Impact of cord clamping on haemodynamic transition in term newborn infants.

OBJECTIVE: To assess the haemodynamic consequences of cord clamping (CC) in healthy term infants. DESIGN: Cohort study. SETTING: Tertiary maternity hospital. PATIENTS: 46 full-term vigorous infants born by caesarean section. INTERVENTIONS: Echocardiography was performed before CC, immediately after CC and at 5 min after birth. MAIN OUTCOME MEASURES: Pulsed wave Doppler-derived cardiac output and the pulmonary artery acceleration time indexed to the right ventricle ejection time were obtained. As markers of loading fluctuations, the myocardial performance indexes and the velocities of the tricuspid and mitral valve annuli were determined with tissue Doppler imaging. Heart rate was derived from Doppler imaging throughout the assessments. RESULTS: Left ventricular output increased throughout the first minutes after birth (mean (SD) 222.4 (32.5) mL/kg/min before CC vs 239.7 (33.6) mL/kg/min at 5 min, p=0.01), while right ventricular output decreased (306.5 (48.2) mL/kg/min before vs 272.8 (55.5) mL/kg/min immediately after CC, p=0.001). The loading conditions of both ventricles were transiently impaired by CC, recovering at 5 min. Heart rate progressively decreased after birth, following a linear trend temporarily increased by CC. The variation in left ventricular output across the CC was directly correlated to the fluctuation of left ventricular preload over the same period (p=0.03). CONCLUSIONS: This study illustrates the cardiovascular consequences of CC in term vigorous infants and offers insight into the haemodynamic transition from fetal to neonatal circulation in spontaneously breathing newborns. Strategies that aim to enhance left ventricular preload before CC may prevent complications of perinatal cardiovascular imbalance.

Survival in a young child with out-of-hospital cardiac arrest: diagnostic dilemma and when to deviate from standard resuscitation guidelines.

A boy in early childhood presented in cardiac arrest. Care was provided out of hospital and in the emergency department as per standard paediatric resuscitation guidelines. Despite initial return of spontaneous circulation following cardiopulmonary resuscitation, two defibrillation shocks and epinephrine via intraosseous access, he had recurrent episodes of pulseless ventricular tachycardia and ventricular fibrillation. In total, 40 defibrillation shocks were administered, and he subsequently stabilised on combined treatment with intravenous esmolol, amiodarone and milrinone. He was transferred to the paediatric intensive care unit and had an automated implantable cardioverter-defibrillator inserted prior to discharge. Genetic testing has confirmed a diagnosis of catecholaminergic polymorphic ventricular tachycardia and it is hypothesised that the childhood excitement at a popular time of year, combined with caffeinated drinks, instigated his initial cardiac arrest which was propagated with iatrogenic epinephrine. He has remained stable since, with no neurological sequelae thus far from a significantly prolonged downtime.

Non-invasive continuous cardiac output monitoring in infants with hypoxic ischaemic encephalopathy.

OBJECTIVE: To describe early, continuous, non-invasive measures of cardiac output (CO) and evolution over time in infants with hypoxic-ischaemic encephalopathy (HIE). STUDY DESIGN: Prospective observational study of 44 infants with HIE (23 mild, 17 moderate, 4 severe) and 17 term controls. Infants with HIE had non-invasive CO monitoring (NICOM) continuously in the neonatal unit. Term controls had NICOM recorded at 6 and 24 h. A mixed-modelling approach was used to assess change in CO over time by group. RESULTS: Infants with moderate HIE have significantly lower CO than the mild group at all timepoints (10.7 mls/kg/min lower, 95% CI:1.0,20.4, p = 0.03) which increases over time, driven by a gradual increase in stroke volume (SV). CO increased further during rewarming predominantly due to an increase in HR. CONCLUSION: TH has a significant impact on HR but SV appears largely unaffected. NICOM may provide a non-invasive, continuous, low-cost alternative to monitoring CO in infants with HIE however further research is warranted.

Effect of Maternal Prepregnancy/Early-Pregnancy Body Mass Index and Pregnancy Smoking and Alcohol on Congenital Heart Diseases: A Parental Negative Control Study.

Background Congenital heart diseases (CHDs) are the most common congenital anomaly. The causes of CHDs are largely unknown. Higher prenatal body mass index (BMI), smoking, and alcohol consumption are associated with increased risk of CHDs. Whether these are causal is unclear. Methods and Results Seven European birth cohorts, including 232 390 offspring (2469 CHD cases [1.1%]), were included. We applied negative exposure paternal control analyses to explore the intrauterine effects of maternal BMI, smoking, and alcohol consumption during pregnancy, on offspring CHDs and CHD severity. We used logistic regression, adjusting for confounders and the other parent's exposure and combined estimates using a fixed-effects meta-analysis. In adjusted analyses, maternal overweight (odds ratio [OR], 1.15 [95% CI, 1.01-1.31]) and obesity (OR, 1.12 [95% CI, 0.93-1.36]), compared with normal weight, were associated with higher odds of CHD, but there was no clear evidence of a linear increase in odds across the whole BMI distribution. Associations of paternal overweight, obesity, and mean BMI were similar to the maternal associations. Maternal pregnancy smoking was associated with higher odds of CHD (OR, 1.11 [95% CI, 0.97-1.25]) but paternal smoking was not (OR, 0.96 [95% CI, 0.85-1.07]). The positive association with maternal smoking appeared to be driven by nonsevere CHD cases (OR, 1.22 [95% CI, 1.04-1.44]). Associations with maternal moderate/heavy pregnancy alcohol consumption were imprecisely estimated (OR, 1.16 [95% CI, 0.52-2.58]) and similar to those for paternal consumption. Conclusions We found evidence of an intrauterine effect for maternal smoking on offspring CHDs, but no evidence for higher maternal BMI or alcohol consumption. Our findings provide further support for the importance of smoking cessation during pregnancy.

The effect of maternal pre-/early-pregnancy BMI and pregnancy smoking and alcohol on congenital heart diseases: a parental negative control study.

BACKGROUND: Congenital heart diseases (CHDs) are the most common congenital anomaly. The causes of CHDs are largely unknown. Higher prenatal body mass index (BMI), smoking and alcohol consumption are associated with increased risk of CHDs. Whether these are causal is unclear. METHODS AND RESULTS: Seven European birth cohorts including 232,390 offspring (2,469 CHD cases [1.1%]) were included. We applied negative exposure paternal control analyses to explore the intrauterine effects of maternal BMI, smoking and alcohol consumption during pregnancy, on offspring CHDs and CHD severity. We used logistic regression and combined estimates using a fixed-effects meta-analysis. Analyses of BMI categories resulted in similar increased odds of CHD in overweight (mothers OR: 1.15 (1.01, 1.31) and fathers 1.10 (0.96, 1.27)) and obesity (mothers OR: 1.12 (0.93, 1.36) and fathers 1.16 (0.90, 1.50)). The association of mean BMI with CHD was null. Maternal smoking was associated with increased odds of CHD (OR: 1.11 (0.97, 1.25)) but paternal smoking was not (OR: 0.96 (0.85, 1.07)). The difference increased when removing offspring with genetic/chromosomal defects (mothers OR: 1.15 (1.01, 1.32) and fathers 0.93 (0.83, 1.05)). The positive association with maternal pregnancy smoking appeared to be driven by non-severe CHD cases (OR: 1.22 (1.04, 1.44)). Associations with maternal (OR: 1.16 (0.52, 2.58)) and paternal (OR: 1.23 (0.74, 2.06)) moderate/heavy pregnancy alcohol consumption were similar. CONCLUSIONS: We found evidence of an intrauterine effect for maternal smoking on offspring CHDs, but no evidence for higher maternal BMI or alcohol consumption. Our findings provide further support for why smoking cessation is important during pregnancy.

No effect of a musical intervention on stress response to venepuncture in a neonatal population.

AIM: To investigate the effect of a musical intervention on neonatal stress response to venepuncture as measured by salivary cortisol levels and pain profile scores. METHODS: In a randomised control crossover trial, participants were randomised to both a control arm (sucrose) and intervention arm (sucrose and music) for routine venepuncture procedures. Salivary swabs were collected at baseline, 20 minutes post-venepuncture and 4 hours post-venepuncture. Pain levels were assessed using the Premature Infant Pain Profile (PIPP). A total of 16 preterm neonates participated in both arms to complete the study. RESULTS: Cortisol values were elevated at all timepoints in the intervention arm (baseline, 20 minutes, and 4 hours post-procedure) but not significantly so (P = .056, P = .3, and P = .575, respectively). Median change in cortisol values from baseline was +128.48 pg/mL (-47.66 to 517.02) at 20 minutes and +393.52 pg/mL (47.88-1221.34) at 4 hours post-procedure in the control arm compared to -69.564 pg/mL (-860.96 to 397.289) and +100.48 pg/mL (-560.46 to 842.99) at 20 minutes and 4 hours post-procedure in the intervention arm. There was no statistically significant difference observed between groups (P = .311 at 20 minutes, and P = .203 at 4 hours post-procedure). PIPP scores were not significantly different between study arms. CONCLUSION: Our findings did not support the additional benefit of music intervention on neonatal stress response to venepuncture in preterm infants.

Clamping the Umbilical Cord in Premature Deliveries (CUPiD): Neuromonitoring in the Immediate Newborn Period in a Randomized, Controlled Trial of Preterm Infants Born at <32 Weeks of Gestation.

OBJECTIVE: To compare cerebral activity and oxygenation in preterm infants (<32 weeks of gestation) randomized to different cord clamping strategies. STUDY DESIGN: Preterm infants born at <32 weeks of gestation were randomized to immediate cord clamping, umbilical cord milking (cord stripped 3 times), or delayed cord clamping for 60 seconds with bedside resuscitation. All infants underwent electroencephalogram (EEG) and cerebral near infrared spectroscopy for the first 72 hours after birth. Neonatal primary outcome measures were quantitative measures of the EEG (17 features) and near infrared spectroscopy over 1-hour time frames at 6 and 12 hours of life. RESULTS: Forty-five infants were recruited during the study period. Twelve infants (27%) were randomized to immediate cord clamping, 19 (42%) to umbilical cord milking, and 14 (31%) to delayed cord clamping with bedside resuscitation. There were no significant differences between groups for measures of EEG activity or cerebral near infrared spectroscopy. Three of the 45 infants (6.7%) were diagnosed with severe IVH (2 in the immediate cord clamping group, 1 in the umbilical cord milking group; P = .35). CONCLUSIONS: There were no differences in cerebral EEG activity and cerebral oxygenation values between cord management strategies at 6 and 12 hours. TRIAL REGISTRATION: ISRCTN92719670.

Transition from tube feeding to oral feeding: experience in a tertiary care paediatric cardiology unit.

BACKGROUND: Home enteral tube feeding (HETF) is imperative for many infants and children with congenital heart disease (CHD). Tube weaning (TW) facilitates the progression from tube feeding to oral diet. There is limited literature on TW practices, protocols and success for children with CHD that have been tube fed. AIMS: The objective of this study is to assess the process of weaning HETF in a tertiary referral centre for paediatric CHD. Specifically, we aimed to assess the duration of HETF, duration of TW and the interventions involved. METHODS: We retrospectively reviewed the medical and dietetic records of all infants and children that were successfully weaned off HETF over a 12-month period from January 2015 to December 2015. RESULTS: There were 30 children included in the study, 9 boys and 21 girls. The diagnoses included 15 septal defects, 8 univentricular diagnosis and other diagnoses in 7 children. The median age at initiation of enteral tube feeding was 45 days (range 2-169). The median duration to wean from enteral tube feeding was 52 days (range 2-359). Number of dietetic consults required for successful TW varied among patients, median 5 (range 2-23). The number of days required for successful TW was associated with age and duration on HETF. Dietetic interventions included discontinuation of nutrient dense feeds, altering feed schedule and reduction of feed volume. CONCLUSIONS: Weaning HETF is possible in the outpatient setting. Early and frequent dietetic intervention is recommended to ensure prompt discontinuation of HETF when appropriate.

Correction to: Transition from tube feeding to oral feeding: experience in a tertiary care paediatric cardiology unit.

The original version of this article inadvertently used early drafts of Figs. 1 and 2. The correct figures are shown here. The original article has been corrected.

EEG for the assessment of neurological function in newborn infants immediately after birth.

OBJECTIVE: To assess the neurological function of newborn infants in the first minutes after birth using EEG. DESIGN AND PATIENTS: We obtained electroencephalography (EEG) recordings in term infants following elective caesarean section. After delivery, disposable EEG electrodes were attached to the infants' scalp over the frontal and central regions bilaterally and EEG was recorded for 10 min. Both visual and quantitative measures were used to analyse the EEGs. SETTING: The operative delivery theatre of Cork University Maternity Hospital, Ireland. RESULTS: Forty-nine infants had EEG recordings over the frontal and central regions. The median (IQR) age at time of initial EEG recording was 3.0 (2.5-3.8) min. While movement artefact contaminated parts of many recordings, good-quality EEG, with mixed-frequency activity with a range of 25-50 µV, was observed in all infants. The majority of EEG spectral power was within the delta band: the median (IQR) relative delta power was 87.8% (83.7%-90%). Almost all (95%) spectral power was below a median (IQR) of 7.56 Hz (6.17-9.76 Hz). CONCLUSIONS: EEG recording is very feasible in the immediate newborn period. This study provides valuable objective information about neurological function during this transitional period.

Skin Punctures in Preterm Infants in the First 2 Weeks of Life.

OBJECTIVE: The objective of this study was to investigate frequency and trends of skin punctures in preterm infants. STUDY DESIGN: A prospective audit of preterm infants less than 35 weeks admitted over a 6-month period to a tertiary neonatal intensive care unit. Each skin puncture performed in the first 2 weeks of life was documented in a specifically designed audit sheet. RESULTS: Ninety-nine preterm infants were enrolled. Infants born at < 32 weeks' gestation had significantly more skin punctures than infants > 32 weeks (median skin punctures 26.5 vs. 17, p-value < 0.05). The highest frequency of skin punctures occurred during the first week of life for infants > 28 weeks' gestation (medians 17.5 in 28-31 + 6 weeks' gestation, and 15 in > 32 weeks), and during the second week of life for those born at < 28 weeks (median 17.5). Infants with sepsis had more skin punctures (p-value < 0.001), but this was not significant on multivariate analysis. Median skin punctures in the second week of life were statistically higher in the sepsis group on multivariate analysis (odds ratio: 1.07, 95% confidence interval: 1.00-1.14, p = 0.041). CONCLUSION: Frequency of skin punctures is influenced by gestational age and postnatal age. Skin punctures were not an independent risk factor for sepsis.

Respiratory adaptation in term infants following elective caesarean section.

OBJECTIVE: To determine respiratory rate (RR), tidal volume (TV) and end-tidal carbon dioxide (EtCO2) values in full-term infants immediately after caesarean section, and to assess whether infants that develop transient tachypnoea of the newborn (TTN) follow the same physiological patterns. DESIGN AND PATIENTS: A Respironics NM3 Monitor (Philips, Netherlands) continuously measured RR, TV and EtCO2 for 7 min in infants >37 weeks' gestation following elective caesarean section (ECS). Monitoring was repeated at 2 hours of age for 2 min. Gestation, birth weight, Apgar scores and admissions to neonatal unit were documented. SETTING: The operative delivery theatre of Cork University Maternity Hospital, Ireland. RESULTS: There were 95 term infants born by ECS included. Median (IQR) gestation was 39 weeks (38.2-39.1) and median (IQR) birth weight 3420 g (3155-3740). Median age at initiation of monitoring was 26.5 s (range: 20-39). Data were analysed for the first 7 min of life. Mean breaths per minute (bpm) increased over the first 7 min of life (44.31-61.62). TV and EtCO2 values were correlated and increased from 1 min until maximum mean values were recorded at 3 min after delivery (5.18 mL/kg-6.44 mL/kg, and 4.32 kPa-5.64 kPa, respectively). Infants admitted to the neonatal unit with TTN had significantly lower RRs from 2 min of age compared with infants not admitted for TTN. CONCLUSIONS: TV and EtCO2 values are correlated and increase significantly over the first few minutes following ECS. RR increases gradually from birth, and rates were lower in infants that develop TTN.

Myocardial Fistulisation and Coronary Arterial Ectasia in Children with Univentricular Circulation: An Under-Recognised Problem.

Among 241 children with univentricular circulation who underwent total cavopulmonary connection (Glenn or Fontan) over a 17 years period (January 2000-April 2017), we found two patients who had diffuse coronary fistulisation of their myocardium (0.8%). We also report an additional third case from Oak Lawn, Illinois, USA. One of the children had documented normal coronary arteries and myocardium at catheterisation prior to development of the fistulisation process. The same child also developed extensive veno-venous collaterals. All children had evidence of elevated pulmonary arterial pressures and were treated with a combination of pulmonary vasodilators. The presence of chronic hypoxaemia and elevated filling pressures could potentially have contributed to coronary endothelial dysfunction, thereby giving rise to the coronary vasculopathy and myocardial fistulisation. Alternatively, this myocardial fistulisation process may be present from early in life and not recognised. This may necessitate early referral for orthotopic cardiac transplantation. Diffuse fistulisation of the myocardium in children and young adults with univentricular circulation may be an under-recognised occurrence and coronary angiography should be considered in these patients.

Optimal Line and Tube Placement in Very Preterm Neonates: An Audit of Practice.

BACKGROUND: Placement of endotracheal tubes (ETTs) and umbilical catheters (UCs) is essential in very preterm infant care. The aim of this study was to assess the effect of an educational initiative to optimize correct placement of ETTs and UCs in very preterm infants. METHODS: A pre-post study design, evaluating optimal radiological position of ETTs and UCs in the first 72 h of life in infants <32 weeks gestational age (GA) was performed. Baseline data was obtained from a preceding 34-month period. The study intervention consisted of information from the pre-intervention audit, surface anatomy images of the newborn for optimal UC positioning, and weight-based calculations to estimate insertion depths for endotracheal intubation. A prospective evaluation of radiological placement of ETTs and UCs was then conducted over a 12-month period. RESULTS: During the study period, 211 infants had at least one of the three procedures performed. One hundred and fifty-seven infants were included in the pre-education group, and 54 in the post-education group. All three procedures were performed in 50.3% (79/157) in the pre-education group, and 55.6% (30/54) in the post-education group. There was no significant difference in accurate placement following the introduction of the educational sessions; depth of ETTs (50% vs. 47%), umbilical arterial catheter (UAC) (40% vs. 43%,), and umbilical venous catheter (UVC)(14% vs. 23%). CONCLUSION: Despite education of staff on methods for appropriate ETT, UVC and UAC insertion length, the rate of accurate initial insertion depth remained suboptimal. Newer methods of determining optimal position need to be evaluated.

Lost in Transition: A Systematic Review of Neonatal Electroencephalography in the Delivery Room-Are We Forgetting an Important Biomarker for Newborn Brain Health?

BACKGROUND: Electroencephalography (EEG) monitoring is routine in neonatal intensive care units (NICUs) for detection of seizures, neurological monitoring of infants following perinatal asphyxia, and increasingly, following preterm delivery. EEG monitoring is not routinely commenced in the delivery room (DR). OBJECTIVES: To determine the feasibility of recording neonatal EEG in the DR, and to assess its usefulness as a marker of neurological well-being during immediate newborn transition. METHODS: We performed a systematic stepwise search of PubMed using the following terms: infant, newborns, neonate, DR, afterbirth, transition, and EEG. Only human studies describing EEG monitoring in the first 15 min following delivery were included. Infants of all gestational ages were included. RESULTS: Two original studies were identified that described EEG monitoring of newborn infants within the DR. Both prospective observational studies used amplitude-integrated EEG (aEEG) monitoring and found it feasible in infants >34 weeks' gestation; however, technical challenges made it difficult to obtain continuous reliable data. Different EEG patterns were identified in uncompromised newborns and those requiring resuscitation. CONCLUSION: EEG monitoring is possible in the DR and may provide an objective baseline measure of neurological function. Further feasibility studies are required to overcome technical challenges in the DR, but these challenges are not insurmountable with modern technology.

Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge.

Volume resuscitation (VR) for the treatment of newborn shock is a rare but potentially lifesaving intervention. Conducting clinical studies to assess the effectiveness of VR in the delivery room during newborn stabilization is challenging. We review the available literature and current management guidelines to determine which infants will benefit from VR, the frequency of VR, and the choice of agents used. In addition, the potential role for placental transfusion in the prevention of newborn shock is explored.

A Randomized Controlled Trial of End-Tidal Carbon Dioxide Detection of Preterm Infants in the Delivery Room.

OBJECTIVE: To compare the ability of qualitative versus quantitative methods of end-tidal carbon dioxide (EtCO2) detection to maintain normocarbia during face mask ventilation (FMV) of preterm infants (<32 weeks) in the delivery room. STUDY DESIGN: Preterm infants <32 weeks were randomly assigned to the use of a disposable PediCap EtCO2 detector (Covidien, Dublin, Ireland) (qualitative) or a Microstream side stream capnography device (Covidien) (quantitative) for FMV in the delivery room, via a NeoPuff T-piece resuscitator (Fisher and Paykel, Auckland, New Zealand). The primary outcome was the presence of normocarbia, based on partial pressure of CO2 (PaCO2) readings obtained in the neonatal intensive care unit within an hour of birth. Normocarbia was defined as a PaCO2 measure between 37.5 and 60 mm Hg (5-8 kPa). RESULTS: Of the 59 infants included, 59% (35/59) were within the PaCO2 target range within an hour of birth. There was no difference in the primary outcome; 64% (21/33) of infants in the quantitative group were within the PaCO2 range compared with 54% (14/26) in the qualitative group (P = .594); and 93% of participants <28 weeks' gestation were within the PaCO2 normocarbic range (90% [9/10] in quantitative group and 100% [5/5] in the qualitative group [P = 1]). There was no difference in the intubation rate, days of ventilation, or bronchopulmonary dysplasia rates between the 2 groups. CONCLUSIONS: Quantitative or qualitative EtCO2 detection methods are both feasible for FMV in the delivery room. Although there was no difference in the incidence of normocarbia, the use of either form of EtCO2 monitoring should be considered during newborn stabilization, especially in infants less than 28 weeks' gestation. TRIAL REGISTRATION: ISRCTN: ISRCTN10934870.

Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room.

Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization.