Air or Oxygen for Infant Resuscitation: A Prospective Cohort Study of Moderate-Late Preterm Infants Requiring Delivery Room Resuscitation.

INTRODUCTION: Due to concerns of oxidative stress and injury, most clinicians currently use lower levels of fractional inspired oxygen (FiO2, 0.21-0.3) to initiate respiratory support for moderate to late preterm (MLPT, 32-36 weeks gestation) infants at birth. Whether this practice achieves recommended oxygen saturation (SpO2) targets is unknown. METHODS: We aimed to determine SpO2 trajectories of MLPT infants requiring respiratory support at birth. We conducted a prospective, opportunistic, observational study with consent waiver. Preductal SpO2 readings were obtained during the first 10 min of life from infants between 32 and 36 weeks gestation requiring respiratory support in the delivery room. Primary outcome was reaching a minimum SpO2 80% at 5 min of life. The study was prospectively registered (ACTRN12620001252909). RESULTS: A total of 76 eligible infants were recruited between February 2021 and March 2022 from 5 hospitals in Australia. Most (n = 58, 76%) had respiratory support initiated with FiO2 0.21 (range 0.21-1.0) using CPAP (92%). Median SpO2 at 5 min was 81% (interquartile range [IQR] 67-90) and 93% (IQR 86-96) at 10 min. At 5 min, 18/43 (42%) infants had SpO2 below 80% and only 8/43 (19%) reached SpO2 80-85%. CONCLUSIONS: Many MLPT infants requiring respiratory support do not achieve recommended SpO2 targets. In very preterm infants, SpO2 <80% at 5 min of life increases risk of death, intraventricular haemorrhage, and neurodevelopmental impairment. The implications on this practice on the health outcomes of MLPT infants are unclear and require further research.

Thermoregulation, incubator humidity, and skincare practices in appropriate for gestational age ultra-low birth weight infants: need for more evidence.

BACKGROUND: Although not universal, active care is being offered to infants weighing < 500 g at birth, referred to as ultra-low birth weight (ULBW) infants appropriate for gestational age. These infants have the greatest risk of dying or developing major morbidities. ULBW infants face challenges related to fluid and heat loss as well as skin injury in the initial days of life from extreme anatomical and physiological immaturity of the skin. Although there is an emerging literature on the outcomes of ULBW infants, there is a paucity of evidence to inform practice guidelines for delivering optimal care to this cohort of infants. DATA SOURCES: A comprehensive review of the literature was performed using the PubMed and Embase databases. Searched keywords included "thermoregulation or body temperature regulation", "incubator humidity", "skin care", "infant, extremely low birth weight" and "ultra-low birth weight infants". RESULTS: Evidences for thermoregulation, incubator humidity, and skincare practices are available for preterm infants weighing < 1500 g at birth but not specifically for ULBW infants. Studies on thermoregulation, incubator humidity, or skincare practices had a small sample size and did not include a sub-group analysis for ULBW infants. Current practice recommendations in ULBW infants are adopted from research in very and/or extremely low birth weight infants. CONCLUSIONS: This narrative review focuses on challenges in thermoregulation, incubator humidity, and skincare practices in ULBW infants, highlights current research gaps and suggests potential developments for informing practices for improving health outcomes in ULBW infants. Video abstract (MP4 1,49,115 kb).

Randomised study of a new inline respiratory function monitor (Juno) to improve mask seal and delivered ventilation with neonatal manikins.

BACKGROUND: Respiratory function monitors (RFMs) have been used extensively in manikin and infant studies yet have not become the standard of training. We report the outcomes of a new portable, lightweight RFM, the Juno, designed to show mask leak and deflation tidal volume to assist in positive pressure ventilation (PPV) competency training using manikins. METHODS: Two leak-free manikins (preterm and term) were used. Participants provided PPV to manikins using two randomised devices, self-inflating bag (SIB) and T-piece resuscitator (TPR), with Juno display initially blinded then unblinded in four 90 s paired sequences, aiming for adequate chest wall rise and target minimal mask leak with appropriate target delivered volume when using the monitor. RESULTS: 49 experienced neonatal staff delivered 15 569 inflations to the term manikin and 14 580 inflations to the preterm. Comparing blinded to unblinded RFM display, there were significant reductions in all groups in the number of inflations out of target range volumes (preterm: SIB 22.6-6.6%, TPR 7.1-4.2% and term: SIB 54.8-37.8%, TPR 67.2-63.8%). The percentage of mask leak inflations >60% was reduced in preterm: SIB 20.7-7.2%, TPR 23.4-7.4% and in term: SIB 8.7-3.6%, TPR 23.5-6.2%). CONCLUSIONS: Using the Juno monitor during simulated resuscitation significantly improved mask leak and delivered ventilation among otherwise experienced staff using preterm and term manikins. The Juno is a novel RFM that may assist in teaching and self-assessment of resuscitation PPV technique.

Towards Accurate Search for Neonatal Heartbeat: Weighted Algorithm for Reliable ECG Analysis of Premature Infants.

Accurate identification of the QRS complex is critical to analyse heart rate variability (HRV), which is linked to various adverse outcomes in premature infants. Reliable and accurate extraction of HRV characteristics at a large scale in the neonatal context remains a challenge. In this paper, we investigate the capabilities of 15 state-of-the-art QRS complex detection implementations using two real-world preterm neonatal datasets. As an attempt to improve the accuracy and reliability, we introduce a weighted ensemble-based method as an alternative. Obtained results indicate the superiority of the proposed method over the state of the art on both datasets with an F1-score of 0.966 (95% CI 0.962-0.97) and 0.893 (95% CI 0.892-0.894). This motivates the deployment of ensemble-based methods for any HRV-based analysis to ensure robust and accurate QRS complex detection.

Development of an Interactive Dashboard to Analyse Physiological Signals in the Neonatal Intensive Care Unit.

Premature babies and those born with a medical condition are cared for within the neonatal intensive care unit (NICU) in hospitals. Monitoring physiological signals and subsequent analysis and interpretation can reveal acute and chronic conditions for these neonates. Several advanced algorithms using physiological signals have been built into existing monitoring systems to allow clinicians to analyse signals in real time and anticipate patient deterioration. However, limited enhancements have been made to interactively visualise and adapt them to neonatal monitoring systems. To bridge this gap, we describe the development of a user-friendly and interactive dashboard for neonatal vital signs analysis written in the Python programming language where the analysis can be performed without prior computing knowledge. To ensure practicality, the dashboard was designed in consultation with a neonatologist to visualise electrocardiogram, heart rate, respiratory rate and oxygen saturation data in a time-series format. The resulting dashboard included interactive visualisations, advanced electrocardiogram analysis and statistical analysis which can be used to extract important information on patients' conditions.Clinical Relevance- This will support the care of preterm infants by allowing clinicians to visualise and interpret physiological data in greater granularity, aiding in patient monitoring and detection of adverse conditions. The detection of adverse conditions could allow timely and potentially life-saving interventions for conditions such as sepsis and brain injury.

Comparison of simultaneous auscultation and ultrasound for clinical assessment of bowel peristalsis in neonates.

Introduction: Assessment of bowel health in ill preterm infants is essential to prevent and diagnose early potentially life-threatening intestinal conditions such as necrotizing enterocolitis. Auscultation of bowel sounds helps assess peristalsis and is an essential component of this assessment. Aim: We aim to compare conventional bowel sound auscultation using acoustic recordings from an electronic stethoscope to real-time bowel motility visualized on point-of-care bowel ultrasound (US) in neonates with no known bowel disease. Methods: This is a prospective observational cohort study in neonates on full enteral feeds with no known bowel disease. A 3M™ Littmann® Model 3200 electronic stethoscope was used to obtain a continuous 60-s recording of bowel sounds at a set region over the abdomen, with a concurrent recording of US using a 12l high-frequency Linear probe. The bowel sounds heard by the first investigator using the stethoscope were contemporaneously transferred for a computerized assessment of their electronic waveforms. The second investigator, blinded to the auscultation findings, obtained bowel US images using a 12l Linear US probe. All recordings were analyzed for bowel peristalsis (duration in seconds) by each of the two methods. Results: We recruited 30 neonates (gestational age range 27-43 weeks) on full enteral feeds with no known bowel disease. The detection of bowel peristalsis (duration in seconds) by both methods (acoustic and US) was reported as a percentage of the total recording time for each participant. Comparing the time segments of bowel sound detection by digital stethoscope recording to that of the visual detection of bowel movements in US revealed a median time of peristalsis with US of 58%, compared to 88.3% with acoustic assessment (p < 0.002). The median regression difference was 26.7% [95% confidence interval (CI) 5%-48%], demonstrating no correlation between the two methods. Conclusion: Our study demonstrates disconcordance between the detection of bowel sounds by auscultation and the detection of bowel motility in real time using US in neonates on full enteral feeds and with no known bowel disease. Better innovative methods using artificial intelligence to characterize bowel sounds, integrating acoustic mapping with sonographic detection of bowel peristalsis, will allow us to develop continuous neonatal bowel sound monitoring devices.

Incomplete Exhalation during Resuscitation-Theoretical Review and Examples from Ventilation of Newborn Term Infants.

BACKGROUND: Newborn resuscitation guidelines recommend positive pressure ventilation (PPV) for newborns who do not establish effective spontaneous breathing after birth. T-piece resuscitator systems are commonly used in high-resource settings and can additionally provide positive end-expiratory pressure (PEEP). Short expiratory time, high resistance, rapid dynamic changes in lung compliance and large tidal volumes increase the possibility of incomplete exhalation. Previous publications indicate that this may occur during newborn resuscitation. Our aim was to study examples of incomplete exhalations in term newborn resuscitation and discuss these against the theoretical background. METHODS: Examples of flow and pressure data from respiratory function monitors (RFM) were selected from 129 term newborns who received PPV using a T-piece resuscitator. RFM data were not presented to the user during resuscitation. RESULTS: Examples of incomplete exhalation with higher-than-set PEEP-levels were present in the recordings with visual correlation to factors affecting time needed to complete exhalation. CONCLUSIONS: Incomplete exhalation and the relationship to expiratory time constants have been well described theoretically. We documented examples of incomplete exhalations with increased PEEP-levels during resuscitation of term newborns. We conclude that RFM data from resuscitations can be reviewed for this purpose and that incomplete exhalations should be further explored, as the clinical benefit or risk of harm are not known.

Neonatologist-performed point-of-care abdominal ultrasound: What have we learned so far?

This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound.

A Narrative Review of the Rationale for Conducting Neonatal Emergency Studies with a Waived or Deferred Consent Approach.

Emergency research studies are high-stakes studies that are usually performed on the sickest patients, where many patients or guardians have no opportunity to provide full informed consent prior to participation. Many emergency studies self-select healthier patients who can be informed ahead of time about the study process. Unfortunately, results from such participants may not be informative for the future care of sicker patients. This inevitably creates waste and perpetuates uninformed care and continued harm to future patients. The waiver or deferred consent process is an alternative model that may be used to enroll sick patients who are unable to give prospective consent to participate in a study. However, this process generates vastly different stakeholder views which have the potential to create irreversible impediments to research and knowledge. In studies involving newborn infants, consent must be sought from a parent or guardian, and this adds another layer of complexity to already fraught situations if the infant is very sick. In this manuscript, we discuss reasons why consent waiver or deferred consent processes are vital for some types of neonatal research, especially those occurring at and around the time of birth. We provide a framework for conducting neonatal emergency research under consent waiver that will ensure the patient's best interests without compromising ethical, beneficial, and informative knowledge acquisition to improve the future care of sick newborn infants.

One-person versus two-person mask ventilation in preterm infants at birth: a pilot randomised controlled trial.

BACKGROUND: Mask leak and airway obstruction are common with mask ventilation in newborn infants, leading to suboptimal ventilation. We aimed to perform a pilot study measuring respiratory mechanics during one-person and two-person mask ventilation in preterm infants at birth. METHODS: Infants less than 30 weeks' gestation were eligible for the study. In the two-person method, one person holds the mask in place and the other provides positive pressure ventilation compared with the standard one-person mask hold. A respiratory function monitor was used in line with a T-piece resuscitator to measure mask leak and airway obstruction. Deferred consent was obtained. RESULTS: Twenty-five infants were recruited. The mean (SD) birth weight was 920.4 g (188.3), and mean (SD) gestational age was 27.3 weeks (3.0). Percentage mask leak was higher in the one-person mask method (26.4±18.5) compared with the two-person mask method (17.6±9.3) (p=0.018). The mean (SD) expired tidal volume (VTe, mL) in breaths with leak was 3.9 (1.57) in the one-person method compared with 3.05 (1.0) the two-person method (p=0.31). A significantly lower mean (SD) end-tidal carbon dioxide (EtCO2, mm Hg) was measured at 25.3 (9.9) in breaths with mask leak, compared with 30.8 (12.1) in breaths without leak. The breaths with airway obstruction had lower mean EtCO2 (25.9 vs 30.8, p=0.003) and lower mean VTe (1.71 vs 6.95, p<0.001). CONCLUSION: Mask leak and airway obstruction are common in resuscitation of preterm infants at birth. The use of the two-person mask technique is effective and it could be a useful option if mask ventilation with the one-person method is not effective. TRIAL REGISTRATION NUMBER: ACTRN12614000245695.

High continuous positive airway pressures versus non-invasive positive pressure ventilation in preterm neonates: protocol for a multicentre pilot randomised controlled trial.

INTRODUCTION: Low pressure nasal continuous positive airway pressure (nCPAP) has long been the mainstay of non-invasive respiratory support for preterm neonates, at a constant distending pressure of 5-8 cmH2O. When traditional nCPAP pressures are insufficient, other modes including nasal intermittent positive pressure ventilation (NIPPV) are used. In recent years, high nCPAP pressures (≥9 cmH2O) have also emerged as an alternative. However, the comparative benefits and risks of these modalities remain unknown. METHODS AND ANALYSIS: In this multicentre pilot randomised controlled trial, infants <29 weeks' gestational age (GA) who either: (A) fail treatment with traditional nCPAP or (B) being extubated from invasive mechanical ventilation with mean airway pressure ≥10 cmH2O, will be randomised to receive either high nCPAP (positive end-expiratory pressure 9-15 cmH2O) or NIPPV (target mean Paw 9-15 cmH2O). Primary outcome is feasibility of the conduct of a larger, definitive trial as assessed by rates of recruitment and protocol violations. The main secondary outcome is failure of assigned treatment within 7 days postrandomisation. Multiple other clinical outcomes including bronchopulmonary dysplasia will be ascertained. All randomised participants will be analysed using intention to treat. Baseline and demographic variables as well as outcomes will be summarised and compared using univariate analyses, and a p<0.05 will be considered significant. ETHICS AND DISSEMINATION: The trial has been approved by the respective research ethics boards at each institution (McMaster Children's Hospital: Hamilton integrated REB approval #2113; Royal Alexandra Hospital: Health Research Ethics Board approval ID Pro00090244; Westmead Hospital: Human Research Ethics Committee approval ID 2022/ETH01343). Written, informed consent will be obtained from all parents/guardians prior to study enrolment. The findings of this pilot study will be disseminated via presentations at national and international conferences and via publication in a peer-reviewed journal. Social media platforms including Twitter will also be used to generate awareness. TRIAL REGISTRATION NUMBER: NCT03512158.

Developing and evaluating Birthing on Country services for First Nations Australians: the Building On Our Strengths (BOOSt) prospective mixed methods birth cohort study protocol.

BACKGROUND: With the impact of over two centuries of colonisation in Australia, First Nations families experience a disproportionate burden of adverse pregnancy and birthing outcomes. First Nations mothers are 3-5 times more likely than other mothers to experience maternal mortality; babies are 2-3 times more likely to be born preterm, low birth weight or not to survive their first year. 'Birthing on Country' incorporates a multiplicity of interpretations but conveys a resumption of maternity services in First Nations Communities with Community governance for the best start to life. Redesigned services offer women and families integrated, holistic care, including carer continuity from primary through tertiary services; services coordination and quality care including safe and supportive spaces. The overall aim of Building On Our Strengths (BOOSt) is to facilitate and assess Birthing on Country expansion into two settings - urban and rural; with scale-up to include First Nations-operated birth centres. This study will build on our team's earlier work - a Birthing on Country service established and evaluated in an urban setting, that reported significant perinatal (and organisational) benefits, including a 37% reduction in preterm births, among other improvements. METHODS: Using community-based, participatory action research, we will collaborate to develop, implement and evaluate new Birthing on Country care models. We will conduct a mixed-methods, prospective birth cohort study in two settings, comparing outcomes for women having First Nations babies with historical controls. Our analysis of feasibility, acceptability, clinical and cultural safety, effectiveness and cost, will use data including (i) women's experiences collected through longitudinal surveys (three timepoints) and yarning interviews; (ii) clinical records; (iii) staff and stakeholder views and experiences; (iv) field notes and meeting minutes; and (v) costs data. The study includes a process, impact and outcome evaluation of this complex health services innovation. DISCUSSION: Birthing on Country applies First Nations governance and cultural safety strategies to support optimum maternal, infant, and family health and wellbeing. Women's experiences, perinatal outcomes, costs and other operational implications will be reported for Communities, service providers, policy advisors, and for future scale-up. TRIAL REGISTRATION: Australia & New Zealand Clinical Trial Registry # ACTRN12620000874910 (2 September 2020).

Ensemble Approach on Deep and Handcrafted Features for Neonatal Bowel Sound Detection.

For the care of neonatal infants, abdominal auscultation is considered a safe, convenient, and inexpensive method to monitor bowel conditions. With the help of early automated detection of bowel dysfunction, neonatologists could create a diagnosis plan for early intervention. In this article, a novel technique is proposed for automated peristalsis sound detection from neonatal abdominal sound recordings and compared to various other machine learning approaches. It adopts an ensemble approach that utilises handcrafted as well as one and two dimensional deep features obtained from Mel Frequency Cepstral Coefficients (MFCCs). The results are then refined with the help of a hierarchical Hidden Semi-Markov Models (HSMM) strategy. We evaluate our method on abdominal sounds collected from 49 newborn infants admitted to our tertiary Neonatal Intensive Care Unit (NICU). The results of leave-one-patient-out cross validation show that our method provides an accuracy of 95.1% and an Area Under Curve (AUC) of 85.6%, outperforming both the baselines and the recent works significantly. These encouraging results show that our proposed Ensemble-based Deep Learning model is helpful for neonatologists to facilitate tele-health applications.

Quantitative end-tidal carbon dioxide at initiation of resuscitation may help guide the ventilation of infants born at less than 30 weeks gestation.

AIM: Estimation of end-tidal carbon dioxide (EtCO2 ) with capnography can guide mask ventilation in infants born at less than 30 weeks of gestation. Chemical-sensitive colorimetric devices to detect CO2 are widely used at resuscitation. We aimed to quantify EtCO2 in the first breaths following initiation of mask ventilation at birth and correlated need for endotracheal intubation. METHODS: Infants <30 weeks gestation receiving mask ventilation were randomised into two groups of mask-hold technique (one-person vs. two-person). Data on EtCO2 in the first 30 breaths, time to achieve 5 mmHg, 10 mmHg and 15 mmHg CO2 using a respiratory function monitor was determined. RESULTS: Twenty-five infants with a mean gestation of 27.3 (±3 weeks) and mean birth weight 920.4 (±188.3 g) were analysed. The median EtCO2 was 5.6 mmHg in the first 10 breaths, whereas it was 12.6 mmHg for 11-20 breaths and 18 mmHg for 21-30 breaths. There was no significant difference in maximum median EtCO2 for the first 20 breaths, although EtCO2 was significantly lower in infants who were intubated (32.0 vs. 15.0, p = 0.018). CONCLUSION: EtCO2 monitoring in infants <30 weeks gestation at birth is feasible and reflective of alveolar ventilation. EtCO2 may help guide ventilation of preterm infants at birth.

Positive end expiratory pressure and respiratory system resistance between self-inflating bag and T-piece resuscitator in a cadaveric piglet lung model.

Introduction: In neonatal resuscitation, T-piece resuscitator (TPR) are used widely, but the evidence is limited for their use in infants born at term gestation. The aim of this study was to compare the delivered positive end expiratory pressure (PEEP) and respiratory system resistance (Rrs) using TPR and self-inflating bag (SIB) in a cadaveric piglet model. Methods: Cadaveric newborn piglets were tracheotomised, intubated (cuffed tube) and leak tested. Static lung compliance was measured. Positive pressure ventilation was applied by TPR and SIB in a randomized sequence with varying, inflations per minute (40, 60 and 80 min) and peak inspiratory pressures (18 and 30 cmH2O). PEEP was constant at 5 cmH2O. The lungs were washed with saline and static lung compliance was re-measured; ventilation sequences were repeated. Lung inflation data for the respiratory mechanics were measured using a respiratory function monitor and digitally recorded for both pre and post-lung wash inflation sequences. A paired sample t-test was used to compare the mean and standard deviation. Results: The mean difference in PEEP (TPR vs. SIB) was statistically significant at higher inflation rates of 60 and 80 bpm. At normal lung compliance, mean difference was 1.231 (p = 0.000) and 2.099 (p = 0.000) with PIP of 18 and 30 cmH2O respectively. Significantly higher Rrs were observed when using a TPR with higher inflation rates of 60 and 80 bpm at varying lung compliance. Conclusion: TPR is associated with significantly higher PEEP in a compliant lung model, which is probably related to the resistance of the TPR circuit. The effect of inadvertent PEEP on lung mechanics and hemodynamics need to be examined in humans. Further studies are needed to assess devices used to provide PEEP (TPR, SIB with PEEP valve, Anaesthetic bag with flow valve) during resuscitation of the newborn.

Timing errors and temporal uncertainty in clinical databases-A narrative review.

A firm concept of time is essential for establishing causality in a clinical setting. Review of critical incidents and generation of study hypotheses require a robust understanding of the sequence of events but conducting such work can be problematic when timestamps are recorded by independent and unsynchronized clocks. Most clinical models implicitly assume that timestamps have been measured accurately and precisely, but this custom will need to be re-evaluated if our algorithms and models are to make meaningful use of higher frequency physiological data sources. In this narrative review we explore factors that can result in timestamps being erroneously recorded in a clinical setting, with particular focus on systems that may be present in a critical care unit. We discuss how clocks, medical devices, data storage systems, algorithmic effects, human factors, and other external systems may affect the accuracy and precision of recorded timestamps. The concept of temporal uncertainty is introduced, and a holistic approach to timing accuracy, precision, and uncertainty is proposed. This quantitative approach to modeling temporal uncertainty provides a basis to achieve enhanced model generalizability and improved analytical outcomes.

Regional oxygenation, perfusion and body and/or head position: Are preterm infants adversely impacted? A systematic review.

This review addresses regional oxygenation and perfusion changes for preterm infants and changes with body position, with or without head rotation. Future directions for improving neurodevelopmental and clinical outcomes are suggested. The MEDLINE, Embase and Scopus databases were searched up to July 2021. Fifteen out of 470 studies met the inclusion criteria. All were prospective, observational studies with a moderate risk of bias. Significant variation was found for the baseline characteristics of the cohort, postnatal ages, and respiratory support status at the time of monitoring. When placed in a non-supine position, preterm infants showed a transient reduction in cardiac output and stroke volume without changes to heart rate or blood pressure. No studies reported on long-term neurodevelopmental outcomes. Overall, side lying or prone position does not appear to adversely affect regional, and specifically cerebral, oxygenation or cerebral perfusion. The effect of head rotation on regional oxygenation and perfusion remains unclear.

Regional Oxygenation and Perfusion Monitoring to Optimize Neonatal Packed Red Blood Cell Transfusion Practices: A Systematic Review.

Contemporary packed red blood cell transfusion practices in anaemic preterm infants are primarily based on measurement of hemoglobin or haematocrit. In neonatal intensive care units, most preterm infants receive at least 1 packed red cell transfusion as standard treatment for anaemia of prematurity. Clinicians are faced with a common question "at what threshold should anaemic preterm infants receive packed red blood cell transfusion?". While evidence from interventional trials offers a range of haemoglobin levels to clinicians on thresholds to initiate red cell transfusion, it does not offer identification of exact haemoglobin level at which regional oxygenation and perfusion gets compromised. Assessment of regional oxygenation using near infrared spectroscopy and perfusion using ultrasound could offer a personalized transfusion medicine approach to optimize transfusion practices. We conducted a systematic review of the literature to identify the role of both regional oxygenation and/or ultrasound-based perfusion monitoring as a potential trigger to initiate packed red blood cell transfusion in anaemic preterm infants. MEDLINE, Embase, Maternity and Infant Care database were searched up to March 2021. Publications identified were screened and relevant data was extracted. Changes to regional oxygenation and/or perfusion monitoring before and after packed red blood cell transfusion were the primary outcomes. 44 out of 755 studies met the inclusion criteria and were included in the final analysis. Most were prospective, observational studies in stable preterm infants. Overall, studies reported an improvement in regional oxygenation and/or ultrasound-based perfusion after packed red blood cell transfusion. These changes were more consistently observed when hemoglobin <9.6g/dL or hematocrit was <0.30. Significant variation was found for patient characteristics, postnatal age at the time of monitoring, criteria for diagnosis of anaemia, and period of monitoring as well as regional oxygenation monitoring methodology. Regional oxygenation and/or perfusion monitoring can identify at-risk anaemic preterm infants and are promising tools to individualize packed red blood cell transfusion practices. However, there is lack of evidence for incorporating this monitoring, in their present form, into standard clinical practice. Additionally, consistency in reporting of study methodology should be improved.

Clinical Outcomes of Single vs. Two-Strain Probiotic Prophylaxis for Prevention of Necrotizing Enterocolitis in Preterm Infants.

Background: The administration of live microbiota (probiotic) via enteral route to preterm infants facilitates intestinal colonization with beneficial bacteria, resulting in competitive inhibition of the growth of pathogenic bacteria preventing gut microbiome dysbiosis. This dysbiosis is linked to the pathogenesis of necrotizing enterocolitis (NEC), an acquired multi-factorial intestinal disease characterized by microbial invasion of the gut mucosa, particularly affecting preterm infants. Probiotic prophylaxis reduces NEC; however, variations in strain-specific probiotic effects, differences in administration protocols, and synergistic interactions with the use of combination strains have all led to challenges in selecting the optimal probiotic for clinical use. Aim: To compare any differences in NEC rates, feeding outcomes, co-morbidities in preterm infants receiving single or two-strain probiotics over a 4-year period. The two-strain probiotic prophylaxis was sequentially switched over after 2 years to the single strain probiotic within this 4-year study period, in similar cohort of preterm infants. Methods: During two consecutive equal 2-year epochs, preterm infants (<32 weeks and or with birth weight <1,500 g) receiving two-strain (Lactobacillus acidophilus and Bifidobacterium bifidum) and single strain (Bifidobacterium breve M-16 V,) probiotic prophylaxis for prevention of NEC were included in this retrospective, observational study. The primary outcome included rates of NEC; secondary outcomes included prematurity related co-morbidities and feeding outcomes. Time to reach full enteral feeds was identified as the first day of introducing milk feeds at 150 ml/kg/day. Results: There were 180 preterm infants in the two-strain, 196 in the single strain group from the two equal consecutive 2-year epochs. There were no differences in the NEC rates, feeding outcomes, all-cause morbidities except for differences in rates of retinopathy of prematurity. Conclusion: In our intensive-care setting, clinical outcomes of single vs. two-strain probiotic prophylaxis for prevention of NEC were similar. Although our study demonstrates single strain probiotic may be equally effective than two-strain in the prevention of NEC, small sample size and low baseline incidence of NEC in our unit were not sufficiently powered to compare single vs. two-strain probiotic prophylaxis in preventing NEC. Further clustered randomized controlled trials are required to study the effects of single vs. multi-strain probiotic products for NEC prevention in preterm infants.

Intrapartum interventions and outcomes for women and children following induction of labour at term in uncomplicated pregnancies: a 16-year population-based linked data study.

OBJECTIVES: We compared intrapartum interventions and outcomes for mothers, neonates and children up to 16 years, for induction of labour (IOL) versus spontaneous labour onset in uncomplicated term pregnancies with live births. DESIGN: We used population linked data from New South Wales, Australia (2001-2016) for healthy women giving birth at 37+0 to 41+6 weeks. Descriptive statistics and logistic regression were performed for intrapartum interventions, postnatal maternal and neonatal outcomes, and long-term child outcomes adjusted for maternal age, country of birth, socioeconomic status, parity and gestational age. RESULTS: Of 474 652 included births, 69 397 (15%) had an IOL for non-medical reasons. Primiparous women with IOL versus spontaneous onset differed significantly for: spontaneous vaginal birth (42.7% vs 62.3%), instrumental birth (28.0% vs 23.9%%), intrapartum caesarean section (29.3% vs 13.8%), epidural (71.0% vs 41.3%), episiotomy (41.2% vs 30.5%) and postpartum haemorrhage (2.4% vs 1.5%). There was a similar trend in outcomes for multiparous women, except for caesarean section which was lower (5.3% vs 6.2%). For both groups, third and fourth degree perineal tears were lower overall in the IOL group: primiparous women (4.2% vs 4.9%), multiparous women (0.7% vs 1.2%), though overall vaginal repair was higher (89.3% vs 84.3%). Following induction, incidences of neonatal birth trauma, resuscitation and respiratory disorders were higher, as were admissions to hospital for infections (ear, nose, throat, respiratory and sepsis) up to 16 years. There was no difference in hospitalisation for asthma or eczema, or for neonatal death (0.06% vs 0.08%), or in total deaths up to 16 years. CONCLUSION: IOL for non-medical reasons was associated with higher birth interventions, particularly in primiparous women, and more adverse maternal, neonatal and child outcomes for most variables assessed. The size of effect varied by parity and gestational age, making these important considerations when informing women about the risks and benefits of IOL.