Methods for Estimating Endotracheal Tube Insertion Depth in Neonates: A Systematic Review and Meta-Analysis.

OBJECTIVE: To systematically review the methods for estimating endotracheal tube (ETT) insertion depth in neonates. STUDY DESIGN: Medline, Embase, Cochrane Central, and Cumulative Index to Nursing and Allied Health Literature databases searched for randomized clinical trials (RCTs). RCTs comparing two or more different methods to estimate ETT insertion depth were included. Two co-authors independently extracted the data and assessed the risk of bias. The primary outcome includes the proportion of optimally placed ETT tips identified on chest X-ray. RESULTS: Eight RCTs evaluating seven different estimation methods were included. Trials varied defining the optimal position of the ETT tip. Overall, the percentage of optimal position ranged from 8.8 to 93%. The weight, gestation nomogram, and vocal cord estimation methods resulted in malpositioning of ETT tips in more than half of infants ≤30 weeks' gestational age. The rates of optimal ETT tip placement with the digital palpation method differ between moderately (83-93%; two RCTs) and extremely (47%; one RCT) preterm infants. Meta-analysis showed no difference between weight-based and digital palpation methods (relative risk = 0.88; 95% confidence interval = 0.75-1.04; three RCTs; participants = 205; I 2 = 0%; quality of evidence, low). CONCLUSION: Commonly used estimation methods for ETT tip placement are inaccurate and unreliable. Further research is required to improve the accuracy of estimation methods and also to identify the usefulness of the digital palpation method in large clinical trials.

Association of small for gestational age with retinopathy of prematurity: a systematic review and meta-analysis.

CONTEXT: The association between small for gestational age (SGA) and retinopathy of prematurity (ROP) is unclear. OBJECTIVE: A systematic review and meta-analysis was conducted to evaluate the association between ROP and SGA in preterm infants <37 weeks' gestational age (GA) admitted to neonatal intensive care unit. METHODS: Medline, PubMed, Web of Science and Cochrane Central databases were searched from inception through 15 January 2019. Studies reporting outcomes based on SGA as the primary exposure variable were included. Data were extracted independently by two coauthors. Modified Newcastle-Ottawa scale was used for risk of bias assessment. RESULTS: Database search yielded 536 records (Medline=152, PubMed=171, Web of Science=144 and Cochrane Central=69). Twenty-one studies evaluating 190 946 infants were included. SGA was associated with significantly higher odds of any stage of ROP on unadjusted analysis (unadjusted OR (uOR) 1.55; 95% CI 1.22 to 1.98; 10 studies) but not on adjusted analysis (adjusted OR (aOR) 2.16; 95% CI 0.66 to 7.11; 3 studies). SGA was associated with significantly higher odds of severe ROP (aOR 1.92; 95% CI 1.57 to 2.34; nine studies). SGA was also significantly associated with higher odds of treated ROP (aOR 1.39; 95% CI 1.18 to 1.65; three studies). In subgroup analysis of infants <29 weeks' GA, SGA was significantly associated with increased odds of ROP (uOR 1.64; 95% CI 1.19 to 2.26; two studies), severe ROP (aOR 1.61; 95% CI 1.23 to 2.10; four studies) and treated ROP (aOR 1.37; 95% CI 1.16 to 1.62; two studies). CONCLUSION: SGA was associated with increased odds of any stage of ROP, severe ROP and treated ROP in preterm infants. Neonatologists should incorporate SGA into the risk assessment during ROP evaluation and while providing counselling to the families of preterm SGA infants. ROP screening guidelines should look into the frequency of follow-up examination in SGA infants in aim to offer early detection and treatment.

Neonatal lung ultrasonography to evaluate need for surfactant or mechanical ventilation: a systematic review and meta-analysis.

CONTEXT: Lung ultrasonography (LUS) is increasingly used to identify various neonatal respiratory disorders. There is emerging evidence that it can identify infants with significant lung disease who need surfactant treatment or mechanical ventilation. OBJECTIVE: To systematically review the accuracy of LUS in determining the need for surfactant treatment or mechanical ventilation in infants with respiratory distress treated with nasal continuous positive airway pressure (NCPAP). METHODS: Database search include EMBASE, Medline, CINAHL and Cochrane central from inception until 17 October 2018. Included is diagnostic accuracy studies reporting LUS evaluating surfactant therapy/mechanical ventilation. Two authors extracted data independently and assessed quality. Quality Assessment of Diagnostic Accuracy Studies-2 tool was used to determine the methodological quality. RESULTS: Six studies involving 485 infants included in the review. Three studies used LUS score, two used type 1 lung profile, and one used high-risk LUS to evaluate the outcome. The pooled sensitivity and specificity at LUS score cut-off >5-6 was 88% (95% CI 80% to 93%) and 82% (95% CI 74% to 89%), respectively. Infants with LUS score >5-6 were at significantly increased risk of surfactant treatment compared with infants with LUS score <5-6 (relative risk=7.51; 95% CI 4.16 to 13.58; two studies; participants=189; I2=0%). The diagnostic accuracy of type 1 lung profile was better in younger preterm infants (sensitivity 88.9%, specificity 100%) compared with late preterm and term infants (sensitivity 100%, specificity 28%). CONCLUSIONS: LUS, particularly LUS score, can be used accurately to determine the need for surfactant replacement treatment or mechanical ventilation in infants with respiratory distress treated with NCPAP support. The accuracy is better in younger preterm infants compared with late preterm and term infants. PROSPERO REGISTRATION NUMBER: CRD42018115135.