Does an elevated midline head position prevent periventricular–intraventricular haemorrhage in extremely low birth weight neonates?

Abstract

Germinal matrix-intraventricular haemorrhage (IVH) of the premature infant is the most common form of neonatal intracranial haemorrhage. A portion of infants with IVH suffer a related parenchymal injury called periventricular haemorrhagic infarction. Fluctuations in cerebral blood flow and increases in cerebral venous pressure have been implicated in the pathogenesis of these injuries (1). Head position can affect cerebral haemodynamics and has been evaluated for preventing IVH (2). A recent systematic review evaluated trials involving head positioning strategies to prevent IVH, reviewed two trials (n = 110), and found insufficient evidence to determine the effectiveness of a particular strategy (3). Both trials reviewed and examined the effect of head rotation. No trials were identified which investigated head elevation (3,4). The current study aims to close this knowledge gap. This single-centre, prospective, randomized trial compared the use of an elevated midline head position to a flat head position for the prevention of intracranial haemorrhage in neonates <1000 g at birth. Baseline characteristics differed among the groups with more preeclampsia in the treatment group and more prolonged rupture in the control group. There was no difference in the primary outcome. However, there was improved survival and decreased grade IV (but not grade III) IVH in the treatment group. There was a trend towards escalating respiratory support in the treatment group. Of interest, none of the infants with grade IV IVH developed cystic PVL. A strength of the study included the early enrolment by four hours of life. Although enrolment at birth (with prenatal consent) would be preferred, this may be impractical as flat positioning may be required during initial stabilization procedures. There is a risk for bias with this study as it is unclear if allocation was concealed. Although the interpreting radiologists were blinded, blinding of all caretakers is not possible when evaluating this intervention. It is unclear if the effect of the intervention was due to the absence of periodic turning or the elevation, as infants in the two groups were treated differently in both regards. In fact, the control group may have been affected by compromised venous return due to turning the head only rather than head and body. A weakness of the study is the lack of longterm developmental follow-up. As demonstrated in the largest trial of prophylactic indomethacin, a decrease in severe IVH does not always produce an improvement in longterm developmental outcome (5). Another weakness is the lack of magnetic resonance imaging (MRI) to assess for periventricular leukomalacia (PVL). Mean blood pressures were slightly higher in the elevated group, but cerebral perfusion may have been affected by the elevation placing the infants at risk for PVL. These results suggest that an elevated head position may be beneficial over flat supine head positioning with periodic turning for improving survival and decreasing grade IV IVH. Further, the results suggest that the control and intervention conditions are both safe with no harm shown in either group. With the differences in baseline characteristics, lack of allocation concealment, lack of MRI to assess for PVL, and most importantly, lack of developmental followup, it is not possible to strongly suggest a practice change from the results of this trial. However, these results should inform the design of a large, multicentre trial of this simple intervention.