. Success rates can be optimized by limiting MIST to clinicians with greater competence in endotracheal intubation.

Characterization of the pathoimmunology of necrotizing enterocolitis reveals novel therapeutic opportunities

Necrotizing enterocolitis (NEC) is a severe, currently untreatable intestinal disease that predominantly affects preterm infants and is driven by poorly characterized inflammatory pathways. Here, human and murine NEC intestines exhibit an unexpected predominance of type 3/T_H17 polarization. In murine NEC, pro-inflammatory type 3 NKp46⁻RORγt⁺Tbet⁺ innate lymphoid cells (ILC3) are 5-fold increased, whereas ILC1 and protective NKp46⁺RORγt⁺ ILC3 are obliterated. Both species exhibit dysregulation of intestinal TLR repertoires, with TLR4 and TLR8 increased, but TLR5-7 and TLR9-12 reduced. Transgenic IL-37 effectively protects mice from intestinal injury and mortality, whilst exogenous IL-37 is only modestly efficacious. Mechanistically, IL-37 favorably modulates immune homeostasis, TLR repertoires and microbial diversity. Moreover, IL-37 and its receptor IL-1R8 are reduced in human NEC epithelia, and IL-37 is lower in blood monocytes from infants with NEC and/or lower birthweight. Our results on NEC pathomechanisms thus implicate type 3 cytokines, TLRs and IL-37 as potential targets for novel NEC therapies.

Necrotizing Enterocolitis (NEC) is an untreatable intestinal disease in infants. Here the authors show that human and experimental mouse NEC is associated with altered toll-like receptor expression in the intestine, enhanced Th17/type 3 polarization in adaptive immune and innate lymphoid cells, dysregulated microbiota, and reduced interleukin-37 signaling.

Optimal human and system performance during neonatal resuscitation

Performance in the delivery of care to sick neonates in need of resuscitation has long been defined primarily in terms of the extent of the knowledge possessed and hands-on skill demonstrated by physicians and other healthcare professionals. This definition of performance in neonatal resuscitation is limited by its focus solely on the human beings delivering care and a perceived set of the requisite skills to do so. This manuscript will expand the definition of performance to include all of the skill sets that humans must use to resuscitate newborns as well as the often complex systems in which those humans operate while delivering that care. It will also highlight how the principles of human factors and ergonomics can be used to enhance human and system performance during patient care. Finally, it will describe the role of simulation and debriefing in the assessment of human and system performance.

Baby-directed umbilical cord clamping: A feasibility study

INTRODUCTION

Over five percent of infants born worldwide will need help breathing after birth. Delayed cord clamping (DCC) has become the standard of care for vigorous infants. DCC in non-vigorous infants is uncommon because of logistical difficulties in providing effective resuscitation during DCC. In Baby-Directed Umbilical Cord Clamping (Baby-DUCC), the umbilical cord remains patent until the infant's lungs are exchanging gases. We conducted a feasibility study of the Baby-DUCC technique.

METHODS

We obtained antenatal consent from pregnant women to enroll infants born at ≥32 weeks. Vigorous infants received ≥2 min of DCC. If the infant received respiratory support, the umbilical cord was clamped ≥60 s after the colorimetric carbon dioxide detector turned yellow. Maternal uterotonic medication was administered after umbilical cord clamping. A paediatrician and researcher entered the sterile field to provide respiratory support during a cesarean birth. Maternal and infant outcomes in the delivery room and prior to hospital discharge were analysed.

RESULTS

Forty-four infants were enrolled, 23 delivered via cesarean section (8 unplanned) and 15 delivered vaginally (6 via instrumentation). Twelve infants were non-vigorous. ECG was the preferred method for recording HR. Two infants had a HR < 100 BPM. All HR values were >100 BPM by 80 s after birth. Median time to umbilical cord clamping was 150 and 138 s in vigorous and non-vigorous infants, respectively. Median maternal blood loss was 300 ml.

CONCLUSIONS

It is feasible to provide resuscitation to term and near-term infants during DCC, after both vaginal and cesarean births, clamping the umbilical cord only when the infant is physiologically ready.

Respiratory changes in term infants immediately after birth

INTRODUCTION

Over 5% of infants worldwide receive breathing support immediately after birth. Our goal was to define references ranges for exhaled carbon dioxide (ECO₂), exhaled tidal volume (VTe), and respiratory rate (RR) immediately after birth in spontaneously breathing, healthy infants born at 36 weeks' gestational age or older.

METHODS

This was a single-centre, observational study at the Royal Women's Hospital in Melbourne, Australia, a busy perinatal referral centre. Immediately after the infant's head was delivered, we used a face mask to measure ECO₂, VTe, and RR through the first ten minutes after birth. Respiratory measurements were repeated at one hour.

RESULTS

We analysed 14,731 breaths in 101 spontaneously breathing infants, 51 born via planned caesarean section and 50 born vaginally with a median (IQR) gestational age of 39^1/7 weeks (38^3/7-39^5/7). It took a median of 7 (4-10) breaths until ECO₂ was detected. ECO₂ quickly increased to peak value of 48 mmHg (43-53) at 143 s (76-258) after birth, and decreased to post-transitional values, 31 mmHg (28-24), by 7 min. VTe increased after birth, reaching a plateau of 5.3 ml/kg (2.5-8.4) by 130 s for the remainder of the study period. Maximum VTe was 19 ml/kg (16-22) at 257 s (82-360). RR values increased slightly over time, being higher from minute five to ten as compared to the first two minutes after birth.

CONCLUSIONS

This study provides reference ranges of exhaled carbon dioxide, exhaled tidal volumes, and respiratory rate for the first ten minutes after birth in term infants who transition without resuscitation.

Suction Mask vs Conventional Mask Ventilation in Term and Near-Term Infants in the Delivery Room: A Randomized Controlled Trial

OBJECTIVE

To compare the suction mask, a new facemask that uses suction to create a seal between the mask and the infant's face, with a conventional soft, round silicone mask during positive pressure ventilation (PPV) in the delivery room in newborn infants >34 weeks of gestation.

STUDY DESIGN

Single-center randomized controlled trial in the delivery room. The primary outcome was mask leak.

RESULTS

Forty-five infants were studied at a median gestational age of 38.1 weeks (IQR, 36.4-39.0 weeks); 22 were randomized to the suction mask and 23 to the conventional mask. The suction mask did not reduce mask leak (49.9%; IQR, 11.0%-92.7%) compared with the conventional mask (30.5%; IQR, 10.6%-48.8%; P = .51). The suction mask delivered lower peak inspiratory pressure (27.2 cm H₂O [IQR, 25.0-28.7 cm H₂O] vs 30.4 cm H₂O [IQR, 29.4-32.5 cm H₂O]; P < .05) and lower positive end expiratory pressure (3.7 cm H₂O [IQR, 3.1-4.5 cm H₂O] vs 5.1 cm H₂O [IQR, 4.2-5.7 cm H₂O ]; P < .05). There was no difference in the duration of PPV or rates of intubation or admission to the neonatal intensive care unit. In 5 infants (23%), the clinician switched from the suction to the conventional mask, 2 owing to intermittently low peak inspiratory pressure, 2 owing to failure to respond to PPV, and 1 owing to marked facial bruising after 6 minutes of PPV.

CONCLUSIONS

The use of the suction mask to provide PPV in newborn infants did not reduce facemask leak. Adverse effects such as the inability to achieve the set pressures and transient skin discoloration are concerning.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry ACTRN12616000768493.

Cerebral oxygenation during skin-to-skin care in preterm infants not receiving respiratory support

OBJECTIVE

Skin-to-skin care (SSC) has proven benefits in preterm infants, but increased hypoxic and bradycardic events have been reported. This may make clinicians hesitant to recommend SSC as standard care. We hypothesised that regional cerebral oxygenation (rStO₂) measured with near infrared spectroscopy is not worse during SSC compared with standard incubator care.

DESIGN

Prospective, observational, non-inferiority study.

SETTING

Single tertiary perinatal centre in Australia.

PATIENTS

Forty preterm infants (median (IQR) 30.6 (29.1-31.7) weeks' gestation) not receiving respiratory support were studied on day 14 (8-38).

INTERVENTIONS

Recordings during 90 min of incubator care, followed by 90 min of SSC. Each infant acted as their own control and caregivers were blinded to the rStO₂ measurements.

MAIN OUTCOME MEASURES

The primary outcome was the mean difference in rStO₂ between SSC and incubator care. The prespecified margin of non-inferiority was -1.5%. Secondary outcomes included heart rate (HR), peripheral oxygen saturation (SpO₂), time in quiet sleep, temperature and hypoxic (SpO₂ <80% for >5 s) or bradycardic events (HR <80 bpm for >5 s) and time spent in cerebral hypoxia (rStO₂<55%) and hyperoxia (rStO₂>85%).

RESULTS

Mean (SD) rStO₂ was lower during SSC compared with incubator care: 73.6 (6.0)% vs 74.8 (4.6)%, mean difference (95% CI) 1.3 (2.2 to 0.4)%. HR was 5 bpm higher, SpO₂ 1% lower and time in quiet sleep 24% longer during SSC. Little evidence of a difference was observed in temperature. The number of hypoxic or bradycardic events as well as the proportion of time spent in cerebral hypoxia and hyperoxia was very low in both periods.

CONCLUSIONS

Mean rStO₂ was marginally lower during SSC without observed differences in hypoxic or bardycardic events but an increase in time spent in quiet sleep.

TRIAL REGISTRATION NUMBER

This trial is linked to Australian New Zealand Clinical Trials Registry: identifier 12616000240448. It was registered pre-results.

The effect of skin-to-skin care on cerebral oxygenation during nasogastric feeding of preterm infants

AIM

To describe cerebral oxygenation during gavage feeding of preterm infants during incubator and skin-to-skin care.

METHODS

Further analysis of data from two crossover studies comparing cerebral oxygenation, heart rate and oxygen saturation during skin-to-skin care with incubator care. Data were analysed in three epochs; 10 minutes prefeed, during-feed and 10 minutes postfeed. Measurements from infants fed during incubator care were compared with those obtained during skin-to-skin care.

RESULTS

In 39 infants [median (IQR) 27.8 (26.1-30.0) weeks' gestation], there was no difference in cerebral oxygenation between pre-, during- and postfeed. Heart rate increased by three beats per minute postfeed compared with during-feed. Twenty infants received two gavage feeds, one feed in the incubator and another during skin-to-skin care. There was no difference in cerebral oxygenation and heart rate; peripheral oxygen saturation decreased by 3% during feeding whilst skin-to-skin care compared with feeding in the incubator.

CONCLUSION

Cerebral oxygenation remained stable before, during and after gavage feeding in an incubator and during skin-to-skin care. The small decrease in oxygen saturation whilst receiving gavage feeding during skin-to-skin care is unlikely to be clinically important, providing reassurance that preterm infants maintain physiological stability during skin-to-skin care.

A Randomized Trial of Conditioned or Unconditioned Gases for Stabilizing Preterm Infants at Birth

OBJECTIVE

To determine whether the use of heated-humidified gases for respiratory support during the stabilization of infants <30 weeks of gestational age (GA) in the delivery room reduces rates of hypothermia on admission to the neonatal intensive care unit (NICU).

STUDY DESIGN

A multicenter, unblinded, randomized trial was conducted in Melbourne, Australia, between February 2013 and June 2015. Infants <30 weeks of GA were randomly assigned to receive either heated-humidified gases or unconditioned gases during stabilization in the delivery room and during transport to NICU. Infants born to mothers with pyrexia >38°C were excluded. Primary outcome was rate of hypothermia on NICU admission (rectal temperature <36.5°C).

RESULTS

A total of 273 infants were enrolled. Fewer infants in the heated-humidified group were hypothermic on admission to NICU (36/132 [27%]) compared with controls (61/141 [43%], P < .01). There was no difference in rates of hyperthermia (>37.5°C); 20% (27/132) in the heated-humidified group compared with 16% (22/141) in the controls (P = .30). There were no differences in mortality or respiratory outcomes.

CONCLUSIONS

The use of heated-humidified gases in the delivery room significantly reduces hypothermia on admission to NICU in preterm infants, without increased risk of hyperthermia.

CLINICAL TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Register (www.anzctr.org.au) ACTRN12613000093785.

Skin-to-skin care in preterm infants receiving respiratory support does not lead to physiological instability

OBJECTIVE

Providing skin-to-skin care (SSC) to preterm infants is standard practice in many neonatal intensive care units. There are conflicting reports on the stability of oxygen saturation (SpO₂) during SSC, which may create a barrier to a wider implementation of SSC to infants receiving respiratory support. Regional cerebral oxygenation (rcO₂) measured using near-infrared spectroscopy can serve as a surrogate parameter for cerebral oxygen delivery and consumption. We hypothesised that rcO₂ during SSC would be similar to standard care in preterm infants receiving respiratory support.

DESIGN

Prospective observational non-inferiority study.

SETTING

Single tertiary perinatal centre in Australia.

PATIENTS

Forty preterm infants (median (IQR) of 27.6 (26.0-28.9) weeks' gestation) receiving respiratory support were studied on day 8 (5-18).

INTERVENTIONS

Ninety minutes of SSC, with infants in incubators acting as their own control. Parents and caregivers were blinded to the measurements.

MAIN OUTCOME MEASURES

Mean difference in rcO₂ between SSC and incubator care; as well as heart rate (HR), SpO₂, fraction of inspired oxygen (FiO₂) and temperature, were compared using a paired t-test.

RESULTS

rcO₂ was similar during SSC (mean (SD) 74.9 (6.5)%)% compared with incubator care (74.7 (6.1)%, mean difference (95% CI) 0.2 (-0.8 to 1.1)%, p=0.71). No clinically important differences in HR, SpO₂, FiO₂ or temperature were observed in the whole cohort and by mode of respiratory support (endotracheal tube mechanical ventilation, continuous positive airway pressure and high-flow nasal cannulae).

CONCLUSIONS

Cerebral oxygenation and other physiological measurements in ventilated preterm infants did not differ between SSC and incubator care.

TRIAL REGISTRATION NUMBER

12615000959572.

Orotracheal intubation in infants performed with a stylet versus without a stylet

BACKGROUND

Neonatal endotracheal intubation is a common and potentially life-saving intervention. It is a mandatory skill for neonatal trainees, but one that is difficult to master and maintain. Intubation opportunities for trainees are decreasing and success rates are subsequently falling. Use of a stylet may aid intubation and improve success. However, the potential for associated harm must be considered.

OBJECTIVES

To compare the benefits and harms of neonatal orotracheal intubation with a stylet versus neonatal orotracheal intubation without a stylet.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library; MEDLINE; Embase; the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and previous reviews. We also searched cross-references, contacted expert informants, handsearched journals, and looked at conference proceedings. We searched clinical trials registries for current and recently completed trials. We conducted our most recent search in April 2017.

SELECTION CRITERIA

All randomised, quasi-randomised, and cluster-randomised controlled trials comparing use versus non-use of a stylet in neonatal orotracheal intubation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed results of searches against predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used the standard methods of the Cochrane Collaboration, as documented in the Cochrane Handbook for Systemic Reviews of Interventions, and of the Cochrane Neonatal Review Group.

MAIN RESULTS

We included a single-centre non-blinded randomised controlled trial that reported a total of 302 intubation attempts in 232 infants. The median gestational age of enrolled infants was 29 weeks. Paediatric residents and fellows performed the intubations. We judged the study to be at low risk of bias overall. Investigators compared success rates of first-attempt intubation with and without use of a stylet and reported success rates as similar between stylet and no-stylet groups (57% and 53%) (P = 0.47). Success rates did not differ between groups in subgroup analyses by provider level of training and infant weight. Results showed no differences in secondary review outcomes, including duration of intubation, number of attempts, participant instability during the procedure, and local airway trauma. Only 25% of all intubations took less than 30 seconds to perform. Study authors did not report neonatal morbidity nor mortality. We considered the quality of evidence as low on GRADE analysis, given that we identified only one unblinded study.

AUTHORS' CONCLUSIONS

Current available evidence suggests that use of a stylet during neonatal orotracheal intubation does not significantly improve the success rate among paediatric trainees. However, only one brand of stylet and one brand of endotracheal tube have been tested, and researchers performed all intubations on infants in a hospital setting. Therefore, our results cannot be generalised beyond these limitations.

A systematic review of novel technology for monitoring infant and newborn heart rate

Heart rate (HR) is a vital sign for assessing the need for resuscitation. We performed a systematic review of studies assessing novel methods of measuring HR in newborns and infants in the neonatal unit. Two investigators completed independent literature searches. Identified papers were independently evaluated, and relevant data were extracted and analysed.

CONCLUSION

This systematic review identified seven new technologies, including camera-based photoplethysmography, reflectance pulse oximetry, laser Doppler methods, capacitive sensors, piezoelectric sensors, electromyography and a digital stethoscope. Clinicians should be aware of several of these, which may become available for clinical use in the near future.

Lung ultrasound during the initiation of breathing in healthy term and late preterm infants immediately after birth, a prospective, observational study

INTRODUCTION

Lung ultrasound (LUS) has shown promise for evaluation of newborns with respiratory distress. However, no study has described the appearance of LUS during the initiation of breathing. We used LUS to describe the appearance of the lungs in healthy infants immediately after birth, starting with the infant's first breath, through the first 20min after birth.

METHODS

This was a single-center observational study enrolling neonates born at ≥35 weeks. We obtained LUS video recordings with the initiation of breathing. Recordings that captured one of the 1st four breaths after birth were included. We also obtained recordings at 1-10 and 11-20min after birth. Recordings were graded using a modified version of a previously published system, with additional grades to describe the appearance of the lungs prior to establishment of the pleural line.

RESULTS

We studied 63 infants, mean gestational age=39^1/7±2 days, mean weight=3473g±422, 33 infants were delivered vaginally and 30 via cesarean section. We captured the first breath after birth in 28 infants and within the first four breaths from the remaining 35 infants. The pleural line was established by a median of 4 breaths (3-6). At the 1-10min examination, all infants had an established pleural line and 89% demonstrated substantial liquid clearance. At the 11-20min examination, all infants had substantial liquid clearance.

CONCLUSION

Establishment of the pleural line, indicating lung aeration and substantial liquid clearance is achieved with the first few breaths after birth in term and near term infants.

A new suction mask to reduce leak during neonatal resuscitation: a manikin study

OBJECTIVE

Leak around the face mask is a common problem during neonatal resuscitation. A newly designed face mask using a suction system to enhance contact between the mask and the infant's face might reduce leak and improve neonatal resuscitation. The aim of the study is to determine whether leak is reduced using the suction mask (Resusi-sure mask) compared with a conventional mask (Laerdal Silicone mask) in a manikin model.

METHODS

Sixty participants from different professional categories (neonatal consultants, fellows, registrars, nurses, midwives and students) used each face mask in a random order to deliver 2 min of positive pressure ventilation to a manikin. Delivered airway pressures were measured using a pressure line. Inspiratory and expiratory flows were measured using a flow sensor, and expiratory tidal volumes and mask leaks were derived from these values.

RESULTS

A median (IQR) leak of 12.1 (0.6-39.0)% was found with the conventional mask compared with 0.7 (0.2-4.6)% using the suction mask (p=0.002). 50% of the participants preferred to use the suction mask and 38% preferred to use the conventional mask. There was no correlation between leak and operator experience.

CONCLUSIONS

A new neonatal face mask based on the suction system reduced leak in a manikin model. Clinical studies to test the safety and effectiveness of this mask are needed.

A randomised trial of placing preterm infants on their back or left side after birth

BACKGROUND

Basic life support guidelines recommend placing spontaneously breathing children and adults on their side. Though the majority of preterm newborns breathe spontaneously, they are routinely placed on their back after birth. We hypothesised that they would breathe more effectively when placed on their side.

OBJECTIVE

To determine whether preterm newborns placed on their left side at birth, compared with those placed on their back, have higher preductal oxygen saturation (SpO2) at 5 min of life.

DESIGN/METHODS

We randomised infants <32 weeks to be placed on their back or on their left side immediately after birth. Respiratory support was given with a T-piece and face mask with initial fraction of inspired oxygen (FiO2) of 0.3. The FiO2 was increased if SpO2 was <70% at 5 min.

RESULTS

We enrolled 87 infants, 41 randomised to back and 46 to left side. The groups were well matched for demographic variables. Fourteen (6 back and 8 left side) infants did not receive respiratory support in the first 5 min. The mean (SD) SpO2 was not different between the groups (back 72 (23) % versus left side 71 (24) %, p=0.956). We observed no adverse effects of placing infants on their side and found no differences in secondary outcomes between the groups.

CONCLUSIONS

Preterm infants on their left side did not have higher SpO2 at 5 min of life. Placing preterm infants on their side at birth is feasible and appears to be a reasonable alternative to placing them on their back.

TRIAL REGISTRATION NUMBER

ISRCTN74486341.

Incidence and Outcome of CPAP Failure in Preterm Infants

BACKGROUND AND OBJECTIVES

Data from clinical trials support the use of continuous positive airway pressure (CPAP) for initial respiratory management in preterm infants, but there is concern regarding the potential failure of CPAP support. We aimed to examine the incidence and explore the outcomes of CPAP failure in Australian and New Zealand Neonatal Network data from 2007 to 2013.

METHODS

Data from inborn preterm infants managed on CPAP from the outset were analyzed in 2 gestational age ranges (25-28 and 29-32 completed weeks). Outcomes after CPAP failure (need for intubation <72 hours) were compared with those succeeding on CPAP using adjusted odds ratios (AORs).

RESULTS

Within the cohort of 19 103 infants, 11 684 were initially managed on CPAP. Failure of CPAP occurred in 863 (43%) of 1989 infants commencing on CPAP at 25-28 weeks' gestation and 2061 (21%) of 9695 at 29-32 weeks. CPAP failure was associated with a substantially higher rate of pneumothorax, and a heightened risk of death, bronchopulmonary dysplasia (BPD) and other morbidities compared with those managed successfully on CPAP. The incidence of death or BPD was also increased: (25-28 weeks: 39% vs 20%, AOR 2.30, 99% confidence interval 1.71-3.10; 29-32 weeks: 12% vs 3.1%, AOR 3.62 [2.76-4.74]). The CPAP failure group had longer durations of respiratory support and hospitalization.

CONCLUSIONS

CPAP failure in preterm infants is associated with increased risk of mortality and major morbidities, including BPD. Strategies to promote successful CPAP application should be pursued vigorously.

Exhaled carbon dioxide in healthy term infants immediately after birth

OBJECTIVE

To measure exhaled carbon dioxide (ECO2) in term infants immediately after birth.

STUDY DESIGN

Infants >37 weeks gestation born at The Royal Women's Hospital, Melbourne, Australia were eligible. A combined flow sensor and mainstream carbon dioxide (CO2) analyzer was placed in series proximal to a facemask to measure ECO2 and tidal volumes in the first 120 seconds after birth.

RESULTS

Term infants (n = 20) with a mean (SD) birth weight of 2976 (697) g and gestational age of 38 (2) weeks were included. Infants took a median (range) 3 (1-8) breaths before ECO2 was detected. The median (range) of maximum ECO2 was 51 (40-73) mm Hg at 70 (21-106) seconds after birth. Within the first 10 breaths, CO2 increased from 0-27 (22-34) mm Hg. The median (IQR) tidal volume during the breaths without CO2 was 1.2 (0.8-3.1) mL/kg compared with 7.3 (3.2-10.9) mL/kg during the first 10 breaths where CO2 was exhaled.

CONCLUSIONS

The first breaths for an infant after birth did not contain ECO2. With aeration of the distal gas exchange regions, tidal volume and ECO2 significantly increased. ECO2 can be used to monitor lung aeration immediately after birth.

Assessing the tongue colour of newly born infants may help to predict the need for supplemental oxygen in the delivery room

AIM

It takes several minutes for infants to become pink after birth. Preductal oxygen saturation (SpO2) measurements are used to guide the delivery of supplemental oxygen to newly born infants, but pulse oximetry is not available in many parts of the world. We explored whether the pinkness of an infant's tongue provided a useful indication that supplemental oxygen was required.

METHODS

This was a prospective observational study of infants delivered by Caesarean section. Simultaneous recording of SpO2 and visual assessment of whether the tongue was pink or not was made at 1-7 and 10 min after birth.

RESULTS

The 38 midwives and seven paediatric trainees carried out 271 paired assessments on 68 infants with a mean (SD) birthweight of 3214 (545) grams and gestational age of 38 (2) weeks. When the infant did not have a pink tongue, this predicted SpO2 of <70% with a sensitivity of 26% and a specificity of 96%.

CONCLUSION

Tongue colour was a specific but insensitive sign that indicated when SpO2 was <70%. When the tongue is pink, it is likely that an infant has an SpO2 of more than 70% and does not require supplemental oxygen.

Timing of interventions in the delivery room: does reality compare with neonatal resuscitation guidelines?

OBJECTIVE

To determine the proportion of infants who had the tasks recommended in the neonatal resuscitation guidelines performed within 30 and 60 seconds of birth, and the time taken to perform each task.

STUDY DESIGN

From video recordings in delivery rooms, we determined the time from birth and arrival on a resuscitation table to warm, assess heart rate (HR), attach an oximeter, and provide respiratory support for each infant. We determined the proportion of infants who had these tasks completed by 30 and 60 seconds, and the median time taken to perform each task.

RESULTS

We reviewed and analyzed data from 189 infants (median gestational age, 29 weeks [IQR, 27-34 weeks]; median birth weight, 1220 g [IQR, 930-2197 g]). Twelve infants (6%) were not on the resuscitation table within 30 seconds of birth. Less than 10% of infants were placed in polyethylene bags or had their HR determined by 30 seconds. By 60 seconds, 48% were in polyethylene bags, 33% had their HR determined, 38% received respiratory support, and 60% had an oximeter attached. The median time taken to perform all tasks was greater than that recommended in the guidelines.

CONCLUSION

Most newborns were not managed within the time frame recommended in resuscitation guidelines. The recommended 30- and 60-second intervals may be too short.

Comparison of heart rate and oxygen saturation measurements from Masimo and Nellcor pulse oximeters in newly born term infants

AIM

To compare heart rate (HR) measurements from Masimo and Nellcor pulse oximeters (POs) against HR measured via a three lead electrocardiograph (ECG) (HRECG ). We also compared peripheral oxygen saturation (SpO2 ) measurements between Nellcor and Masimo oximeters.

METHOD

Term infants born via elective caesarean section were studied. ECG leads were placed on the infant's chest and abdomen. Masimo and Nellcor PO sensors were randomly allocated to either foot. The monitors were placed on a trolley, and data from each monitor screen captured by a video camera. HR, SpO2 measurements and signal quality were extracted. Bland-Altman analysis was used to determine agreement between HR from the ECG and each oximeter, and between SpO2 from the oximeters.

RESULTS

We studied 44 infants of whom 4 were resuscitated. More than 8000 pairs of observations were used for each comparison of HR and SpO2. The mean difference (±2SD) between HRECG and HRN ellcor was -0.8 (±11) beats per minute (bpm); between HRECG and HRM asimo was 0.2 (±9) bpm. The mean (±2SD) difference between SpO2Masimo and SpO2Nellcor was -3 (±15)%. The Nellcor PO measured 20% higher than the Masimo PO at SpO2 <70%.

CONCLUSION

Both oximeters accurately measure HR. There was good agreement between SpO2 measurements when SpO2 ≥70%. At lower SpO2 , agreement was poorer.

Mask ventilation of preterm infants in the delivery room

OBJECTIVE

To measure tidal volumes (VT) and describe the interactions between spontaneous breaths and positive pressure ventilation (PPV) inflations during stabilisation of preterm infants in the delivery room (DR). We used a respiratory function monitor (RFM) to evaluate the first 5 min of mask respiratory support provided to preterm infants.

STUDY DESIGN

An observational study of infants <32 weeks gestation, born in a single tertiary perinatal centre receiving mask PPV in the DR. PPV was delivered with a round silicone facemask connected to a T-piece device and RFM. The RFM display was not visible to the resuscitator. Respiratory function parameters in the first 5 min after birth were analysed by breath-type (inflations, assisted inflations, spontaneous breaths between PPV, and breaths during continuous positive airway pressure (CPAP)). Parameters measured included VT, peak inspiratory pressure, peak end expiratory pressure and mask leak.

RESULTS

A total of 2605 inflations and breaths from 29 subjects were analysed. Substantial leak was observed during all four breath types with median leaks ranging from 24% to 59%. Median tidal volumes were greater during inflations (8.3 ml/kg) and assisted inflations (9.3 ml/kg) than spontaneous breaths between PPV (3.2 ml/kg) and breaths during CPAP (3.3 ml/kg).

CONCLUSIONS

Facemask leak is large during resuscitation of preterm infants using round silicone masks. Tidal volumes delivered during PPV inflations are much higher than those generated during spontaneous breathing by an infant on CPAP.

Mask versus nasal tube for stabilization of preterm infants at birth: a randomized controlled trial

OBJECTIVE

Positive-pressure ventilation (PPV) using a manual ventilation device and a face mask is recommended for compromised newborn infants in the delivery room (DR). Mask ventilation is associated with airway obstruction and leak. A nasal tube is an alternative interface, but its safety and efficacy have not been tested in extremely preterm infants.

METHODS

An unblinded randomized controlled trial was conducted in Australia, and the Netherlands. Infants were stratified by gestational age (24-25/26-29 weeks) and center. Immediately before birth infants were randomly assigned to receive PPV and/or continuous positive airway pressure with either a nasal tube or a size 00 soft, round silicone mask. Resuscitation protocols were standardized; respiratory support was provided using a T-piece device commencing in room air. Criteria for intubation included need for cardiac compressions, apnea, continuous positive airway pressure >7 cm H2O, and fraction of inspired oxygen >0.4. Primary outcome was endotracheal intubation in the first 24 hours from birth.

RESULTS

Three hundred sixty-three infants were randomly assigned; the study terminated early on the grounds of futility. Baseline variables were similar between groups. Intubation rates in the first 24 hours were 54% and 55% in the nasal tube and face mask groups, respectively (odds ratio: 0.97; 95% confidence interval: 0.63-1.50). There were no important differences in any of the secondary outcomes within the whole cohort or between the 2 gestational age subgroups.

CONCLUSIONS

In infants at <30 weeks' gestation receiving PPV in the DR, there were no differences in short-term outcomes using the nasal tube compared with the face mask.

Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure

OBJECTIVE

To evaluate the applicability and potential effectiveness of a technique of minimally-invasive surfactant therapy (MIST) in preterm infants on continuous positive airway pressure (CPAP).

METHODS

An open feasibility study of MIST was conducted at two sites. Infants were eligible for MIST if needing CPAP pressure ≥7 cm H(2)O and FiO(2) ≥0.3 (25-28 weeks gestation, n=38) or ≥0.35 (29-32 weeks, n=23). Without premedication, a narrow-bore catheter was inserted through the vocal cords under direct vision. Surfactant (100 or 200 mg/kg Curosurf) was then instilled, followed by reinstitution of CPAP. Outcomes were compared between surfactant-treated infants and historical controls achieving the same CPAP and FiO(2) thresholds.

RESULTS

Surfactant was successfully administered via MIST in all cases, with a rapid and sustained reduction in FiO(2) thereafter. For infants at 25-28 weeks gestation, need for intubation <72 h was diminished after MIST compared with controls (32% vs 68%; OR 0.21, 95% CI 0.083 to 0.55), with a similar trend at 29-32 weeks (22% vs 45%; OR 0.34, 95% CI 0.11 to 1.1). Duration of ventilation and incidence of bronchopulmonary dysplasia were similar, but infants receiving MIST had a shorter duration of oxygen therapy.

CONCLUSION

Surfactant delivery via a narrow-bore tracheal catheter is feasible and potentially effective, and deserves further investigation in clinical trials.

Medical retrieval and needs of infants with bronchiolitis: an analysis by gestational age

AIM

Viral bronchiolitis is the most common lower respiratory tract infection in children less than 12 months of age. Prematurity is an independent risk factor for disease severity. Many infected infants require hospitalisation and those living in regional centres frequently require transfer to metropolitan hospitals capable of providing assisted ventilation.

METHOD

We reviewed infants with bronchiolitis transported by the Victorian Newborn Emergency Transport Service between January 2003 and June 2007. We compared the clinical presentation and treatment required by infants born preterm with those of their term counterparts.

RESULTS

Of the 192 infants transported, 92 were born preterm. Preterm infants were younger at time of transport (mean post-menstrual age 41 weeks vs. 45 weeks) and were more likely to require invasive ventilation (60% vs. 32%, P < 0.001) and to receive a fluid bolus (47% vs. 34%, P = 0.04) when compared with infants who had been born at term. Apnoea, either as a presenting symptom or in combination with respiratory distress, was more common in the preterm group (70% vs. 36%, P < 0.001).

CONCLUSION

Higher illness severity should be anticipated in ex-preterm infants who present with bronchiolitis. Preterm infants with bronchiolitis are more likely to require invasive ventilation and fluid resuscitation than term infants, suggesting the need for a lower threshold for referral and medical retrieval.

A randomized trial of stylets for intubating newborn infants

OBJECTIVE

Endotracheal intubation of newborn infants is a common and potentially lifesaving procedure but a skill that trainees find difficult. Despite widespread use, no data are available on whether the use of a stylet (introducer) improves success rates. We aimed to determine whether pediatric trainees were more successful at neonatal orotracheal intubation when a stylet was used.

METHODS

An unblinded randomized controlled trial conducted between July 2006 and January 2009 at a tertiary perinatal center, the Royal Women's Hospital, Melbourne, Australia. Eligible participants were newborn infants in the delivery room or NICU requiring endotracheal intubation for respiratory support. Infants were intubated by pediatric residents or fellows. Infants were randomized to have the procedure performed by using either an endotracheal tube alone or with a stylet. Successful intubation at the first attempt assessed by colorimetric detection of expired carbon dioxide was the primary outcome.

RESULTS

Three hundred two intubations were performed in 232 infants (residents performed 75%, fellows 25%). Intubation was successful in 57% of the stylet group and 53% of the no stylet group (P = .47); odds ratio 1.18 (95% confidence interval 0.75-1.86). There were no differences in the duration of attempts or in the rate of upper airway trauma between the 2 groups. These results were consistent across subgroups of infants based on birth weight, gestational age, and site of intubation (delivery room or NICU).

CONCLUSIONS

Using an endotracheal stylet did not significantly improve the success rate of pediatric trainees at neonatal orotracheal intubation.

Use of continuous positive airway pressure during stabilisation and retrieval of infants with suspected bronchiolitis

AIM

Infants with viral bronchiolitis are often hospitalised with a proportion requiring respiratory support. The aim of this review was to examine the use of nasal prong continuous positive airway pressure (CPAP) as a management strategy for infants with a diagnosis of bronchiolitis, who required stabilisation and transport to a tertiary centre.

METHOD

A retrospective audit of infants with bronchiolitis requiring CPAP during transport between January 2003 and June 2007.

RESULTS

Nasal CPAP was initiated in 54 infants with 51 of these (34 ex-preterm, 17 term) subsequently continuing on CPAP during retrieval. Mean CPAP pressure was 7 cmH(2)O. Oxygenation improved between stabilisation and the end of retrieval (P < 0.01). During retrieval, there was no significant increase in transcutaneous CO(2), no infant required endotracheal ventilation and no adverse events were noted. Five infants were intubated within the first 24 h of admission at the receiving hospital.

CONCLUSION

This review demonstrated that use of nasal prong CPAP to transport infants with bronchiolitis was a safe management strategy in those with moderate to severe disease severity.

Determining the best method of Nellcor pulse oximeter sensor application in neonates

AIM

To identify the optimal sensor application method that gave the quickest display of accurate heart rate (HR) data using the Nellcor OxiMax N-600x pulse oximeter (PO).

METHODS

Stable infants who were monitored with an electrocardiograph were included. Three sensor application techniques were studied: (i) sensor connected to cable, then applied to infant; (ii) sensor connected to cable, applied to investigator's finger, and then to infant; (iii) sensor applied to infant, then connected to cable. The order of techniques tested was randomized for each infant. Time taken to apply the PO sensor, to display data and to display accurate data (HR(PO) = HR(ECG) ± 3 bpm) were recorded using a stopwatch.

RESULTS

Forty infants were studied [mean (SD) birthweight, 1455 (872) g; gestational age, 31 (4) weeks; post-menstrual age, 34 (4) weeks]. Method 3 acquired any data significantly faster than methods 1 (p = 0.013; CI, -9.6 to -3.0 sec) and 2 (p = 0.004; CI, -5.9 to -1.2 sec). Method 3 acquired accurate data significantly faster than method 1 (p = 0.016; CI, -9.4 to -1.0 sec), but not method 2 (p = 0.28).

CONCLUSION

Applying the sensor to the infant before connecting it to the cable yields the fastest acquisition of accurate HR data from the Nellcor PO.

Providing PEEP during neonatal resuscitation: which device is best?

AIM

The study aims to compare three commonly used neonatal resuscitation devices, the Laerdal self-inflating bag with a positive end expiratory pressure (PEEP) valve, a T-piece resuscitator (T-piece) and a flow-inflating bag to provide peak inflation pressure (PIP) and PEEP.

METHODS

Participants were asked to use each device to give positive pressure ventilation to a modified neonatal mannequin via a face mask to achieve 40-60 inflations per minute, aiming for a PIP/PEEP of 30/5 cm H₂O. A manometer was visible to participants with each device. PIP, PEEP, percentage leak at the face mask and expired tidal volume were measured using a hot-wire anemometer. We analysed 20 inflations from each participant for each device.

RESULTS

Fifty participants provided PIP and PEEP with each device. The T-piece was the most accurate and consistent. The flow-inflating bag had the most variation. The leak was lowest with the self-inflating bag and PEEP and highest with the flow-inflating bag, but all had wide variation.

CONCLUSION

Each device was able to provide PIP and PEEP when used appropriately. When compared with other resuscitation devices, the T-piece provided the most accurate and consistent PIP and PEEP.

Airway obstruction and gas leak during mask ventilation of preterm infants in the delivery room

INTRODUCTION

Preterm infants with inadequate breathing receive positive pressure ventilation (PPV) by mask with variable success. The authors examined recordings of PPV given to preterm infants in the delivery room for prevalence of mask leak and airway obstruction.

METHODS AND PATIENTS

The authors reviewed recordings of infants at <32 weeks' gestation born between February 2006 and March 2009. PPV was delivered with a T-piece or self-inflating bag and a round silicone face mask. Airway pressures and gas flow were recorded with a respiratory function monitor (RFM). Videos recorded from a web camera were used to review the resuscitation. The first 2 min of PPV were analysed for each infant. Obstruction was arbitrarily defined as a 75% reduction in delivered expired tidal volume (V(Te)) and significant face-mask leak as >75%.

RESULTS

The authors analysed recordings of 56 preterm infants. Obstruction occurred in 14 (26%) recordings and leaks in 27 (51%). Both obstruction and mask leaks were seen in eight (14%) recordings, and neither was seen in 15 (27%). Obstruction occurred at a median (IQR) of 48 (24-60) s after the start of PPV. A median (range) of 22 (3-83) consecutive obstructed inflations were delivered. Face-mask leaks occurred from the first inflation in 19/27 (70%) and in the remaining eight at a median (IQR) of 30 (24-46) s after the start of PPV. A median (range) of 10 (3-117) consecutive inflations with a leak >75% were delivered.

CONCLUSION

Airway obstruction and face-mask leak are common during the first 2 min of PPV. An RFM enables detection of important airway obstruction and mask leak.

Oxygenation with T-piece versus self-inflating bag for ventilation of extremely preterm infants at birth: a randomized controlled trial

OBJECTIVE

To investigate whether infants < 29 weeks gestation who receive positive pressure ventilation (PPV) immediately after birth with a T-piece have higher oxygen saturation (SpO₂) measurements at 5 minutes than infants ventilated with a self inflating bag (SIB).

STUDY DESIGN

Randomized, controlled trial of T-piece or SIB ventilation in which SpO₂ was recorded immediately after birth from the right hand/wrist with a Masimo Radical pulse oximeter, set at 2-second averaging and maximum sensitivity. All resuscitations started with air.

RESULTS

Forty-one infants received PPV with a T-piece and 39 infants received PPV with a SIB. At 5 minutes after birth, there was no significant difference between the median (interquartile range) SpO₂ in the T-piece and SIB groups (61% [13% to 72%] versus 55% [42% to 67%]; P = .27). More infants in the T-piece group received oxygen during delivery room resuscitation (41 [100%] versus 35 [90%], P = .04). There was no difference in the groups in the use of continuous positive airway pressure, endotracheal intubation, or administration of surfactant in the delivery room.

CONCLUSION

There was no significant difference in SpO₂ at 5 minutes after birth in infants < 29 weeks gestation given PPV with a T-piece or a SIB as used in this study.

Sustained inflations: comparing three neonatal resuscitation devices

BACKGROUND

Some national resuscitation guidelines advocate using sustained initial inflations (2-3 s) for babies requiring resuscitation. Inflation times ≥10 s have been used for preterm infants.

OBJECTIVES

This study examines the ability of operators of varying experience to provide a sustained inflation using three different manual ventilation devices.

METHODS

We compared a self-inflating bag, a flow-inflating bag and a pressure-limited T-piece device. Fifty clinical staff members from five professional groups gave a sustained inflation with a target peak pressure of 30 cm H2O and target duration of 10 s to an internal leak-free manikin. We measured peak inflating pressure (PIP) and mean inflating pressure (MIP) during the sustained inflation, and the duration of inflating pressure (IP) >20 and 25 cm H2O.

RESULTS

Median (IQR) duration of IP >25 cm H2O was: self-inflating bag 2.5 s (0.8-5.7), flow-inflating bag 10.6 s (8.4-12.9) and the T-piece 10.7 s (8.9-11.9). There was a weak correlation between experience using a self-inflating bag and longer inflation times (R = 0.290, p = 0.041). When compared with the T-piece, the flow-inflating bag had lower mean MIP (27.0 ± 1.8 vs. 28.8 ± 2.0 cm H2O) and higher mean PIP (32.3 ± 3.7 vs. 29.8 ± 1.8 cm H2O). There were no differences in performance between operator groups.

CONCLUSION

The T-piece provided consistent PIP during a single 10 s sustained inflation with less variation in pressure compared with the flow-inflating bag. Sustained inflations >3 s were difficult to achieve with a self-inflating bag.

Assessment of flow waves and colorimetric CO2 detector for endotracheal tube placement during neonatal resuscitation

AIM

Clinical assessment and end-tidal CO(2) (ETCO(2)) detectors are routinely used to verify endotracheal tube (ETT) placement. However, ETCO(2) detectors may mislead clinicians by failing to identify correct placement under a variety of conditions. A flow sensor measures gas flow in and out of an ETT. We reviewed video recordings of neonatal resuscitations to compare a colorimetric CO(2) detector (Pedi-Cap®) with flow sensor recordings for assessing ETT placement.

METHODS

We reviewed recordings of infants <32 weeks gestation born between February 2007 and January 2010. Airway pressures and gas flow were recorded with a respiratory function monitor. Video recording were used (i) to identify infants who were intubated in the delivery room and (ii) to observe colour change of the ETCO(2) detector. Flow sensor recordings were used to confirm whether the tube was in the trachea or not.

RESULTS

Of the 210 infants recorded, 44 infants were intubated in the delivery room. Data from 77 intubation attempts were analysed. In 35 intubations of 20 infants both a PediCap® and flow sensor were available for analysis. In 21 (60%) intubations, both methods correctly identified successful ETT placement and in 3 (9%) both indicated the ETT was not in the trachea. In the remaining 11 (31%) intubations the PediCap® failed to change colour despite the flow wave indicating correct ETT placement.

CONCLUSION

Colorimetric CO(2) detectors may mislead clinicians intubating very preterm infants in the delivery room. They may fail to change colour in spite of correct tube placement in up to one third of the cases.

Defining the reference range for oxygen saturation for infants after birth

OBJECTIVE

The goal was to define reference ranges for pulse oxygen saturation (Spo(2)) values in the first 10 minutes after birth for infants who received no medical intervention in the delivery room.

METHODS

Infants were eligible if a member of the research team was available to record Spo(2) immediately after birth. Infants were excluded if they received supplemental oxygen or any type of assisted ventilation. Spo(2) was measured with a sensor applied to the right hand or wrist as soon as possible after birth; data were collected every 2 seconds.

RESULTS

We studied 468 infants and recorded 61650 Spo(2) data points. The infants had a mean + or - SD gestational age of 38 + or - 4 weeks and birth weight of 2970 + or - 918 g. For all 468 infants, the 3rd, 10th, 50th, 90th, and 97th percentile values at 1 minute were 29%, 39%, 66%, 87%, and 92%, respectively, those at 2 minutes were 34%, 46%, 73%, 91%, and 95%, and those at 5 minutes were 59%, 73%, 89%, 97%, and 98%. It took a median of 7.9 minutes (interquartile range: 5.0-10 minutes) to reach a Spo(2) value of >90%. Spo(2) values for preterm infants increased more slowly than those for term infants. We present percentile charts for all infants, term infants of > or = 37 weeks, preterm infants of 32 to 36 weeks, and extremely preterm infants of <32 weeks.

CONCLUSION

These data represent reference ranges for Spo(2) in the first 10 minutes after birth for preterm and term infants.

Changes in heart rate in the first minutes after birth

The normal range of heart rate (HR) in the first minutes after birth has not been defined. Objective To describe the HR changes of healthy newborn infants in the delivery room (DR) detected by pulse oximetry. Study Design All inborn infants were eligible and included if a member of the research team attended the birth. Infants were excluded if they received any form of medical intervention in the DR including supplemental oxygen, or respiratory support. HR was measured using a pulse oximeter (PO) with the sensor applied to the right hand or wrist immediately after birth. PO data (oxygen saturation, HR and signal quality) were downloaded every 2 sec and analysed only when the signal had no alarm messages (low IQ signal, low perfusion, sensor off, ambient light). Results Data from 468 infants with 61 650 data points were included. Infants had a mean (range) gestational age of 38 (25-42) weeks and birth weight 2970 (625-5135) g. At 1 min the median (IQR) HR was 96 (65-127) beats per min (bpm) rising at 2 min and 5 min to 139 (110-166) bpm and 163 (146-175) bpm respectively. In preterm infants, the HR rose more slowly than term infants. Conclusions The median HR was <100 bpm at 1 min after birth. After 2 min it was uncommon to have a HR <100 bpm. In preterm infants and those born by caesarean section the HR rose more slowly than term vaginal births.

Crying and breathing by extremely preterm infants immediately after birth

We reviewed videos of 61 extremely preterm infants taken immediately after birth. The majority cried (69%) and breathed (80%) without intervention. Most preterm infants are not apneic at birth.

Oral continuous positive airway pressure (CPAP) following nasal injury in a preterm infant

Non-invasive respiratory support is increasingly popular but is associated with complications including nasal trauma. The present report describes a novel method of oral continuous positive airway pressure (CPAP) delivery in an extremely premature infant with severe nasal septum erosion. The distal end of a cut down endotracheal tube was passed through a small hole made in the teat of a dummy (infant pacifier) and sutured in place. The dummy was secured in the infant's mouth and CPAP was delivered to the pharynx. The device was well tolerated and the infant was successfully managed using this technique for 48 days, avoiding endotracheal intubation and ventilation.

Clinical assessment of extremely premature infants in the delivery room is a poor predictor of survival

BACKGROUND

Some neonatologists state that at the delivery of extremely premature infants they rely on "how the baby looks" when deciding whether to initiate resuscitation. Previous studies have reported poor correlation between early clinical signs and prognosis.

OBJECTIVE

To determine if neonatologists can accurately predict survival to discharge of extremely premature infants on the basis of observations in the first minutes after birth.

METHODS

We showed videos of the resuscitation of 10 extremely premature infants (<26 weeks' gestation) to attending neonatologists and fellows from the 3 major perinatal centers in Melbourne, Australia. Antenatal information was available to the observers. A monitor visible in each video displayed the heart rate and oxygen saturation of the infant. Observers were asked to estimate the likelihood of survival to discharge for each infant at 3 time points: 20 seconds, 2 minutes, and 5 minutes after birth. The predictive ability of observers was expressed as the area (95% confidence interval [CI]) under the receiver-operating-characteristic curve.

RESULTS

Seventeen attending neonatologists and 17 neonatal fellows completed the study. Receiver-operating-characteristic curves were generated for the combined and individual groups. Observers' ability to predict survival was poor (combined results): 0.61 (95% CI: 0.54-0.67) at 20 seconds, 0.59 (95% CI: 0.52-0.64) at 2 minutes, and 0.61 (95% CI: 0.55-0.67) at 5 minutes. Level of experience did not affect the observers' accuracy of predicting survival.

CONCLUSION

Neonatologists' reliance on initial appearance and early response to resuscitation in predicting survival for extremely premature infants is misplaced.