Chest shielding for prevention of a haemodynamically significant patent ductus arteriosus in preterm infants receiving phototherapy.

BACKGROUND: Patent ductus arteriosus (PDA) is associated with mortality and morbidity in preterm infants. Phototherapy is a common treatment for jaundice in preterm infants. However, phototherapy has been associated with failure of closure of the ductus arteriosus in preterm infants. OBJECTIVES: To determine if chest shielding of preterm infants receiving phototherapy reduces the incidence of clinically and/or haemodynamically significant PDA and reduces morbidity secondary to PDA. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2015, Issue 3), MEDLINE, EMBASE, CINAHL, previous reviews, cross-references, abstracts, proceedings of scientific meetings, and trial registries through March 2015. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-RCTs, or quasi-RCTs of chest shielding during phototherapy compared to sham shielding or no shielding for the prevention of a haemodynamically or clinically significant PDA in preterm infants. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed studies for eligibility and quality and extracted data. We defined a clinically significant PDA as the presence of a PDA with clinical signs of an effect on organ function attributable to the ductus arteriosus. We defined a haemodynamically significant PDA as clinical and/or echocardiographic signs of a significant ductus arteriosus effect on blood flow. MAIN RESULTS: We included two small trials enrolling very preterm infants (Rosenfeld 1986; Travadi 2006). We assessed both as at high risk of bias. No study reported clinically significant PDA, defined as the presence of a PDA with clinical symptoms or signs attributable to the effect of a ductus arteriosus on organ function. Rosenfeld 1986 reported a non-significant reduction in haemodynamically significant PDA with left atrial to aortic root ratio greater than 1.2 (risk ratio (RR) 0.23, 95% confidence interval (CI) 0.05 to 1.01; 74 infants) but a statistically significant risk difference (RD -0.18, 95% CI -0.34 to -0.03; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 3 to 33). Rosenfeld 1986 reported a significant reduction in PDA detected by murmur (RR 0.50, 95% CI 0.29 to 0.88; RD -0.30, 95% CI -0.52 to -0.08; NNTB 3, 95% CI 2 to 12; 74 infants). Rosenfeld 1986 reported a significant reduction in treatment with indomethacin (RR 0.12, 95% CI 0.02 to 0.88; RD -0.21, 95% CI -0.35 to -0.06; NNTB 5, 95% CI 3 to 17; 74 infants), and only one infant had a ductal ligation in the no-shield group. There were no other significant outcomes, including mortality to discharge or 28 days, days in oxygen, days on mechanical ventilation, days in hospital, intraventricular haemorrhage, retinopathy of prematurity, or exchange transfusion. AUTHORS' CONCLUSIONS: The available evidence is very low quality and insufficient to assess the safety or efficacy of chest shield during phototherapy for prevention of PDA in preterm infants. Further trials of chest shielding are warranted, particularly in settings where infants are not receiving prophylactic or early echocardiographic targeted cyclo-oxygenase inhibitors for PDA.

Post-implementation review of pulse oximetry screening of well newborns in an Australian tertiary maternity hospital.

AIM: Despite there being evidence that pulse oximetry screening is better than clinical examination alone in early detection of CHD, implementation has been slow. The aim of this paper was to evaluate the practice after its implementation into routine care at Royal Prince Alfred Hospital in 2008. METHODS: A single pulse oximetry measurement was incorporated in the routine discharge newborn examination or, with early discharge, as a part of the Midwife Discharge Support Programme. An oxygen saturation level greater than or equal to 95% was considered normal, and a level less than 95%, confirmed on a repeat measure, triggered a review and examination by a consultant neonatal paediatrician. The saturation levels were recorded in the hospital database. Ascertainment of major CHD requiring surgery in the first 12 months was performed by searching the cardiac surgery database of the Heart Centre for Children. RESULTS: A total of 18 801 babies were screened over a 42-month period. Of these, four babies with major CHD were diagnosed prior to discharge with the main clinical alert resulting from routine pulse oximetry screening (true positive). Of the 11 cases with saturation <95% but no CHD (false positive cases), six had respiratory pathology. One baby with normal saturation level needed surgery in the first year for a large ventricular septal defect (false negative). The false positive rate of pulse oximetry screening for CHD was 0.13% with sensitivity 80%, specificity of 99.8%, a positive predictive value of 13.3% and a negative predictive value of 99.9%. Nine additional echocardiogram were required over 42 months. CONCLUSIONS: These post-implementation data confirm that pulse oximetry screening increases early diagnosis of major CHD as well as other important pathology with a very low false positive rate and minimal requirement for extra echocardiograms. Pulse oximetry screening of apparently well newborns should become a standard of care.

Use of oxygen for delivery room neonatal resuscitation in non-tertiary Australian and New Zealand hospitals: a survey of current practices, opinions and equipment.

BACKGROUND: Delivery room resuscitation of hypoxic newborn infants with pure or 100% oxygen causes oxidative toxicity and increases mortality. Current international resuscitation guidelines therefore recommend that oxygen be used judiciously. However, this requires staff education and special equipment that may not be available in non-tertiary maternity hospitals where the majority of births occur. AIM: To determine current attitudes, practices and available equipment for the use of air and blended oxygen for newborn delivery room resuscitation in non-tertiary maternity hospitals of Australia and New Zealand (ANZ). METHODS: Structured questionnaires sent by mail and e-mail after personal phone contact. A total of 203 eligible hospitals in ANZ were identified. A second mailing was conducted a month later for non-responders. RESPONDERS: Final response rate was 64% (n= 130: 70% physicians, 30% midwives). The majority (121, 93%) of respondents were aware of Australian Resuscitation Council recommendations, but only one in five hospitals had the capacity to deliver blended oxygen and 38% used pulse oximeters at delivery. Only 24 (18.5%) hospitals had guidelines. Air would be used by 68 (57%) hospitals to resuscitate term infants compared to 35 (31%) for preterm infants. Most (111, 91%) advocated the use of blended oxygen despite the lack of facilities. CONCLUSION: Only one in five ANZ non-tertiary maternity hospitals had the capacity to resuscitate newborn infants with air or blended oxygen. Most are aware of current recommendations and agreed that the use of less oxygen would be beneficial for this purpose. Further study into the necessary infrastructure required to implement these guidelines are recommended.

Placental cultures in the era of peripartum antibiotic use.

BACKGROUND: Histological examination of the placenta can provide valuable information that aids diagnosis and management for both the mother and the fetus. Positive placental cultures may also provide the clinician with valuable information on which to base therapy. AIMS: To determine the incidence of positive placental cultures, the association with chorioamnionitis and whether the rate is affected by antibiotic administration in the peripartum period. METHODS: A retrospective study of placentas submitted for histopathology and microbiology culture in higher risk deliveries over a 12-month period in a laboratory at a tertiary facility. Data collected included gestation age, duration of rupture of membranes, maternal fever, group B Streptococcus status, intrapartum antibiotics, placental culture result and the histopathology result. RESULTS: Of the 412 placentas submitted, 26% (106 of 412) had histological evidence of in utero inflammation. Sixty-three percent (259 of 412) of placentas were submitted for culture. Of these, only 4.6% (12 of 259) had a positive culture result, with 75% (nine of 12) having histological evidence of acute inflammation. Group B streptococcus and Escherichia coli were the most common isolates. Forty-two per cent (five of 12) of these women had received peripartum antibiotics. CONCLUSIONS: Positive placental cultures are found in only a small number of placentas with histological evidence of chorioamnionitis and funisitis. The current method of placental swabbing and culture technique is highly specific but not sensitive. The value of performing current routine placental cultures appears limited.