Peripherally Inserted Central Catheters vs Peripheral Cannulas for Delivering Parenteral Nutrition in Neonates.

CLINICAL QUESTION: Is parenteral nutrition via peripherally inserted central catheters (PICCs) associated with better delivery of nutrition and growth and fewer adverse events compared with short peripheral cannulas in neonates? BOTTOM LINE: Compared with short peripheral cannulas, parenteral nutrition via PICCs is associated with better nutrient delivery and lower rates of subsequent catheters or cannulas placed and is not associated with increased rates of invasive infection.

How does the BAPM Framework for Practice on Perinatal Management of Extreme Preterm Birth Before 27 Weeks of Gestation impact delivery of Newborn Life Support? A Resuscitation Council UK response.

In October 2019, the British Association of Perinatal Medicine (BAPM) published a Framework1 and associated infographic2 for 'Practice on Perinatal Management of Extreme Preterm Birth Before 27 Weeks of Gestation' This outlined an approach, based on data from the UK and abroad, to assist clinicians in decision-making relating to perinatal care at ≤26+6 weeks gestation. Many frontline providers of delivery room care of extremely preterm infants will have completed a Resuscitation Council UK (RCUK) Newborn Life Support or Advanced Resuscitation of the Newborn Infant course. This RCUK response to the BAPM Framework highlights how this might impact on their approach.

Pathophysiology of neonatal respiratory distress syndrome: implications for early treatment strategies.

Neonatal respiratory distress syndrome (RDS) remains one of the major causes of neonatal mortality and morbidity despite advances in perinatal care. The initial management of infants with RDS has almost become 'too routine' with little thought about the pathophysiological processes that lead to the disease and how the clinician can use the existing therapeutic interventions to optimize care. The transition from fetus to infant involves many complex adaptations at birth; the most important is the function of the lungs as a gas exchange organ. Preterm surfactant-deficient infants are less well equipped to deal with this transition. Optimum gas exchange is achieved through matching of ventilation and perfusion. In RDS, ventilation may be affected by homogeneity of the airways with atelectasis and over distension, as hyaline membranes block small airways. In turn this contributes to the inflammation that becomes bronchopulmonary dysplasia. Exogenous surfactant given early, particularly with positive end-expiratory pressure and, where necessary, gentle ventilation, would seem to be the optimum way to prevent atelectasis. How this can be achieved in neonates after surfactant therapy is explored through a review of the normal physiology of the newborn lung and how this is affected by RDS. The therapeutic interventions of resuscitation, exogenous surfactant, ventilation and inhaled nitric oxide are discussed in relation to their effects and what are currently the optimum ways to use these. It is hoped that with a better understanding of the normal physiology in the newborn lung, and the effects of both disease and interventions on that physiology, the practising clinician will have a greater appreciation of management of preterm infants with, or at risk of, RDS.

Population-based outcomes after acute antenatal transfer.

Acute antenatal transfer to specialist centres is an accepted practice but few or no regular data are collected regarding the numbers of transfers performed or subsequent pregnancy outcome. We wished to determine the numbers, and the maternal and fetal outcomes following acute antenatal transfer between consultant obstetric units in the former Northern Region of the UK over a 12-month period (1 January-31 December 99). This is a geographically defined population in terms of provision of perinatal services. All acute antenatal transfers were notified centrally. Data pertaining to each transfer were collected at the time of transfer. Subsequent maternal and fetal outcomes were determined from patient records and neonatal databases. The regional annual acute antenatal transfer rate was 3.7 per 1000 deliveries. Most were for fetal reasons, although transfer rates varied between hospitals. The decision to transfer was influenced by distance and availability of paediatric staff. Even units that have similar characteristics show considerable variation in their transfer rates. No adverse incidents occurred during transfer and no major changes in maternal management occurred following transfer. Twenty-four per cent of women remained undelivered following transfer. Women with preterm labour in the absence of ruptured membranes were less likely to deliver than those transferred for other reasons and if they did deliver, their infants were also less likely to need intensive care. We believe audit of acute antenatal transfers should be routinely undertaken. Numbers of transfers might be reduced if delivery and the need for neonatal intensive care could be predicted with greater accuracy. The psychological and financial costs of transfer to women and healthcare providers need to be addressed.

Surfactant therapy for respiratory distress syndrome in premature neonates: a comparative review.

Exogenous surfactant therapy has been part of the routine care of preterm neonates with respiratory distress syndrome (RDS) since the beginning of the 1990s. Discoveries that led to its development as a therapeutic agent span the whole of the 20th century but it was not until 1980 that the first successful use of exogenous surfactant therapy in a human population was reported. Since then, randomized controlled studies demonstrated that surfactant therapy was not only well tolerated but that it significantly reduced both neonatal mortality and pulmonary air leaks; importantly, those surviving neonates were not at greater risk of subsequent neurological impairment. Surfactants may be of animal or synthetic origin. Both types of surfactants have been extensively studied in animal models and in clinical trials to determine the optimum timing, dose size and frequency, route and method of administration. The advantages of one type of surfactant over another are discussed in relation to biophysical properties, animal studies and results of randomized trials in neonatal populations. Animal-derived exogenous surfactants are the treatment of choice at the present time with relatively few adverse effects related largely to changes in oxygenation and heart rate during surfactant administration. The optimum dose of surfactant is usually 100 mg/kg. The use of surfactant with high frequency oscillation and continuous positive pressure modes of respiratory support presents different problems compared with its use with conventional ventilation. The different components of surfactant have important functions that influence its effectiveness both in the primary function of the reduction of surface tension and also in secondary, but nonetheless just as important, role of lung defense. With greater understanding of the individual surfactant components, particularly the surfactant-associated proteins, development of newer synthetic surfactants has been made possible. Despite being an effective therapy for RDS, surfactant has failed to have a significant impact on the incidence of chronic lung disease in survivors. Paradoxically the cost of care has increased as surviving neonates are more immature and consume a greater proportion of neonatal intensive care resources. Despite this, surfactant is considered a cost-effective therapy for RDS compared with other therapeutic interventions in premature infants.