Jamie B. Warren

Plastic Bags for Prevention of Hypothermia in Preterm and Low Birth Weight Infants

BACKGROUND AND OBJECTIVES: Hypothermia contributes to neonatal mortality and morbidity, especially in preterm and low birth weight infants in developing countries. Plastic bags covering the trunk and extremities of very low birth weight infants reduces hypothermia. This technique has not been studied in larger infants or in many resource-limited settings. The objective was to determine if placing preterm and low birth weight infants inside a plastic bag at birth maintains normothermia. METHODS: Infants at 26 to 36 weeks’ gestational age and/or with a birth weight of 1000 to 2500 g born at the University Teaching Hospital in Lusaka, Zambia, were randomized by using a 1:1 allocation and parallel design to standard thermoregulation (blanket or radiant warmer) care or to standard thermoregulation care plus placement inside a plastic bag at birth. The primary outcome measure was axillary temperature in the World Health Organization–defined normal range (36.5–37.5°C) at 1 hour after birth. RESULTS: A total of 104 infants were randomized. At 1 hour after birth, infants randomized to plastic bag (n = 49) were more likely to have a temperature in the normal range as compared with infants in the standard thermoregulation care group (n = 55; 59.2% vs 32.7%; relative risk 1.81; 95% confidence interval 1.16–2.81; P = .007). The temperature at 1 hour after birth in the infants randomized to plastic bag was 36.5 ± 0.5°C compared with 36.1 ± 0.6°C in standard care infants (P < .001). Hyperthermia (>38.0°C) did not occur in any infant. CONCLUSIONS: Placement of preterm/low birth weight infants inside a plastic bag at birth compared with standard thermoregulation care reduced hypothermia without resulting in hyperthermia, and is a low-cost, low-technology tool for resource-limited settings.

Using simulation to enhance the acquisition and retention of clinical skills in neonatology.

Neonatal care occurs in extremely complex and dynamic environments and requires providers to operate under intense time pressure in coordination with multiple disciplines. Teaching the clinical skills requisite to effective practice requires the meticulous application of curricular design principles. Simulation can be used as an effective instructional strategy in achieving learner acquisition and retention of the cognitive, technical, and behavioral skills essential to optimal delivery of care in neonatology.

Newborn respiratory disorders.

1. Jamie B. Warren, MD* 2. JoDee M. Anderson, MD, MEd* 1. *Oregon Health & Science University, Portland, Ore. After completing this article, readers should be able to: 1. Evaluate and diagnose the most common causes of respiratory distress in the newborn period. 2. Differentiate between the normal results of a newborn chest radiograph and the radiographic patterns that reflect neonatal respiratory distress syndrome, meconium aspiration syndrome, retained fetal lung liquid syndrome, and neonatal pneumonia. 3. Recognize subglottic stenosis as a complication of endotracheal intubation. 4. Distinguish between pulmonary disease and cyanotic congenital heart disease as a cause of hypoxemia and acidosis in the neonate. 5. Discuss common complications of various respiratory disorders (such as meconium aspiration syndrome) and the untoward effects of specific therapies (intubation and mechanical ventilation). 6. Describe how chronic lung disease may result from meconium aspiration. Neonatal respiratory disorders account for most admissions to intensive care units in the immediate newborn period. Newborns in respiratory distress must be evaluated promptly and accurately; occasionally, neonatal respiratory distress is life-threatening and requires immediate intervention. The causes of respiratory distress in the newborn are numerous and are due to pulmonary or nonpulmonary processes. (1) Initial stabilization of the neonate, through management of the airway, breathing, and circulation, takes precedence over determining the cause. A thorough initial assessment, including maternal and neonatal history, physical examination, and appropriate use of diagnostic tests, is essential to diagnosing the cause of respiratory distress. Respiratory distress in the neonate most commonly presents as one or all of the following physical signs: tachypnea, grunting, nasal flaring, retractions, and cyanosis. (2) A normal respiratory rate in a newborn is between 30 and 60 breaths/min; tachypnea is classified as respiratory rates greater than 60 breaths/min. Patients born with surfactant deficiency and poorly …

Global neonatal and perinatal mortality: a review and case study for the Loreto Province of Peru

Correspondence: Jamie B Warren Department of Pediatrics, Oregon Health and Science University, 707 SW Gaines, Mail Code CDRC-P Portland, OR 97239, USA Tel +1 503 494 5368 Fax +1 503 494 1542 Email warrenja@ohsu.edu Background: Millennium Development Goal 4 calls for the reduction of the under-five mortality rate by two-thirds between 1990 and 2015. To reach this goal, neonatal mortality must be decreased. The lack of information on global neonatal and perinatal mortality impedes appropriate implementation of interventions, as vital registration systems are not available for the majority of the world’s neonatal deaths. Verbal autopsy (VA) is a tool that has been used to determine cause of death. Recent studies have attempted to standardize and validate the use of this tool in resource-limited areas. The World Health Organization (WHO) International Standard VA Questionnaire was used to conduct a needs assessment in nine rural Peruvian villages. The goal was to determine the neonatal mortality rate (NMR), perinatal mortality rate (PMR), and causes of, and risk factors for, death in these villages. Methods: Eligible women were interviewed using the WHO International Standard VA Questionnaire or a set of questions based on the WHO VA Questionnaire. NMR and PMR were calculated using a generalized estimating equation model. Three neonatologists independently reviewed VA records to provide cause of death determination. Reviewer agreement was assessed using percent agreement. Fisher’s exact test was used to determine risk factors associated with death. Results: The NMR was 31.4 per 1000 live births and the PMR was 49.7 per 1000 pregnancies. The main contributor to neonatal death was infection (43%). Percent agreement among reviewers was 90.5% and 38.9% for cause of neonatal death and stillbirth, respectively. Risk factors for death were pregnancy with twins (P = 0.001), preterm delivery (P = 0.003), and cesarean section delivery (P = 0.049). Conclusion: The WHO VA proved useful for NMR and PMR calculation, cause of death determination, and risk factor identification. Information gathered in this needs assessment will allow for the design and implementation of tailored interventions.

Antenatal betamethasone for women at risk for late preterm delivery reduces the rate of neonatal respiratory complications

This study confirmed that provision of antenatal corticosteroids (ANCS) for threatened late preterm delivery decreases the rate of neonatal respiratory complications. Following this publication, the American Congress of Obstetricians andGynecologists (ACOG)(1)andtheSociety for Maternal Fetal Medicine (SMFM) (2) published guidelines regarding use of ANCS in the late preterm period. Both groups recommend a single course of betamethasone for women with singleton pregnancies between 34 weeks 0 days and 36 weeks 6 days who are at risk for preterm delivery within seven days but before 37 weeks. Both recommend against the delay of amedically indicated delivery or tocolysis to complete a betamethasone course, and both recommend against betamethasone in women who have previously received ANCS or who have a diagnosis of chorioamnionitis. Due to exclusion criteria, results cannot be generalised to populations who may be at higher risk of the outcomes studied (e.g. multiple gestations, congenital anomalies, pregestational diabetes), and SMFM does not recommend use of betamethasone in these excluded populations unless part of a researchprotocol or quality improvementproject. The outcome of concern is neonatal hypoglycaemia. As 24% in the betamethasone group and 15% in the placebo group experienced hypoglycaemia, the number needed to harm is 11. In general, hypoglycaemia is a well-known complication in late preterm infants. In this study, there were no reported adverse events related to hypoglycaemia and infants with hypoglycaemia were discharged on average two days prior to those without, suggesting transient and/or easily treated hypoglycaemia. As stated in the ACOG and SMFM guidelines, it is prudent to follow recommendations of the American Academy of Pediatrics (3) in terms of screening for hypoglycaemia in this at-risk population, regardless of maternal medications. From a respiratory standpoint, these findings have implications for public health. In 2014, 6.82% of the 3 998 076 births in the United States occurred in the late preterm period (almost 272 000 births) (4). While the NNT from this study cannot be directly applied to this total number of late preterm births (due to exclusion criteria), we can presume that implementation of this protocol would positively affect thousands of babies each year. While the intervention did not decrease length of stay, it did decrease the likelihood of spending three or more days in an intermediate care unit or intensive care unit, which could decrease overall cost of care. We must decide whether these respiratory benefits outweigh the risks of increased blood glucose monitoring and treatment of hypoglycaemia in this population. Concerns have been raised about neonatal hypoglycaemia (5) and exposure to ANCS (6) in the late preterm population and subsequent lack of data on neurodevelopmental and other health outcomes, such as hypertension or hormonal abnormalities (7). While these are valid concerns, we also know that respiratory conditions requiring mechanical ventilation, CPAP, or oxygen therapy, even in the late preterm population, also likely have long-term consequences (8). By providing antenatal betamethasone to women at risk for delivering in the late preterm period, avoidance of these outcomes may be possible.

Does umbilical cord milking result in higher measures of systemic blood flow in preterm infants

The American Congress of Obstetricians and Gynecologists recommends a 30–60 s delay in umbilical cord clamping for all preterm deliveries, though limited data regarding outcomes by mode of delivery exists (1). Umbilical cord milking (UCM) is a method to auto-infuse blood into the neonate in a shorter amount of time. A 2011 study comparing UCM with delayed cord clamping (DCC) in infants <33 weeks gestation found no major clinical differences between the groups, though the trial did not stratify outcomes by mode of delivery (2). The reviewed study (Katheria et al.) is the first trial to compare UCM and DCC at Caesarean delivery and to evaluate DCC for more than 30 seconds in preterm infants. The authors hypothesised that UCM after Caesarean delivery would improve systemic blood flow and be associated with decreased morbidities compared with DCC. The study was unique in its use of delayed consent, in which parents were informed and consented after delivery. Delayed consent was used because antenatal consent requirements would exclude a subset of newborns, and because UCM and DCC are both standard practices at these institutions. This method of consent may raise ethical concerns; however, others have praised it as a strategy to increase enrolment of high risk infants (3). The study was adequately blinded and used advanced techniques to measure neonatal hemodynamics. The primary outcome of superior vena cava flow was chosen as a marker of neonatal transition that is not affected by foetal shunts. Right ventricular output was lower in the DCC group, which previous studies have shown to be associated with increased oxygen requirement, severe intraventricular haemorrhage (IVH) and death (4). There was no difference in left ventricular output (LVO), but LVO may be confounded by a left to right shunt across a patent ductus arteriosus and thereby overestimate systemic blood flow. The authors argue that given the markers suggestive of improved organ perfusion, UCM may stabilise fluctuations in systemic blood flow and therefore prevent IVH, although the study did not have adequate power to assess this outcome. Despite not being statistically significant, the different rates of IVH appear to be clinically relevant. With an absolute risk difference of 6/100, it is difficult to dismiss the potential decreased risk of IVH associated with UCM. Another limitation of the study is the lack of a control group to undergo immediate cord clamping (ICC). Given improved clinical outcomes associated with placental transfusion, the authors state that they did not have clinical equipoise to assign ICC. Lastly, the study was limited by only including 94/197 infants who were <29 weeks gestational age. It remains uncertain if and how the present studywill influence clinical practice. Larger trials involving smaller, more premature neonates are needed in addition to long-term assessment of neurodevelopmental outcomes. The authors confidently state that UCM should no longer be considered experimental. . .[but] a beneficial option forpreterm infants deliveredbyCaesarean delivery. With the growing body of evidence supporting the safety ofUCM,we concurwith the authors in advocating for this intervention. URL TO THE FULL REVIEW ON THE EBNEO WEB SITE https://ebneo.org/2015/12/does-umbilicalcord-milking-result-in-higher-measures-ofsystemic-blood-flow-in-preterm-infants/