Influence of timing of initiation of therapeutic hypothermia on brain MRI and neurodevelopment at 18 months in infants with HIE: a retrospective cohort study.

OBJECTIVE: To examine the influence of timing of initiation of therapeutic hypothermia (TH) on brain injury on MRI and on neurodevelopmental outcomes at 18 months. DESIGN: Retrospective cohort study. SETTING: Tertiary neonatal intensive care unit in Ontario, Canada. PATIENTS: Ninety-one patients with hypoxic ischaemic encephalopathy (HIE) were included, 54 in the early TH group and 37 in the late TH group. INTERVENTION: Whole-body hypothermia administered for 72 hours, initiated either before 3 hours of life (early TH) or between 3 and 6 hours of life (late TH). MAIN OUTCOME MEASURES: Brain injury on MRI after TH (assessed by two neuroradiologists), and neurodevelopmental outcomes at 18 months old. RESULTS: TH was initiated at a median time of 1.4 hours (early TH) and 4.4 hours (late TH). Sixty-four neonates (early TH=36, late TH=28) survived and completed neurodevelopmental assessment at 18 months. Neonates in the early TH group received more extensive resuscitation than neonates in the late TH group (p=0.0008). No difference was observed between the two groups in the pattern or severity of brain injury on MRI, or in the neurodevelopmental outcomes at 18 months. The non-survivors (n=16) had lower Apgar scores at 10 min, more extensive resuscitation, suffered from more severe HIE and had significantly more abnormal cerebral function monitoring. CONCLUSION: In this retrospective cohort study, TH initiated early was associated neither with a difference in brain injury on MRI nor better neurodevelopmental outcomes at 18 months.

Trainees success rates with intubation to suction meconium at birth.

OBJECTIVES: To assess the success rate and main reasons for failure of intubation performed by medical trainees to suction meconium below the vocal cords in non-vigorous infants delivered at ≥36 week gestation. DESIGN: We conducted a prospective cohort study involving 54 residents and nine neonatology fellows in a Canadian level 3 neonatal intensive care unit. Endotracheal intubation to suction meconium was performed using a videolaryngoscope, the video screen being covered during the procedure. All videos were reviewed by two experts blinded to the procedure and to the identity of the trainee. RESULTS: Sixteen videos were available to review between July 2014 and March 2016. Intubation success rate assessed by the reviewers was 6%, compared with 21% as assessed by the trainees. The most common reasons for intubation failure were an improper view of the glottis (87%) and meconium or secretions obscuring the view (67%). 36 % of the time, the trainees identified different reasons for intubation failure than the reviewers. CONCLUSION: Success rate of neonatal intubation to suction meconium was much lower than the success rate reported on infants without meconium. Teaching should be geared towards the most common reasons for intubation failure, possibly using video-based teaching.

Centile charts for cranial sutures in children younger than 1 year based on ultrasound measurements.

BACKGROUND: Cranial US allows for the evaluation of premature closure (synostosis) or abnormal widening of the cranial sutures. An understanding of the normal anatomy is required to help define the presence or absence of abnormality. OBJECTIVE: To provide reference for normal ultrasound measurements of cranial sutures during the child's first year. MATERIALS AND METHODS: We included children ages 0 to 12 months who were referred to the hospital during 2011-2013 for radiographic evaluation of cranial sutures. Cranial US study was focused on evaluating the sagittal, coronal, lambdoid and metopic sutures. We measured the hypoechoic gap between the bones (patent suture). Two readers performed the measurements, blinded to clinical indications and previous reports. Estimates of the 10th, 25th, 50th, 75th and 90th percentiles were achieved for ages 1-12 months. RESULTS: Of 129 children whose families consented to cranial US, 11 were excluded because of craniosynostosis and 3 for suboptimal quality of cranial US images. In 115 patients measurements of normal cranial sutures were obtained (75 boys [65%], ages 0.26-11.27 months). For each suture, the suture size decreased significantly with age (P<0.001). Only the metopic suture was noted to close completely toward the end of the first year of age. There were no statistically significant differences in age-related suture size by gender. CONCLUSION: The current patient series represents a reference of percentiles of normal ultrasound measurements of cranial sutures during the first year of age.

Cranial Ultrasound as a First-Line Imaging Examination for Craniosynostosis.

BACKGROUND: Radiography, typically the first-line imaging study for diagnosis of craniosynostosis, exposes infants to ionizing radiation. We aimed to compare the accuracy of cranial ultrasound (CUS) with radiography for the diagnosis or exclusion of craniosynostosis. METHODS: Children aged 0 to 12 months who were assessed for craniosynostosis during 2011-2013 by using 4-view skull radiography and CUS of the sagittal, coronal, lambdoid, and metopic sutures were included in this prospective study. Institutional review board approval and parental informed consent were obtained. CUS and radiography were interpreted independently and blindly by 2 pediatric radiologists; conflicts were resolved in consensus. Sutures were characterized as closed, normal, or indeterminate. Correlation between CUS and radiography and interreader agreement were examined for each suture. RESULTS: A total of 126 children (82 boys, 64.5%) ages 8 to 343 days were included. All sutures were normal on CUS and radiography in 115 patients (93.7%); craniosynostosis of 1 suture was detected in 8 (6.3%, 5 sagittal, 2 metopic, 1 coronal). In 3 cases the metopic suture was closed (n = 2) or indeterminate on CUS (n = 1) but normally closed on radiography. CUS sensitivity was 100%, specificity 98% (95% confidence interval 94%-100%). Reader agreement was 100% for sagittal, coronal, and lambdoid sutures (κ = 0.80); after consensus, disagreement remained on 3 metopic sutures. CONCLUSIONS: In this series, CUS could be safely used as a first-line imaging tool in the investigation of craniosynostosis, reducing the need for radiographs in young children. Additional assessment may be required for accurate assessment of the metopic suture.