Maintaining normothermia immediately after birth in preterm infants <34 weeks' gestation: A systematic review and meta-analysis.

AIM: To evaluate delivery room (DR) interventions to prevent hypothermia and improve outcomes in preterm newborn infants <34 weeks' gestation. METHODS: Medline, Embase, CINAHL and CENTRAL were searched till 22nd July 2022. Randomized controlled trials (RCTs), non-RCTs and quality improvement studies were considered. A random effects meta-analysis was performed, and the certainty of evidence was evaluated using GRADE guidelines. RESULTS: DR temperature of ≥23 °C compared to standard care improved temperature outcomes without an increased risk of hyperthermia (low certainty), whereas radiant warmer in servo mode compared to manual mode decreased mean body temperature (MBT) (moderate certainty). Use of a plastic bag or wrap (PBW) improved normothermia (low certainty), but with an increased risk of hyperthermia (moderate certainty). Plastic cap improved normothermia (moderate certainty) and when combined with PBW improved MBT (low certainty). Use of a cloth cap decreased moderate hypothermia (low certainty). Though thermal mattress (TM) improved MBT, it increased risk of hyperthermia (low certainty). Heated-humidified gases (HHG) for resuscitation decreased the risk of moderate hypothermia and severe intraventricular hemorrhage (very low to low certainty). None of the interventions was shown to improve survival, but sample sizes were insufficient. CONCLUSIONS: DR temperature of ≥23 °C, radiant warmer in manual mode, use of a PBW and a head covering is suggested for preterm newborn infants <34 weeks' gestation. HHG and TM could be considered in addition to PBW provided resources allow, in settings where hypothermia incidence is high. Careful monitoring to avoid hyperthermia is needed.

Maintaining normal temperature immediately after birth in late preterm and term infants: A systematic review and meta-analysis.

AIM: Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation). METHODS: Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed. RESULTS: 25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes. CONCLUSIONS: Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation.

Evaluation of a simple intervention to reduce exchange transfusion rates among inborn and outborn neonates in Myanmar, comparing pre- and post-intervention rates.

BACKGROUND: In Myanmar, approximately half of all neonatal hospital admissions are for hyperbilirubinaemia, and tertiary facilities report high rates of Exchange Transfusion (ET). The aim of this study was to evaluate the effectiveness of the pilot program in reducing ET, separately of inborn and outborn neonates. METHODS: The study was conducted in the Neonatal Care Units of four national tertiary hospitals: two exclusively treating inborn neonates, and two solely for outborn neonates. Prior to intervention, no high intensity phototherapy was available in these units. Intervention in late November 2011 comprised, for each hospital, provision of two high intensity LED phototherapy machines, a photo radiometer, and training of personnel. Hospital-specific data were assessed as Relative Risk (RR) ratios comparing ET rates pre- and post-intervention, and individual hospital results were pooled when appropriate. RESULTS: In 2011, there were 118 ETs among inborn neonates and 140 ETs among outborn neonates. The ET rate was unchanged at Inborn Hospital A (RR = 1.07; 95 % CI: 0.80-1.43; p = 0.67), and reduced by 69 % at Inborn Hospital B (RR = 0.31; 95 % CI: 0.17-0.57; p < 0.0001). For outborn neonates, the pooled estimate indicated that ET rates reduced by 33 % post-intervention (RRMH = 0.67; 95 % CI: 0.52-0.87; p = 0.002); heterogeneity was not a problem. CONCLUSION: Together with a photoradiometer and education, intensive phototherapy can significantly reduce the ET rate. Inborn Hospital A had four times as many admissions for jaundice as Inborn Hospital B, and did not reduce ET until it received additional high intensity machines. The results highlight the importance of providing enough intensive phototherapy units to treat all neonates requiring high intensity treatment for a full course. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615001171505 , 2 November 2015.

Risk factors for acute bilirubin encephalopathy on admission to two Myanmar national paediatric hospitals.

BACKGROUND: Jaundice is the commonest neonatal ailment requiring treatment. Untreated, it can lead to acute bilirubin encephalopathy (ABE), chronic bilirubin encephalopathy (CBE) or death. ABE and CBE have been largely eliminated in industrialised countries, but remain a problem of largely undocumented scale in low resource settings. As part of a quality-improvement intervention in the Neonatal Care Units of two paediatric referral hospitals in Myanmar, hospitals collected de-identified data on each neonate treated on new phototherapy machines over 13-20 months. The information collected included: diagnosis of ABE at hospital presentation; general characteristics such as place of birth, source of referral, and sex; and a selection of suspected causes of jaundice including prematurity, infection, G6PD status, ABO and Rh incompatibility. This information was analysed to identify risk factors for hospital presentation with ABE, using multiple logistic regression. RESULTS: Data on 251 neonates was recorded over 20 months in Hospital A, and 339 neonates over 13 months in Hospital B; the number of outborn neonates presenting with ABE was 32 (12.7 %) and 72 (21.2 %) respectively. In the merged dataset the final multivariate model identified the following independent risk and protective factors: home birth, ORadj = 2.3 (95 % CI: 1.04-5.4); self-referral, ORadj = 2.6 (95 % CI: 1.2-6.0); prematurity, ORadj = 0.40 (95 % CI: 0.18-0.85); and a significant interaction between hospital and screening status because screening positive for G6PD deficiency was a strong and significant risk factor at Hospital B (ORadj = 5.9; 95 % CI: 3.0-11.6), but not Hospital A (ORadj = 1.1; 95 % CI: 0.5-2.5). CONCLUSION: The study identifies home birth, self-referral and G6PD screening status as important risk factors for presentation with ABE; prematurity was protective, but this is interpreted as an artefact of the study design. As operational research, there is likely to be substantial measurement error in the risk factor data, suggesting that the identified risk factor estimates are robust. Additional interventions are required to ensure prompt referral of jaundiced neonates to treatment facilities, with particular focus on home births and communities with high rates of G6PD deficiency.

Power spectral analysis of two-channel EEG in very premature infants undergoing heat loss prevention.

OBJECTIVE: To evaluate whether wearing a wool cap, a routine practice used to prevent heat loss in premature infants, affects interpretation of electroencephalogram spectral analysis. METHODS: Eighteen premature infants (median gestational age 28 weeks, range 23-32) without neurological complications were randomized to two channel (C3, C4 referred to Cz) digital electroencephalogram recordings with (90 min) and without (90 min) wearing wool cap, at 4 days of life. Electroencephalogram was analyzed automatically by measurement of burst suppression ratio and asymmetry index and by Fast Fourier Transform to calculate total absolute spectral power; relative spectral power in the δ (0.5-3.5 Hz), θ (4-7.5 Hz), α (8-12.5 Hz), and ß (13-30 Hz) frequency bands; spectral edge frequency; and mean dominant frequency. RESULTS: The use of wool cap had no effect on all electroencephalogram parameters considered. Gestational age showed an effect on relative spectral power of all considered bands, spectral edge frequency and mean dominant frequency, while no effect was seen on burst suppression ratio and asymmetry index. Neonates born at gestational weeks lower than 28 had significantly higher relative power in the δ band and lower relative power in the α and ß bands. CONCLUSIONS: Heat loss prevention using wool cap does not affect interpretation of spectral electroencephalogram. Spectral values in our group of very premature infants without neurological complications correspond to normal data reported in the literature. Maturation changes consist of reduction of relative power of the δ band, spectral edge frequency and mean dominant frequency.

Minimally invasive approaches for surfactant administration.

Respiratory distress syndrome (RDS) is the most common respiratory morbidity in preterm infants. In addition to respiratory support, the current clinical treatment includes endotracheal intubation and rapid instillation of exogenous surfactant. However, this approach needs skilled operators and has been associated with complications such as hemodynamic instability and electroencephalogram abnormalities. New, less invasive methods for surfactant administration are needed. In this article, we reviewed the available noninvasive procedures for surfactant administration. In particular, we focused on aerosolized surfactant and surfactant administration through LMA.

Efficacy of INSURE during nasal CPAP in preterm infants with respiratory distress syndrome.

AIM: INSURE (INtubation, SURfactant, Extubation) is a proven complement of nasal CPAP (nCPAP) for respiratory distress syndrome (RDS) treatment of preterm infants. Early administration is characterized by greater success. We aimed to determine the efficacy and failure or other respiratory outcomes of INSURE administration during nasal continous positive airway pressure (nCPAP) treatment of RDS. METHODS: Among 824 premature infants neonatal intensive care unit (NICU) admitted at Padua University Hospital during 2007-2009, 209 (25.4%) were managed by surfactant replacement (200 mg/kg, Curosurf®) if required >45% oxygen ("rescue" treatment), including 42 (20.1%) during nCPAP. Each premature infant treated with INSURE during nasal CPAP was compared to 2 consecutive control infants treated with surfactant during mechanical ventilation, matched for antenatal steroids, delivery route, gestational age, and sex. RESULTS: Infants with RDS, treated with nCPAP and INSURE-complement (N.=25), were comparable in Apgar score, need of PPV at birth, birth weight, pre-surfactant FiO2 and timing of surfactant replacement to controls. However, nCPAP and INSURE-complement was superior in terms both of oxygenation, evaluated as post-treatment FiO2 (Median, [IQR], 26 [21-40] vs. 21 [21-29]; P=0.03) and (a-A) pO2 (0.48 [0.45-0.60] vs. 0.58 [0.53-0.72]; P=0.03). The improved oxygenation was sustained over the following days. In addition, premature infants treated with nCPAP and INSURE-complement developed less respiratory co-morbidities, including pneumothorax, borncopulmonary disease (BPD), and BPD and death (P=0.04). CONCLUSION: INSURE-complement of nasal CPAP has a superior efficacy in terms of oxygenation improvement, maintenance of optimal oxygenation, and reduction of respiratory comorbidities respect to "rescue" surfactant administration during mechanical ventilation.

Noise exposure is increased with neonatal helmet CPAP in comparison with conventional nasal CPAP.

BACKGROUND: in adults, noninvasive ventilation via a helmet is associated with significantly greater noise than nasal and facial masks. We hypothesized that noise exposure could be increased with neonatal helmet continuous positive airway pressure (CPAP) in comparison with conventional nasal CPAP (nCPAP). Our primary objective was to compare the noise intensity produced by a neonatal helmet CPAP and a conventional nCPAP system. Furthermore, we aimed to evaluate the effect of the gas flow rate and the presence of the humidifier and the filter on noise levels during neonatal helmet CPAP treatment. METHODS: in this bench study, noise intensity was measured in the following settings: helmet CPAP, nCPAP, incubator and the neonatal intensive care unit. In helmet CPAP, noise measurements were performed at different gas flow rates (8, 10 and 12 l/min), while in nCPAP, the flow rate was 8 l/min. For both CPAP systems, the level of pressure was maintained constant at 5 cmH(2) O. RESULTS: during neonatal helmet CPAP, the median (interquartile range) noise levels were significantly higher than those during nCPAP: 70.0 dB (69.9-70.4) vs. 62.7 dB (62.5-63.0); P<0.001. In the helmet CPAP, the noise intensities changed with increasing flow rate and with the presence of a humidifier or a filter. CONCLUSIONS: noise intensities generated by the neonatal helmet CPAP were significantly higher than those registered while using a conventional nCPAP system. In the helmet, the noise intensity depends on the gas flow rate, and the presence of a humidifier and a filter in the system.

Induction of meconium evacuation and stooling habit development in premature infants: role of gestational age.

AIM: Meconium obstruction has been viewed as a cause of bowel dysfunction and poorer outcome in preterm neonates. This study investigated whether the need of meconium induction over the 7th postnatal day would relate with later bowel habit development. The study was carried out at the Department of Pediatrics, University of Padua, Italy. METHODS: This was a prospective study, performed on 80 premature infants, separately analyzed in three subgroups according to the gestational ages (Subgroup A [16]: 23-26/6; Subgroup B [26]: 27/0-30/6; and Subgroup C [38]: 31/0-34/6 weeks), after the induction from 7th day of life of meconium evacuation by saline enema. To evaluate stooling habit development, data on constipation occurrence were obtained via a telephone interview with parents six months after neonatal care. RESULTS: At the 23-26/6 weeks subgroup A there was a significant increased risk (RR; 95%, CI) of saline enema to induce meconium passage as compared to subgroups B (2.27; 1.11-4.47) and subgroup C (2.28; 1.04-4.94), with a significant P per trend decrease (P<0.05) with increasing gestational age. Even, at six months of life, subgroup A showed a significant increased risk of constipation as compared to subgroups B (3.25; 1.04-9.75) and C (3.73; 1.19-11.63), respectively. CONCLUSION: The results of this study indicate that meconium retention over the first week of life is a relatively common features in premature subgroup infants of 23-26/6 weeks of gestation. These premature infants at 6 months of age show a stooling habit characterized by frequent constipation.

Laboratory and clinical features of pregnant women with antiphospholipid syndrome and neonatal outcome.

OBJECTIVE: To evaluate the relationship between the antiphospholipid profile and clinical characteristics of pregnant women with antiphospholipid syndrome (APS) and neonatal outcome. METHODS: We retrospectively considered 109 treated pregnancies of 93 patients with primary APS and reviewed the medical records of their 111 infants. Neonatal outcome was assessed using the following variables: weeks of gestational age at delivery, percentiles of birth weight, Apgar score at 5 minutes, need for cardiopulmonary resuscitation in the delivery room, time in the neonatal intensive care unit, infections, and other neonatal complications. Univariate statistical analysis was performed to evaluate the relationship between APS maternal features and neonatal outcome parameters. RESULTS: When maternal APS features and variables of infant outcome were analyzed, it was evident that lupus anticoagulant (LAC), triple antiphospholipid positivity, and history of vascular thrombosis were significantly associated with some parameters of a poor infant outcome. History of pregnancy morbidity alone was, instead, significantly correlated to the variables of favorable neonatal outcome. CONCLUSION: There seems to be more than one kind of pregnant woman with APS. Even when treated with a second-line therapy plan, mothers with LAC and/or triple antiphospholipid positivity and/or previous thromboembolism seem to have a high probability of poor neonatal outcome, whereas those with pregnancy morbidity alone, treated with conventional drugs, seem to have a high probability of favorable outcome.

Preterm premature rupture of membranes, chorioamnion inflammatory scores and neonatal respiratory outcome.

OBJECTIVE: To evaluate whether histological chorioamnionitis (HCA), in the setting of preterm premature rupture of membranes (PPROM), affects infant respiratory outcome. DESIGN: A prospective histological study on 287 consecutive placentas was performed in preterm infants (

Arterial wall thickness and blood pressure in children who were born small for gestational age: correlation with umbilical cord high-sensitivity C-reactive protein.

BACKGROUND: Small for gestational age (SGA) infants have an increased risk of later cardiovascular disease. At birth, high sensitivity-C reactive protein (hs-CRP), a prognostic marker of cardiovascular disease, is significantly higher in SGA than in appropriate for gestational age (AGA) infants. AIM: To measure aortic and carotid intima-media thickness (aIMT, cIMT) and blood pressure (BP) in children (aged 3-5 years) who were born SGA and AGA, and to assess the correlation between hs-CRP concentrations obtained at birth and these haemodynamic variables. METHODS: Umbilical cord hs-CRP concentrations were obtained in 38 neonates. In the same subjects aged 3-5 years, aIMT and cIMT were measured by high-resolution ultrasound scan, in the dorsal arterial wall. Anthropometric variables and BPs were obtained for each child. RESULTS: Maximum (median 0.700 mm, range 0.500-1.080 vs 0.650 mm, 0.400-0.860; p = 0.32) aIMTs were similar between children who were born SGA (n = 17) and AGA (n = 21), respectively. Concentrations of hs-CRP were not correlated with IMTs. In children who were born SGA, systolic BP was significantly correlated with umbilical cord hs-CRP concentrations (r = 0.60; p = 0.009). CONCLUSIONS: Children who were born SGA have a higher, although not significant, aortic thickening than those who were born AGA. Umbilical cord hs-CRP concentrations do not seem to be involved in this process. Instead, hs-CRP concentrations were significantly related to systolic BP values in children who were born SGA, suggesting that hs-CRP at birth could be associated with sympathetic system hyperactivity and with the stress response during childhood.

Long-term use of neonatal helmet-CPAP: a case report.

In a recent short-term physiological study, we demonstrated a new continuous positive airway pressure (CPAP) system (neonatal helmet-CPAP) that could be a feasible device for managing preterm infants needing continuous distending pressure with better tolerability than nasal-CPAP. However, its application for a long-term period has never been reported in neonates. Here, we describe the use of neonatal helmet-CPAP in a neonate with persistent pulmonary hypertension of the newborn. Twenty minutes after neonatal helmet-CPAP placement, the baseline post-ductal tcSaO2 (66%) and alveolar-arterial gradient O2 improved from 66% and 648 mmHg to 100% and 465 mmHg, respectively. The neonatal helmet-CPAP was applied for 48 hours and was well-tolerated by the patient without complications. Long-term use of neonatal helmet-CPAP appears feasible and well-tolerated. Comparative trials are needed.

Prospective, randomized comparison of ProSeal and Classic laryngeal mask airways in anaesthetized neonates and infants.

BACKGROUND: When compared with the Classic laryngeal mask airway (cLMA), the recently introduced ProSeal laryngeal mask airway (PLMA) has modified features to produce higher airway seal pressures and enable ventilation in circumstances where the cLMA might fail. The first neonatal size 1 PLMA recently became available. This study was designed to compare the effectiveness of the size 1 cLMA and PLMA during positive pressure ventilation in anesthetized neonates and infants. METHODS: Forty-six consecutive patients undergoing elective cardiac surgical procedures were randomized for initial airway management with the cLMA or PLMA. Insertion time (IT), number of placement attempts, ease of placement, quality of the initial airway, maximum tidal volume (TVmax), and airway pressure at which an audible leak in the mouth (P(leak)) occurred were collected. All data were recorded before performing tracheal intubations. RESULTS: IT and success rate were similar for both LMAs. The initial quality of the airway was significantly better for the PLMA (P<0.05). TVmax and P(leak) were significantly higher for PLMA (77 vs 58 ml, P<0.02 and 29.8 vs 24.4 cm H2O, P<0.02). No adverse events were recorded during the study. CONCLUSIONS: The size 1 PLMA forms a more effective seal than size 1 cLMA in neonates. This might allow the PLMA to be used in those newborn infants requiring high airway pressures for ventilation.

Cardiac troponin I at birth is of fetal-neonatal origin.

OBJECTIVE: Neonates produce predominantly skeletal muscle troponin I (TnI) in the myocardium; however, in asphyxiated neonates, high levels of cardiac troponin I (cTnI) have been found. We hypothesised that in these circumstances cTnI could be from the mother or the result of a change in fetal/neonatal production in response to an insult. In this study, we aimed to compare cTnI concentrations in asphyxiated neonates with those of their respective mothers. METHODS: In this prospective observational study, we enrolled all asphyxiated neonates transferred by the Veneto Region Neonatal Transport Service in the period 1 January 2006 to 31 March 2007. Asphyxia was defined as a pH < or =7.00 and/or a base deficit of > or =16 mmol per litre. Neonatal and maternal blood samples were obtained for cTnI determination. RESULTS: We enrolled 19 asphyxiated neonates (median gestational age: 39 weeks, interquartile range 34-40; birth weight 3100 g, 1950-3340). Their cTnI concentrations were significantly higher in comparison with their mothers: 0.24 microg/l (0.13-0.50) vs 0.04 microg/l (0.04-0.04); p<0.01. CONCLUSIONS: Increased cTnI concentrations detected in asphyxiated neonates are of neonatal origin and are not derived from the mother. In asphyxiated neonates, there may be predisposing factors that could cause earlier switching from skeletal TnI to cTnI in the myocardium.

The size 1 LMA-ProSeal: Comparison with the LMA-Classic during pressure controlled ventilation in a neonatal intubation manikin.

BACKGROUND: The classic laryngeal mask airway (cLMA) has been demonstrated to be effective for airway management during neonatal resuscitation. However, high airway pressures, when required, cannot be achieved with this device. A neonatal prototype of the LMA-ProSeal (PLMA), which might improve the oropharyngeal leak pressure, has recently been produced. The airway sealing pressures of the cLMA and the PLMA were compared in a neonatal manikin. METHODS: A neonatal PLMA and a neonatal cLMA were positioned at random in a neonatal intubation manikin (Neonate Airway Trainer; Laerdal, Norway). A Dräeger pressure controlled ventilator (Dräeger 8000; Dräegerwerk AG, Germany) was connected to the airway tubes and increasing inspiratory pressures (from 10 to 40 cm H2O) of positive pressure ventilation applied. The peak and the mean airway pressures obtained with each device were recorded. RESULTS: The airway pressures obtained with PLMA were significantly higher than those obtained with cLMA (p < 0.01) at levels of positive pressure ventilation of 25, 30, 35 and 40 cm H2O. CONCLUSIONS: The neonatal PLMA allows higher airway pressure ventilation than the cLMA, in a neonatal intubation manikin. If confirmed clinically, this may have important implications during neonatal resuscitation when high airway pressures are required.