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

BACKGROUND

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

METHODS/DESIGN

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

DISCUSSION

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

TRIAL REGISTRATION

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

"Trying to Figure Out If You're Doing Things Right, and Where to Get the Info": Parents Recall Information and Support Needed During the First 6 weeks Postpartum

Objectives The first 6 weeks postpartum represent a time of significant adjustment and learning for parents. Healthcare providers accurately understanding parents' needs and preferences regarding support, education, and services during this critical time is essential for optimizing maternal and infant health. The first objective of this study was to explore parents' experiences adjusting to the parenting role during the first 6 weeks postpartum. The second objective was to elicit from parents where and how they sought support and information during the early postpartum period, and what hindered this process. Methods Five focus groups were conducted with 33 mothers and fathers of young children, stratified by ethnicity, education, and income. An interdisciplinary team thematically coded verbatim transcripts and identified emergent themes. Results Main themes included low confidence in parenting and sifting through parenting information. Additional themes included communicating with partner about changing roles, breastfeeding, maternal mental health, and maternal postpartum recovery. Low parenting confidence was closely linked with information seeking, yet participants expressed being overwhelmed by the task of managing conflicting parenting information. Women reported that providers focused on infant needs, leaving them feeling unprepared for their own mental and physical health needs. Conclusions for Practice Parents report extensive needs for education and support in the early postpartum period, yet also report feeling overwhelmed by the quantity of parenting information available. These findings suggest parents need and desire reliable healthcare education after discharge that includes parent health and adjustment.

Differences in inflammatory markers between nulliparous women admitted to hospitals in preactive vs active labor

OBJECTIVE

To determine whether labor-associated inflammatory markers differ between low-risk, nulliparous women in preactive vs active labor at hospital admission and over time.

STUDY DESIGN

Prospective comparative study of low-risk, nulliparous women with spontaneous labor onset at term (n = 118) sampled from 2 large Midwestern hospitals. Circulating concentrations of inflammatory markers were measured at admission and again 2 and 4 hours later: namely, neutrophil, and monocyte counts; and serum inflammatory cytokines (interleukin -1β, interleukin-6, tumor necrosis factor-α, interleukin-10) and chemokines (interleukin-8). Biomarker concentrations and their patterns of change over time were compared between preactive (n = 63) and active (n = 55) labor admission groups using Mann-Whitney U tests.

RESULTS

Concentrations of interleukin-6 and interleukin-10 in the active labor admission group were significantly higher than concentrations in the preactive labor admission group at all 3 time points. Neutrophil levels were significantly higher in the active group at 2 and 4 hours after admission. The rate of increase in neutrophils and interleukin-10 between admission and 2 hours later was faster in the active group (P < .001 and P = .003, respectively).

CONCLUSION

Circulating concentrations of several inflammatory biomarkers are higher and their rate of change over time since admission is faster among low-risk, nulliparous women admitted to hospitals in active labor, as compared with those admitted in preactive labor. More research is needed to determine if progressive changes in inflammatory biomarkers might be a useful adjunct to improving the assessment of labor progression and determining the optimal timing of labor admission.

Outcomes of nulliparous women with spontaneous labor onset admitted to hospitals in preactive versus active labor

INTRODUCTION

The timing of when a woman is admitted to the hospital for labor care following spontaneous contraction onset may be among the most important decisions that labor attendants make because it can influence care patterns and birth outcomes. The aims of this study were to estimate the percentage of low-risk, nulliparous women at term who are admitted to labor units prior to active labor and to evaluate the effects of the timing of admission (ie, preactive vs active labor) on labor interventions and mode of birth.

METHODS

Data from low-risk, nulliparous women with spontaneous labor onset at term gestation were merged from 2 prospective studies conducted at 3 large Midwestern hospitals. Baseline characteristics, labor interventions, and outcomes were compared between groups using Fisher's exact and Mann-Whitney U tests, as appropriate. Likelihoods for oxytocin augmentation, amniotomy, and cesarean birth were assessed by logistic regression.

RESULTS

Of the sample of 216 low-risk nulliparous women, 114 (52.8%) were admitted in preactive labor and 102 (47.2%) were admitted in active labor. Women who were admitted in preactive labor were more likely to undergo oxytocin augmentation (84.2% and 45.1%, respectively; odds ratio [OR], 6.5; 95% confidence interval [CI], 3.43-12.27) but not amniotomy (55.3% and 61.8%, respectively; OR, 0.8; 95% CI, 0.44-1.32) when compared to women admitted in active labor. The likelihood of cesarean birth was higher for women admitted before active labor onset (15.8% and 6.9%, respectively; OR, 2.6; 95% CI, 1.02-6.37).

DISCUSSION

Many low-risk nulliparous women with regular, spontaneous uterine contractions are admitted to labor units before active labor onset, which increases their likelihood of receiving oxytocin and giving birth via cesarean. An evidence-based, standardized approach for labor admission decision making is recommended to decrease inadvertent admissions of women in preactive labor. When active labor cannot be diagnosed with relative certainty, observation before admission to the birthing unit is warranted.

Guiding parents' use of the Internet for newborn education

Shorter hospital stays have had an impact on the traditional role of mother-baby nurses in providing education on parenting to their patients. In recent years, there has been a proliferation of consumer health information available on the Internet related to parenting. Publication of information on the Internet, however, is not monitored and reviewed in the way that traditional print sources are; therefore, there is no guarantee that the information is current, unbiased, or accurate. As more consumers search the World Wide Web for parenting information, nurses need to learn more about this technology so they can assist parents in identifying how to locate information they can trust.