Changes in practice of less-invasive surfactant administration (LISA) in United Kingdom neonatal units.

AIM: To determine whether the use of less-invasive surfactant administration (LISA) had changed between 2018 and 2024. METHODS: An online questionnaire was sent to all 191 neonatal units between June 2023 and May 2024. One consultant from each neonatal unit was randomly selected. Follow-up was done by telephone (middle-grade doctor grade and above or alternatively to Advanced Neonatal Nurse Practitioners) for the non-responders. RESULTS: Response rate was 100%from 191 units neonatal units. LISA was used in 134 (70%) neonatal units in 2024 compared to 35 (18.7%) units in 2018 (p < 0.001). The reason why LISA was not performed was lack of experience/training (51%) or not having a standardised practice/guideline (49%). LISA in the delivery suite (DS) had increased from 2% in 2018 to 16% in 2024, and the use of video laryngoscope for LISA is becoming standard of practice. The oxygen requirement criteria for the use of LISA in both the DS and on neonatal unit had reduced to FiO2 of 0.3 or more. CONCLUSION: The uptake of LISA had increased in the United Kingdom. There is greater use of LISA in the DS. Lack of training and expertise were the major limiting factors for LISA not being performed.

Improved respiratory parameters with skin-to-skin contact in premature infants with bronchopulmonary dysplasia on NIV-NAVA.

AIM: To determine if skin-to-skin contact (SSC) improved respiratory parameters in premature infants with evolving or established bronchopulmonary dysplasia (BPD) on non-invasive neutrally adjusted ventilator assist (NIV-NAVA). METHODS: Premature infants (<32 weeks gestational age) with BPD on NIV-NAVA were studied. Continuous readings from the Edi catheter (modified nasogastric feeding tube inserted for NAVA ventilation) were compared: pre-SSC (baby in incubator) and end-SSC (just before end of SSC). RESULTS: Sixty-five episodes of SSC were recorded in 12 premature infants with median gestational age at birth of 24.4 (23.1-27.0) weeks and birth weight of 642 (530-960) grams. Peak Edi (uV) in end-SSC 11.5 (2.7-38.7) was significantly lower compared to pre-SSC 15.8 (4.0-36.6), p < 0.001. P mean (cmH2 O) was significantly lower in end-SSC 9.7 (7.3-15.4) compared to pre-SSC 10.3 (7.5-15.5), p = 0.008. Respiratory rate (breaths/min) was significantly lower in end-SSC 52.9 (31.1-78.1) compared to pre-SSC 53.4 (35.1-74.1), p = 0.031. There was no significant difference in inspired oxygen requirement or time on back-up mode in end-SSC 40.0 (22.1-56.1) and 5.9 (0.0-56.0) compared to pre-SSC 39.0 (26.0-56.1) and 5.1 (0.0-29.3), p = 0.556 and p = 0.853 respectively. CONCLUSION: SSC improved respiratory parameters in premature infants with evolving or established BPD on NIV-NAVA.

Comparison of Outcomes of Less Invasive Surfactant Administration in Prematurely Born Infants in the Delivery Suite and the Neonatal Unit.

OBJECTIVE: This study aimed to compare outcomes of infants who received less invasive surfactant administration (LISA) in the delivery suite (LISA-DS) with those who received LISA on the neonatal unit (LISA-NNU). STUDY DESIGN: A prospective cohort study was undertaken of all infants who received LISA in a single center. Clinical outcomes included admission temperature, the need for intubation, durations of invasive and noninvasive ventilation, length of hospital stay and the incidences of bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), and requirement for home oxygen were compared between the two groups as were complications of the procedure. RESULTS: The 54 LISA-DS infants had similar gestational ages and birth weights to the 26 LISA-NNU infants (p = 0.732, 0.928, respectively). There were no significant differences between the admission temperatures (median [range]: 36.8 [36-38.7] vs. 36.8°C [36.4-37.7]; p = 0.451) or need for intubation in less than 72 hours of birth (28 vs. 23%, p = 0.656). The durations of invasive ventilation (median: 2 [0-65] vs. 1 [0-35] days; p = 0.188) and noninvasive ventilation (median: 37 [24-81] vs. 37 [3-225] days; p = 0.188) and the incidences of BPD (p = 0.818), IVH (p = 0.106), ROP (p = 0.526), and home oxygen requirement (p = 0.764) were similar. The percentage of successful first attempts with LISA (63 vs. 70%, p = 0.816) or associated with hypoxia episodes (32 vs. 42%, p = 0.194) did not differ significantly by site of administration. CONCLUSION: The outcomes of LISA performed on the DS were similar to those of LISA performed on the NNU. KEY POINTS: · Prematurely born infants who received LISA in the DS had comparable clinical outcomes to infants who received LISA on NNU.. · No significant differences in admission temperature was noticed in infants who received LISA, in DS versus NNU..

Repeatability of PDA diameter measurements on echocardiography.

Diameter of the patent ductus arteriosus (PDA) on transthoracic echocardiography (TTE) is used as a marker of haemodynamic significance. We aimed to assess the intra- and inter-observer variability in PDA diameter in babies born at ≤ 30 weeks' gestation. TTEs for 56 infants were performed by a single neonatologist. Cineloops were stored without measurement annotations. PDAs were measured on 2-dimensional (2D) and Colour Doppler. A second, blinded neonatologist repeated measurements on the same cineloops. The scanning neonatologist repeated measurements at a later date, blinded to original measurements. Inter-observer results showed repeatability coefficients of 1.57 (2D) and 2.18 (Colour), and repeatability index of 73% (2D) and 91% (Colour). Intra-observer results showed repeatability coefficients of 0.99 (2D) and 1.32 (Colour), and repeatability index of 43% (2D) and 49% (Colour).Conclusion: There is significant inter- and intra-observer variability in measurements of PDA diameter, even on the same cineloops. We advise caution when using diameter alone as a marker of haemodynamic significance, and recommend using multiple parameters to determine haemodynamic significance of PDA. What is Known: • PDA is associated with numerous comorbidities such as bronchopulmonary dysplasia, necrotising enterocolitis, intraventricular haemorrhage and mortality. • PDA diameter is commonly measured on transthoracic echocardiography and used as a marker of haemodynamic significance. • A previous, smaller study has shown there may be poor repeatability of PDA diameter measurements in serial echocardiograms. What is New: • There is significant inter-observer variability in 2D and Colour Doppler measurements of PDA internal diameter on TTE in preterm infants. • There is moderate intra-observer correlation of repeated measurements on the same imaging in both 2D and Colour Doppler imaging.

CPAP review.

Continuous positive airway pressure (CPAP) is widely used in neonatal units both as a primary mode of respiratory support and following extubation from mechanical ventilation. In this review, the evidence for CPAP use particularly in prematurely born infants is considered. Studies comparing methods of CPAP generation have yielded conflicting results, but meta-analysis of randomised trials has demonstrated that delivering CPAP via short nasal prongs is most effective in preventing re-intubation. At present, there is insufficient evidence to establish the safety or efficacy of high flow nasal cannulae for prematurely born infants. Observational studies highlighted that early CPAP use rather than intubation and ventilation was associated with a lower incidence of bronchopulmonary dysplasia (BPD), but this has not been confirmed in three large randomised trials. Meta-analysis of the results of randomised trials has demonstrated that use of CPAP reduces extubation failure, particularly if a CPAP level of 5 cm H2O or more is used. Nasal injury can occur and is related to the length of time CPAP is used; weaning CPAP by pressure rather than by "time-cycling" reduces the weaning time and may reduce BPD. In conclusion, further studies are required to identify the optimum mode of CPAP generation and it is important that prematurely born infants are weaned from CPAP as soon as possible.

Neurally Adjusted Ventilatory Assist in Very Prematurely Born Infants with Evolving/Established Bronchopulmonary Dysplasia.

Background During neurally adjusted ventilatory assist (NAVA)/noninvasive (NIV) NAVA, a modified nasogastric feeding tube with electrodes monitors the electrical activity of the diaphragm (Edi). The Edi waveform determines the delivered pressure from the ventilator. Objective Our objective was to determine whether NAVA/NIV-NAVA has advantages in infants with evolving/established bronchopulmonary dysplasia (BPD). Methods Each infant who received NAVA/NIV-NAVA and conventional invasive and NIV was matched with two historical controls. Eighteen NAVA/NIV-NAVA infants' median gestational age, 25.3 (23.6-28.1) weeks, was compared with 36 historical controls' median gestational age 25.2 (23.1-29.1) weeks. Results Infants on NAVA/NIV-NAVA had lower extubation failure rates (median: 0 [0-2] vs. 1 [0-6] p = 0.002), shorter durations of invasive ventilation (median: 30.5, [1-90] vs. 40.5 [11-199] days, p = 0.046), and total duration of invasive and NIV to the point of discharge to the local hospital (median: 80 [57-140] vs. 103.5 [60-246] days, p = 0.026). The overall length of stay (LOS) was lower in NAVA/NIVNAVA group (111.5 [78-183] vs. 140 [82-266] days, p = 0.019). There were no significant differences in BPD (17/18 [94%] vs. 32/36 [89%] p = 0.511) or home oxygen rates (14/18 [78%] vs. 23/36 [64%] p = 0.305). Conclusion The combination of NAVA/NIV-NAVA compared with conventional invasive and NIV modes may be advantageous for preterm infants with evolving/established BPD.

Less Invasive Surfactant Administration in Very Prematurely Born Infants.

Background Less invasive surfactant administration (LISA) is the preferred mode of surfactant administration for spontaneously breathing preterm babies supported by noninvasive ventilation (NIV). Objective The aim of this study was to determine whether LISA on the neonatal unit or in the delivery suite was associated with reduced rates of bronchopulmonary dysplasia (BPD) or the need for intubation, or lower durations of invasive ventilation and length of hospital stay (LOS). Methods A historical comparison was undertaken. Each "LISA" infant was matched with two infants (controls) who did not receive LISA. Results The 25 LISA infants had similar gestational ages and birth weights to the 50 controls (28 [25.6-31.7] weeks vs. 28.5 [25.4-31.9] weeks, p = 0.732; 1,120 (580-1,810) g vs. 1,070 [540-1,869] g, p = 0.928), respectively. LISA infants had lower requirement for intubation (52 vs. 90%, p < 0.001), shorter duration of invasive ventilation (median 1 [0-35] days vs. 6 [0-62] days p = 0.001) and a lower incidence of BPD (36 vs. 64%, p = 0.022). There were no significant differences in duration of NIV (median 26 [3-225] vs. 23 [2-85] days, p = 0.831) or the total LOS (median 76 [24-259] vs. 85 [27-221], p = 0.238). Conclusion LISA on the neonatal unit or the delivery suite was associated with a lower BPD incidence, need for intubation, and duration of invasive ventilation.

Oxygen therapy in premature low birth weight infants is associated with capillary loss and increases in blood pressure: a pilot study.

Low birth weight (LBW) and premature birth are known risk factors for future cardiovascular disease and in particular essential hypertension (EH). Capillary rarefaction (CR) is an established hallmark of EH and is known to occur in individuals with a history of LBW. We previously reported that LBW infants do not have CR at birth but rather increased capillary density (CD). We hypothesized that LBW infants undergo a process of accelerated CR in early life, triggered in part by oxygen therapy. We studied 26 LBW infants, of whom 10 infants received oxygen therapy, and compared them to 14 normal birth weight (NBW) infants. We measured CD at 1, 5 and 10 days after birth and again after 40 weeks adjusted gestational age equivalent to birth at full term. We confirmed that LBW infants had higher CD at birth compared to NBW infants and found that significant structural CR occurred at term age in LBW infants who had received oxygen therapy (mean difference -22 capillaries/field, p = 0.007) and in those who did not receive oxygen therapy (mean difference -29 capillaries/field, p < 0.001) compared to baseline at birth. Both LBW groups showed a significant rise in BP at 40 weeks adjusted term age and the rise in systolic (mean difference 24 mm Hg, p < 0.0001) and diastolic BP (mean difference 14 mm Hg, p < 0.001) was more pronounced in the oxygen treated group compared to the nonoxygen group (mean difference 14 mm Hg, p = 0.043 and mean difference = 9 mm Hg p = 0.056 respectively). In conclusion, oxygen therapy in premature LBW infants may induce significant increases in their BP in early life.

Early Life Microcirculatory Plasticity and Blood Pressure Changes in Low Birth Weight Infants Born to Normotensive Mothers: A Cohort Study.

BACKGROUND: Capillary rarefaction (CR) is an established hallmark of essential hypertension (EH). The aim of this study was to examine early changes in capillary density (CD) and blood pressure (BP) in low birth weight (LBW) infants who are at risk of developing EH in later life. METHODS: We studied 77 LBW infants and 284 normal birth weight (NBW) infants, all born to mothers with normotension, in a longitudinal multicenter study. Intravital capillaroscopy was used to measure functional basal capillary density (BCD) and maximal capillary density (MCD) at birth, 3, 6, and 12 months. RESULTS: We found that LBW infants, born preterm and at term, had a significantly higher CD at birth, then underwent significant CR in the 1st 3 months culminating in a CD similar to that seen in NBW infants. NBW infants showed a gradual reduction in CD between birth and 12 months. Non-Caucasian ethnicity and preterm birth were significant predictors of a higher CD at birth. Systolic BP in NBW infants increased significantly from birth to 3 months, and we identified a significant negative correlation between systolic BP and MCD. CONCLUSIONS: This study has identified a process of early "accelerated capillary remodeling" in LBW infants, which corrects their higher CD at birth. This remodeling is unlikely to explain the CR seen in adult individuals with, or at risk of developing EH. Further follow-up studies are required to determine the timing and mechanisms involved in CR, which is likely to occur after the 1st year of life but before early adulthood.

NICE neonatal early onset sepsis guidance: greater consistency, but more investigations, and greater length of stay.

BACKGROUND: In August 2012, new national guidance (National Institute of Health and Care Excellence (NICE) CG149) for management of early onset sepsis (EOS) was introduced in the UK. The guidance outlined a consistent approach for septic screens in newborn infants based on risk factors, and suggested biochemical and clinical parameters to guide management. In particular, it advised a second C-reactive protein level (CRP) 18-24 h into treatment to help determine length of antibiotic course, need for lumbar puncture (LP), and suggested review of blood culture at 36 h. OBJECTIVE: We evaluated impact of this guidance in our neonatal unit. METHODS: We compared two time periods, before and following the guidance. We evaluated length of stay, second CRP 18-24 h into treatment, percentage of babies having LP and duration of antibiotics. RESULTS: Before NICE guidance, 38.1% of screened babies stayed <72 h. This reduced to 18.4% following guidance. Before guidance, 20.9% babies stayed >5 days, which increased to 27.7% following NICE recommendations. Repeat CRP measurements increased from 45% to 97%. In 58% of these babies, repeat CRPs influenced management and hospital stay. An increase in LPs performed from 14% to 23% was noted. There were no positive blood cultures or LP results. CONCLUSIONS: We envisaged shorter hospital stays with new NICE standards, particularly, with the aim of 36 h blood culture reporting. However, repeat CRP led to further investigations, increased LPs and longer durations of treatment and stay. This, in turn, impacted on workload and cost, and influenced parental experience in the first few days of life.