In November we published a paper on early neonatal sudden unexpected deaths
The study by...]]>
When a transfusion is administered to a newborn infant, the intravenous tubing through which the donor cells are infused is temporarily dedicated to this sole purpose. Specifically, during the 3 or 4 h the donor cells are infusing, no medications or other intravenous fluids are co-infused into the same tubing. When a neonate with only one intravenous tube needs a transfusion, a concern about hypoglycaemia during the transfusion raises the question whether a second intravenous tube should be started for infusion of a dextrose-containing solution. Because neonates needing a transfusion are often the smallest...]]>
Representatives of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada and the Resuscitation Council of South Africa founded the International Liaison Committee on Resuscitation (ILCOR) in 1992. Other organisations subsequently joined and in 1995 the task force of ILCOR established a neonatal subgroup. After the 2005 ILCOR publication,
To conduct a systematic review of the association between chorioamnionitis (CA) and bronchopulmonary dysplasia (BPD) in preterm infants.
The authors searched Medline, Embase, CINAHL, Science Citation Index and PubMed, reviewed reference lists and contacted the primary authors of relevant studies. Studies were included if they had a comparison group, examined preterm or low birthweight infants, and provided primary data. Two reviewers independently screened the search results, applied inclusion criteria and assessed methodological quality. One reviewer extracted data and a second reviewer checked data extraction. Studies were combined with an OR using a random effects model. Meta-regression was used to explore potential confounders.
3587 studies were identified; 59 studies (15 295 patients) were included. The pooled unadjusted OR showed that CA was significantly associated with BPD (OR 1.89, 95% CI 1.56 to 2.3). Heterogeneity was substantial (I2=66.2%) and may be partially explained by the type of CA. Infants exposed to CA were significantly younger and lighter at birth. The pooled adjusted OR was 1.58 (95% CI 1.11 to 2.24); heterogeneity was substantial (I2=65.1%) which may be due to different variables being controlled in each study. There was strong evidence of publication bias which suggests potential overestimation of the measure of association between CA and BPD.
Unadjusted and adjusted analyses showed that CA was significantly associated with BPD; however, the adjusted results were more conservative in the magnitude of association. The authors found strong evidence of publication bias. Despite a large body of evidence, CA cannot be definitively considered a risk factor for BPD.
A female baby was born with APGAR scores of 1, 2 and 4 after 1, 5 and 10 min, respectively. She was intubated and given colloids, epinephrine, bicarbonate and calcium. Placement of an umbilical vein catheter was not possible because of resistance during placement of the catheter. An umbilical arterial blood gas showed a pH of 6.8. The infant was transported to a tertiary referral centre.
Upon arrival, the arterial blood gas revealed pH 6.99, pCO2 18.2 mm Hg, bicarbonate 4.2 mM and haemoglobin 4.9 g/dl. A central venous catheter was placed, packed cells were given,...]]>
Breast pumping or hand expression may be recommended when newborns latch or suck poorly. A recent trial found worse outcomes among mothers who used a breast pump in the early postpartum period. The objective of this study was to compare bilateral electric breast pumping to hand expression among mothers of healthy term infants feeding poorly at 12–36 h after birth.
Randomised controlled trial.
Well-baby nursery and postpartum unit.
68 mothers of newborns 12–36 h old who were latching or sucking poorly were randomly assigned to either 15 min of bilateral electric pumping or 15 min of hand expression.
Milk transfer, maternal pain, breastfeeding confidence and breast milk expression experience (BMEE) immediately after the intervention, and breastfeeding rates at 2 months after birth.
The median volume of expressed milk (range) was 0.5 (0–5) ml for hand expressing mothers and 1 (0–40) ml for pumping mothers (p=0.07). Maternal pain, breastfeeding confidence and BMEE did not differ by intervention. At 2 months, mothers assigned to hand expression were more likely to be breastfeeding (96.1%) than mothers assigned to breast pumping (72.7%) (p=0.02).
Hand expression in the early postpartum period appears to improve eventual breastfeeding rates at 2 months after birth compared with breast pumping, but further research is needed to confirm this. However, in circumstances where either pumping or hand expression would be appropriate for healthy term infants 12–36 h old feeding poorly, providers should consider recommending hand expression.
To assess, in newborn infants submitted to surgical procedures, the efficacy of two opioids—fentanyl and tramadol—regarding time to extubate, time to achieve 100 ml/kg of enteral feeding and pain in the first 72 h after surgery.
Controlled, blind, randomised clinical trial.
Neonatal intensive care unit.
160 newborn infants up to 28 days of life requiring major or minor surgeries.
Patients were randomised to receive analgesia with fentanyl (1–2 μg/kg/h intravenously) or tramadol (0.1–0.2 mg/kg/h intravenously) in the first 72 h of the postoperative period, stratified by surgical size and by patient's gender.
Pain assessed by validated neonatal scales (Crying, Requires oxygen, Increased vital signs, Expression and Sleepless Scale and the Neonatal Facial Coding System), time until extubation and time to reach 100 ml/kg enteral feeding. Statistical analysis included repeated measures analysis of variance adjusted for confounding variables and Kaplan–Meier curve adjusted by a Cox model of proportional risks.
Neonatal characteristics were (mean±SD) birth weight of 2924±702 g, gestational age of 37.6±2.2 weeks and age at surgery of 199±63 h. The main indication of surgery was gastrointestinal malformation (85 newborns; 53%). Neonates who received fentanyl or tramadol were similar regarding time until extubation, time to reach 100 ml/kg of enteral feeding and pain scores in the first 72 h after surgery.
Tramadol was as effective as fentanyl for postoperative pain relief in neonates but does not appear to offer advantages over fentanyl regarding the duration of mechanical ventilation and time to reach full enteral feeding.
NCT00713726
Sudden and unexpected postnatal collapse (SUPC) of a healthy newborn infant is a rare event, which carries a high risk of mortality and significant neurodisability in survivors. An underlying condition can be found in 60% of cases who undergo detailed postmortem but in the remainder there are important associations with prone position, breast feeding and primiparous status. The authors undertook a prospective study to ascertain the population incidence of SUPC in the UK.
Cases were referred through the British Paediatric Surveillance Unit reporting scheme over a 13-month period. Infants were at ≥37 weeks of gestation, had an Apgar score of ≥8 at 5 min, collapsed within 12 h in hospital requiring positive pressure ventilation and either died or received ongoing intensive care. Data were collected on maternal and infant characteristics, clinical investigations and 1-year outcome.
45 cases were reported, an incidence of 0.05/1000 live births of whom 12 infants died. In 15/45 infants, an underlying disease/abnormality was determined. In 30/45 cases (0.035/1000 live births), no such cause was found, but in 24, the clinical/pathological diagnosis was airway obstruction during breast feeding or in prone position. Mothers were commonly primiparous and unattended by clinical staff before collapse was recognised. Approach to investigation was highly disparate and frequently very limited. Of the 30 infants with no underlying disease/abnormality, 22 (73%) developed a postasphyxial encephalopathy and 10 had a poor outcome (33%) – 5 died and 5 had neurological sequelae at 1 year.
SUPC is rare in any one centre and there is no standard approach to investigation. In those cases where collapse is not due to an underlying abnormality, breast feeding and prone position are important associations. Guidelines for safe postnatal care of infants should include appropriate vigilance of infants particularly where mothers are primiparous or where ability to assess the baby may be impaired.
Patent ductus arteriosus (PDA) in preterm infants is often assessed with echocardiographic parameters, especially colour Doppler ductal diameter and pulsed Doppler flow pattern. Clinical algorithms have been proposed in which PDA treatment is indicated by either large diameter or a particular flow pattern, however it is unknown whether ductal diameter and flow pattern provide equivalent stratification of infants.
Retrospectively assess both parameters in 197 echocardiograms from 104 infants (gestational age <31 weeks).
Echocardiograms were independently reviewed and the internal colour Doppler diameter of the PDA and the pulsed Doppler flow pattern were characterised for each study (169 records had both parameters recorded).
Diameter varied widely within each group but was significantly associated with flow pattern: mean diameter was greatest in the pulmonary hypertension (PH) group (2.6 mm), progressively narrowed across growing and pulsatile groups, and was smallest in the closing group (1.3 mm). When echocardiograms were categorised using previously published diameters, 82.4% of the PH group had diameters >2.0 mm, large diameters predominated in the growing and pulsatile groups but to a progressively smaller extent, and 98.1% of closing group had diameters <2.0 mm.
Ductal diameter and flow patterns are significantly associated, consistent with a narrowing of the ductus until closure. Overall, the two parameters are in good agreement but will result in different treatment decisions in some cases. Clinicians might consider using both methods as a cross check against each other, to assist in the management of preterm infants with a clinically detectable PDA.
To determine morbidity, mortality and associated risk factors following patent ductus arteriosus (PDA) ligation in premature infants.
Retrospective case note audit of premature infants referred to a national paediatric cardiothoracic surgical service (2001–2007) with univariate and multivariate analysis of potential risk factors for mortality and morbidity.
125 infants were enrolled (median gestational age 26 weeks (IQR 25–27 weeks), median birth weight 840 g (IQR 730–1035 g)). Referral characteristics were median LA:Ao 1.8 (IQR 1.5–2.0), 80% ventilated, 18.4% continuous positive airway pressure, 70% diuretics and 58% prior treatment with cyclooxygenase inhibitors (COIs). Median age at PDA ligation was 31 days (IQR 25–41 days). Postoperative characteristics were median time to extubation 5 days (IQR 3–10 days), 36.0% corticosteroids, 46.8% domiciliary oxygen and 4.8% vocal cord palsy. The 30-day and 1-year mortality rates were 4.8% and 12.8%, respectively, with neurodisability in 32% of survivors. All deaths occurred in the ventilated group and were mainly attributable to bronchopulmonary dysplasia (BPD). Gestation and fractional inspired oxygen (FiO2)>60% were significantly associated with 30-day mortality. FiO2, ventilation, lack of prior COIs and postoperative corticosteroids were significantly associated with 1-year mortality. Preoperative FiO2>40% and lack of prior COIs retained independent significance for death at 1 year.
PDA ligation is well tolerated, with evidence of early benefit. The incidence of neurodisability or death from BPD at 1 year remains high. Increasing preoperative FiO2 and lack of prior treatment with COIs are associated with increased mortality at 1 year.
Infantile haemangiomas are benign vascular neoplasms that occur frequently in premature infants. The authors hypothesised that in addition to gestational age and birth weight, erythropoietin therapy may influence the incidence of these soft tissue tumours in preterm infants.
2563 infants born prematurely and admitted to the Division of Neonatology, University of Heidelberg Medical School were investigated in a retrospective analysis. Hospital charts for all infants were reviewed for clinical data. The primary endpoint was the percentage of infants who had received erythropoietin treatment and were diagnosed with a haemangioma.
Haemangiomas were diagnosed in 4.3% (n=110) of the 2563 preterm infants. These 110 infants had a median gestational age of 29 weeks (IQR 27–33 weeks) and the female:male ratio was 1.8:1. A higher incidence of haemangiomas (12–15%) was detected in premature infants with a lower gestational age (<31 weeks). Erythropoietin therapy was shown to be an independent risk factor after adjusting for all other known factors and oxygen therapy in multivariable analysis (HR 2.82, 95% CI 1.55 to 5.12). Subgroup analysis revealed that the effect was more pronounced in male than female infants (HR 3.61, 95% CI 1.52 to 8.57).
This retrospective study demonstrates that erythropoietin treatment is associated with an increase in the incidence of these benign vascular tumours after adjusting for all other factors.
Posthaemorrhagic ventricular dilatation (PHVD) is a serious complication of prematurity with subsequent disabilities. The diagnostic and therapeutic approaches to PHVD vary among neonatal centres.
To gain more insight into the different diagnostic criteria and treatment policies on PHVD among neonatal intensive care units across Europe.
A PHVD questionnaire was designed and sent to neonatologists in 37 European centres.
A response was obtained from 32/37 (86%) centres located in 17 European countries. An overall estimated incidence of 7% was reported for severe intraventricular haemorrhages (grades III or IV according to Papile) among premature neonates born below 30 weeks’ gestation. Approximately half of these infants developed PHVD, of whom three-quarters required intervention. Ultrasound measurements of ventricular size were most commonly used to diagnose PHVD (94%). No consensus existed on which ventricular parameters needed to be enlarged and when to start treatment of PHVD. Early intervention (ie, initiated after the ventricular index (VI) exceeded the 97th percentile (p97) according to Levene) was provided in 8/32 centres (25%), whereas 23/32 centres (72%) first started therapy once the VI had crossed the p97+4 mm line and/or when neonates presented with a progressive increase in head circumference or with clinical symptoms of raised intracranial pressure. Wide variation was seen with respect to the applied therapy modalities for cerebrospinal fluid drainage.
This survey shows that diagnostic and therapeutic approaches to neonates with PHVD vary considerably. Uniform diagnostic criteria would facilitate studies to assess optimal timing and mode of intervention.
To evaluate enteral feeding practices in neonatal units in different countries and on different continents.
A web-based survey of 127 tertiary neonatal intensive care units in Australia, Canada, Denmark, Ireland, New Zealand, Norway, Sweden and the UK.
124 units (98%) responded. 59 units (48%) had a breast milk bank or access to donor human milk (Australia/New Zealand 2/27, Canada 6/29, Scandinavia 20/20 and UK/Ireland 31/48). The proportion of units initiating enteral feeding within the first 24 h of life was: 43/124 (35%) if gestational age (GA) <25 weeks, 53/124 (43%) if GA 25–27 weeks and 88/124 (71%) if GA 28–31 weeks. In general, Scandinavian units introduced enteral feeds the earliest, followed by UK/Ireland. Continuous feeding was routinely used for infants below 28 weeks' gestation in almost half of the Scandinavian units and in approximately one sixth of units in UK/Ireland, but rarely in Australia/New Zealand and Canada. Minimal enteral feeding for 4–5 days was common in Canada, but rare in Scandinavia. Target enteral feeding volume in a ‘stable’ preterm infant was 140–160 ml/kg/day in most Canadian units and 161–180 ml/kg/day or higher in units in the other regions. There were also marked regional differences in criteria for use and timing when human milk fortifier was added.
This study highlights areas of uncertainty and demonstrates marked variability in feeding practices. It provides valuable data for planning collaborative feeding trials to optimise outcome in preterm infants.
Transfusion guidelines prohibit co-infusion of maintenance intravenous fluid solutions, with significant consequences for neonatal clinical care. This study investigated co-infusion–related haemolysis in an in vitro model closely resembling clinical practice.
Packed red blood cells (PRBCs, n=8) were co-infused at 5 and 10 ml/h with dextrose 5%, 10% and intravenous amino acid solution (synthamin). Free haemoglobin (fHb), as a measure of haemolysis, was measured by spectrophotometry and presented as % haemolysis and total fHb content (µmol/l).
Following co-infusion, there was no significant increase in PRBC haemolysis with either type of solution co-infused (p=0.82) or infusion rate (p=0.5). Neither macroscopic nor microscopic agglutination was observed during co-infusion for any type of solution co-infused.
Co-infusion does not result in increased haemolysis, with total fHb significantly lower than currently accepted safe thresholds for fHb. Adherence to current guidelines may place undue restrictions on current transfusion practice in neonatal intensive care.
Burns due to alcohol-based chlorhexidine (Chx) solutions have been reported in neonates.
In 2010, the NPSA (National Patient Safety Agency) reported that, over a 1-year period, 507 incidents involving gentamicin treatment of neonates were notified,
The concerns about aminoglycoside toxicity in neonates are largely theoretical, because there is virtually no evidence of normal aminoglycoside dosing causing significant hearing impairment in neonates.
In an attempt to support their conclusion, they compare ibuprofen area under the curve (AUC) 0->24 generated by their study with data generated by two studies of intravenous ibuprofen.
A possible association between IVIg therapy and necrotising enterocolitis (NEC) has been suggested from population studies.
The UK Neonatal Transport Interest Group devised a dataset in 2005 to compare transport teams. The major problem encountered was defining mutually exclusive categories of transfer. The terms ‘planned’ and ‘unplanned’ were agreed, with ‘time-critical’ added following publication of the Neonatal Toolkit.
Is this apparent disparity between teams due to a classification issue? We sent a questionnaire to transport service leads in the UK in December 2010, comprising 10 hypothetical transport scenarios. Respondents...]]>
The Neonatal Survey (TNS) is a validated survey collecting neonatal outcome data. Neonatal encephalopathy (NE) is used as a proxy measure of HIE; grade 2 NE cases require anticonvulsant therapy, grade 3 NE requiring either ventilation and anticonvulsant therapy (grade 3a) or ventilation following birth depression (grade 3b). Previous audits of the criteria suggest a false-positive rate of 10%.
Marked variations in the reported rates of HIE are seen in TNS, the rate in the Leeds Teaching Hospitals NHS Trust approaches six times that of other tertiary units. (Rate per 1000 live births (95% CI) 2007–2009, Leeds Hospital 3.4 (2.5 to 4.6), other tertiary unit 0.4 (0.2 to 0.8).)