Trends in the use of non-invasive respiratory support for term infants in tertiary neonatal units in Australia and New Zealand.

OBJECTIVE: To determine whether the use of non-invasive respiratory support, such as continuous positive airway pressure and nasal high flow, to treat term infants in Australian and New Zealand tertiary neonatal intensive care units (NICUs) has changed over time, and if so, whether there are parallel changes in short-term respiratory morbidities. DESIGN: Retrospective database review of patient-level data from the Australian and New Zealand Neonatal Network (ANZNN) from 2010 to 2018. Denominator data on the number of term inborn livebirths in each facility was only available as annual totals. PATIENTS AND SETTING: Term, inborn infants cared for in NICUs within the ANZNN. MAIN OUTCOME MEASURES: The primary outcome was the annual change in hospital-specific rates of non-invasive respiratory support per 1000 inborn livebirths, expressed as a percentage change. Secondary outcomes were the change in rates of mechanical ventilation, pneumothorax requiring drainage, exogenous surfactant treatment and death before hospital discharge. RESULTS: A total of 14 656 term infants from 21 NICUs were included from 2010 to 2018, of whom 12 719 received non-invasive respiratory support. Non-invasive respiratory support use increased on average by 8.7% per year (95% CI: 7.9% to 9.4% per year); the number of term infants receiving non-invasive respiratory support almost doubled from 980 in 2010 (10.8/1000 livebirths) to 1913 in 2018 (20.8/1000). There was no change over time in rate of mechanical ventilation or death. The rate of pneumothorax requiring drainage increased over time, as did surfactant treatment. CONCLUSIONS: Non-invasive respiratory support use to treat term infants cared for in NICUs within the ANZNN is increasing over time. Clinicians should be diligent in selecting infants most likely to benefit from treatment with non-invasive respiratory support in this relatively low-risk population of term newborn infants. Analysis of patient-level data by individual NICUs is recommended to control for potential confounding due to changes in population over time.

Cost-Effectiveness of Nasal High Flow Versus CPAP for Newborn Infants in Special-Care Nurseries.

BACKGROUND: Treating respiratory distress in newborns is expensive. We compared the cost-effectiveness of 2 common noninvasive therapies, nasal continuous positive airway pressure (CPAP) and nasal high-flow (nHF), for newborn infants cared for in nontertiary special care nurseries. METHODS: The economic evaluation was planned alongside a randomized control trial conducted in 9 Australian special care nurseries. Costs were considered from a hospital perspective until infants were 12 months of age. A total of 754 infants with respiratory distress, born ≥31 weeks' gestation and with birth weight ≥1200 g, <24 hours old, requiring noninvasive respiratory support and/or supplemental oxygen for >1 hour were recruited during 2015-2017. Inpatient costing records were obtained for 753 infants, of whom 676 were included in the per-protocol analysis. Two scenarios were considered: (1) CPAP versus nHF, with infants in the nHF group having "rescue" CPAP backup available (trial scenario); and (2) CPAP versus nHF, as sole primary support (hypothetical scenario). Effectiveness outcomes were rate of endotracheal intubation and transfer to a tertiary-level NICU. RESULTS: As sole primary support, CPAP is more effective and on average cheaper, and thus is superior. However, nHF with back-up CPAP produced equivalent cost and effectiveness results, and there is no reason to make a decision between the 2 treatments on the basis of the cost or effectiveness outcomes. CONCLUSIONS: Nontertiary special care nurseries choosing to use only 1 of the modes should choose CPAP. In units with both modes available, using nHF as first-line therapy may be acceptable if there is back-up CPAP.

Supraglottic airway devices for administration of surfactant to newborn infants with respiratory distress syndrome: a narrative review.

Surfactant is an effective treatment for respiratory distress syndrome, being particularly important for infants in whom continuous positive airway pressure (CPAP) provides insufficient support. Supraglottic airway devices present an attractive option for surfactant delivery, particularly as an alternative to methods dependent on direct laryngoscopy, a procedural skill that is both difficult to learn and in which to maintain competence. Published studies provide encouraging data that surfactant administration by supraglottic airway device can be performed with a high rate of success and may reduce the need for subsequent intubation compared with either continued CPAP or surfactant administration via endotracheal tube. However, existing randomised controlled trials (RCTs) are heterogeneous in design and include just over 350 infants in total. To date, all RCT evidence has been generated in tertiary units, whereas the greatest potential for benefit from the use of these devices is likely to be in non-tertiary settings. Future research should investigate choice and utility of device in addition to safety and effectiveness of procedure. Importantly, studies conducted in non-tertiary settings should evaluate feasibility, meaningful clinical outcomes and the impact that this approach might have on infants and their families. Supraglottic airway devices may represent a simple and effective mode of surfactant administration that can be widely used by a variety of clinicians. However, further well-designed RCTs are required to determine their role, safety and effectiveness in both tertiary and non-tertiary settings before introduction into routine clinical practice.

Predicting Nasal High-Flow Treatment Success in Newborn Infants with Respiratory Distress Cared for in Nontertiary Hospitals.

OBJECTIVE: To evaluate demographic and clinical variables as predictors of nasal high-flow treatment success in newborn infants with respiratory distress cared for in Australian nontertiary special care nurseries. STUDY DESIGN: A secondary analysis of the HUNTER trial, a multicenter, randomized controlled trial evaluating nasal high-flow as primary respiratory support for newborn infants with respiratory distress who were born ≥31 weeks of gestation and with birth weight ≥1200 g, and cared for in Australian nontertiary special care nurseries. Treatment success within 72 hours after randomization to nasal high-flow was determined using objective criteria. Univariable screening and multivariable analysis was used to determine predictors of nasal high-flow treatment success. RESULTS: Infants (n = 363) randomized to nasal high-flow in HUNTER were included in the analysis; the mean gestational age was 36.9 ± 2.7 weeks and birth weight 2928 ± 782 g. Of these infants, 290 (80%) experienced nasal high-flow treatment success. On multivariable analysis, nasal high-flow treatment success was predicted by higher gestational age and lower fraction of inspired oxygen immediately before randomization, but not strongly. The final model was found to have an area under the curve of 0.65, which after adjustment for optimism was found to be 0.63 (95% CI, 0.57-0.70). CONCLUSIONS: Gestational age and supplemental oxygen requirement may be used to guide decisions regarding the most appropriate initial respiratory support for newborn infants in nontertiary special care nurseries. Further prospective research is required to better identify which infants are most likely to be successfully treated with nasal high-flow. TRIAL REGISTRATION: ACTRN12614001203640.

Lost in Transition: Is Early Respiratory Support in Newborn Infants the Best Option?

BACKGROUND: Late preterm and term newborns with respiratory distress are increasingly treated with non-invasive ventilation (NIV) including nasal high-flow or continuous positive airway pressure. For infants with mild distress, NIV may be unnecessary. OBJECTIVES: We speculated that treatment with supplemental oxygen (SO) prior to NIV could help clinicians select infants for NIV treatment, and examined this hypothesis using data from a recently completed trial. METHOD: Post hoc analysis of data from a subset of infants enrolled in the HUNTER trial. Infants born at ≥36 weeks' gestation were categorized by whether they were receiving SO prior to randomization. The 2 groups were compared for illness severity (indicated by treatment failure at 72 h, mechanical ventilation, need for up-transfer, SO requirement post-randomization, and length of time receiving respiratory support), use of selected medical interventions (antibiotics, intravenous fluids), and breastfeeding at discharge. RESULTS: Analysis included 380 infants. Infants not receiving SO had less severe illness; lower rates of treatment failure (7.3 vs. 17.2%), mechanical ventilation (0.6 vs. 5.9%), need for transfer (6.8 vs. 13.8%), and more often did not receive any SO post-randomization (75.1 vs. 3.0%). Most infants in both groups received intravenous fluids (93 and 98%) and antibiotics (81 and 93%); the rate of full breastfeeding was low in both groups (51 and 45%). CONCLUSIONS: Late preterm and term newborn infants without SO requirement at the time of commencing NIV for respiratory distress are at lower risk of requiring treatment escalation. Close observation of these infants (watch and wait strategy) may avoid unnecessary treatment.

Nasal High-Flow Therapy for Newborn Infants in Special Care Nurseries.

BACKGROUND: Nasal high-flow therapy is an alternative to nasal continuous positive airway pressure (CPAP) as a means of respiratory support for newborn infants. The efficacy of high-flow therapy in nontertiary special care nurseries is unknown. METHODS: We performed a multicenter, randomized, noninferiority trial involving newborn infants (<24 hours of age; gestational age, ≥31 weeks) in special care nurseries in Australia. Newborn infants with respiratory distress and a birth weight of at least 1200 g were assigned to treatment with either high-flow therapy or CPAP. The primary outcome was treatment failure within 72 hours after randomization. Infants in whom high-flow therapy failed could receive CPAP. Noninferiority was determined by calculating the absolute difference in the risk of the primary outcome, with a noninferiority margin of 10 percentage points. RESULTS: A total of 754 infants (mean gestational age, 36.9 weeks, and mean birth weight, 2909 g) were included in the primary intention-to-treat analysis. Treatment failure occurred in 78 of 381 infants (20.5%) in the high-flow group and in 38 of 373 infants (10.2%) in the CPAP group (risk difference, 10.3 percentage points; 95% confidence interval [CI], 5.2 to 15.4). In a secondary per-protocol analysis, treatment failure occurred in 49 of 339 infants (14.5%) in the high-flow group and in 27 of 338 infants (8.0%) in the CPAP group (risk difference, 6.5 percentage points; 95% CI, 1.7 to 11.2). The incidences of mechanical ventilation, transfer to a tertiary neonatal intensive care unit, and adverse events did not differ significantly between the groups. CONCLUSIONS: Nasal high-flow therapy was not shown to be noninferior to CPAP and resulted in a significantly higher incidence of treatment failure than CPAP when used in nontertiary special care nurseries as early respiratory support for newborn infants with respiratory distress. (Funded by the Australian National Health and Medical Research Council and Monash University; HUNTER Australian and New Zealand Clinical Trials Registry number, ACTRN12614001203640.).

A multicentre, randomised controlled, non-inferiority trial, comparing nasal high flow with nasal continuous positive airway pressure as primary support for newborn infants with early respiratory distress born in Australian non-tertiary special care nurseries (the HUNTER trial): study protocol.

INTRODUCTION: Nasal high-flow (nHF) therapy is a popular mode of respiratory support for newborn infants. Evidence for nHF use is predominantly from neonatal intensive care units (NICUs). There are no randomised trials of nHF use in non-tertiary special care nurseries (SCNs). We hypothesise that nHF is non-inferior to nasal continuous positive airway pressure (CPAP) as primary support for newborn infants with respiratory distress, in the population cared for in non-tertiary SCNs. METHODS AND ANALYSIS: The HUNTER trial is an unblinded Australian multicentre, randomised, non-inferiority trial. Infants are eligible if born at a gestational age ≥31 weeks with birth weight ≥1200 g and admitted to a participating non-tertiary SCN, are <24 hours old at randomisation and require non-invasive respiratory support or supplemental oxygen for >1 hour. Infants are randomised to treatment with either nHF or CPAP. The primary outcome is treatment failure within 72 hours of randomisation, as determined by objective oxygenation, apnoea or blood gas criteria or by a clinical decision that urgent intubation and mechanical ventilation, or transfer to a tertiary NICU, is required. Secondary outcomes include incidence of pneumothorax requiring drainage, duration of respiratory support, supplemental oxygen and hospitalisation, costs associated with hospital care, cost-effectiveness, parental stress and satisfaction and nursing workload. ETHICS AND DISSEMINATION: Multisite ethical approval for the study has been granted by The Royal Children's Hospital, Melbourne, Australia (Trial Reference No. 34222), and by each participating site. The trial is currently recruiting in eight centres in Victoria and New South Wales, Australia, with one previous site no longer recruiting. The trial results will be published in a peer-reviewed journal and will be presented at national and international conferences. TRIAL REGISTRATION NUMBER: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001203640; pre-results.

Mild encephalopathy with reversible splenial lesion: an important differential of encephalitis.

Mild encephalopathy with a reversible splenial lesion (MERS) is a clinico-radiological syndrome characterized by a transient mild encephalopathy and a reversible lesion in the splenium of the corpus callosum on MRI. This syndrome has almost universally been described in children from Japan and East Asia. Here we describe seven cases of MERS occurring in Caucasian Australian children from one centre seen over a 3 year period. All patients had a fever-associated encephalopathy (n = 7), which presented with confusion (n = 4), irritability (n = 3), lethargy (n = 3), slurred speech (n = 3), drowsiness (n = 2) and hallucinations (n = 2). Other neurological symptoms included ataxia (n = 5) and seizures (n = 1). These symptoms resolved rapidly over 4-6 days followed by complete neurological recovery. In all patients, MRI performed within 1-3 days of onset of encephalopathy demonstrated a symmetrical diffusion-restricted lesion in the splenium of the corpus callosum. Three patients had additional lesions involving other parts of the corpus callosum and adjacent periventricular white matter. These same three patients had mild persisting white matter changes evident at followup MRI, while the other patients had complete resolution of radiological changes. A potential trigger was present in five of the seven cases: Kawasaki disease, Salmonella, cytomegalovirus, influenza B and adenovirus (all n = 1). Elevated white cell count (n = 4), elevated C reactive protein (n = 5) and hyponatremia (n = 6) were commonly observed. CSF was performed in four patients, which showed no pleocytosis. This case series of MERS demonstrates this condition occurs outside of East Asia and is an important differential to consider in children presenting with acute encephalopathy.

Need for intensive care for neonates born between 29 and 34 weeks inclusive gestation.

AIMS: To identify the proportion of preterm infants needing neonatal intensive care (NIC) between 29 and 34 weeks gestation. To identify any associated risk factors. METHODS: This population-based study identified all babies, born without congenital abnormalities, between 29 and 34 weeks gestation inclusive. A 21-month period ending September 2009 was used. The need for NIC was defined using specific cardiorespiratory and nutritional criteria. The use of continuous positive airway pressure alone was not included as a need for NIC. Data were extracted from a neonatal clinical database and individual medical records. RESULTS: Complete data were available from 707 out of 709 eligible infants born in the study period. The percentage of infants requiring cardiorespiratory support varied from 39 to 2.7% at 29 and 34 weeks, respectively. If nutritional criteria were included, this increased to 77% at 29 weeks and 7.2% at 34 weeks. Multivariate analysis determined that gestational age and delivery by Caesarean section increased the need for intensive care (P-value <0.01). Antenatal steroids, gender, underlying maternal medical conditions, being small for gestational age or twin pregnancy had no statistically significant impact. CONCLUSIONS: This study supports the National Health and Medical Research Council Guidelines of in-utero transfer at <33 weeks gestation. Gestational age and delivery by Caesarean section remain major indicators for the need for NIC. In special care nurseries that have the capability and expertise to use nasal continuous positive airway pressure, the main indication for NIC is for nutritional support.

Nasal continuous positive airway pressure for respiratory distress in non-tertiary care centres: what is needed and where to from here?

Respiratory distress is one of the commonest reasons for admission to a special care nursery (SCN) affecting between 2.5 and 5.0% of all babies born per year. While most recover with supplemental oxygen, some require transfer to a neonatal intensive care leading to significant family disruption, and financial cost. Does nasal continuous positive airway pressure (nCPAP) improve outcomes in babies with respiratory distress? What are the risks of its use? Should it be used in SCNs, and, if so, what is required in order to undertake nCPAP safely? There is strong evidence to support the use of nCPAP in the treatment of babies with respiratory distress. The risk benefit ratio of providing nCPAP in SCNs depends upon many factors including the ability to maintain the skills required and the distance/time to the nearest tertiary centre. Appropriate nurseries should be identified with the aim of supporting them in the provision of nCPAP in a safe manner.

Targeted oxygen therapy in special care nurseries: is uniformity a good thing?

AIM: There is wide variation in the commencement of inspired oxygen (FiO2) and the oxygen saturation (SpO(2) ) targets set in special care nurseries (SCNs). Evidence supports minimising unnecessary oxygen exposure. Does the introduction of a protocol advocating the uniform approach of commencing FiO2 at 30% and targeting SpO2 of 94-96% for infants ≥ 33 weeks gestation with respiratory distress reduce oxygen exposure? METHODS: A 'Before After' study was undertaken in three SCNs. Data were recorded for all infants admitted to the SCNs who required oxygen over a 3-year period. Infants were analysed in gestational age groups: 33-36 weeks (late preterm) and +37 weeks (term/post-term). RESULTS: Of the 19,830 infants born, 868 (4%) were treated with oxygen. The introduction of an oxygen-targeting protocol resulted in a statistically and clinically significant reduction in the proportion of infants who were treated with any oxygen for 1 h or more, 4 h or more and in the proportion who received >30% FiO2 for 1 h or more (all P ≤ 0.01). This reduction was significant for infants of both gestational age groups. The median duration of oxygen for term/post-term infants was reduced from 12 h pre-protocol to 10 h post-protocol (P= 0.01); however, no significant difference was found for the preterm group (reduced from 11 to 8 h, P= 0.07). CONCLUSION: Introduction of a uniform oxygen protocol in SCNs for infants ≥ 33 weeks gestation with respiratory distress reduces the number of infants receiving oxygen and, in term infants, the duration of oxygen exposure.

Ethical issues in preventing mother-to-child transmission of hepatitis B by immunisation.

Without intervention, a pregnant woman who is a chronic hepatitis B carrier is at risk of transmitting hepatitis B and of her infant becoming a chronic carrier and having a significantly increased lifetime risk of developing liver cancer or cirrhosis. Hepatitis B vaccine and immunoglobulin reduce the risk of the baby becoming a carrier, but with only a short window period after birth to deliver this potentially life-saving intervention. We reviewed the evidence on the magnitude of the risk. If the carrier mother is e antigen positive (highly infective), the calculated risk to the infant without intervention is 75.2%, reduced to 6.0% by giving vaccine and immunoglobulin at birth. If the mother is surface antigen positive but e antigen negative, the risk to the infant without intervention is 10.3%, reduced to 1.0% by giving vaccine and immunoglobulin. If vaccine is accepted but immunoglobulin refused, as for example by some Jehovah's Witnesses, the risk to babies of e antigen positive mothers is reduced to 21.0% and to babies of e antigen negative mothers to 2.6%. These figures can be used to inform parents and as a possible basis for child protection proceedings if parents decline vaccine and/or immunoglobulin. We argue from the perspective of the best interests of the child that the severity of the condition justifies initiating child protection proceedings whenever a baby is born to a hepatitis B carrier mother and, despite concerted attempts to persuade them, the parents refuse vaccine and/or immunoglobulin.

'Halving the heel pricks': evaluation of a neonatal jaundice protocol incorporating the use of a transcutaneous bilirubinometer.

AIM: This study aimed to assess the impact of implementing a new jaundice protocol incorporating the use of the Konica Minolta/Air Shields JM 103 Jaundice Meter (JM103) (Konica Minolta Sensing Inc., Osaka, Japan) in the setting of an Australian post-natal ward. METHODS: A before-and-after study was completed following the introduction of a protocol integrating the use of the JM103 monitor on to the post-natal ward. Eligible infants were ≥ 36 weeks gestation, > 24 h and < 8 days of age. The number of Total Serum Bilirubin tests (TSBRs) were compared for the 12 months prior (T1) with a 6-month period and 6 months after protocol introduction (T2). Transcutaneous bilirubin (TcBR) results were also collected in T2. Rates of phototherapy and peak TSBRs at commencement were also compared as measures of safety. RESULTS: Four hundred and twenty-six of the 2197 live births in T1 required one or more TSBRs compared with 119 of the 1169 live births in T2. This represents an odds ratio of 0.47 (95% confidence interval 0.38-0.58) for infants in T2 having ≥ 1 TSBR compared with T1. There was no difference between the groups for rates of phototherapy (3.8% vs. 3.0%; P= 0.2) nor any difference between the groups for peak SBR during phototherapy (301.9 µmol/L (standard deviation, SD 58) for T1 vs. 303.2 µmol/L (SD 54) for T2; P= 0.45). The estimated cost saving per year is $6966.00. CONCLUSION: TcBR measurement in conjunction with our protocol significantly reduces painful procedures and costs without increasing the risk of delaying treatment with phototherapy.

Iron supplementation for breath-holding attacks in children.

BACKGROUND: Breath-holding attacks are common during childhood. Iron supplementation has been claimed to reduce the frequency or severity, or both, of breath-holding attacks in children. OBJECTIVES: To assess the effect of iron supplementation on the frequency and severity of breath-holding attacks in children. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE, PsycINFO, CINAHL and the metaRegister of Controlled Trials (up to April 2009). We scanned references of included trials. Pharmaceutical companies manufacturing oral iron supplements and some trial authors were contacted for any unpublished data or trials. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing iron supplementation with placebo or no therapy in children < 18 years with recurrent (more than three) breath-holding episodes. These were reported by an observer. DATA COLLECTION AND ANALYSIS: The primary outcome was reduction in the frequency (number over time) or severity (leading to cessation of loss of consciousness or convulsive movements), or both, of breath-holding attacks. Two authors (AZ and NO) independently selected studies and extracted data. Study authors were contacted for missing data, where necessary. Risk of bias was assessed using domain-based evaluation. In the presence of low heterogeneity, a fixed-effect meta-analysis was performed with pooled results presented as odds ratios (OR) and 95% confidence intervals (CIs). MAIN RESULTS: Two trials (87 children) fulfilled the inclusion criteria. In these trials, iron supplementation significantly reduced the frequency of breath-holding attacks in children (OR 76.48; 95% CI 15.65 to 373.72; P < 0.00001). A meta-analysis that solely examined iron supplementation causing complete resolution of breath-holding attacks maintained this significance (OR 53.43; 95% CI 6.57 to 434.57; P = 0.0002). AUTHORS' CONCLUSIONS: Iron supplementation (at 5 mg/kg/day of elemental iron for 16 weeks) appears to be useful in reducing the frequency and severity of breath-holding attacks. Supplementation is of particular benefit in children with iron deficiency anaemia, responses correlating with the improvements in haemoglobin values. Iron may still be of assistance in children who are not anaemic or who have low, normal haemoglobin levels. Further high-quality randomised control trials of iron supplementation to treat breath-holding attacks in children are required.

Parental stress and satisfaction in the non-tertiary special care nursery.

AIM: This paper is a report of a study examining the effects of using headbox oxygen and continuous oxygen positive airway pressure treatments for respiratory distress on stress and satisfaction of parents with infants in a special care nursery, and the relationship between parental stress and satisfaction. BACKGROUND: Continuous positive airway pressure respiratory support is increasingly used in special care nurseries worldwide. Almost nothing is known about effects of different types of respiratory support on the stress and satisfaction of parents with babies in the special care nursery. METHOD: Questionnaires were used from August 2004 to June 2006 in five special care nurseries to measure parental stress using an adaptation of the Parental Stressor Scale: Neonatal Intensive Care Unit and 5-point scales to measure overall stress and satisfaction. FINDINGS: Questionnaires were returned from 42 parents of babies receiving headbox oxygen and 51 parents of babies receiving continuous positive airway pressure (62% response rate). High stress was commonly reported. Stress did not differ statistically significantly between the two treatments. Parents with babies receiving continuous positive airway pressure were more satisfied compared to the headbox group. Stress and satisfaction were not statistically significantly correlated. CONCLUSION: Clinicians need not favour either method of respiratory support when attempting to minimize parental experience of environmental stress. Further research is needed to test parental stress reduction strategies in the special care nursery.

Continuous positive airway pressure therapy for infants with respiratory distress in non tertiary care centers: a randomized, controlled trial.

OBJECTIVE: Our objective was to determine whether continuous positive airway pressure therapy would safely reduce the need for up-transfer of infants with respiratory distress from nontertiary centers. METHODS: We randomly assigned 300 infants at >30 weeks of gestation with respiratory distress to receive either Hudson prong bubble continuous positive airway pressure therapy or headbox oxygen treatment (standard care). The primary end point was "up-transfer or treatment failure." Secondary end points included death, length of nursery stay, time receiving oxygen therapy, cost of care, and other measures of morbidity. RESULTS: Of 151 infants who received continuous positive airway pressure therapy, 35 either were up-transferred or experienced treatment failure, as did 60 of the 149 infants given headbox oxygen treatment. There was no difference in the length of stay or the duration of oxygen treatment. For every 6 infants treated with continuous positive airway pressure therapy, there was an estimated cost saving of $10,000. Pneumothorax was identified for 14 infants in the continuous positive airway pressure group and 5 in the headbox group. There was no difference in any other measure of morbidity or death. CONCLUSIONS: Hudson prong bubble continuous positive airway pressure therapy reduces the need for up-transfer of infants with respiratory distress in nontertiary centers. There is a clinically relevant but not statistically significant increase in the risk of pneumothorax. There are significant benefits associated with continuous positive airway pressure use in larger nontertiary centers.

CPAP use in babies with respiratory distress in Australian special care nurseries.

AIM: This study sought to identify the number of special care nurseries (SCNs) already using CPAP in 2004, and the number considering its use in the following 2 years, and to describe the characteristics of those hospitals. METHODS: All Australian hospitals with >200 registered deliveries in the year 2002, a SCN and at least one paediatrician were eligible (n = 157). Separate questionnaires were sent to the nurse unit manager (NUM) and the paediatrician responsible for the SCN in late 2004. RESULTS: Of 157 eligible SCNs, 143 (91%) responded. CPAP was being used in 24/143 (17%). Of those nurseries not already using CPAP a further 45/119 (38%) were considering doing so in 2005/2006. State/Territory, greater availability of junior medical staff, use of a helicopter/airplane for transferring infants to tertiary centres and number of paediatricians were significantly associated with use of CPAP (all P < 0.05). Consideration of use was significantly associated with greater availability of junior medical staff, larger numbers of births and time to nearest (tertiary) centre (all P < 0.05). CONCLUSION: There is a strong predisposition for the use of CPAP in SCNs despite the lack of evidence for its benefits or risks there. Studies are urgently required on the clinical benefits and risks of CPAP in a non-tertiary centre before the widespread introduction of CPAP takes place.

Practice variation in initial management and transfer thresholds for infants with respiratory distress in Australian hospitals. Who should write the guidelines?

AIM: In Australian hospitals: (i) to identify current practices in the initial oxygen management of infants with respiratory distress; (ii) to identify factors important in deciding to transfer an infant; and (iii) to identify thresholds for transfer. METHODS: All Australian hospitals with: >200 registered deliveries, a special care unit (SCU) or neonatal intensive care unit (NICU), and at least one paediatrician were surveyed in 2004 (n=176). The questionnaire sought information on the initial oxygen management and factors important in deciding to transfer. Three scenarios were also used to identify thresholds for pH, carbon dioxide and oxygen levels at which transfer should occur. Responses from SCU were compared with those from NICU. RESULTS: 15/19 (79%) NICUs and 118/157 (75%) SCUs responded. Initial oxygen management varies widely among SCUs and NICUs. NICUs set significantly lower saturation (SaO(2)) targets in two of the three scenarios. NICUs are statistically significantly more likely to regard 'Medical Staff Experience' and 'Time to Nearest NICU' as important compared with SCUs (P<0.05). NICUs would 'Probably' and 'Definitely Transfer' infants at significantly lower oxygen levels in all three cases (P<0.05). SCUs are significantly less likely to transfer babies with pH of <7.25 compared with NICUs. There was no difference between the centres for CO(2) level. CONCLUSION: The wide variation that exists between nurseries in the initial management of infants with respiratory distress and in the thresholds for transfer strongly suggests the need for the development of practice guidelines.