Cerebral oxygenation monitoring of ex-preterm infants during the infant car seat challenge test.

The American Academy of Pediatrics and until recently the Canadian Paediatric Society recommend preterm infants undergo an Infant Car Seat Challenge test prior to discharge to rule out systemic oxygen desaturation when placed at a 45-degree angle in a car seat. Near-infrared spectroscopy (NIRS) provides objective measurements of the impact of systemic oxygen (SO2) desaturation, bradycardia, or both on cerebral regional oxygen saturation (rSO2). OBJECTIVE: To characterize baseline cerebral rSO2 during a car seat trial in preterm infants ready for discharge. DESIGN/METHODS: A prospective observational study was performed in 20 infants (32 ± 5 weeks [mean] at a postmenstrual age 37 ± 6 weeks [mean]). Cerebral rSO2 was continuously monitored by placing a NIRS transducer on head during Infant Car Seat Challenge (ICSC). Failure of an ICSC was defined as two SO2 desaturation events below 85% for more than 20 seconds or one event below 80% for 10 seconds. RESULTS: The lowest SO2 was 70% with a lowest NIRS recording of 68%. Three infants failed their ICSC, with the lowest rSO2 in these three infants being 68%, above the lowest acceptable limit of 55%. Heart rate but not SO2 appears to influence rSO2 over the range of cerebral oxygenation seen. CONCLUSIONS: Baseline cerebral rSO2 during ICSC oscillates between 68 and 90%. There were no episodes of significant cerebral oxygen desaturation in studied infants regardless of whether they passed or failed the ICSC. We postulate that former preterm infants are capable through cerebral autoregulation, of maintaining adequate cerebral blood flow in the presence of either systemic oxygen desaturation or bradycardia when they are otherwise ready for discharge.

Car Seat Tolerance Screening in the Neonatal Intensive Care Unit: Failure Rates, Risk Factors, and Adverse Outcomes.

OBJECTIVE: To characterize the epidemiology of Car Seat Tolerance Screening (CSTS) failure and the association between test failure and all-cause 30-day postdischarge mortality or hospital readmission in a large, multicenter cohort of preterm infants receiving neonatal intensive care. STUDY DESIGN: This retrospective cohort study used the prospectively collected Optum Neonatal Database. Study infants were born at <37 weeks of gestation between 2010 and 2016. We identified independent predictors of CSTS failure and calculated the risk-adjusted odds of all-cause 30-day mortality or hospital readmission associated with test failure. RESULTS: Of 7899 infants cared for in 788 hospitals, 334 (4.2%) failed initial CSTS. Greater postmenstrual age at testing and African American race were independently associated with decreased failure risk. Any treatment with an antacid medication, concurrent use of caffeine or supplemental oxygen, and a history of failing a trial off respiratory support were associated with increased failure risk. The mean adjusted post-CSTS duration of hospitalization was 3.1 days longer (95% CI, 2.7-3.6) among the infants who failed the initial screening. Rates of 30-day all-cause mortality or readmission were higher among infants who failed the CSTS (2.4% vs 1.0%; P = .03); however, the difference was not significant after confounder adjustment (OR, 0.38; 95% CI, 0.11-1.31). CONCLUSION: CSTS failure was associated with longer post-test hospitalization but no difference in the risk-adjusted odds for 30-day mortality or hospital readmission. Whether CSTS failure unnecessarily prolongs hospitalization or results in appropriate care that prevents adverse postdischarge outcomes is unknown. Further research is needed to address this knowledge gap.

Factors associated with car seat test failure in late preterm infants: A retrospective chart review.

BACKGROUND: Professional organizations recommend car seat testing of preterm infants before discharge from hospital. Late preterm infants (LPIs, 34(0/7) to 36(6/7) weeks' gestational age) are at the greatest risk for failure, despite often being well. OBJECTIVE: To determine the incidence of car seat testing failure in LPIs and associative factors. METHODS: A retrospective chart review was performed of inborn LPIs admitted to all levels of newborn care between July 1, 2012 and June 30, 2013. Data collected included maternal demographics, labour and delivery history, and neonatal course. Data were analyzed using backward logistic regression. RESULTS: A total of 511 charts were reviewed and 367 LPIs were eligible for inclusion. Of the 313 LPIs tested (mean [± SD] gestational age 36 weeks ±6 days and birth weight 2614±405 g), 80 (26%) failed (95% CI 21% to 31%). Most failed due to desaturations (≥2) of <88% for ≥10 s (n=33 [41%]). Multiple gestation was associated with failure (adjusted OR 2.45 [95% CI 1.44 to 4.18]; P=0.001), and there was a trend toward statistical significance for the variable postnatal age (0.996 [95% CI 0.99 to 1.00]; P=0.05). Infants who passed their car seat test had higher postnatal ages than those who failed (mean difference 39.4 h [95% CI 12.7 h to 66.0 h]; P=0.004). CONCLUSION: Twenty-six percent of LPIs failed car seat testing. Ideally, infants should be tested after an appropriate transitional period. The authors identified factors that may be important in designing future, prospective studies in this area. Future research should evaluate the clinical significance of car seat testing and resource utilization.

HISTORIQUE: Les organisations professionnelles recommandent de vérifier les sièges d'auto des nourrissons prématurés avant leur congé de l'hôpital. Les nourrissons peu prématurés (NPP; de 340/7 à 366/7 semaines d'âge gestationnel) risquent le plus d'échouer cette vérification, même s'ils sont souvent en bonne santé. OBJECTIF: Déterminer l'incidence d'échec de la vérification des sièges d'auto chez les NPP, ainsi que les facteurs s'y associant. MÉTHODOLOGIE: Les chercheurs ont procédé à l'analyse rétrospective des dossiers de NPP nés à l'hôpital et admis à tous les niveaux de soins des nouveau-nés entre le 1er juillet 2012 et le 30 juin 2013. Les données colligées incluaient les renseignements démographiques sur la mère, les données sur le travail et l'accouchement et l'évolution néonatale. Les chercheurs ont analysé les données à l'aide de la régression logistique rétrograde. RÉSULTATS: Les chercheurs ont examiné 511 dossiers, et 367 NPP étaient admissibles à l'inclusion. Des 313 NPP vérifiés (âge gestationnel moyen [± ÉT] de 36 semaines ±6 jours et poids de naissance de 2 614±405 g), 80 (26 %) ont échoué (95 % IC 21 % à 31 %), la plupart à cause d'une désaturation (≥2) de moins de 88 % pendant au moins 10 s (n=33 [41 %]). La gestation multiple s'associait à un échec (RC rajusté 2,45 [95 % IC 1,44 à 4,18]; P=0,001), et on remarquait une tendance vers une signification statistique de la variable d'âge postnatal (0,996 [95 % IC 0,99 à 1,00]; P=0,05). Les nourrissons pour qui la vérification du siège d'auto ne posait pas de problème avaient un âge postnatal plus avancé que ceux qui l'échouaient (différence moyenne de 39,4 h [95 % IC 12,7 h à 66,0 h]; P=0,004). CONCLUSION: Vingt-six pour cent des NPP échouaient la vérification du siège d'auto. Dans l'idéal, il faudrait vérifier les nourrissons après une période transitoire pertinente. Les chercheurs ont déterminé des facteurs susceptibles d'être importants pour concevoir de futures études prospectives dans ce domaine. De futures recherches devraient évaluer la signification clinique de la vérification des sièges d'auto et l'utilisation des ressources.

Epidemiology and predictors of failure of the infant car seat challenge.

OBJECTIVES: The American Academy of Pediatrics recommends all neonates born at <37 weeks' gestation receive a predischarge Infant Car Seat Challenge (ICSC), a resource-intensive test with little information on failure rates and risk factors. We sought to determine incidence and predictors of failure to allow more selective testing. METHODS: We conducted a retrospective medical record review of 1173 premature neonates qualifying for the ICSC between 2009 and 2010. We looked at ICSC result and potential risk factors and then performed bivariate and multivariable logistic analyses to evaluate for predictors of failure. RESULTS: Overall incidence of failure was 4.3%. Infants who failed were less premature and had higher birth weights. Late-preterm infants made up 60% of our study population but accounted for 78% of failures (P = .019). Infants who passed had older chronologic ages at time of testing, were more likely to have been exposed to caffeine, and were more likely to have required some type of respiratory support than those that failed. Final multivariable model demonstrated that increasing birth gestational age (GA) increased the odds of failure when corrected for gender, race, and small for GA status. For every 1-day increase in birth GA the odds ratio of failure was 1.03 (95% confidence interval 1.01-1.05). CONCLUSIONS: We found that increasing birth GA was a significant predictor of failure, and that late-preterm infants comprised a significant percentage of infants who failed. This suggests that limiting testing to extremely premature infants would miss most cases of ICSC failure.