Non-invasive ventilatory support in neonates: An evidence-based update.

Non-invasive ventilatory support (NIV) is considered the gold standard in the care of preterm infants with respiratory distress syndrome (RDS). NIV from birth is superior to mechanical ventilation (MV) for the prevention of death or bronchopulmonary dysplasia (BPD), with a number needed to treat between 25 and 35. Various methods of NIV are available, some of them extensively researched and with well proven efficacy, whilst others are needing further research. Nasal continuous positive airway pressure (nCPAP) has replaced routine invasive mechanical ventilation (MV) for the initial stabilization and the treatment of RDS. Choosing the most suitable form of NIV and the most appropriate patient interface depends on several factors, including gestational age, underlying lung pathophysiology and the local facilities. In this review, we present the currently available evidence on NIV as primary ventilatory support to preventing intubation and for secondary ventilatory support, following extubation. We review nCPAP, nasal high-flow cannula, nasal intermittent positive airway pressure ventilation, bi-level positive airway pressure, nasal high-frequency oscillatory ventilation and nasal neurally adjusted ventilatory assist modes. We also discuss most suitable NIV devices and patient interfaces during resuscitation of the newborn in the delivery room.

Rate of rise of total serum bilirubin in very low birth weight preterm infants.

BACKGROUND: To assess the postnatal rate of rise (ROR) of total serum bilirubin (TSB) in very low birth weight (VLBW) preterm infants, to determine risk factors associated with a rapid rise (>90th percentile), and to compare ROR and hour-specific TSB at postnatal 12-48 h with data of term infants retrieved from the literature. METHODS: Retrospective analysis of 2430 routine TSB concentrations obtained between birth and initiation of phototherapy in 483 VLBW infants. RESULTS: TSB increased by a median (interquartile range) ROR of 0.15 (0.11-0.19) mg/dL/h. The 50th percentile of TSB was below the 40th percentile of (near-)term counterparts at 12-48 h. TSB ROR correlated with the age at initiation (RS = -0.687; p < 0.001) and the duration (RS = 0.444; p < 0.001) of phototherapy. ROR >90th percentile (>0.25 mg/dL/h) was associated with lower gestational ages [27.2 (25.4-29.3) vs. 28.4 (26.4-30.4) weeks], lower birth weights [978 (665-1120) vs. 1045 (814-1300) g], and lower 5-min Apgar scores [7 (7-8) vs. 8 (7-9)]. CONCLUSION: ROR of TSB is an indicator for early and prolonged phototherapy. While hour-specific TSB and ROR at 12-48 h are lower than those reported for (near-)term infants, TSB appears to rise more rapidly in infants with low gestational age, low birth weight, and low 5-min Apgar score.

Lung function in very low birth weight infants after pharmacological and surgical treatment of patent ductus arteriosus - a retrospective analysis.

BACKGROUND: The indications and strategies for treatment of patent ductus arteriosus (PDA) are controversial, and the safety and long-term benefits of surgical PDA closure remain uncertain. The aim of this study was to compare the lung function of very low birth weight (VLBW) infants after successful PDA treatment with a cyclooxygenase inhibitor or secondary surgical ligation. METHODS: A total of 114 VLBW infants (birth weight < 1500 g), including 94 infants (82%) with a birth weight < 1000 g, who received treatment for hemodynamically significant PDA (hsPDA), were examined at a median postmenstrual age of 48 weeks. All infants were initially given pharmacological treatment, and 40 infants (35%) required PDA ligation. Lung function testing (LFT) included tidal breathing measurements, measurement of respiratory mechanics assessed by the occlusion test, whole-body plethysmography, SF6 multiple breath washout, forced expiratory flow (V'maxFRC) by the rapid thoracoabdominal compression technique, exhaled NO (FeNO), and arterialized capillary blood gas analysis. RESULTS: On the day of the LFT, the 2 groups had similar postconceptional age and body weight. However, the PDA ligation group was more immature at birth (p < 0.001) and had reduced respiratory compliance (p < 0.001), lower V'maxFRC (p = 0.006), increased airway resistance (Raw) (p < 0.001), and impaired blood gases (p < 0.001). Multivariate analysis showed that PDA surgery was an independent risk factor for increased Raw. CONCLUSION: PDA ligation after failed pharmacological treatment is associated with impaired lung function as compared to successful pharmacological closure in infants at a postmenstrual age of 48 weeks. However, only Raw was independently affected by PDA ligation, while all other differences were merely explained by patient characteristics.

Basic principles of respiratory function monitoring in ventilated newborns: A review.

Respiratory monitoring during mechanical ventilation provides a real-time picture of patient-ventilator interaction and is a prerequisite for lung-protective ventilation. Nowadays, measurements of airflow, tidal volume and applied pressures are standard in neonatal ventilators. The measurement of lung volume during mechanical ventilation by tracer gas washout techniques is still under development. The clinical use of capnography, although well established in adults, has not been embraced by neonatologists because of technical and methodological problems in very small infants. While the ventilatory parameters are well defined, the calculation of other physiological parameters are based upon specific assumptions which are difficult to verify. Incomplete knowledge of the theoretical background of these calculations and their limitations can lead to incorrect interpretations with clinical consequences. Therefore, the aim of this review was to describe the basic principles and the underlying assumptions of currently used methods for respiratory function monitoring in ventilated newborns and to highlight methodological limitations.

Current methodological and technical limitations of time and volumetric capnography in newborns.

Although capnography is a standard tool in mechanically ventilated adult and pediatric patients, it has physiological and technical limitations in neonates. Gas exchange differs between small and adult lungs due to the greater impact of small airways on gas exchange, the higher impact of the apparatus dead space on measurements due to lower tidal volume and the occurrence of air leaks in intubated patients. The high respiratory rate and low tidal volume in newborns, especially those with stiff lungs, require main-stream sensors with fast response times and minimal dead-space or low suction flow when using side-stream measurements. If these technical requirements are not fulfilled, the measured end-tidal CO2 (P et CO 2 ), which should reflect the alveolar CO2 and the calculated airway dead spaces, can be misleading. The aim of this survey is to highlight the current limitations of capnography in very young patients to avoid pitfalls associated with the interpretation of capnographic parameters, and to describe further developments.

Nasal high-frequency oscillation ventilation in neonates: a survey in five European countries.

UNLABELLED: Nasal high-frequency oscillation ventilation (nHFOV) is a non-invasive ventilation mode that applies an oscillatory pressure waveform to the airways using a nasal interface. nHFOV has been shown to facilitate carbon dioxide expiration, but little is known about its use in neonates. In a questionnaire-based survey, we assessed nHFOV use in neonatal intensive care units (NICUs) in Austria, Switzerland, Germany, the Netherlands, and Sweden. Questions included indications for nHFOV, equipment used, ventilator settings, and observed side effects. Of the clinical directors of 186 NICUs contacted, 172 (92 %) participated. Among those responding, 30/172 (17 %) used nHFOV, most frequently in premature infants <1500 g (27/30) for the indication nasal continuous positive airway pressure (nCPAP) failure (27/30). Binasal prongs (22/30) were the most common interfaces. The median (range) mean airway pressure when starting nHFOV was 8 (6-12) cm H2O, and the maximum mean airway pressure was 10 (7-18) cm H2O. The nHFOV frequency was 10 (6-13) Hz. Abdominal distension (11/30), upper airway obstruction due to secretions (8/30), and highly viscous secretions (7/30) were the most common nHFOV side effects. CONCLUSION: In a number of European NICUs, clinicians use nHFOV. The present survey identified differences in nHFOV equipment, indications, and settings. Controlled clinical trials are needed to investigate the efficacy and side effects of nHFOV in neonates.

Validation of computerized wheeze detection in young infants during the first months of life.

BACKGROUND: Several respiratory diseases are associated with specific respiratory sounds. In contrast to auscultation, computerized lung sound analysis is objective and can be performed continuously over an extended period. Moreover, audio recordings can be stored. Computerized lung sounds have rarely been assessed in neonates during the first year of life. This study was designed to determine and validate optimal cut-off values for computerized wheeze detection, based on the assessment by trained clinicians of stored records of lung sounds, in infants aged <1 year. METHODS: Lung sounds in 120 sleeping infants, of median (interquartile range) postmenstrual age of 51 (44.5-67.5) weeks, were recorded on 144 test occasions by an automatic wheeze detection device (PulmoTrack®). The records were retrospectively evaluated by three trained clinicians blinded to the results. Optimal cut-off values for the automatically determined relative durations of inspiratory and expiratory wheezing were determined by receiver operating curve analysis, and sensitivity and specificity were calculated. RESULTS: The optimal cut-off values for the automatically detected durations of inspiratory and expiratory wheezing were 2% and 3%, respectively. These cutoffs had a sensitivity and specificity of 85.7% and 80.7%, respectively, for inspiratory wheezing and 84.6% and 82.5%, respectively, for expiratory wheezing. Inter-observer reliability among the experts was moderate, with a Fleiss' Kappa (95% confidence interval) of 0.59 (0.57-0.62) for inspiratory and 0.54 (0.52 - 0.57) for expiratory wheezing. CONCLUSION: Computerized wheeze detection is feasible during the first year of life. This method is more objective and can be more readily standardized than subjective auscultation, providing quantitative and noninvasive information about the extent of wheezing.

How ABBA may help improve neonatal resuscitation training: auditory prompts to enable coordination of manual inflations and chest compressions.

AIM: Resuscitation guidelines recommend 90 chest compressions (CCs) and 30 inflations (INFs) per minute for neonatal cardiopulmonary resuscitation (nCPR). We hypothesised that auditory prompts would help coordinate these actions. Our aim was to investigate the effect of musical prompts during nCPR training on adherence to recommended CC and INF rates and on the quality of delivered INFs. METHODS: A simulation study was conducted employing 30 experienced neonatal staff, a respiratory function monitor and a neonatal manikin. The effects of five different auditory prompts on adherence to recommended rates of CC and INF were tested against baseline (no music). The five auditory prompts (popular musical tunes) were investigated in random order. Quality of INFs was assessed by comparing the peak inflation pressures (PIP), positive end-expiratory pressures (PEEP), percentage mask leak and tidal volumes (VT). RESULTS: Mean baseline rates at which CCs and INFs were delivered were 80 (SD 6) per minute and 28 (SD 2) per minute, respectively. Listening to auditory prompts had varying effects on CC and INF delivery rates. For CCs, a significant difference to baseline was found only when participants listened to ABBA's 'SOS', with 86 (SD 7) per minute (P = 0.04). For INFs, we found a statistically significant improvement to baseline rate only for 'SOS', with 29 (SD 2) per minute (P = 0.04), and there was no significant difference in INF quality among the auditory prompts. CONCLUSIONS: Musical prompts can help with adherence to recommended CC and INF rates but do not improve the quality of INFs during nCPR training. The lasting effect of auditory prompts as musical mnemonics on nCPR performance in vivo needs to be established.

Training neonatal cardiopulmonary resuscitation: can it be improved by playing a musical prompt? A pilot study.

OBJECTIVE: Effective neonatal cardiopulmonary resuscitation (CPR) requires 3:1 coordinated manual inflations (MI) and chest compressions (CC). We hypothesized that playing a musical prompt would help coordinate CC and MI during CPR. STUDY DESIGN: In this pilot trial we studied the effect the "Radetzkymarsch" (110 beats per minute) on neonatal CPR. Thirty-six medical professionals performed CPR on a neonatal manikin. CC and MI were recorded with and without the music played, using a respiratory function monitor and a tally counter. Statistical analysis included Wilcoxon test. RESULTS: Without music, the median (interquartile range) rate of CC was 115 (100 to 129) per minute and the rate of MI was 38 (32 to 42) per minute. When listening to the auditory prompt, the rate of CC decreased significantly to 96 (96 to 100) per minute (p = 0.002) and the rate of MI to 32 (30 to 34) per minute (p = 0.001). The interquartile range of interoperator variability decreased up to 86%. CONCLUSION: Listening to an auditory prompt improved compliance with the recommended delivery rates of CC and MI during neonatal CPR.

Time to adjust to changes in ventilation settings varies significantly between different T-piece resuscitators, self-inflating bags, and manometer equipped self-inflating bags.

OBJECTIVE: Resuscitation guidelines give no preference over use of self-inflating bags (SIBs) or T-piece resuscitators (TPR) for manual neonatal ventilation. We speculated that devices would differ significantly regarding time required to adjust to changed ventilation settings. STUDY DESIGN: This was a laboratory study. Time to adjust from baseline peak inflation pressure (PIP) (20 cmH2O) to target PIP (25 and 40 cmH2O), ability to adhere to predefined ventilation settings (PIP, PEEP, and inflation rate [IR]), and the variability within and between operators were assessed for a SIB without manometer, SIB with manometer (SIBM), and two TPRs. RESULTS: Adjustment time was significantly longer with TPRs, compared with SIB and SIBM. The SIBM and TPRs were < 5% (median) off target PIP, and the SIB was 14% off target PIP. Significant variability between operators (interquartile range [IQR]: 71%) was seen with SIBs. CONCLUSION: PIP adjustment takes longer with TPRs, compared with SIB/SIBM. TPRs and SIBM allow satisfactory adherence to ventilation parameters. SIBs should only be used with manometer attached.

Dead space reduction by Kolobow's endotracheal tube does not justify the waiving of volume monitoring in small, ventilated lungs.

In ventilated preterm infants the flow sensor contributes significantly to the total apparatus dead space, which may impair gas exchange. The aim of the study was to quantify to which extent a dead space reduced Kolobow tube (KB) without flow sensor improves the gas exchange compared with a conventional ventilator circuit with flow sensor [Babylog 8000 (BL)]. In a cross-over trial in 14 tracheotomized, surfactant-depleted (saline lavage) and mechanically ventilated newborn piglets (age <12 h; body weight 705-1200 g) BL and KB was applied alternately for 15 min and blood gases were recorded. The inner diameter of the endotracheal tube was 3.6 mm and the apparatus dead space of BL and KB including the endotracheal tube were 3.0 and 1.34 mL. Despite a 50 % apparatus dead space reduction with KB compared to BL statistically significant improvements were only observed for body weights <900 g. In this weight group median paCO2 was decreased by 5 mmHg (p < 0.01), whereas the improvement decreased with decreasing baseline paCO2. Furthermore, median paO2 was increased by 4 mmHg (p < 0.05) and O2 saturation was increased by 2.5 % (p < 0.05). No significant changes were seen in the circulatory parameters. In very small, ventilated lungs the use of KB improved the gas exchange; however, the improvement was moderate and does not justify the waiving of volume monitoring.

Fetal and neonatal samples of a precursor surfactant protein B inversely related to gestational age.

BACKGROUND: Alveolar-capillary membrane leaks can increase the amount of surfactant protein B (SP-B) in the bloodstream. The purpose of this study was to measure the concentration of C-proSP-B, a SP-B precursor that includes C-terminal domains, in various body fluids of newborn infants and determine its dependence on gestational age. METHODS: C-pro-SPB was measured in amniotic fluid and umbilical cord blood at birth, and in peripheral blood and urine on postnatal day 3 in 137 newborn infants with a median birth weight of 2015 g (range, 550-4475 g) and gestational age of 34 weeks (range, 23-42 weeks). RESULTS: C-proSP-B levels differed more than 100-fold among samples. The levels (median; interquartile range) were highest in peripheral blood (655.6 ng/mL; 419.0-1467.0 ng/mL) and lowest in urine (3.08 ng/mL; 2.96-3.35 ng/mL). C-proSP-B levels in amniotic fluid (314.9 ng/mL; 192.7-603.6 ng/mL) were approximately half of those in peripheral blood. In cord blood C-proSP-B was slightly lower (589.1 ng/mL; 181.2-1129.0 ng/mL) compared with peripheral blood. C-proSP-B levels significantly increased in all the fluids sampled except urine with decreasing gestational age (p < 0.001). CONCLUSIONS: This novel assay allows for the quantitative measurement of C-proSP-B in blood and amniotic fluid. The dependence of C-proSP-B on gestational age may hamper its use for the detection of alveolar leaks in preterm newborns.

Repeated thermo-sterilisation further affects the reliability of positive end-expiratory pressure valves.

AIM: Positive end-expiratory pressure (PEEP) valves are used together with self-inflating bags (SIB) to provide a preset PEEP during manual ventilation. It has recently been shown that these valves deliver highly variable levels of PEEP. We hypothesised that material fatigue due to repeated thermo-sterilisation (TS) may contribute to varying reliability of PEEP valves. METHODS: In a laboratory study 10 new PEEP valves were tested before and after 10, 20 and 30 cycles of routine TS (7 min at 134°C) by using a neonatal lung model (compliance 0.2 mL/kPa). Settings were positive inflation pressure = 20 and 40 cm H(2)O, PEEP = 5 and 10 cm H(2)O, respiratory rate = 40 and 60/min, flow = 8l/min. PEEP was recorded using a respiratory function monitor. RESULTS: Before TS, a mean (standard deviation) PEEP of 4.0 (0.9) and 7.7 (1.0) cm H(2)O was delivered by the 10 valves when the PEEP was set to 5 and 10 cm H(2)O, respectively. One new valve only delivered 2.0 (0.0) and 5.0 (0.0) cm H(2)O when the PEEP was adjusted to 5 and 10 cm H(2)O, respectively. Four of the 10 investigated valves showed significant variations in PEEP (coefficient of variation >10%) throughout the autoclaving process. One valve completely lost its function after the 20th TS. Common defects were tears in the softer materials or displacement of the rubber seal. Six of the 10 valves continued to provide PEEP in spite of repeated TS. CONCLUSION: The reliability of PEEP valves is affected by repeated TS. Multi-use PEEP valves should be tested for reliable PEEP provision following TS.

Development of lung function in very low birth weight infants with or without bronchopulmonary dysplasia: longitudinal assessment during the first 15 months of corrected age.

BACKGROUND: Very low birth weight (VLBW) infants (< 1,500 g) with bronchopulmonary dysplasia (BPD) develop lung damage caused by mechanical ventilation and maturational arrest. We compared functional lung development after discharge from hospital between VLBW infants with and without BPD. METHODS: Comprehensive lung function assessment was performed at about 50, 70, and 100 weeks of postmenstrual age in 55 sedated VLBW infants (29 with former BPD [O2 supplementation was given at 36 weeks of gestational age] and 26 VLBW infants without BPD [controls]). Mean gestational age (26 vs. 29 weeks), birth weight (815 g vs. 1,125 g), and the proportion of infants requiring mechanical ventilation for ≥7 d (55% vs. 8%), differed significantly between BPD infants and controls. RESULTS: Both body weight and length, determined over time, were persistently lower in former BPD infants compared to controls, but no significant between-group differences were noted in respiratory rate, respiratory or airway resistance, functional residual capacity as determined by body plethysmography (FRC(pleth)), maximal expiratory flow at the FRC (V'max (FRC)), or blood gas (pO2, pCO2) levels. Tidal volume, minute ventilation, respiratory compliance, and FRC determined by SF6 multiple breath washout (representing the lung volume in actual communication with the airways) were significantly lower in former BPD infants compared to controls. However, these differences became non-significant after normalization to body weight. CONCLUSIONS: Although somatic growth and the development of some lung functional parameters lag in former BPD infants, the lung function of such infants appears to develop in line with that of non-BPD infants when a body weight correction is applied. Longitudinal lung function testing of preterm infants after discharge from hospital may help to identify former BPD infants at risk of incomplete recovery of respiratory function; such infants are at risk of later respiratory problems.

Manual neonatal ventilation training: a respiratory function monitor helps to reduce peak inspiratory pressures and tidal volumes during resuscitation.

BACKGROUND: Neonatal resuscitation training is considered to be multifarious and includes manual ventilation as an essential competence for any health-care provider. Usually, ventilation is applied with self-inflating bags (SIBs). These devices have been shown to produce highly variable, operator-dependent peak inspiratory pressures (PIPs) and tidal volumes (V(T)). Excessive PIP and V(T) contribute to lung injury. We studied a simple tool to improve resuscitation skills. OBJECTIVE: The objectives of this study were to train healthcare providers to avoid excessive PIP and V(T) by visualizing these values by using a respiratory function monitor (RFM) and to study the sustainability of such a training. MATERIAL AND METHODS: Previously untrained medical professionals were educated and trained to ventilate a neonatal preterm manikin. PIP and V(T) were measured with an RFM. Graphical representations of the measurements were displayed during training, but the RFM was blinded during subsequent recordings. Participants were reassessed directly after training and 1 month later. RESULTS: In total, 37 participants were trained and assessed three times during the study. Median PIPs (range) were 32.3 (4.1 ­ 44) cm H(2)O before training, 17.8 (9.6 ­ 23.6) cm H(2)O directly after training (P < 0.05), and 18.7 (7.5 ­ 41.6) cm H(2)O 1 month later, and the values remained low, compared with before training (P < 0.05). Median V(T)s were 6.7 (4.2 ­ 44) mL before training, 3.5 (1.8 ­ 7.3) mL directly after training (P < 0.05), and 4.1 (1.9 ­ 9.7 mL) 1 month after training (P < 0.05). CONCLUSION: Using a SIB, untrained staff produced excessive PIP and V(T). Training with a simple RFM significantly reduced the occurrence of excessive PIP and V(T). The effect was sustained for at least 1 month.

Current methods of non-invasive ventilatory support for neonates.

Non-invasive ventilatory support can reduce the adverse effects associated with intubation and mechanical ventilation, such as bronchopulmonary dysplasia, sepsis, and trauma to the upper airways. In the last 4 decades, nasal continuous positive airway pressure (CPAP) has been used to wean preterm infants off mechanical ventilation and, more recently, as a primary mode of respiratory support for preterm infants with respiratory insufficiency. Moreover, new methods of respiratory support have been developed, and the devices used to provide non-invasive ventilation (NIV) have improved technically. Use of NIV is increasing, and a variety of equipment is available in different clinical settings. There is evidence that NIV improves gas exchange and reduces extubation failure after mechanical ventilation in infants. However, more research is needed to identify the most suitable devices for particular conditions; the NIV settings that should be used; and whether to employ synchronized or non-synchronized NIV. Furthermore, the optimal treatment strategy and the best time for initiation of NIV remain to be identified. This article provides an overview of the use of non-invasive ventilation (NIV) in newborn infants, and the clinical applications of NIV.

Tracheal tube airleak in clinical practice and impact on tidal volume measurement in ventilated neonates.

OBJECTIVE: To determine the prevalence, size, and factors affecting tracheal tube (TT) leak in clinical practice and their influence on the displayed tidal volume (Vt) in ventilated newborn infants using uncuffed TTs. Monitoring of Vt is important for implementation of lung-protective ventilation strategies but becomes meaningless in the presence of large TT airleaks. DESIGN: Retrospective clinical study. SETTING: Neonatal intensive care unit. PATIENTS: Patient records of 163 neonates ventilated with Babylog 8000 for ≥ 5 hrs with a median (range) gestation age of 31.1 wks (23.3-41.9 wks) and a median birth weight of 1470 g (410-4475 g) were evaluated. INTERVENTIONS: : Ventilatory settings, TT leak, and Vt were recorded every 3 hrs. The lowest, median, and highest TT leaks were noted on the day the first TT leak (>5%) occurred, the day on which TT leak peaked, and the day of extubation. MEASUREMENTS AND MAIN RESULTS: A TT leak of >5% was seen in 122 (75%) infants. Neonates with TT leak, compared with those without TT leak, had a longer duration of mechanical ventilation (p < .001), a lower gestational age (p = .004), a reduced birth weight (p = .005), and a higher prevalence of reintubation (p = .003). The greatest TT leak was seen in infants ventilated with a TT of <3-mm diameter. During the entire duration of mechanical ventilation, 42.3% of all neonates experienced at least one TT leak of >40% commonly seen on the third day of mechanical ventilation. Regression analysis showed that a TT leak of 40% indicated that the displayed Vt was underestimated by 1.2 mL/kg (about 24% of target Vt). CONCLUSIONS: TT leak is highly variable, and TT leak of >40% with clinically relevant Vt errors occurred in nearly half of all ventilated neonates. Preterm infants of low birth weight and with small-diameter TTs ventilated for a long period were at greater risk of TT leak.

O father, where art thou? Parental NICU visiting patterns during the first 28 days of life of very low-birth-weight infants.

To study the frequency and duration of parental visits to neonatal intensive care units (NICU) during the first 28 days of life of preterm infants in relation to medical variables, sociodemographic factors, and subsequent outpatient follow-up examinations. Retrospective chart review of 127 infants with a birth weight less than 1500 g born between Jan 1, 2009, and Dec 31, 2009, at 2 tertiary NICUs. The average frequency of parental visits during the first 28 days of life declined significantly over time (P < .05) while the duration of visits remained constant. Average frequency and duration of visits per day were consistently lower in fathers than in mothers (median [interquartile range]: 0.6 [0.4-1.0] per day vs 1.1 [0.9-1.4] per day, 72.5 [32.1-108.9 [min/d vs 133.4 [75.4-174.3] min/d). While a history of treatment for infertility was correlated with significantly more frequent and longer parental NICU visits in the first 2 weeks, having older children at home was correlated with shorter visits during the first week. Visiting patterns showed no relation to attendance at follow-up examinations at 6 months corrected age. Mothers spend more time with their preterm infants in NICUs than fathers. We suggest measures to increase paternal involvement with hospitalized preterm infants.

Differences in anthropometric measurements between Sudanese newborn twins and singletons.

UNLABELLED: Twin pregnancies are associated with disturbed fetal growth and a higher risk of low birthweight (LBW), which is one of the most important determinants of perinatal morbidity and mortality in Africa. In this study, we compare anthropometric measurements in Sudanese twins and their mothers with singletons. METHODS: In 1000 Sudanese mothers with singleton births and 30 mothers with twins, maternal (weight, height, mid-arm circumference) and 11 newborn anthropometric measurements were taken within 24 hours of delivery. Maternal education and socio-economic status were additionally recorded. RESULTS: Mothers of twins had a significantly higher body weight (p = .045) and lean body mass (p = .02) after delivery, and were from higher social classes in general (p = .014). In addition to gestational age, twins displayed a statistically significant reduction in all anthropometric data, compared to singletons, mainly in terms of birth-weight, chest and head circumference, whereas differences in triceps and subscapular skin fold thickness and ponderal index were distinctly lower. The LBW rate in twins was markedly higher than that in singletons (43.3% vs. 8.3%, p < .001). In 20 out of 30 twins (66.7%), Twin A weighed more than Twin B (difference (SD) of 443 (335) g), and in the remaining 10 cases (33.7%), the weight of Twin B was equal to or more than that of twin A (difference (SD) of 211 (240) g, p = .039). In unlike-sex pairs, the mean (SD) difference between Twins A and B in birthweight was 459 (481) g, which was distinctly higher, compared to same-sex pairs (boys, 180 (325) g and girls, 36 (413) g). CONCLUSIONS: Sudanese twins displayed significantly reduced anthropometric measurements compared to singletons, but to different degrees. Gender had a higher impact on birthweight in twins than in singletons.