Ann Hickey

Effect of posture on oxygenation and respiratory muscle strength in convalescent infants

Objective: To determine if differences in respiratory muscle strength could explain any posture related effects on oxygenation in convalescent neonates. Methods: Infants were examined in three postures: supine, supine with head up tilt of 45°, and prone. A subsequent study was performed to determine the influence of head position in the supine posture. In each posture/head position, oxygen saturation (Sao2) was determined and respiratory muscle strength assessed by measurement of the maximum inspiratory pressure (Pimax). Patients: Twenty infants, median gestational age 34.5 weeks (range 25–43), and 10 infants, median gestational age 33 weeks (range 30–36), were entered into the first and second study respectively. Results: Oxygenation was higher in the prone and supine with 45° head up tilt postures than in the supine posture (p<0.001), whereas Pimax was higher in the supine and supine with head up tilt of 45° postures than in the prone posture (p<0.001). Head position did not influence the effect of posture on Pimax or oxygenation. Conclusion: Superior oxygenation in the prone posture in convalescent infants was not explained by greater respiratory muscle strength, as this was superior in the supine posture.

Managed Care Network for the assessment of cardiac problems in children in a district general hospital: a working model.

Aim: To assess a model for cardiology assessments in children with suspected heart disease by a general paediatrician with special expertise in paediatric cardiology (PsePC) in a district general hospital. Methods: A new monthly “screening” clinic was established in May 2004 by the PsePC to reduce the burden of new referrals on outreach tertiary paediatric cardiology services. All patients were to have echocardiograms as part of their referral for cardiac assessment. Over a one year period (May 2004–April 2005), through audit, details of referrers, indications for referral, echocardiography assessments, and subsequent management were recorded. This was compared with the pattern of patients seen in the joint paediatric cardiology outreach clinics over a two year period (May 2003–April 2005). Results: In the “screening” clinic, there were 75 appointments for 65 patients seen in 12 months. Fifty five of these patients had normal echocardiographic studies. Of the 47 referrals with heart murmurs in asymptomatic children, four had structurally abnormal hearts on echocardiographic assessment. Between May–October 2003 and November 2003–April 2004, the number of new patients with normal echocardiographic studies seen in the paediatric cardiology outreach clinic was 33/106 (31%) and 28/110 (25.4%) respectively. Following the introduction of the “screening” clinic, the number decreased to 21/99 (21%) during May–October 2004, and 10/102 (9.8%) during November 2004–April 2005. Conclusion: This model can work effectively in order to identify pathology requiring input of a paediatric cardiologist more appropriately. Paediatricians with specific training in paediatric cardiology are potentially well equipped to provide this basic screening service.

Work of breathing during CPAP and heated humidified high-flow nasal cannula

Objective To determine whether continuous positive airway pressure (CPAP) compared with heated humidified, high-flow nasal cannula (HHFNC) in infants with evolving or established bronchopulmonary dysplasia (BPD) reduced the work of breathing (WOB) and thoracoabdominal asynchrony (TAA) and improved oxygen saturation (SaO2). Design Randomised crossover study. Setting Tertiary neonatal unit. Patients 20 infants (median gestational age of 27.6 weeks (range 24.6–31.9 weeks)) were studied at a median postnatal age of 30.9 weeks (range 28.1–39.1 weeks). Interventions Infants were studied on 2 consecutive days. On the first study day, they were randomised to either CPAP or HHFNC each for 2 h, the order being reversed on the second day. Main outcome measures The WOB was assessed by measuring the pressure time product of the diaphragm (PTPdi). PTPdi, TAA and SaO2 were assessed during the final 5 min of each 2 h period and the results on the two study days were meaned. Results There were no significant differences in the results on CPAP versus HHFNC: mean PTPdi 226 (range 126–294) versus 224 cm H2O/s/min (95% CI for difference: −27 to 22; p=0.85) (range 170–318) (p=0.82), mean TAA 13.4° (range 4.51°–23.32°) versus 14.01° (range 4.25°–23.86°) (95% CI for difference: −3.9 to 2.8: p=0.73) (p=0.63) and mean SaO2 95% (range 93%–100%) versus 95% (94%–99%), (95% CI for difference −1.8 to 0.5; p=0.25) (p=0.45). Conclusion In infants with evolving or established BPD, CPAP compared with HHFNC offered no significant advantage with regard to the WOB, degree of asynchrony or oxygen saturation.

High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia

Objective To determine whether the time to achieve full oral feeding differed between infants with bronchopulmonary dysplasia (BPD) supported by nasal continuous positive airway pressure (nCPAP) compared with those supported by nCPAP and subsequently transferred to heated, humidified, high-flow nasal cannula oxygen (HHFNC). Design Two-cohort comparison. Setting Tertiary neonatal unit. Patients –72 infants, median gestational age 27 (range 24–32) weeks in the nCPAP group, and 44 infants, median gestational age 27 (range 24–31) weeks in the nCPAP/HHFNC group. Interventions Between 2011 and 2013, infants post extubation were supported by nCPAP and from 2013 infants were supported by nCPAP and then HHFNC. Main outcome measures The postnatal age at which oral feeds were first trialled and full oral feeds established. The length of respiratory support as either nCPAP or nCPAP/HHFNC and the total length of respiratory support and hospital stay were also determined. Subanalysis was undertaken of infants requiring respiratory support beyond 34 weeks postmenstrual age (PMA). Results The postnatal age at trial of first oral feeds was earlier in the nCPAP/HHFNC group (p=0.012), but infants were a shorter time on nCPAP compared with nCPAP/HHFNC (p=0.003). On subgroup analysis, the age to achieve full oral feeds was earlier in the nCPAP/HHFNC group (p<0.001). Conclusions In infants with BPD who required respiratory support beyond 34 weeks PMA, use of nCPAP then HHFNC was associated with earlier establishment of full oral feeds. Consideration should be given to assessing stable BPD infants with regard to oral feeding while on CPAP.

Admissions for hypoglycaemia after 35 weeks of gestation: perinatal predictors of cost of stay

Abstract Background: Hypoglycaemia accounts for approximately one-tenth of term admissions to neonatal units can cause long-term neurodevelopmental impairment and is associated with the significant burden to the affected infants, families and the health system. Objective: To define the prevalence, length and cost of admissions for hypoglycaemia in infants born at greater than 35 weeks gestation and to identify antenatal and perinatal predictors of those outcomes. Materials and methods: This was a retrospective audit of infants admitted for hypoglycaemia between 1 January 2012 and 31 December 2015, in a level three neonatal intensive care unit at King’s College Hospital NHS Foundation Trust, London. The main outcome measures were the prevalence, length and cost of admissions for hypoglycaemia and antenatal and postnatal predictors of the length and cost of the stay. Results: There were 474 admissions for hypoglycaemia (17.8% of total admissions). Their median (IQR) blood glucose on admission was 2.1 (1.7–2.4) mmol/l, gestation at delivery 38.1 (36.7–39.3) weeks, birthweight percentile 31.4 (5.4–68.9), their length of stay was 3.0 (2.0–5.0). Admissions equated to a total of 2107 hospital days. The total cost of the stay was 1,316,591 Great Britain pound. The antenatal factors associated with admission for hypoglycaemia were maternal hypertension (19.8%), maternal diabetes (24.5%), foetal growth restriction (FGR) (25.9%) and pathological intrapartum cardiotocograph (23.4%). In 13.7% of cases, there was no associated pregnancy complication. Multivariate logistic regression analysis demonstrated lower gestational age, z-score birthweight squared, exclusive breastfeeding and maternal prescribed nifedipine were independently associated with the length and cost of the stay. Conclusion: Hypoglycaemia accounted for approximately one-fifth of admissions after 35-week gestation. Lower gestational age and admission blood glucose, low and high z-score birthweight, maternal nifedipine and exclusive breastfeeding are associated with longer duration of stay.

Mortality following congenital diaphragmatic hernia repair: the role of anesthesia.

Mortality following surgical repair of congenital diaphragmatic hernia (CDH) remains high. The volume and type of perioperative intravenous fluid administered, baro‐trauma, oxygen toxicity, and the duration of anesthesia are thought to affect outcome in surgical populations.

Mortality and short-term morbidity in infants with exomphalos

Infants with exomphalos major have a high mortality and morbidity. The aims of this study were to identify predictors of survival regardless of the size of the exomphalos, and to analyze morbidity in infants with exomphalos minor.

Physiological and anatomical dead space in mechanically ventilated newborn infants

To compare the anatomical (VD‐Ana) and alveolar dead space (VD‐Alv) in term and prematurely born infants and identify the clinical determinants of those indices.

Small for gestational age and extremely low birth weight infant outcomes

Abstract Background Small for gestational age (SGA) infants are less likely to develop respiratory distress syndrome (RDS), but more likely to develop bronchopulmonary dysplasia (BPD) and have a higher mortality. Our aim was to focus on outcomes of those with a birth weight less than or equal to 750 g. Methods The mortality, BPD severity, necrotising enterocolitis (NEC), home oxygen requirement and length of hospital stay were determined according to SGA status of all eligible infants in a 5-year period admitted within the first 24 h after birth. Results The outcomes of 84 infants were assessed, and 35 (42%) were SGA. The SGA infants were more mature (P<0.001), had a lower birth weight centile (P<0.001) and a greater proportion exposed to antenatal corticosteroids (P=0.022). Adjusted for gestational age (GA), there was no significant difference in mortality between the two groups (P=0.242), but a greater proportion of the SGA infants developed severe BPD (P=0.025). The SGA infants had a lower weight z-score at discharge (−3.64 vs. −1.66) (P=0.001), but a decrease in z-score from birth to discharge was observed in both groups (median −1.53 vs. −1.07, P=0.256). Conclusion Despite being more mature, the SGA infants had a similar mortality rate and a greater proportion developed severe BPD.

G202(P) Outcomes of extremely low birth weight infants – the effect of being small for gestational age

Aims Prematurely-born infants who are small for gestational age (SGA) have worse outcomes than those who are born appropriate for gestational age (AGA).1,2 There has, however, been little focus on SGA infants born at extremely low birth weights (BW <750 g). Methods A retrospective study was undertaken of all babies BW <750 gm born between 2012 and 2016. Centiles and z-scores were calculated using the UK WHO preterm reference ranges (British 1990 reference data, reanalysed 2009). The infants were divided into SGA (<10 th centile) and AGA (10th – 90th centile) groups. Multiple logistic regression analysis was performed to adjust for gestational age to relate individual outcome variables to SGA. Results Eighty-four infants were included, 35 (42%) were SGA. The SGA infants were more mature (median gestational age 26.9 versus 24.3 weeks, p<0.001), had a lower birth weight centile (median 1 versus 26, p<0.001); their mothers were more likely to have received antenatal steroids (94% versus 78%, p=0.022), had hypertension (49% versus 8%, p<0.001) and be delivered by caesarean section (69% versus 8%, p<0.001). Neither the mortality (31% versus 32%) nor the incidence of NEC (17% versus 16%) differed significantly between the two groups, but more of the SGA developed severe BPD (p=0.025). The SGA infants achieved full enteral feeds at an older postnatal age (median 54 versus 48 days, p=0.019). The length of stay was similar in the two groups (127 versus 131 days), but the weight z score at discharge was lower in the SGA group (−3.6 versus −1.7) (p=0.001). Indeed, there was no significant difference in the change in z score from birth between the two groups (median −1.53 versus −1.07, p=0.306). Conclusions Amongst infants with a BW <750 gm, SGA compared to AGA suffered greater morbidity, but not mortality. These data are important for counselling parents as, in this population, any advantage of later gestation may be negated by being SGA. References . Peacok JL, et al. Pediatr Res2013;73:457–63. . Tsai L-Y, et al. Pediatr Neonatol2015;56:101–7.