Resuscitation of premature infants: what are we doing wrong and can we do better?

Neonatal resuscitation is based on experience with little evidence to support the methods advocated. Current guidelines make no distinction between the techniques for term and very premature infants. The guidelines support the use of 100%, cold, dry oxygen delivered with devices that provide variable peak inspiratory pressures and tidal volumes with no positive end-expiratory pressure (PEEP). It is possible that these techniques damage the lungs. Self-inflating resuscitation bags give no indication about leaks, produce variable inflating pressures, do not provide PEEP and cannot deliver prolonged inflations. Flow-inflating bags will not work if there is leak at the facemask and also have variable inflating pressures. Although they can provide PEEP and deliver prolonged inflations, they require considerable skill to use. The Neopuff is relatively easy to use, provides PEEP and steady inflating pressure and does not achieve the set pressures if there is a mask leak. Continuous positive airway pressure and PEEP are used in the neonatal intensive care unit to maintain lung volume. It is surprising they are not routinely recommended for resuscitation when establishing the lung volume is paramount. Volutrauma is a potential problem in neonatal resuscitation and yet none of the devices give any indication of the tidal volume delivered. There is considerable potential for improvement in techniques of neonatal resuscitation through the application of evidence already available and much scope for further research in this field.     

Frequent wheeze at follow up of very preterm infants: which factors are predictive?

OBJECTIVE: To determine if chest radiograph appearance at 28 days or 36 weeks postmenstrual age (PMA) can predict recurrent wheeze or cough at follow up in prematurely born infants more effectively than readily available clinical data. DESIGN: Chest radiographs of infants entered into the UKOS trial, who had had a chest radiograph at 28 days and 36 weeks PMA and completed six months of follow up, were assessed for the presence of fibrosis, interstitial shadows, cystic elements, and hyperinflation. At 6 months of corrected age, the occurrence and frequency of wheeze and cough since discharge were determined using a symptom questionnaire. PATIENTS: A total of 185 infants with a median gestational age of 26 (range 23-28) weeks. RESULTS: Thirty seven infants wheezed more than once a week, compared with the rest of the cohort. These infants had significantly higher chest radiograph scores at 28 days (p = 0.020) and 36 weeks PMA (p = 0.005), with significantly higher scores at 28 days for fibrosis (p = 0.017) and at 36 weeks PMA for fibrosis (p = 0.001) and cystic elements (p = 0.0007). They had also been ventilated for longer (p = 0.013). Forty four infants coughed more than once a week; they did not differ significantly from the rest of the cohort. An abnormal chest radiograph score at 36 weeks PMA had the largest area under the receiver operator characteristic curve with regard to prediction of frequent wheeze. CONCLUSION: An abnormal chest radiograph appearance at 36 weeks PMA predicts frequent wheeze at follow up and appears to be a better predictor than readily available clinical data.     

Is hypotension a major risk factor for neurological morbidity at term age in very preterm infants?

OBJECTIVE: To investigate the influence of perinatal risk factors, especially hypotension, on neuromotor status at term in surviving preterm infants born before 32 weeks of gestation. METHODS: This study is part of the Leiden Follow-Up Project on Prematurity: a prospective, regional study of 266 live born infants with a gestational age (GA) < 32 weeks born in 1996-1997. Twenty-eight infants died before term age. Two hundred and eleven infants were examined neurologically at term according to Prechtl. The findings were classified as normal (N), mildly abnormal (MA) or definitely abnormal (DA). Hypotension was defined as a mean arterial blood pressure (MABP) < 30 mm Hg on at least two occasions. RESULTS: One hundred and six (50%) infants were classified as neurologically N, 92 (44%) infants were classified as MA and 13 (6%) infants as DA. Hypotension, bronchopulmonary dysplasia (BPD), flaring and cystic periventricular leucomalacia (PVL) were risk factors for neurological morbidity. Of the 68 infants with hypotension, 33 (49%) were classified as MA and 7 (10%) as DA. Of the 141 infants without hypotension, 58 (41%) were MA, and 5 (4%) were DA. The odds ratio of hypotension for neurological morbidity was 1.9 (95% CI 1.06-3.40), adjusted for gestational age, birth weight, small for gestational age (SGA) and gender, it was 1.96 (95% CI 1.02-3.77). The adjusted odds ratio of PVL was 18.6 (4.4-78.5), of flaring was 2.37 (1.18-4.74) and of BPD was 2.44 (1.08-5.5). CONCLUSIONS: Apart from gestational age, periventricular leucomalacia, and bronchopulmonary dysplasia, hypotension in preterm infants is a major risk factor for neurological morbidity at term.     

Are we over-treating hypoxic spells in preterm infants?

A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.     

Early assessment of visual function in preterm infants: How early is early?

Background

Several studies reported on various aspects of visual function at term age and in the first months after birth but less has been reported in preterm infants before they reach termequivalent age.

Aims

To assess the suitability of a battery of tests of visual function for use in infants born at < 33 weeks gestation (GA) and assessed before 34 weeks post-menstrual age (PMA); to evaluate the distribution of the findings according to GA, and to compare the data with those previously published on preterm infants assessed at 35 weeks PMA.

Study design

Cross-sectional study.

Subjects

Sixty-four preterm infants with a GA < 33 weeks were studied.

Outcome measures

We used a battery of visual function tests previously validated at 35 and 40 weeks PMA in low-risk preterm infants. All the infants in this current study underwent the same assessment before 34 weeks PMA.

Results

Before 31 weeks PMA most infants could not be reliably assessed because of clinical instability, whilst after 31 weeks PMA most infants could be assessed and they showed progressive maturation in their responses with PMA. Some items (spontaneous ocular motility, horizontal tracking, tracking a coloured stimulus, and ocular fixation) showed similar results at 32-33 weeks PMA to those found in low-risk preterm at 35 weeks PMA. Ocular movements to a target and arc tracking were the items with the most immature responses.

Conclusions

Our results provide further evidence that a structured assessment of visual function can be used in clinical routine and for research purposes in infants as young as 31 weeks PMA.     

How should we report early childhood outcomes of very low birth weight infants?

Reports of outcomes for very low birth weight infants have evolved from an early focus on survival and neonatal morbidities to the comprehensive analysis and evaluation of the relationships between neonatal interventions and morbidity and neurodevelopmental status in early childhood. Post discharge findings are frequently the primary outcome for antenatal and neonatal intervention trials, and the 97 approved neonatal fellowship training programs in the United States require participation in a follow-up program. Very low birth weight survivors remain at increased risk of neurodevelopmental impairments, vision and hearing impairment, growth failure, behavior morbidities and chronic health problems. Identification of the most appropriate outcome assessment for the study objective, and the ideal timing of the assessment remains a challenge for investigators.     

Drug utilisation in very preterm infants: any changes during the past decade?

BACKGROUND: Improved standards of perinatal care for preterm infants led to decreased hospital mortality rates during the past decade. However, studies investigating changes in drug utilisation in neonatal intensive care units (NICU) during this period are missing. OBJECTIVE: The aim of the present study therefore was to evaluate the most frequently used groups of drugs in preterm infants treated in NICUs and to analyse potential changes in drug utilisation over a period of ten years. METHODS: Drug utilisation patterns in 164 preterm infants born between 1989 and 1990 (group I; gestational age 27.2+/-1.2 weeks, birth weight 970+/-145 g) were compared to those in 113 preterm infants born between 2001 and 2004 (group II; gestational age 26.9+/-1.65 weeks, birth weight 930+/-253 g, mean and standard deviation each) with need for postnatal mechanical ventilation. RESULTS: Significant changes in drug utilisation patterns were observed for complete courses of antenatal corticosteroids (40 vs. 51.5%), diuretics (78 vs. 36.6%), surfactant (63.3 vs. 75%), methylxanthines (89.9 vs. 56.7%), sedatives/analgesics (82.4 vs. 91.5%) and catecholamines (38.3 vs. 52.4%) (group II vs. group I each). Postnatal corticosteroids were applied more often in group II (17.4 vs. 13.4%). However, duration of postnatal corticosteroid treatment has decreased (6 d vs. 13 d). The use of antibiotics remained unchanged (100 vs. 98.9%). Comparison of clinical outcome variables showed a decreased duration of mechanical ventilation and a significantly increased survival rate. CONCLUSION: Drug utilisation patterns in preterms have changed considerably during the past decade. Improved standards of care and shorter duration of mechanical ventilation may be operative.     

Opportunistic immunisation of infants admitted to hospital: Are we doing enough?

Aim:   To determine the accuracy and effectiveness of opportunistic immunisation of children admitted to the paediatric unit of a large teaching hospital using retrospectively collected data.
Methods:   Immunisation status, documented using clinical indicator (CI) forms, of all admissions over a 1-year period was compared with that recorded by the Australian Childhood Immunisation Register. In order to determine the effectiveness of providing catch-up plans, we analysed the difference in catch-up times of the children with and without a catch-up plan on their CI form.
Results:   The details of 614 admissions in the study period were included. Comparing the Australian Childhood Immunisation Register with the CI for assessing immunisation status, we found that 83 of the 573 (14.5%) were incorrectly recorded, and only 25 of the 82 admissions in which the infant was overdue were identified on the ward. Children were more likely to be vaccinated within 30 days and 90 days of admission if they had been given a catch-up plan. Of the children who had not been given a catch-up plan, almost half were still overdue at 90 days.
Conclusions:   Admission to hospital provides opportunities for both routine and catch-up immunisation; however, for opportunistic immunisation to be effective, health service screening and immunisation documentation must be accurate.