Sascha Ifflaender

Positioning of term infants during delivery room routine handling – analysis of videos

BackgroundDelivery room management (DR) of the newly born infant should be performed according to international guidelines, but no recommendations are available for an infant’s position immediately after birth. The present study was performed to answer the following questions: 1. How often is DR-management performed in term infants in side position? 2. Is routine DR-management possible in side position? 3. Is there any benefit of side position with respect to agitation or vital parameters?MethodsCross-sectional study of video-recorded DR-management in term newborns delivered by C-section in 2012. Videos were analysed for infant’s position, administered interventions, vital parameters and agitation.Results187 videos were analysed. The Main Position (defined as position spent more than 70% of the time) was “supine” in 91, “side” in 63 and “not determinable” in 33 infants. “Supine” infants received significantly (p < 0.001) more often stimulation (12.5% of the total time) than “side” infants (3.9% of time). There were no differences between both groups with regard to suctioning; CPAP was exclusively (98%) administered in supine position. Newborns on side were less agitated than those on supine. There was a trend towards a better oxygenation in “side” positioned infants (p = 0.055) and significantly (p = 0.04) higher saturation values in “left-sided” infants than “right-sided” infants at 8th minute. “Side” positioned infants reached oxygen saturation values >90% earlier than “supine” positioned infants (p = 0.16).ConclusionsDR-management is feasible in the side position in term infants. Side position seems to be associated with reduced agitation and improved oxygenation. However, it remains unclear whether this represents a causal relationship or an association. The study supports the need for a randomized controlled trial.

Prevalence of head deformities in preterm infants at term equivalent age.

INTRODUCTION Due to a rising number of head deformities in healthy newborns, there has been an increasing interest in nonsynostotic head deformities in children over recent years. Although preterm infants are more likely to have anomalous head shapes than term newborns, there is limited data available on early prevalence of head deformities in preterm infants. AIMS The purposes of the present study were to acquire quantitative data on head shape of preterm infants at Term Equivalent Age (TEA), to determine the prevalence of symmetrical and asymmetrical head deformities and to identify possible risk factors. METHODS In a cross-sectional study design, Cranial Vault Asymmetry Index (CVAI) and Cranial Index (CI) calculated from routine head-scans with a non-invasive laser shape digitizer were recorded and categorized in type and severity of deformation for three different groups of gestational age. Perinatal and postnatal patient data was tested for possible associations. RESULTS Scans of 195 infants were included in the study. CVAI at TEA was higher in very preterm (4.1%) compared to term and late preterm infants. Prevalence of deformational plagiocephaly was 38% in very preterm infants. CI was lower in very (71.4%) and late (77.2%) preterm infants compared to term infants (80.0%). Compared to term babies (11%), a large number of very (73%) and late (28%) preterm infants exhibited dolichocephaly at TEA. DISCUSSION Prevalence of symmetrical and asymmetrical head deformities in preterm infants is high at TEA. Interventions are required to prevent head deformities in preterm infants during the initial hospital stay.

Three-Dimensional Digital Capture of Head Size in Neonates – A Method Evaluation

Introduction The quality of neonatal care is mainly determined by long-term neurodevelopmental outcome. The neurodevelopment of preterm infants is related to postnatal head growth and depends on medical interventions such as nutritional support. Head circumference (HC) is currently used as a two-dimensional measure of head growth. Since head deformities are frequently found in preterm infants, HC may not always adequately reflect head growth. Laser aided head shape digitizers offer semiautomatic acquisition of HC and cranial volume (CrV) and could thus be useful in describing head size more precisely. Aims 1) To evaluate reproducibility of a 3D digital capture system in newborns. 2) To compare manual and digital HC measurements in a neonatal cohort. 3) To determine correlation of HC and CrV and predictive value of HC. Methods Within a twelve-month period data of head scans with a laser shape digitizer were analysed. Repeated measures were used for method evaluation. Manually and digitally acquired HC was compared. Regression analysis of HC and CrV was performed. Results Interobserver reliability was excellent for HC (bias-0.005%, 95% Limits of Agreement (LoA) −0.39–0.39%) and CrV (bias1.5%, 95%LoA-0.8–3.6%). Method comparison data was acquired from 282 infants. It revealed interchangeability of the methods (bias-0.45%; 95%LoA-4.55–3.65%) and no significant systematic or proportional differences. HC and CrV correlated (r2 = 0.859, p<0.001), performance of HC predicting CrV was poor (RSD ±24 ml). Correlation was worse in infants with lower postmenstrual age (r2 = 0.745) compared to older infants (r2 = 0.843). Discussion The current practice of measuring HC for describing head growth in preterm infants could be misleading since it does not represent a 3D approach. CrV can vary substantially in infants of equal HC. The 3D laser scanner represents a new and promising method to provide reproducible data of CrV and HC. Since it does not provide data on cerebral structures, additional imaging is required.

Continuous Non-Invasive Monitoring of Tidal Volumes by Measurement of Tidal Impedance in Neonatal Piglets

Background Electrical Impedance measurements can be used to estimate the content of intra-thoracic air and thereby give information on pulmonary ventilation. Conventional Impedance measurements mainly indicate relative changes, but no information concerning air-volume is given. The study was performed to test whether a 3-point-calibration with known tidal volumes (VT) during conventional mechanical ventilation (CMV) allows subsequent calculation of VT from total Tidal-Impedance (tTI) measurements using Quadrant Impedance Measurement (QIM). In addition the distribution of TI in different regions of the thorax was examined. Methodology and Principal Findings QIM was performed in five neonatal piglets during volume-controlled CMV. tTI values at three different VT (4, 6, 8 ml/kg) were used to establish individual calibration curves. Subsequently, each animal was ventilated with different patterns of varying VT (2–10 ml/kg) at different PEEP levels (0, 3, 6, 9, 12 cmH2O). VT variation was repeated after surfactant depletion by bronchoalveolar lavage. VT was calculated from tTI values (VTcalc) and compared to the VT delivered by the ventilator (VTPNT). Bland-Altman analysis revealed good agreement between VTcalc and VTPNT before (bias −0.08 ml; limits of agreement −1.18 to 1.02 ml at PEEP = 3 cmH2O) and after surfactant depletion (bias −0.17 ml; limits of agreement −1.57 to 1.22 ml at PEEP = 3 cmH2O). At higher PEEP levels VTcalc was lower than VTPNT, when only one fixed calibration curve (at PEEP 3 cmH2O) was used. With a new calibration curve at each PEEP level the method showed similar accuracy at each PEEP level. TI showed a homogeneous distribution over the four assessed quadrants with a shift toward caudal regions of the thorax with increasing VT. Conclusion Tidal Impedance values could be used for precise and accurate calculation of VT during CMV in this animal study, when calibrated at each PEEP level.

Suctioning habits in the delivery room and the influence on postnatal adaptation - a video analysis.

Abstract Aims: To determine how often infants are suctioned during delivery and how it affects the neonate. Methods: Single-center analysis of video-recorded delivery room management after c-section from January 2012 until April 2013. Time point, duration, and frequency of suctioning in term and preterm newborns were analyzed along with vital parameters (heart rate (HR) and saturation values). Results: Three hundred forty-six videos were analyzed. Twenty-three percent of term and 66% of preterm newborns were suctioned. Newborns were suctioned up to 14 times; total duration spent for suctioning was between 2 and 154 s. Suctioning before face mask application occurred in 31% of the suctioned newborns requiring respiratory support. No severe bradycardia (<60 bpm) was noticed. Suctioning did not have an effect on HR and saturation in preterm infants but was associated with significantly higher HR in term infants requiring respiratory support. Term infants who did not require respiratory support showed significantly higher saturation values at 3, 5, 6, 7, 8, 9, and 10 min if they were not suctioned. Conclusions: Suctioning of newborns in the delivery room does not adhere to recommendations of international guidelines. However, previously described side effects of suctioning could not be confirmed.

Individual course of cranial symmetry and proportion in preterm infants up to 6 months of corrected age

INTRODUCTION A significant proportion of preterm infants have dolichocephaly and/or deformational plagiocephaly (DP) at term equivalent age. However, quantitative data on the clinical course after discharge is limited in these infants. AIMS To quantify the individual course of cranial symmetry and proportion in infants born <32 gestational weeks up to six months of corrected age (CA) and to investigate, whether measurements at discharge predict subsequent cranial deformations. METHODS A total of 56 infants were examined at discharge, three and six months of CA. Cranial proportion and symmetry were quantified using a 3D laser scan method. Classification and prevalence data were obtained using age related reference values. Predictive value of DP at discharge regarding subsequent deformation was evaluated. RESULTS Cranial Vault Asymmetry Index was 3.9% at discharge, 4.5% at three months and 3.7% at six months of CA. Prevalence of DP was 34% at discharge, 46% at three months and 27% at six months. Cranial Index was 71.4% at discharge and constantly increased over the examination period. Prevalence of dolichocephaly was high at discharge (77%) and subsequently decreased. While severe DP at discharge was predictive for a persistent deformation (PPV 0.78), 46% of infants without DP at discharge developed DP by six months of CA. DISCUSSION Despite a high prevalence at discharge, the decreased prevalence of DP and dolichocephaly at six months of CA suggests an optimistic course. However, changes in head shape are hardly predictable for the individual infant. Thus, an accurate quantification should be part of neonatal follow-up programs.

PO-0404 3d Surface Imaging Of Head Shape And Head Deformities In Healthy Newborns – A Cross-sectonal Study

Background and aims Congenital cranial asymmetry is a precursor for the development of head deformities. However, early changes are often subtle and can be overlooked. Surface imaging improves detection of postnatal head deformities. The purposes of the present study were 1) to determine normative values of head shape at birth with a 3D laser system and 2) to identify potential risk-factors for congenital head shape abnormalities. Methods In a cross-sectional study design healthy neonates born in a university hospital between 2/2013 and 3/2014 were scanned between 12 and 72 h after birth with a non-invasive laser scanner (STARScanner™). Normative values of established indices (Cranial Index - CI; Cranial Vault Asymmetry Index - CVAI) were computed. Infants with cranial asymmetry were analysed for pre- and perinatal risk factors. Results Scans of 1095 newborns (m557, f538; 3373 ± 477g) were analysed. 1) Normative values of cranial measures and indices were calculated and are presented. 2) Cranial asymmetry was due to Cephalohematoma or Caput succedaneum in 4.5% of infants. In remaining infants it was not related to multiple birth, gender, gestational age, birth-presentation or delivery mode. Conclusions The present study provides normative cranial data from 3D surface scans in a cohort of healthy newborns in the first 72 h of life. This allows a precise classification of head shape and an improved identification of abnormalities. In contrast to previous investigations, head asymmetry was not associated with any prenatal and perinatal factors. Long term consequences of congenital head shape abnormalities need to be further investigated in longitudinal studies.

PO-0746 Respiratory Support In Term Newborns After C-section

Background and aims After c-section term newborns are at risk of respiratory problems. Whereas some newborns require respiratory support only for a short time in the delivery room (DR), others are admitted to the NICU for prolonged therapy. Our aim was to compare differences between newborns with respiratory support in DR only and those admitted to the NICU. Methods Retrospective analysis of video recorded DR-management of term newborns born between January 2012 and November 2013 via c-section. Results 368 newborns were analysed with 82 (22%) receiving respiratory support. From them, 26 (32%) were transported to NICU for further treatment, the remaining 56 (68%) were stabilised after a short period of CPAP treatment. There were no demographic differences between both groups. CPAP-administration started after a median of 3.4 (0.2–27) in NICU and 3.7 (0.03–17) minutes in DR infants. At the start of CPAP administration infants had a median heart rate of 161 (75–195) in NICU and 153 (56–200) in DR newborns and SpO2 of 69 (41–100) and 80 (55–100) respectively (p = 0.01). 8 (31%) NICU and 15 (27%) DR newborns received a sustained inflation; mechanical ventilation via face-mask received 4 and 6 newborns respectively. In infants remaining in the DR respiratory support was stopped after a median of 7.6 (0.2–21) minutes, infants were transferred to the NICU after a respiratory support of 17.7 (4–29.6) minutes respectively. Discussion Except for lower SpO2 values there are no parameters to predict the need for the length of treatment in respiratory depressed term newborns.

1113 3D Digital Capture of Head Circumference and Volume in Neonates - A Method Evaluation

Background Manual measurement of head circumference (HC) is used to quantify head growth in preterm infants. Laser shape digitizers offer semi-automatic HC measuring and additional information on head volume (HV). Reliability and accuracy in obtaining HC and HV in neonates has not been investigated yet. Aims To determine intraobserver and interobserver variability of HC and HV measurements in neonates with a 3D digital capture system. To compare the method with manual HC measurements. Methods Standard weekly HC measurements on a neonatal unit were conducted manually and digitally with STARScanner laser shape digitizer (Vorum Research Corp., Vancouver, BC) over 12 months. Method comparison was performed using Passing-Bablok-Regression (PBR), Cusum test and Bland-Altman (BA) analyses. Multiple scan examinations by different trained observers were performed to obtain intraobserver/interobserver data. Results Intraobserver coefficient of variation was low for HC (0.1–0.9%) and HV (0.54–1.1%). BA (mean percentage of difference M d ; 95% CI) of interobserver data showed interchangeability for HC (M d –0.005; CI-0.39–0.39) and HV (M d 1.51; CI –1.17–4.1). 2. Method comparison data was acquired from 446 measurements in 258 infants (HC 318±19.5mm). Overall agreement was good (M d –0.82; CI –4.89–3.24), PBR showed no significant systematic or proportional differences (a=1.03, CI 0.99–1.06; b= –7.06 CI –17.7–3.01). There was no significant deviation from linearity (p=0.62). Conclusions Infant head shape capturing with the examined device is reliable, accurate and save. It offers additional information on HV. Possible benefits of HV in quantifying head growth in preterm infants need to be further investigated.

1080 3D Digital Capture of Head Growth in Neonates - Correlation of Head Circumference and Head Volume

Background Head circumference (HC) is measured in newborns to evaluate head growth. It is not known, whether HC is always an appropriate measure of head volume (HV). Digital capture of the neonatal head offers information on HC and HV. Aims To determine overall correlation of HC and HV and with regard to postmenstrual age (PMA) and with regard to the actual body weight (BW). Methods Head measurements with STARscanner laser shape digitizer (Vorum research Corp., Vancouver, BC) were performed in preterm infants prior to discharge over a 12 month period. Data on HC and HV were calculated with STARscanner Laser Data Acquisiton System (Orthomerica, Orlando, FL) and analyzed in different subgroups. Results Included were 243 neonates at time of discharge (mean HC 32.8±1.9 cm, mean HV 356.7±64.3 ml). a) There was an overall correlation between HC and HV (r=0.90, R²=0.81, p<0.001). Correlation between HC and HV was: b) in infants with a PMA < 37 (r= 0.71, R²=0.52, p=0.001) vs. PMA > 37 weeks (r=0.92, R²=0.85, p<0.001) and c) in BW < 2500g (r=0.69, R²= 0.49, p=0.04) vs. BW >2500g (r=0.88, R²=0.77, p<0.001). Conclusions Neonates with comparable HC can show very different HV, especially in infants with low PMA or BW. Thus additional measurement of HV enables to detect variable patterns of head growth and shape. Underlying causes and the meaning for neurological outcome need to be determined.