Manuel Sánchez Luna

Pulse oximetry screening for congenital heart defects

856 www.thelancet.com Vol 382 September 7, 2013 screening did not discuss CCHD screening. However, in Switzerland and Sweden most infants are now screened with pulse oximetry, and the Royal College of Physicians of Ireland has recommended screening. In the UK, approximately 20% of maternity units use pulse oximetry screening; Nordic countries are surveying implementation but its use in the rest of Europe is unknown. In June, 2013, an international group of neonatologists and cardiologists met in Turin, Italy, with the chief investigators from two European screening studies of pulse oximetry (AKE, AD-WG), to discuss strategies to develop Europe-wide recommendations for CCHD screening. Members of the group included a leader in US CCHD implementation (GRM), and chair and board members of international and European neonatology societies (PM, MSL). The discussion confirmed that the evidence for CCHD screening was suffi ciently robust to consider European implementation, but concern arose over the wide variation in routine maternity care (eg, antenatal detection rates of CCHD and length of stay after delivery) and the impact of screening on clinical services. Additional barriers identifi ed included increasing trends for home births, cost of implementation (staff and equipment costs), and management of test positives (neonatal admissions and echocardiography). Evidence suggests that routine CCHD screening is cost-eff ective. Additional benefi ts (eg, giving confi dence to allow earlier discharge and identifi cation of non-cardiac conditions) might further improve cost-effectiveness, but need careful consideration by individual countries. The group concluded that the maxim that no newborn baby should have unexplained persistent hypoxaemia and be discharged home is true. The importance of detection of babies with CCHD before acute collapse is clear, because existing screening methods still miss up to 30% of cases; the addition of pulse oximetry screening Jeanette Teo, Sean Yang-Yi Tan, Martin Tay, Yichen Ding, Staff an Kjelleberg, Michael Givskov, Raymond T P Lin, *Liang Yang yangliang@ntu.edu.sg

Pulse oximetry screening for critical congenital heart defects: a European consensus statement

Critical congenital heart defects (CCHD) are life-threatening and timely detection is essential for optimal outcome. Experts in CCHD screening and representatives from major European paediatric and neonatal societies convened to develop suitable and implementable evidencebased recommendations on pulse oximetry screening (POS) for CCHD across Europe. POS has been shown to be a simple, quick and painless tool for identifying babies with CCHD which is inexpensive, acceptable and has a high specificity and moderate sensitivity. POS should be performed in two extremities (right hand and either foot) using new generation, motion tolerant equipment after 6 hours of life or before discharge (preferably before 24 hours of life). Several screening protocols are available and current data does not differentiate a ‘best’ protocol; thus, countries may decide upon which protocol best fits their population. Adopting POS at a national level across Europe will help improve management of these lifethreatening conditions.

Criterios de alta hospitalaria para el recién nacido de muy bajo peso al nacimiento

Hospital discharge criteria for the pre-term newborn are mainly based on physiological competences (thermoregulation, respiratory stability, and feeding skills), although family support and ability to care for the baby, as well as a well-planned discharge are also cornerstones to ensure a successful discharge. In this article, the Committee of Standards of the Spanish Society of Neonatology reviews the current hospital discharge criteria in order for it to be useful as a clinical guide in Spanish neonatal units.

Spanish population-study shows that healthy late preterm infants had worse outcomes one year after discharge than term-born infants

This study assessed the risks associated with healthy late preterm infants and healthy term‐born infants using national hospital discharge records.

Mejorando la seguridad del paciente: utilidad de las listas de verificación de seguridad en una unidad neonatal

INTRODUCTION Due to the complexity and characteristics of their patients, neonatal units are risk areas for the development of adverse events (AE). For this reason, there is a need to introduce and implement some tools and strategies that will help to improve the safety of the neonatal patient. Safety check-lists have shown to be a useful tool in other health areas but they are not sufficiently developed in Neonatal Units. MATERIAL AND METHODS A quasi-experimental prospective study was conducted on the design and implementation of the use of a checklist and evaluation of its usefulness for detecting incidents. The satisfaction of the health professionals on using the checklist tool was also assessed. RESULTS The compliance rate in the neonatal intensive care unit (NICU) was 56.5%, with 4.03 incidents per patient being detected. One incident was detected for every 5.3 checklists used. The most frequent detected incidents were those related to medication, followed by inadequate alarm thresholds, adjustments of the monitors, and medication pumps. The large majority (75%) of the NICU health professionals considered the checklist useful or very useful, and 68.75% considered that its use had managed to avoid an AE. The overall satisfaction was 83.33% for the professionals with less than 5 years working experience, and 44.4% of the professionals with more than 5 years of experience were pleased or very pleased. CONCLUSION The checklists have shown to be a useful tool for the detection of incidents, especially in NICU, with a positive assessment from the health professionals of the unit.

Cribado de cardiopatías congénitas críticas en el periodo neonatal. Recomendación de la Sociedad Española de Neonatología

Due to its severity, as well as the consequences of a late diagnosis, critical congenital heart defects (CCHD) represent a challenging situation, making an early diagnosis necessary and ideally before symptoms appear when circulatory collapse or death of the newborn can occur. Due to this, a prenatal and very early postnatal diagnosis is very important. Prenatal ultrasound screening and physical examination of the newborn can miss a considerable number of CCHD cases. Pulse oximetry screening has been demonstrated to be an effective, non-invasive, inexpensive, and well accepted tool in the early diagnosis of CCHD. The Spanish National Society of Neonatology, through its Standards Committee, and based on the current evidence, recommend the implementation of pulse oximetry screening of CCHD in Spain, and then to offer the best therapy possible to these newborn infants.

Survival estimations at the limit of viability

Abstract Objective: The purpose of this study was to assess the variability in neonatal survival to discharge from the neonatal unit by using different inclusion criteria. Methods: An observational and descriptive study was performed between January 2008 and December 2013 which included infants born between 22 weeks and 31 weeks and 6 d of gestation. The rate of survival was calculated using three different inclusion criteria: the total number of preterm births, the number of all preterm live births, and the number of preterm newborns admitted to the neonatal unit. Results: A total of 783 patients met the inclusion criteria. The survival rate for births between 22 and 31 weeks and 6 d of gestation was 72.8% of total births, 82.3% of live births, and 84.0% of all admissions to the neonatal unit. Therefore, we found a significant difference in survival rates according to whether or not foetal mortality (11.6%) and mortality in the delivery room (2.0%) were included. This variation increased with decreasing gestational age: 17,2%, 25%, and 38,4% at 23 weeks gestation. Conclusions: Late foetal mortality and the mortality in the delivery room affect the survival rates of preterm infants significantly, especially the most immature newborns.

How useful and feasible are early biochemical markers of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is currently the most frequent cause of morbidity in the most immature infants, and the multiple factors implicated in its aetiology make it a difficult disease to prevent and treat. The new form of BPD, as compared to the classic, old or traumatic disease, is mostly related to arrested lung growth and development associated with pulmonary hypertension and a decrease in lung function (1). This new disease appears after less severe respiratory distress, due to the use of antenatal steroids, the more judicious use of oxygen, less invasive respiratory support and surfactant administration. This decreases the lung trauma and represents a different disease where other pathogenic factors are now more relevant than before. Although less invasive and more protective lung therapy is now applied, the incidence of the disease is not decreasing, probably due to the increase in survival of the most immature infants (2). Clinical or biochemical markers have been described to improve the detection of patients at the highest risk in the earliest stage of the disease. BPD may begin in utero and be altered by several other factors after delivery, such as oxygen exposure and, or, the impact of invasive mechanical ventilation on immature infants. Some clinical markers, such as the need for mechanical ventilation for more than two hours after delivery – which indicates severe respiratory failure – have been described and are a good way of detecting preterm infants at high risk of developing BPD (3). Fabiano et al. (4) have suggested a new combination of biochemical markers that appear to be sensitive to the development of BPD in immature newborn infants. In this prospective study, the concentrations of lipid hydroperoxide (LOOH) and glutathione in bronchoalveolar lavage fluid (BALF) were correlated with the incidence of BPD in a small population of 44 very low birthweight (VLBW) infants with respiratory distress syndrome requiring mechanical ventilation. The only two statistically significant differences found among the patients with and without BPD were the level of the fraction of inspired oxygen (FiO2) and the duration of mechanical ventilation. As BALF was performed to obtain the bronchial samples on admission to the neonatal intensive care unit, and before surfactant administration within two hours of birth, early inflammation was expected in the group who finally developed BPD. Although no differences were found between the groups in the duration of rupture of membranes, chorioamnionitis and the interval from rupture of membranes to delivery, a postnatal trigger could have been expected in this population. As discussed by the authors (4), the finding that there was a higher LOOH content in the BALF samples of those patients who finally developed BPD could be related to a higher need for FiO2, as the LOOH content may have been released by a cascade of oxygen-mediated events. However, it is unknown whether the higher LOOH content in the BALF was due to this higher oxygen exposure in the lung itself or to other factors, such as the severity of the disease. In accordance with that, a lower glutathione level in the BPD group could not have been related to the low gestational age or to the development of asphyxia, because no significant differences were found in the gestational age or risk of asphyxia between the groups. Again a higher oxygen exposure could explain this finding. The inflammatory aetiology of BPD has been recognised for many years, but the relationship with immaturity is not so clear. BPD is a disease that occurs in very immature babies and is not seen in preterm babies with an older gestational age or in full-term newborn infants. So a higher risk of damage due to lower antioxidant content in the most immature infants is expected. If the inflammatory process was initiated in utero (5), a very sensitive biochemical test could be used to detect infants with a high risk of developing BPD shortly after delivery, as they would display high levels of lipid peroxidation. In addition, the imbalance between these products and the anti-oxidants could be explained because the glutathione content in the BALF decreases in those infants who develop BPD. It is clear that the beneficial effect of less invasive respiratory support and the decrease in the oxygen exposure can reduce the risk of BPD. However, it has recently been suggested that the need to use high FiO2, due to more severe respiratory failure, can trigger BPD, and therefore, decreasing the FiO2 threshold to administer surfactant (6) could help to reduce the risk of BPD. In Fabiano et al.’ study (4), an FiO2 of at least 50% was chosen as an indication of the need for mechanical ventilation.

Human Milk Oligosaccharides: 2′-Fucosyllactose (2′-FL) and Lacto-N-Neotetraose (LNnT) in Infant Formula

The authors reviewed the published evidence on the presence of oligosaccharides in human milk (HMO) and their benefits in in vitro and in vivo studies. The still limited data of trials evaluating the effect of mainly 2′-fucosyllactose (2′-FL) on the addition of some of HMOs to infant formula were also reviewed. PubMed was searched from January 1990 to April 2018. The amount of HMOs in mother’s milk is a dynamic process as it changes over time. Many factors, such as duration of lactation, environmental, and genetic factors, influence the amount of HMOs. HMOs may support immune function development and provide protection against infectious diseases directly through the interaction of the gut epithelial cells or indirectly through the modulation of the gut microbiota, including the stimulation of the bifidobacteria. The limited clinical data suggest that the addition of HMOs to infant formula seems to be safe and well tolerated, inducing a normal growth and suggesting a trend towards health benefits. HMOs are one of the major differences between cow’s milk and human milk, and available evidence indicates that these components do have a health promoting benefit. The addition of one or two of these components to infant formula is safe, and brings infant formula closer to human milk. More prospective, randomized trials in infants are need to evaluate the clinical benefit of supplementing infant formula with HMOs.

Recomendaciones para la identificación inequívoca del recién nacido

Newborn identification is a legal right recognised by international and national laws. Moreover, improving the accuracy of correct patient identification is an important goal of patient safety solutions programs. In this article, the Standards Committee of the Spanish Society of Neonatology establishes recommendations to ensure correct identification of the newborn whilst in hospital. Currently, the most reliable method of identification of the newborn is the combination of identification cord clamp and bracelets (mother bracelet, newborn bracelet and cord clamp with the same number and identical and exclusive barcode system for each newborn) and the collection of maternal and umbilical cord blood samples (for DNA testing only for identification purposes).