Margaret Broom

Methods of weaning preterm babies <30 weeks gestation off CPAP: a multicentre randomised controlled trial

Background Controversy exists whether different continuous positive airway pressure (CPAP) weaning methods influence time to wean off CPAP, CPAP duration, oxygen duration, Bronchopulmonary Dysplasia (BPD) or length of admission. Aims In a multicentre randomised controlled trial, the authors have primarily compared CPAP weaning methods impact on time to wean off CPAP and CPAP duration and secondarily their effect on oxygen duration, BPD and time of admission. Methods Between April 2006 and October 2009, 177 infants <30 weeks gestational age (GA) who fulfilled stability criteria on CPAP were randomised to one of the three CPAP weaning methods (M). M1: Taken ‘OFF’ CPAP with the view to stay ‘OFF’. m2: Cycled on and off CPAP with incremental time ‘OFF’. M3: As with m2, cycled on and off CPAP but during ‘OFF’ periods were supported by 2 mm nasal cannula at a flow of 0.5 l/min. Results Based on intention to treat analysis, there was no significant difference in mean GA or birthweight between the groups (27.1±1.4, 26.9±1.6 and 27.3±1.5 (weeks±1SD) and 988±247, 987±249 and 1015±257 (grams±1SD), respectively). Primary outcomes showed M1 produced a significantly shorter time to wean from CPAP (11.3±0.8, 16.8±1.0, 19.4±1.3 (days±1SE) p<0.0001, respectively) and CPAP duration (24.4±0.1, 38.6±0.1, 30.5±0.1 (days±1SE) p<0.0001, respectively). All the secondary outcomes were significantly shorter with M1, (oxygen duration: 24.1±1.5, 45.8±2.2, 34.1±2.0 (days±1SE) p<0.0001, BPD: 7/56 (12.5%), 29/69 (42%), 10/52 (19%) p=0.011 and length of admission: 58.5±0.1, 73.8±0.1 69.5±0.1 (days±1SE) p<0.0001, respectively). Conclusion Method 1 significantly shortens CPAP weaning time, CPAP duration, oxygen duration, BPD and admission time.

CeasIng Cpap At standarD criteriA (CICADA): impact on weight gain, time to full feeds and caffeine use

Introduction In our previous randomised controlled trial (RCT), we have shown in preterm babies (PBs) <30 weeks gestation that CeasIng Cpap At standarD criteriA (CICADA (method 1)) compared with cycling off continuous positive airway pressure (CPAP) gradually (method 2) or cycling off CPAP gradually with low flow air/oxygen during periods off CPAP (method 3) reduces CPAP cessation time in PBs <30 weeks gestation. Method This retrospective study reviewed weight gain, time to reach full feeds and time to cease caffeine in PBs previously enrolled in the RCT. Results Data were collected from 162 of the 177 PBs, and there was no significant difference in the projected weight gain between the three methods. Based on intention to treat, the time taken to reach full feeds for all three methods showed no significant difference. However, post hoc analysis showed the CICADA method compared with cycling off gradually just failed significance (30.3±1.6 vs 31.1±2.4 (weeks corrected gestational age (Wks CGA±SD)), p=0.077). Analysis of time to cease caffeine showed there was a significant difference between the methods with PBs randomised to the CICADA method compared with the cycling off method ceasing caffeine almost a week earlier (33.6±2.4 vs 34.5±2.8 (Wks CGA±SD), p=0.02). Conclusions This retrospective study provides evidence to substantiate the optimum method of ceasing CPAP; the CICADA method, does not adversely affect weight gain, time to reach full feeds and may reduce time to cease caffeine in PBs <30 weeks gestation.

Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion

Background There are limited data to inform the choice between parental presence at clinical bedside rounds (PPCBR) and non-PPCBR in neonatal intensive care units (NICUs). Methods We performed a single-centre, survey-based, crossed-over randomised trial involving parents of all infants who were admitted to NICU and anticipated to stay >11 days. Parents were randomly assigned using a computer-generated stratified block randomisation protocol to start with PPCBR or non-PPCBR and then crossed over to the other arm after a wash-out period. At the conclusion of each arm, parents completed the ‘NICU Parental Stressor Scale’ (a validated tool) and a satisfaction survey. After completion of the trial, we surveyed all healthcare providers who participated at least in one PPCBR rounding episode. We also offered all participating parents and healthcare providers the opportunity to partake in a focus group discussion regarding PPCBR. Results A total of 72 parents were enrolled in this study, with 63 parents (87%) partially or fully completing the trial. Of the parents who completed the trial, 95% agreed that parents should be allowed to attend clinical bedside rounds. A total of 39 healthcare providers’ surveys were returned and 35 (90%) agreed that parents should be allowed to attend rounds. Nine healthcare providers and 8 parents participated in an interview or focus group, augmenting our understanding of the ways in which PPCBR was beneficial. Conclusions Parents and healthcare providers strongly support PPCBR. NICUs should develop policies allowing PPCBR while mitigating the downsides and concerns of parents and healthcare providers such as decreased education opportunity and confidentiality concerns. Trial registration number Australia and New Zealand Clinical Trials Register number, ACTRN12612000506897.

Respiratory outcomes study (RESPOS) for preterm infants at primary school age

Abstract Objective: Pulmonary function abnormalities and hospital re-admissions in survivors of neonatal lung disease remain highly prevalent. The respiratory outcomes study (RESPOS) aimed to investigate the respiratory and associated atopy outcomes in preterm infants <30 weeks gestational age (GA) and/or birth-weight (BWt) <1000 g at primary school age, and to compare these outcomes between infants with and without chronic lung disease (CLD). Methods: In the RESPOS 92 parents of preterm infants admitted to the Neonatal unit in Canberra Hospital between 1/1/2001 and 31/12/2003 were sent a questionnaire regarding their respiratory, atopy management and follow-up. Results: Fifty-three parents responded, including 28 preterm infants who had CLD and 25 who had no CLD. The gestational age was significantly lower in the CLD group compared to the non-CLD group [26.9 (26.3–27.5) CLD and 28.6 (28.3–29.0) non-CLD] [weeks [95% confidence interval (CI)]], as was the birth weight [973 (877.4–1068.8) CLD versus 1221 (1135.0–1307.0) non-CLD] [g (CI)]. CLD infants compared to non-CLD infants were significantly more likely to have been: given surfactant, ventilated and on oxygen at 28 days and 36 weeks. These neonates were also more likely to have: been discharged from the neonatal unit on oxygen, exhibit a history of PDA or sepsis and to have a current paediatrician. However, despite these differences, there was no significant difference in the proportion of asthma or atopic disease between the two groups. Conclusions: The RESPOS could not demonstrate respiratory and/or atopy differences between the CLD and the non-CLD groups at primary school age.

CeasIng Cpap At standarD criteriA (CICADA): Implementation improves neonatal outcomes

A previous randomised controlled trial (RCT) in babies born < 30 weeks gestation found the so‐called CICADA method (ceasing continuous positive airways pressure (CPAP) with a view to remain off rather than slow weaning) significantly reduced CPAP time. Post‐RCT we introduced the CICADA method and evaluated whether the improved outcomes of the CICADA method during the RCT were replicated in clinical practice.

PC.69 CeasIng Cpap At standarD criteriA (CICADA): Does implementation of CICADA make a difference?

Background Our multicentre RCT showed that CeasIng Cpap At standarD criteriA (CICADA) compared to cycling off CPAP significantly reduced time on CPAP and weaning time.1 We hypothesised that implementation of CICADA would reduce CPAP time. We compared premature babies (PB) <30 weeks gestation (GA) during the trial period (2007–2009) and post implementation of CICADA in our Neonatal Unit (2010–2012). Methodology The study compared prospectively collected data: GA, Birth weight (BWt), Gender, corrected GA (CGA) at the: commencement of CPAP, time of ceasing CPAP and time on CPAP. Data were compared with general linear models adjusting for BWt and gender (SPSS). Results Survival rates were 95/120(79.2%) and 118/147(80.3%) respectively. No significant differences were recorded in baseline characteristics between the two epochs (Table). The comparison of outcome measures showed CGA for starting and ceasing CPAP were not significant. Support for the hypothesis was found with significantly shorter time on CPAP in the post trial epoch (Table 1). Abstract PC.69 Table 1 Baseline characteristics and outcomes over the two epochs 2007–2009 (n = 94 ** ) 2010–2012 (n = 118) p GA (weeks) 27.7 ± 0.15 28.1 ± 0.13 0.08 BWt (grams) 1098 ± 31 1093 ± 27 0.9 Gender (M:F[%M]) 43:51(45.7%) 62:56(52.5%) 0.34 CGA start CPAP * 28.0 ± 0.12 28.3 ± 0.11 0.09 CGA cease CPAP * 32.9 ± 0.30 32.3 ± 0.27 0.16 Time on CPAP (wks) * 4.9 ± 0.30 4.1 ± 0.27 0.044 * Estimated marginal means±SE ** One PB excluded as CGA to cease CPAP > 50 weeks Conclusions The introduction of CICADA for ceasing CPAP has significantly reduced time on CPAP in PBs <30 weeks GA. CICADA may have benefits including earlier breastfeeding and lower hospitalisation costs. Reference Todd, et al . Methods of weaning preterm babies <30 weeks gestation off CPAP: A multicentre randomised controlled trial. Arch Dis Child Fetal Neonatal 2012: doi:10.1136/F2 of F5 adc.2011-300133: 97(4): F236–F240

Smoking in the family is most predictive of the development of childhood asthma in preterm babies <30 weeks gestation: Results of the Respiratory Outcomes Study 2 (RESPOS2)

ABSTRACT Objectives: The Respiratory Outcomes Study 2 (RESPOS2) investigated the relationship between neonatal outcomes (specifically, chronic lung disease [CLD]) and environmental factors on the development of asthma and atopic outcomes at primary school age for preterm babies (PBs) <30 weeks gestational age (GA). Methods: The study included all surviving PBs <30 weeks GA admitted to the Neonatal Intensive Care Unit at Canberra Hospital, Australian Capital Territory between 2007 and 2009. Parents were sent a questionnaire regarding asthma and atopy symptoms when the PBs were aged 5–7 years old. Data were compared based on CLD status. Results: There were 103 PBs included in the study with a 68.9% response rate to the respiratory questionnaire (71/103). Of these PBs, 15/71 (21.1%) received a diagnosis of CLD. There were no significant differences with regards to asthma, hay fever or eczema in PBs either with or without CLD. The most significant predictor for the development of asthma was smoking in the family (Odds Ratio [OR]: 11.66, 95% Confidence Interval [CI]: 2.01–67.56) with a trend toward significance for family history of asthma (OR: 3.83, 95% CI: 0.85–17.25). Conclusion: The RESPOS2 has confirmed previous reports that CLD in PBs <30 weeks GA is not associated with the development of childhood asthma, hay fever or eczema. In our group of PBs, the strongest predictor of the development of asthma was smoking in the family.

Increased use of heated humidified high flow nasal cannula is associated with longer oxygen requirements

There has been an increased use of heated humidified high flow nasal canula (HFNC) in premature babies (PBs) admitted to our neonatal unit. The aim of this study is to identify clinical characteristics in PBs < 29 weeks gestational age (GA) that distinguish between those who did not or did receive HFNC.

Exploring Parental and Staff Perceptions of the Family-Integrated Care Model: A Qualitative Focus Group Study

Background: Family-integrated care (FICare) is an innovative model of care developed at Mount Sinai Hospital, Canada, to better integrate parents into the team caring for their infant in the neonatal intensive care unit (NICU). The effects of FICare on neonatal outcomes and parental anxiety were assessed in an international multicenter randomized trial. As an Australian regional level 3 NICU that was randomized to the intervention group, we aimed to explore parent and staff perceptions of the FICare program in our dual occupancy NICU. Subjects and Design: This qualitative study took place in a level 3 NICU with 5 parent participants and 8 staff participants, using a post implementation review design. Methods: Parents and staff perceptions of FICare were explored through focus group methodology. Thematic content analysis was done on focus group transcripts. Results: Parents and staff perceived the FICare program to have had a positive impact on parental confidence and role attainment and thought that FICare improved parent-to-parent and parent-to-staff communication. Staff reported that nurses working with families in the program performed less hands-on care and spent more time educating and supporting parents. Implications for Practice: FICare may change current NICU practice through integrating and accepting parents as active members of the infants care team. In addition, nurses roles may transition from bedside carer to care coordinator, educating and supporting parents during their journey through the NICU. Implications for Research: Further research is needed to assess the long-term impact of FICare on neonates, parents, and staff.

A safety and feasibility study of the use of 670?nm red light in premature neonates

Objective:Retinopathy of prematurity (ROP) is a vasoproliferative disorder of the retina affecting extremely preterm or low birth weight infants The aim of this study was to assess the feasibility and safety of 670 nm red light use in a neonatal intensive care unit.Study Design:Neonates <30 weeks gestation and <1150 g were enrolled within 48 h of birth. Data collected included cause of preterm delivery, Apgar scores and birthweight. 670 nm red light was administered for 15 min per day from a distance of 25 cm, delivering 9 J cm−2, from the time of inclusion in the study until 34 weeks postmenstrual age. Infants were assessed daily for the presence of any skin burns or other adverse signs.Result:Twenty-eight neonates were enrolled, seven 24 to 26 weeks and twenty-one 27 to 29 weeks gestation. The most common cause for preterm delivery was preterm labor (14/28) with five of these having evidence of chorioamnionitis. There were no skin burns or other documented adverse events. Entry into the study was readily achieved and treatment was well accepted by parents and nursing staff.Conclusion:670 nm red light appears to be a safe and feasible treatment for further research in respect to ROP.