Electronic Heart (ECG) Monitoring at Birth and Newborn Resuscitation.

BACKGROUND: Approximately 10% of newborns require assistance at delivery, and heart rate (HR) is the primary vital sign providers use to guide resuscitation methods. In 2016, the American Heart Association (AHA) suggested electrocardiogram in the delivery room (DR-ECG) to measure heart rate during resuscitation. This study aimed to compare the frequency of resuscitation methods used before and after implementation of the AHA recommendations. METHODS: This longitudinal retrospective cohort study compared a pre-implementation (2015) cohort with two post-implementation cohorts (2017, 2021) at our Level IV neonatal intensive care unit. RESULTS: An initial increase in chest compressions at birth associated with the introduction of DR-ECG monitoring was mitigated by focused educational interventions on effective ventilation. Implementation was accompanied by no changes in neonatal mortality. CONCLUSIONS: Investigation of neonatal outcomes during the ongoing incorporation of DR-ECG may help our understanding of human and system factors, identify ways to optimize resuscitation team performance, and assess the impact of targeted training initiatives on clinical outcomes.

Laryngeal mask use during neonatal resuscitation at birth: A United States-based survey of neonatal resuscitation program providers and instructors.

Aim: Neonatal resuscitation guidelines promote the laryngeal mask (LM) interface for positive pressure ventilation (PPV), but little is known about how the LM is used among Neonatal Resuscitation Program (NRP) Providers and Instructors. The study aim was to characterize the training, experience, confidence, and perspectives of NRP Providers and Instructors regarding LM use during neonatal resuscitation at birth. Methods: A voluntary anonymous survey was emailed to all NRP Providers and Instructors. Survey items addressed training, experience, confidence, and barriers for LM use during resuscitation. Associations between respondent characteristics and outcomes of both LM experience and confidence were assessed using logistic regression. Results: Between 11/7/22-12/12/22, there were 5,809 survey respondents: 68% were NRP Providers, 55% were nurses, and 87% worked in a hospital setting. Of these, 12% had ever placed a LM during newborn resuscitation, and 25% felt very or completely confident using a LM. In logistic regression, clinical or simulated hands-on training, NRP Instructor role, professional role, and practice setting were all associated with both LM experience and confidence.The three most frequently identified barriers to LM use were insufficient experience (46%), preference for other interfaces (25%), and failure to consider the LM during resuscitation (21%). One-third (33%) reported that LMs are not available where they resuscitate newborns. Conclusion: Few NRP providers and instructors use the LM during neonatal resuscitation. Strategies to increase LM use include hands-on clinical training, outreach promoting the advantages of the LM compared to other interfaces, and improving availability of the LM in delivery settings.

Laryngeal Mask Airway (LMA) Placement in a Neonatal Patient Simulator Using a Non-Inflatable Supraglottic Airway (SGA).

The effective delivery of positive pressure ventilation (PPV) can be challenging during neonatal resuscitation. Achieving a patent airway through an appropriate interface during neonatal resuscitation is critical for avoiding airway obstruction and leakage and optimizing access to PPV. Due to the complexity of face mask ventilation, providers have explored corrective steps. However, these methods are difficult to master and thus may present a risk for ventilation delay and/or interruptions at the critical time of resuscitation and the development of complications. In addition, neonatal endotracheal intubation is an invasive procedure that requires significant practice and training. The supraglottic airway (SGA) is a useful laryngeal mask airway (LMA) interface that decreases the time required to achieve a secure airway and reduces the need for endotracheal intubation. Despite the available evidence regarding its effectiveness, insufficient training and awareness limit SGA use in the real world, and frontline providers report low confidence in SGA placement. Here we provide a detailed description of SGA placement, the instruction of which requires only minimal training and leads to a short time to proficiency. Briefly, after the administration of initial ventilatory corrective steps in a neonatal manikin, a provider inserts a non-inflatable SGA into the larynx. This method allows for a single individual to provide effective delivery of PPV in a noninvasive manner without the need for expensive equipment such as video laryngoscopy. Instructors can easily teach this technique with ease and little cost in any clinical and research setting. This is also true for different income settings, including high-, middle-, and low-income countries.

Laryngeal Mask Use in the Neonatal Population: A Survey of Practice Providers at a Regional Tertiary Care Center in the United States.

OBJECTIVE: The aim of this study was to evaluate the level of training, awareness, experience, and confidence of neonatal practice providers in the use of laryngeal mask (LM), and to identify the barriers in its implementation in the neonatal population. STUDY DESIGN: Descriptive observational study utilizing an anonymous online questionnaire among healthcare providers at the Oklahoma Children's Hospital who routinely respond to newborn deliveries and have been trained in the Neonatal Resuscitation Program (NRP). Participants included physicians, trainees, nurse practitioners, nurses, and respiratory therapists. RESULTS: Ninety-five participants completed the survey (27.5% response rate). The sample consisted of 77 NRP providers (81%), 11 instructors (12%), and 7 instructor mentors (7%). Among 72 respondents who had undergone LM training, 51 (54%) had hands-on manikin practice, 4 (4%) watched the American Academy of Pediatrics (AAP) NRP educational video, and 17 (18%) did both. Nurses (39 out of 46) were more likely to have completed LM training than were physicians (31 out of 47). With only 11 (12%) participants having ever placed a LM in a newly born infant, the median confidence for LM placement during neonatal resuscitation was 37 on a 0 to 100 scale. Frequently reported barriers for LM use in neonates were limited experience (81%), insufficient training (59%), preference for endotracheal tube (57%), and lack of awareness (56%). CONCLUSION: While the majority of the neonatal practice providers were trained in LM placement, only a few had ever placed one in a live newborn, with a low degree of confidence overall. Future practice improvement should incorporate ongoing interdisciplinary LM education, availability of LM in the labor and delivery units, and promotion of awareness of LM as an alternative airway. KEY POINTS: · LM is underutilized as an alternative airway.. · Insufficient experience and training limit LM use.. · Providers confidence with LM placement is low..

Continuous positive airway pressure for term and ≥34+0 weeks' gestation newborns at birth: A systematic review.

Background: Respiratory distress is common during transition after birth, but the effect of continuous positive airway pressure applied in the delivery room has not been systematically evaluated in spontaneously breathing term and ≥34+0 weeks' gestation infants.We aimed to compare delivery room continuous positive airway pressure with no delivery room continuous positive airway pressure for term and ≥34+0 weeks' gestation newborn infants at birth. Methods: Information sources: Medline, Embase, Cochrane Databases, Database of Abstracts of Reviews of Effects, and Cumulative Index to Nursing and Allied Health Literature. The Databases were last searched in October 2021.Eligibility criteria: Randomized, quasi-randomized, interrupted time series, controlled before-after, and cohort studies with English abstracts.Synthesis of results: Two authors independently extracted data, assessed risk of bias, and certainty of evidence. The main outcome was admission to the neonatal intensive care unit (NICU) or higher level of care receiving any positive pressure support. Data were pooled using fixed effects models.Risk of bias: Was assessed using the Cochrane Risk of Bias Tool for randomized trials and the Non-Randomized Studies of Interventions Tool (ROBINS-I) for observational studies. Results: In this meta-analysis, two randomized control trials (323 newborns delivered by cesarean section) showed that delivery room continuous positive airway pressure decreased the likelihood of NICU admission (risk ratio (RR) 95% confidence interval (CI) 0.27 (0.11-0.66), p < 0.005) and NICU respiratory support (RR (95% CI) 0.18 (0.05-0.60), p = 0.005) when compared with no delivery room continuous positive airway pressure. However, in two before-after studies (8,476 newborns), delivery room continuous positive airway pressure use was associated with an increased risk of air leak syndrome when compared with no delivery room continuous positive airway pressure. Discussion: Certainty of evidence was very low for all outcomes. Among term and ≥34+0 weeks' gestation infants having or at risk of having respiratory distress, there is insufficient evidence to suggest for or against routine use of continuous positive airway pressure in the delivery room.Funding: No Funding has been received to conduct this study.Clinical Trial Registration: This systematic review has been registered with the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/prospero/) [identifier: CRD42021225812].

Risk calculator for advanced neonatal resuscitation.

In order to predict which newborns will require advanced resuscitation (ANR), we developed an ANR risk calculator (calculator) using a bootstrap sample size of 52 973 from a case-control study of newborns ≥34 weeks gestation. Multivariable logistic regression coefficients were obtained for the 10 original risk factors and two interaction terms. The area under the receiving-operating characteristic curve predicting ANR was 0.9243. ANR prediction is improved by accounting for perinatal variables, beyond factors known prenatally. Prospective validation of this model is warranted in a clinical setting.

Positive pressure ventilation at birth.

OBJECTIVE: To review the current state of the art of positive pressure ventilation (PPV) during resuscitation FINDINGS: The frequency of PPV during delivery room resuscitation varies across settings and gestational age subgroups. Goal targets and parameters for delivery room PPV remain undefined. The T-piece resuscitator provides the most consistent pressures during PPV and may improve clinical outcomes. The laryngeal mask may be an important alternative interface for PPV, but more data are needed to identify the optimal role of the supraglottic airway during PPV. No objective monitors of PPV have conclusively demonstrated improved outcomes to date. CONCLUSION: More information, including real-world data from population-based studies, is needed to provide data-driven guidelines for positive pressure ventilation during neonatal transition after birth.

Laryngeal Mask Ventilation during Neonatal Resuscitation: A Case Series.

Positive pressure ventilation via a facemask is a critical step in neonatal resuscitation but may be a difficult skill for frontline providers or trainees to master. A laryngeal mask is an alternative to endotracheal intubation for some newborns who require an advanced airway. We present the first case series in the United States in which a laryngeal mask was successfully utilized during resuscitation of newborns greater than or equal to 34 weeks' gestation following an interdisciplinary quality improvement collaborative and focused training program.

Effect of rotating providers on chest compression performance during simulated neonatal cardiopulmonary resuscitation.

OBJECTIVE: Simulation studies in adults and pediatrics demonstrate improvement in chest compression (CCs) quality as providers rotate every two minutes. There is paucity of studies in neonates on this matter. This study hypothesized that frequent rotation while performing CCs improves provider performance and decreases fatigue. STUDY DESIGN: Prospective randomized, observational crossover study where 51 providers performed 3:1 compression-ventilation CPR as a pair on a term manikin. Participants performed CCs as part of 3 simulation models, rotating every 3, 5 and 10 minutes. Data on various CC metrics were collected. Participant vitals were recorded at multiple points during the simulation and participants reported their level of fatigue at completion of simulation. RESULTS: No statistically significant difference was seen in any of the compression metrics. However, differences in the providers' fatigue scores were statistically significant. CONCLUSION: CC performance metrics did not differ significantly, however, providers' vital signs and self-reported fatigue scores significantly increased with longer CC durations.

A Male Case of Kagami-Ogata Syndrome Caused by Paternal Unipaternal Disomy 14 as a Result of a Robertsonian Translocation.

Kagami-Ogata syndrome (KOS) is a rare imprinting disorder characterized by skeletal abnormalities, dysmorphic facial features, growth retardation and developmental delay. The genetic etiology of KOS includes paternal uniparental disomy 14 [upd(14)pat], epimutations and microdeletions affecting the maternally derived imprinted region of chromosome 14q32.2. More than seventy KOS cases have been reported thus far; however, only 10, including two familial, are associated with upd(14)pat harboring Robertsonian translocation (ROB). Here, we reported a male infant with clinical manifestations of facial dysmorphism, bell-shaped small thorax, and omphalocele. Karyotype analyses identify a balanced ROB involving the long arms of chromosomes 13 and 14 both in the patient and his father. We further confirm the pattern of upd(14)pat utilizing DNA polymorphic markers. In conclusion, our case report provides a new male KOS case caused by upd(14)pat with paternally inherited Robertsonian translocation, which represents the second male case officially reported. Notably, a KOS case due to upd(14)pat and ROB is rare. An accurate diagnosis requires not only the identification of the characteristic clinical features but also systemic cytogenetic and molecular studies.

Impact of electronic cardiac (ECG) monitoring on delivery room resuscitation and neonatal outcomes.

AIM: In 2016, the neonatal resuscitation guidelines suggested electronic cardiac (ECG) monitoring to assess heart rate for an infant receiving positive pressure ventilation immediately after birth. Our aim was to study the impact of ECG monitoring on delivery room resuscitation interventions and neonatal outcomes. METHODS: Observational cohort study compared maternal, perinatal and infant characteristics, before (retrospective cohort, calendar year 2015) and after (prospective cohort, calendar year 2017) implementation of ECG monitoring in the delivery room. Association of ECG monitoring with delivery room resuscitation practice interventions and neonatal outcomes was assessed using unadjusted and adjusted multivariable regression analyses. RESULTS: Of 632 newly born infants who received positive pressure ventilation in the delivery room, ECG monitoring was performed in 369 (the prospective cohort) compared with no ECG monitoring in 263 (the retrospective cohort). Compared to neonates in the retrospective cohort, neonates with ECG monitoring had a significantly lower endotracheal intubation rate (36% vs 48%, P < .005) in the delivery room and higher 5-min Apgar scores (7 [5-8] vs 6 [5-8], P < .05). There was no difference in mortality (31 [8%] vs 23 [9%]), but infants who received ECG monitoring had increased odds of receiving chest compressions with an adjusted odds ratio of 3.6 (95% confidence interval: 1.4-9.5). CONCLUSION: Introduction of ECG monitoring in the delivery room was associated with fewer endotracheal intubations, and an increase use of chest compressions with no difference in mortality.

Recent Recommendations and Emerging Science in Neonatal Resuscitation.

The Neonatal Resuscitation Program, initially an expertise- and consensus-based approach, has evolved into an evidence-based algorithm. Ventilation remains the key component of successful resuscitation of neonates. Recent changes in recommendations include management of cord clamping, multiple methods to prevent hypothermia, rescinding of mandatory intubation and suction of the nonvigorous meconium-stained infant, electrocardiographic monitoring, and establishing an airway for ventilation before initiation of chest compressions. Emerging science, including issues such as cord milking, oxygen targeting, and laryngeal mask use, may lead to future program modifications. Technology such as video laryngoscopy and telemedicine will affect the way training and care is delivered.

Vitamin D and associated perinatal-neonatal outcomes among extremely low-birth-weight infants.

OBJECTIVE: To evaluate vitamin D inadequacy among extremely low-birth-weight (ELBW, <1000 g) infants and the association between circulating vitamin D concentrations and perinatal-neonatal outcomes. STUDY DESIGN: Prospective cohort study of ELBW infants in the neonatal ICU. Blood was collected within the first 3 days after birth after obtaining informed consent. Circulating 25-hydroxyvitamin D concentrations (25(OH)D) were quantified using liquid chromatography-tandem mass spectroscopy and classified as vitamin D deficient, insufficient, or adequate ( < 20, 20-30, or > 30 ng/mL, respectively). Associations between 25(OH)D and perinatal-neonatal outcomes were determined by multivariable regression, adjusted for covariates that differ in the bivariate analysis. RESULTS: Of the 60 ELBW infants enrolled, 13 (22%) were vitamin D deficient, 15 (25%) were insufficient, and 32 (53%) were adequate. 25(OH)D levels were positively associated with fetal growth restriction and prolonged rupture of the membranes. CONCLUSIONS: Vitamin D inadequacy was frequent among ELBW infants. Circulating vitamin D concentrations were significantly associated with perinatal outcomes in this contemporary cohort.

Fatigue during Chest Compression Using a Neonatal Patient Simulator.

OBJECTIVE: The objective of this study was to evaluate chest compression (CC) quality and operator fatigue during CC, with coordinated ventilation, on a neonatal simulator and to explore its association with provider aerobic activity and body mass index. METHODS: This was a prospective observational experimental study on pediatricians, neonatologists, and neonatal nurses who frequently deliver newborns and who have signed the informed consent. Subjects performed CC coordinated with ventilations at a ratio of 3:1 for 10 minutes on a neonatal mannequin. Proxy of fatigue was defined as four consecutive CC below target. RESULTS: Forty subjects participated; 62% were women. Twenty one (52%) evidenced weariness, as they performed. No gender-based differences were found in weariness. No subject abandoned the procedure due to fatigue. Subjects who participated in aerobic exercise had a significantly better performance than those who did not participate. Early fatigue was significantly associated with higher BMI. The reduction in effectiveness occurred at a mean time of 7.7 minutes (range 3.5-9 minutes). CONCLUSION: CC performance quality decreased and fatigue was frequent before 10 minutes had elapsed on a neonatal simulator. Provider fatigue was associated with both lack of aerobic activity and BMI ≥ 25. Our findings support the need for guidelines requiring frequent rotation of CC providers during prolonged neonatal resuscitation.

Blood Level of Inter-Alpha Inhibitor Proteins Distinguishes Necrotizing Enterocolitis From Spontaneous Intestinal Perforation.

OBJECTIVE: To examine circulating levels of inter-alpha inhibitor protein (IaIp) in infants with necrotizing enterocolitis (NEC), spontaneous intestinal perforation (SIP), and matched controls to assess the diagnostic accuracy of IaIp to differentiate NEC from SIP and to compare receiver operating characteristics of IaIp for NEC with C-reactive protein (CRP). STUDY DESIGN: A prospective, nested case-control study of infants with feeding intolerance was carried out. Blood and clinical data were collected from 27 infants diagnosed with NEC or SIP and from 26 matched controls admitted to our unit. Infants with modified Bell criteria stage 2 or greater were included as NEC. Clinical, radiologic, and/or surgical findings were used to identify infants with SIP. Controls were matched for gestational age, postnatal age, sex, and birth weight. RESULTS: Mean ± SD IaIp blood levels were 147 ± 38 mg/L, 276 ± 67 mg/L, and 330 ± 100 mg/L in infants with NEC, SIP, and matched controls, respectively (P < .004 and P < .01). Receiver operating characteristics analysis to establish the predictive value of NEC demonstrated areas under curve of 0.98 and 0.63 for IaIp and CRP, respectively. CONCLUSIONS: IaIp levels were significantly decreased in infants with NEC compared with SIP and matched controls. The diagnostic accuracy of IaIp for NEC was superior to that of CRP.

A case of galactosialidosis with novel mutations of the protective protein/cathepsin a gene: diagnosis prompted by trophoblast vacuolization on placental examination.

Galactosialidosis (GS) is a rare autosomal recessive lysosomal storage disease caused by a combined deficiency of lysosomal ß-galactosidase and neuraminidase as a result of a genetic defect in the protective protein/cathepsin A gene. We report a case of unsuspected fetal galactosialidosis presenting as severe intrauterine growth restriction and oligohydramnios prenatally and as hyperinsulinemic hypoglycemia in the immediate postnatal period. Placental pathology examination showed striking vacuolations of the villous syncytiotrophoblast, extravillous trophoblast, and villous Hofbauer cells. Electron microscopy revealed numerous membrane-bound electron-lucent lysosomes, mainly within the syncytiotrophoblast. The characteristic histologic and ultrastructural placental findings prompted biochemical and molecular genetic testing for fetal storage disease. Enzyme activity of ß-galactosidase was decreased in leukocytes and fibroblasts. Sialic acid content was elevated. Molecular genetic studies revealed 3 variants--c.108, 110delGCT(L37del), c.1045T>A (C349S), and c.1321C>T(R441C)--of the cathepsin A gene, the latter 2 of which have not been previously reported. These findings are consistent with galactosialidosis. We emphasize the importance of following the accepted practice guideline for the examination of the placenta in discovering unsuspected fetal metabolic disorders.

Neonatal sepsis: an old problem with new insights.

Neonatal sepsis continues to be a common and significant health care burden, especially in very-low-birth-weight infants (VLBW<1500 g). Though intrapartum antibiotic prophylaxis has decreased the incidence of early-onset group B streptococcal infection dramatically, it still remains a major cause of neonatal sepsis. Moreover, some studies among VLBW preterm infants have shown an increase in early-onset sepsis caused by Escherichia coli. As the signs and symptoms of neonatal sepsis are nonspecific, early diagnosis and prompt treatment remains a challenge. There have been a myriad of studies on various diagnostic markers like hematological indices, acute phase reactants, C-reactive protein, procalcitonin, cytokines, and cell surface markers among others. Nonetheless, further research is needed to identify a biomarker with high diagnostic accuracy and validity. Some of the newer markers like inter α inhibitor proteins have shown promising results thereby potentially aiding in early detection of neonates with sepsis. In order to decrease the widespread, prolonged use of unnecessary antibiotics and improve the outcome of the infants with sepsis, reliable identification of sepsis at an earlier stage is paramount.