Emily A Kieran

Randomized Trial of Prongs or Mask for Nasal Continuous Positive Airway Pressure in Preterm Infants

OBJECTIVE: To determine whether nasal continuous positive airway pressure (NCPAP) given with nasal prongs compared with nasal mask reduces the rate of intubation and mechanical ventilation in preterm infants within 72 hours of starting therapy. METHODS: Infants <31 weeks’ gestation treated with NCPAP were randomly assigned to receive it via either prongs or mask. Randomization was stratified by gestational age (<28 weeks, 28–30 weeks) and according to whether NCPAP was started as a primary treatment for respiratory distress or postextubation. Infants were intubated and ventilated if they fulfilled 2 or more of 5 failure criteria (worsening signs of respiratory distress; recurrent apnea treated with mask positive pressure ventilation; fraction of inspired oxygen >0.4 to keep oxygen saturation >88% sustained for 30 minutes; pH <7.2 on 2 blood gases ≥30 minutes apart; Pco2 >9 kPa [68 mm Hg] on 2 blood gases ≥30 minutes apart) within 72 hours of starting therapy. The groups were treated the same in all other respects. We recorded relevant secondary outcomes and analyzed data by using the intention-to-treat principle. RESULTS: We enrolled 120 infants. Thirty-two of 62 (52%) infants randomly assigned to prongs were intubated within 72 hours, compared with 16/58 (28%) of those randomly assigned to mask (P = .007). There were no statistically significant differences between the groups in any secondary outcomes. CONCLUSIONS: In premature infants, NCPAP was more effective at preventing intubation and ventilation within 72 hours of starting therapy when given via nasal masks compared with nasal prongs.

Survey of nasal continuous positive airways pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) use in Irish newborn nurseries

Nasal continuous positive airways pressure (NCPAP) reduces duration of ventilation and extubation failure in preterm infants with respiratory distress.1 Although starting preterm infants on NCPAP without prior ventilation (ie, primary treatment of respiratory distress) is as effective a strategy as routine ventilation2 and surfactant,3 NCPAP is rarely used in this way in the UK (reportedly 2% of units).4 A systematic review of interfaces and pressure sources found binasal prongs to be more effective than a single prong.5 A superior pressure source was not identified, although a recent randomised trial found advantages with bubble NCPAP (Fisher & Paykel Healthcare, Auckland, New Zealand) compared to the Infant Flow Driver (Viasys, Warwick …

Unlicensed and off-label drug use in an Irish neonatal intensive care unit: a prospective cohort study.

Many drugs are not licensed for use in children and drugs that are licensed may be given to them in an unapproved manner. We wanted to determine the extent of unlicensed and off‐label prescribing in our neonatal intensive care unit (NICU).

Estimating umbilical catheter insertion depth in newborns using weight or body measurement: a randomised trial

Objective Incorrectly positioned umbilical venous and arterial catheters (UVC and UAC) are associated with increased rates of complications in newborns. Catheter insertion depth is often estimated using body surface measurement. We wished to determine whether estimating insertion depth of umbilical catheters using birth weight (BW), rather than surface measurements, results in more correctly positioned catheters. Interventions/outcome Newborns were randomised to have UVC and UAC insertion depth estimated using formulae based on BW or using graphs based on shoulder-umbilicus length. The primary outcome was correct catheter tip position on X-ray determined by one radiologist masked to group assignment. Results UVC insertion was successful in 97/101 (96%) infants but the catheter was not advanced to the estimated depth in 22. There was no difference in the proportion of correctly positioned UVCs between groups (weight 16/51 (31%) vs measurement 13/46 (28%), p=0.826). The tips of 52 (54%) UVCs were in the portal venous system or too low on X-ray. Attempted UAC insertion was successful in 62/87 (71%) infants. More infants in the weight group had a correctly positioned UAC tip (weight 29/32 (91%) vs measurement 15/30 (50%), p=0.001). Conclusions UVCs were often not inserted to the estimated depth, and their tips were in the portal venous system or too low on X-ray. Using BW to estimate insertion depth did not result in more correctly positioned UVCs. UAC insertion attempts were often unsuccessful, but when successful, using BW to estimate insertion depth resulted in more correctly positioned catheters. Trial registration number (ISRCTN17864069).

Serum magnesium in the first week of life in extremely low birth weight infants.

Background: Evidence that antenatal administration of magnesium sulfate (MgSO4) to women in preterm labor may confer fetal neuroprotection is growing. MgSO4 crosses the placenta and can affect the neonate. Magnesium homeostasis in extremely low birth weight (ELBW) infants remains to be clarified. Objectives: We aimed to assess the natural progression of serum magnesium (Mg) in ELBW infants not exposed to antenatal MgSO4 during the first month of life. Methods: Laboratory data of a group of ELBW infants born in a tertiary center over a 1-year period were analyzed. Serum Mg was recorded daily for the first week and thereafter each week for a month for each infant. Concurrent calcium, phosphate and alkaline phosphatase were measured. Results: 51 preterm infants (24 female) with a birth weight <1,000 g were included (33 were born at <27 weeks’ gestation). The mean magnesium ranged from 0.9 to 1.1 mmol/l over the first week with a minimum of 0.62 mmol/l and maximum of 1.53 mmol/l. Mg rises in the first few days before stabilizing and remains within a narrow range thereafter. Conclusions: In ELBW infants, Mg tends to rise initially then stabilize and remain normal thereafter. The effect of antenatal MgSO4 on magnesium homeostasis requires further study.

2% chlorhexidine–70% isopropyl alcohol versus 10% povidone–iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial

Objective To determine whether 2% chlorhexidine gluconate–70% isopropyl alcohol (CHX–IA) is superior to 10% aqueous povidone–iodine (PI) in preventing catheter-related blood stream infection (CR-BSI) when used to clean insertion sites before placing central venous catheters (CVCs) in preterm infants. Design Randomised controlled trial. Setting Two neonatal intensive care units (NICUs). Patients Infants <31 weeks’ gestation who had a CVC inserted. Interventions Insertion site was cleaned with CHX–IA or PI. Caregivers were not masked to group assignment. Main outcome measures Primary outcome was CR-BSI determined by one microbiologist who was masked to group assignment. Secondary outcomes included skin reactions to study solution and thyroid dysfunction. Results We enrolled 304 infants (CHX–IA 148 vs PI 156) in whom 815 CVCs (CHX–IA 384 vs PI 431) were inserted and remained in situ for 3078 (CHX–IA 1465 vs PI 1613) days. We found no differences between the groups in the proportion of infants with CR-BSI (CHX–IA 7% vs PI 5%, p=0.631), the proportion of CVCs complicated by CR-BSI or the rate of CR-BSI per 1000 catheter days. Skin reaction rates were low (<1% CVC insertion episodes) and not different between the groups. More infants in the PI group had raised thyroid-stimulating hormone levels and were treated with thyroxine (CHX–IA 0% vs PI 5%, p=0.003). Conclusions We did not find a difference in the rate of CR-BSI between preterm infants treated with CHX–IA and PI, and more infants treated with PI had thyroid dysfunction. However, our study was not adequately powered to detect a difference in our primary outcome and a larger trial is required to confirm our findings. Trial registration This study was registered with the EU clinical trials register before the first patient was enrolled (Eudract 2011-002962-19). (https://www.clinicaltrialsregister.eu)

Positioning newborns on their back or right side for umbilical venous catheter insertion.

Newborns are placed supine for umbilical venous catheter insertion, and catheter tip position is confirmed with X‐ray. Umbilical venous catheters are considered correctly positioned when the tip is in the inferior vena cava; however, frequently, the catheter tip enters the portal venous circulation. We wished to determine whether placing infants on their right side, rather than on the back, for umbilical venous catheter insertion results in more correctly placed catheters.

Variation in size of laryngoscope blades used in preterm newborns

Many preterm infants are intubated for breathing support and/or surfactant administration. Intubation attempts in newborns are often unsuccessful.1 ,2 Laryngoscopes are used to visualise the vocal cords when attempting intubation. To successfully intubate a baby, the operator needs a good view of the larynx and vocal cords. If the blade of the laryngoscope is too short, the vocal cords will not be visualised.3 If the blade is too long, it may cause trauma to fragile structures in the oropharynx. Inadequate views of the vocal cords have been identified as the reason for the majority of failed intubation attempts in the delivery room.1 Poor visualisation of the vocal cords can also increase the duration …

A randomised trial of placing preterm infants on their back or left side after birth

Background Basic life support guidelines recommend placing spontaneously breathing children and adults on their side. Though the majority of preterm newborns breathe spontaneously, they are routinely placed on their back after birth. We hypothesised that they would breathe more effectively when placed on their side. Objective To determine whether preterm newborns placed on their left side at birth, compared with those placed on their back, have higher preductal oxygen saturation (SpO2) at 5 min of life. Design/methods We randomised infants <32 weeks to be placed on their back or on their left side immediately after birth. Respiratory support was given with a T-piece and face mask with initial fraction of inspired oxygen (FiO2) of 0.3. The FiO2 was increased if SpO2 was <70% at 5 min. Results We enrolled 87 infants, 41 randomised to back and 46 to left side. The groups were well matched for demographic variables. Fourteen (6 back and 8 left side) infants did not receive respiratory support in the first 5 min. The mean (SD) SpO2 was not different between the groups (back 72 (23) % versus left side 71 (24) %, p=0.956). We observed no adverse effects of placing infants on their side and found no differences in secondary outcomes between the groups. Conclusions Preterm infants on their left side did not have higher SpO2 at 5 min of life. Placing preterm infants on their side at birth is feasible and appears to be a reasonable alternative to placing them on their back. Trial registration number ISRCTN74486341.

Accuracy of length measurements on neonatal umbilical catheters.

Umbilical venous catheters (UVCs) and umbilical arterial catheters (UACs) are marked at intervals indicating the distance in centimetres (cm) from the tip. When inserting umbilical catheters, clinicians estimate the depth to which they should insert them using birth weight1 or shoulder, umbilicus length,2 and secure them at this depth as indicated on the catheter. Complications occur more frequently with umbilical catheters when the tip is incorrectly positioned.3 ,4 We suspected that the marks on UVCs and UACs might not accurately indicate the …