James R Holberton

Comparison of the pharyngeal pressure provided by two heated, humidified high-flow nasal cannulae devices in premature infants

This study aims to determine if there is a difference in the pharyngeal pressure, measured as a surrogate for continuous positive distending airway pressure, delivered to premature infants between two commonly used heated, humidified high‐flow nasal cannulae (HHHFNC) devices: Fisher & Paykel Healthcare HHHFNC and Vapotherm 2000i.

Docosahexaenoic Acid and Bronchopulmonary Dysplasia in Preterm Infants

BACKGROUND Studies in animals and in humans have suggested that docosahexaenoic acid (DHA), an n‐3 long‐chain polyunsaturated fatty acid, might reduce the risk of bronchopulmonary dysplasia, but appropriately designed trials are lacking. METHODS We randomly assigned 1273 infants born before 29 weeks of gestation (stratified according to sex, gestational age [<27 weeks or 27 to <29 weeks], and center) within 3 days after their first enteral feeding to receive either an enteral emulsion providing DHA at a dose of 60 mg per kilogram of body weight per day or a control (soy) emulsion without DHA until 36 weeks of postmenstrual age. The primary outcome was bronchopulmonary dysplasia, defined on a physiological basis (with the use of oxygen‐saturation monitoring in selected infants), at 36 weeks of postmenstrual age or discharge home, whichever occurred first. RESULTS A total of 1205 infants survived to the primary outcome assessment. Of the 592 infants assigned to the DHA group, 291 (49.1% by multiple imputation) were classified as having physiological bronchopulmonary dysplasia, as compared with 269 (43.9%) of the 613 infants assigned to the control group (relative risk adjusted for randomization strata, 1.13; 95% confidence interval [CI], 1.02 to 1.25; P=0.02). The composite outcome of physiological bronchopulmonary dysplasia or death before 36 weeks of postmenstrual age occurred in 52.3% of the infants in the DHA group and in 46.4% of the infants in the control group (adjusted relative risk, 1.11; 95% CI, 1.00 to 1.23; P=0.045). There were no significant differences between the two groups in the rates of death or any other neonatal illnesses. Bronchopulmonary dysplasia based on a clinical definition occurred in 53.2% of the infants in the DHA group and in 49.7% of the infants in the control group (P=0.06). CONCLUSIONS Enteral DHA supplementation at a dose of 60 mg per kilogram per day did not result in a lower risk of physiological bronchopulmonary dysplasia than a control emulsion among preterm infants born before 29 weeks of gestation and may have resulted in a greater risk. (Funded by the Australian National Health and Medical Research Council and others; Australian New Zealand Clinical Trials Registry number, ACTRN12612000503820.)

A weight-based formula for the estimation of gastric tube insertion length in newborns.

OBJECTIVE:Safe and effective functioning of nasogastric and orogastric tubes in the neonatal intensive care unit (NICU) is achieved by ensuring their correct placement within the stomach. Insertion length has traditionally been estimated using morphological measures, but studies have indicated that these are frequently inaccurate. This study aimed to evaluate the frequency of correct tube placement and to determine a weight-based formula for estimation of insertion length. STUDY DESIGN:A prospective study was performed over a 6-month period in a tertiary NICU. Infants with gastric tubes who required radiography for clinical reasons were included. The infants weight and the type and length of tube were documented. A radiologist assessed the tube position to be high, borderline, correct, or long. RESULTS:A total of 218 radiographs of infants weighing 397 to 4131 g were included. Correct tube position was achieved on 74% of occasions. By analyzing data for correct tube positions, formulas were derived to predict tube insertion length in centimeters: orogastric = [3 × weight (kg) + 12] and nasogastric = [3 × weight (kg) + 13]. The formulas correctly predicted 60% of misplaced orogastric tubes and 100% of misplaced nasogastric tubes. CONCLUSION:We propose a novel weight-based formula for estimation of gastric tube insertion length in newborn infants to improve the accuracy of this routine procedure.

Neonatal outcomes after introduction of a national intrapartum fetal surveillance education program: a retrospective cohort study.

Abstract Objective: To determine the impact of a multidisciplinary fetal surveillance education program (FSEP) on term neonatal outcomes. Methods: A retrospective cohort study of term neonatal outcomes before (1998–2004) and after (2005–2010) introduction of a FSEP. Clinical data was collected for all term infants admitted to a neonatal intensive care unit (NICU) in Australia between 1998 and 2010. Infants with congenital abnormalities were excluded. Neonatal mortality and severe neonatal morbidity (admission to a NICU, respiratory support, hypoxic encephalopathy) were compared before and after the FSEP was introduced. The rates of operative delivery during this time were assessed. Results: There were 3 512 596 live term births between 1998 and 2010. The intrapartum hypoxic death rate at term decreased from 2.02 to 1.07 per 10 000 total births. More neonates were admitted to NICU after 2005 (10.6 versus 14.6 per 10 000 live births), however fewer babies admitted to the neonatal unit had Apgar scores < 5 at five minutes (55.1–45.5%, RR 0.82, 95% CI 0.7–0.87); and rates of hypoxic ischemic encephalopathy fell from 36% to 30% (RR 0.83, 95% CI 0.76–0.90). There was no increase in rates of emergency in labour caesarean sections (11.7% pre versus 11.1% post, RR 0.95, 95% CI 0.95–0.96). Conclusions: Introduction of a national FSEP was associated with increased neonatal admissions but a reduction in intrapartum hypoxia, without increasing emergency caesarean section rates.

137 High Flow Nasal Cannulae (HFNC) or Nasal Continuous Positive Airway Pressure (NCPAP) Post-Extubation in Premature Infants? a Randomised Controlled Trial

Background NCPAP facilitates successful extubation. It is unclear whether HFNC are as effective as NCPAP in preventing extubation failure. In addition to an alternative modality of respiratory support HFNC may result in less nasal trauma than NCPAP. Methods 132 preterm ventilated infants were randomised and stratified by gestation(< 28 vs 28–32 weeks). Primary outcome was extubation failure defined by a composite of 3 pre-specified failure criteria in the 7 days post-extubation. Individual failure criteria were not mutually exclusive and are defined; Apnoea, > 6 episodes in 6 hours or 1 requiring IPPV, Acidosis, pH< 7.25 & pCO2>66mmHg, and >15% increase in FiO2 from extubation. A nasal trauma score was adapted from Kaufman [E-PAS 2007:61390]. Results Abstract 137 Table 1 HFNC N=67 NCPAP N=65 Male n (%) 33 (49) 41 (63) Birthweight g mean (SD) 1123 (317) 1105 (374) Mean Completed Weeks gestation (SD) 27.9 (1.95) 27.6 (1.97) Failed Extubation in 1st week by Composite Criteria n (%) 15 (22) 22 (34) Apnoea: > 6 in 6hrs or 1 needing IPPV n (%) 14 (21) 17(26) Acidosis:pH < 7.25 & pCO2 > 66mmHg n(%) 0 3 (5) > 15% increase in FiO2 post-extubation n(%) 7 (10) 12 (18) Reintubated in 1st week n(%) 7 (10) 8 (12) Nasal Trauma Score 1st week mean (SD) 3.1 (7.2) 11.8 (10.7) p<0.001* Conclusions Rates of extubation failure were not significantly different between the groups. HFNC resulted in significantly less nasal trauma than NCPAP. This benefit may need to be considered in post-extubation respiratory support for preterm infants.

Amniotic fluid lamellar body concentration as a marker of fetal lung maturity at term elective caesarean delivery

Background:  Caesarean birth, without prior labour, is associated with an increased risk of neonatal respiratory morbidity among term infants. The concentration of lamellar bodies in amniotic fluid reflects pulmonary surfactant production and release, and is thus used in preterm populations as a marker of fetal lung maturity. Whether amniotic fluid lamellar body concentration (AFLBC) may correlate with risk factors for term respiratory distress has not previously been evaluated.

Cerebral blood flow velocities and cerebrovascular resistance in normal-term neonates in the first 72 hours

To determine the range of cerebral blood flow velocities (CBFVs) and Doppler indices of cerebrovascular resistance in normal‐term neonates as a baseline for a study of hypoxic‐ischaemic encephalopathy.

Reference Echocardiographic Measurements in Very Low Birth Weight Preterm Infants

Background Echocardiography is an important technique in neonatal care. The heart of a premature baby is known to be different from that of a term baby, and there is a paucity of literature regarding reference cardiac measurements for this population, especially for the very low birth weight (VLBW) infants. Objective We aimed to present reference values for echocardiography in VLBW preterm infants. Study Design This was a retrospective observational study taking place over an 11‐year period. We collected data from the reports of echocardiographic examinations performed in a population of preterm infants born with gestational age ≤ 32 weeks and birth weight (BW) ≤ 1,500 g in the first week of life. Results Our study population included 1,244 preterm infants. We found BW to be an adequate and practical variable to use in relation to the cardiac measurements. We propose reference values for seven cardiac measurements presented in tables for each 100 g weight subgroup. Conclusion Our study, to the best of our knowledge, has the largest sample of VLBW preterm infants and provides easy‐to‐use information on cardiac measurements by echocardiography for both pediatric cardiologists and neonatologists.

Current practice of pulse oxygen saturation targets and limits in neonatal intensive care units in Australia and New Zealand

Lower pulse oxygen saturation (SpO2) targets have been advocated for preterm infants over the last decade and have been associated with less morbidity (1–3). However, most data are based on observational studies. Only one randomized-controlled trial compared two SpO2 target regimens, 91–94% versus 95–98%, in preterm infants born <30 weeks gestational age once they had reached a corrected age of 32 weeks gestational age. This trial showed a significant increase in bronchopulmonary dysplasia and home oxygen therapy in the high-saturation study arm but no difference in mortality or retinopathy of prematurity (4). Further controlled studies were lacking until recently. In 2010, the SUPPORT trial revealed a moderate, though, significant increase in mortality in extremely low gestational age infants when nursed in SpO2 targets of 85–89% versus 91– 95% (5). Subsequently, the BOOST-II trials in the UK, Australia and New Zealand with a similar study design closed enrolment prematurely following a preliminary meta-analysis of their and the SUPPORT trial’s mortality data (6). A pooled analysis confirmed better survival in the higher SpO2 target group. Long-term outcome data are not available yet. We surveyed current practice of SpO2 targets and limits in neonatal intensive care units (NICU) in Australia and New Zealand 5 months after publication of the preliminary SUPPORT ⁄ BOOST-II meta-analysis. An email survey was sent to all 26 tertiary NICUs in Australia and New Zealand in September 2011. A reminder email was sent 3 weeks after the first email to those who had not replied to the survey. The survey included the following items: • Did your NICU participate in the BOOST-II trial? • Please specify your unit’s SpO2 targets ⁄ limits according to gestational age before publication of the SUPPORT trial. • Did your unit change your SpO2 targets ⁄ limits after publication of the SUPPORT trial in May 2010? • Did your unit change your SpO2 targets ⁄ limits after closure of BOOST-II recruitment and communication of its preliminary results in April 2011? • If your unit changed SpO2 targets ⁄ limits, please specify your new SpO2 targets ⁄ limits. • If your unit has not changed the SpO2 targets ⁄ limits, are you considering a change, or will you keep your current SpO2 targets ⁄ limits? All survey participants consented their survey data to be used for publication. As the survey did not include any patient data, ethics committee approval was not sought. Twenty (76.9%) completed surveys returned after the reminder email. Of those, 18 NICUs participated in the BOOST-II trial. None of the units changed their SpO2 targets ⁄ limits after publication of the SUPPORT trial; however, eleven NICUs changed them following the communication of the preliminary mortality analysis of the pooled SUPPORT ⁄ BOOST-II data. Table 1 shows those NICUs that have made changes to their SpO2 targets ⁄ limits; Table 2 shows those that have not made any changes. Our survey, conducted 5 months after publication of the preliminary meta-analysis, shows a rather scattered picture how tertiary neonatal units in Australia and New Zealand managed SpO2 targets prior to the preliminary meta-analysis, and how they responded to its results. Half of the NICUs used SpO2 targets of 88–92% prior to SUPPORT ⁄ BOOST-II, a range exactly in the middle of the two trialled SpO2 ranges in SUPPORT ⁄ BOOST-II. However, some units used this target for all infants whereas others use higher targets for infants above 31–32 weeks gestation, or for term infants. Five NICUs do not have defined SpO2 targets, and Acta Pædiatrica ISSN 0803–5253