Siddarth Ramji

Resuscitation of Asphyxic Newborn Infants with Room Air or 100% Oxygen

ABSTRACT: To test the hypothesis that room air is superior to 100% oxygen when asphyxiated newborns are resuscitated, 84 neonates (birth weight > 999 g) with heart rate <80 and/or apnea at birth were allocated to be resuscitated with either room air (n = 42) or 100% oxygen (n = 42). Serial, unblinded observations of heart rates at 1, 3, 5, and 10 min and Apgar scores at 1 min revealed no significant differences between the two groups. At 5 min, median (25th and 75th percentile) Apgar scores were higher in the room air than in the oxygen group [8 (7–9) versus 7 (6–8), p = 0.03]. After the initial resuscitation, arterial partial pressure of oxygen, pH, and base excess were comparable in the two groups. Assisted ventilation was necessary for 2.4 (1.5–3.4) min in the room air group and 3.0 (2.0–4.0) min in the oxygen group (p = 0.14). The median time to first breath was 1.5 (1.0–2.0) min in both the room air and oxygen groups (p = 0.59), and the time to first cry was 3.0 (2.0–4.0) min and 3.5 (2.5–5.5) min in the room air and oxygen groups, respectively (p = 0.19). Three neonates in the room air group and four in the oxygen group died in the neonatal period. At 28 d, 72 of the 77 surviving neonates were available for follow-up (36 in each group), and none had any neurologic sequelae. This preliminary study did not provide conclusive evidence that room air is superior to 100% oxygen in the resuscitation of asphyxiated newborns, although it indicated that room air is as effective as 100% oxygen. Additional trials with increased numbers of patients are necessary before deciding whether room air or oxygen should be used in clinical practice.

Resuscitation of depressed newborn infants with ambient air or pure oxygen: a meta-analysis.

Background: It is discussed whether depressed newborn infants should be resuscitated with room air or 100% O2. Objective: To perform a systematic review and meta-analysis including studies that report resuscitation of depressed newly born infants with 21 or 100% O2. Methods: Inclusion criterion was randomized or pseudo-randomized, blinded or not, studies of depressed newborn infants resuscitated with either 21 or 100% O2. The literature was searched in Medline/Pubmed/EMBASE and The Cochrane library databases. All identified studies were included. Results: Five studies fulfilled the inclusion criterion in which 881 infants were resuscitated with 21% O2 and 856 with 100% O2. Neonatal mortality was 8.0 vs. 13.0% in the 21 and 100% O2 groups respectively, OR 0.57, 95% CI 0.42–0.78. In term infants neonatal mortality was 5.9% in the 21% O2 group and 9.8% in the 100% O2 group, OR 0.59, 95% CI 0.40–0.87. The figures for the premature infants were very similar. In infants with 1-min Apgar score <4, OR for neonatal mortality was 0.81 (95% CI 0.54–1.21). Apgar score at 5 min and heart rate at 90 s were significantly higher, and time to first breath significantly earlier in infants given 21% O2 compared with 100% O2. Conclusions: A systematic review and meta-analysis demonstrated that neonatal mortality is significantly reduced when depressed newly born infants are resuscitated with ambient air instead of pure oxygen. For infants with low 1-min Apgar score (<4), no significant difference in neonatal mortality was found. Recovery was faster in infants resuscitated with 21% O2 than 100% O2.

Setting Research Priorities to Reduce Almost One Million Deaths from Birth Asphyxia by 2015

Joy Lawn and colleagues used a systematic process developed by the Child Health Nutrition Research Initiative (CHNRI) to define and rank research options to reduce mortality from intrapartum-related neonatal deaths (birth asphyxia) by the year 2015.

Response to resuscitation of the newborn: Early prognostic variables

AIM To characterize the development of clinically relevant variables the first minutes after birth and identify early prognostic markers in newborn infants requiring resuscitation. METHODS A database of 591 infants resuscitated with either 21% or 100% oxygen was analysed. Time to first breath, development in heart rate, Apgar scores, arterial oxygen saturation (SaO(2)), and base deficit (BD) are described in relation to different degrees of birth depression and outcomes. RESULTS Heart rate and Apgar scores increased quickly even in the most depressed infants but were significantly lower in those having a poor outcome. By contrast, BD normalized at the same rate, 6-7 mmol/l/h, in the first hour of life regardless of the degree of birth depression and outcome. SaO(2) values increased as quickly in room air as in 100%-oxygen-resuscitated infants. Time to first breath was prolonged threefold, from 1 to 3 min, in the most depressed (1-min Apgar score < 4) compared with the less depressed infants. Highest odds ratio (OR) for death in the first week of life or for development of hypoxic-ischaemic encephalopathy (HIE) stage 2 and 3 was a 5-min heart rate < or =60 bpm (OR 16.5 for both death and HIE) and Apgar < 4 (OR 14 and 18.8). Neonatal survival for HIE stage 1, 2, and 3 was 93%, 63%, and 11%, respectively. OR for early neonatal death, if SaO(2) < or =60% at 1 min, was 8.6 (sensitivity 0.82 and specificity 0.65). CONCLUSION Apgar scores, heart rate, SaO(2), and time to first breath in newly born infants in need of resuscitation may be used for early identification of infants with a poor prognosis. These data may be helpful in describing the severity of depression in single infants and to select infants in need of interventional therapy.

Oxygen for newborn resuscitation: how much is enough?

The new guidelines for newborn resuscitation from the American Heart Association (AHA), the International Liaison Committee on Resuscitation (ILCOR), and the European Resuscitation Council are based on the International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations of 2005.1,2 Since the publication of the previous guidelines from the ILCOR and AHA in 1999 and 2000,3,4 controversial issues within neonatal resuscitation have been identified, and a consensus was reached on (1) the role of supplementary oxygen, (2) peripartum management of meconium, (3) ventilation strategies, (4) devices to confirm placement of an advanced airway, (5) medications, (6) maintenance of body temperature, (7) postresuscitation management, and (8) considerations for withholding and discontinuing resuscitation. In this commentary we discuss the use of supplementary oxygen only. When considering the guidelines provided by the AHA in 1992, the change in attitude regarding use of supplementary oxygen has been substantial. In 1992 it was clearly stated that resuscitation should be conducted with oxygen and that such a brief exposure of pure oxygen is not harmful: “Hypoxia is nearly always present in the newborn requiring resuscitation at birth. Therefore, if cyanosis, bradycardia, or other signs of neonatal distress are noted in a breathing newborn during stabilization, early administration of 100% oxygen is important.”5 In addition: “The hazards of administering too much oxygen during the brief period required for resuscitation should not be a concern.”5 In the AHA guidelines from 2000 it still was stated that 100% oxygen should be used if ventilation is needed: “If assisted ventilation is required, 100% oxygen should be delivered by positive pressure ventilation” and “[i]f supplemental oxygen is not available, resuscitation of the newly born infant should be initiated with positive pressure ventilation and room air.”4 At that time … Address correspondence to Ola Didrik Saugstad, MD, PhD, Department of Pediatric Research, Rikshospitalet University Hospital, 0027 Oslo, Norway. E-mail: o.d.saugstad{at}medisin.uio.no

Ages and Stages Questionnaire as a Screening Tool for Developmental Delay in Indian Children

ObjectiveTo evaluate the ability of ‘Ages and Stages Questionnaire’, a parent completed developmental screening questionnaire to detect developmental delay in Indian children.DesignCross-sectional study.SettingChild Development Clinic of a tertiary care center located in Northern IndiaParticipants and Methods200 children, 50 each in the age groups of 4±1, 10±1, 18±1 and 24±1 months were recruited (20 high risks and 30 low risks in each age group). The Ages and Stages Questionnaire (ASQ) was translated into Hindi and administered to the parents, followed by standardized development assessment using Developmental Assessment Scale for Indian Infants (DASII).Results102 (51%) children failed on ASQ and 90 (45%) children failed on DASII. The overall sensitivity of ASQ for detecting developmental delay was 83.3% and specificity was 75.4%. The sensitivity was best for the 24-months questionnaire (94.7%) and specificity was best for the 4-month questionnaire (86.4%). The sensitivity of ASQ was much higher in the high risk group (92.3%) as compared to the low risk group (60%).ConclusionASQ has strong test characteristics for detecting developmental delay in Indian children, especially in high risk cases. It may be easily converted into other Indian languages and used widely for developmental screening.

Neurodevelopmental Outcome of Infants Resuscitated with Air or 100% Oxygen: A Systematic Review and Meta-Analysis

Background: The use of air for the initial resuscitation of newborn infants has been shown to reduce neonatal mortality. However, a precise estimate of the neurodevelopmental status upon follow-up of infants resuscitated in air is lacking. Objective: To perform a meta-analysis of all studies reporting resuscitation of newborn infants with air or 100% oxygen that included follow-up data. Methods: Bibliographic databases were searched. In addition, we estimated the effect of loss to follow-up on our analysis of abnormal neurodevelopmental outcome. Results: We identified 10 studies in which newborn infants had been randomly or quasi-randomly assigned to resuscitation with air or 100% oxygen. Three of these 10 studies had available follow-up data. A total of 678 infants were enrolled at centers that performed follow-up of these infants. Of these, 113 died, leaving 565 infants potentially eligible for follow-up. A total of 414 children were evaluated (73% of eligible children; 195 resuscitated with air and 219 with 100% oxygen). In the air group, 12.8% of infants had an abnormal neurodevelopmental outcome, compared with 10.5% in the 100% oxygen group [typical relative risk (RR) 1.24, 95% confidence interval 0.73–2.10]. This is consistent with an RR of abnormal development as low as 0.41 or as high as 2.28. Conclusions: Long-term follow-up did not detect any significant differences in these two groups regarding abnormal development. However, the results are imprecise and could be consistent with significant harm or benefit.

Birth Status, Child Growth, and Adult Outcomes in Low- and Middle-Income Countries

Objective To assess the impact of being born preterm or small for gestational age (SGA) on several adult outcomes. Study design We analyzed data for 4518 adult participants in 5 birth cohorts from Brazil, Guatemala, India, the Philippines, and South Africa. Results In the study population, 12.8% of males and 11.9% of females were born preterm, and 26.8% of males and 22.4% of females were born term but SGA. Adults born preterm were 1.11 cm shorter (95% CI, 0.57-1.65 cm), and those born term but SGA were 2.35 cm shorter (95% CI, 1.93-2.77 cm) compared with those born at term and appropriate size for gestational age. Blood pressure and blood glucose level did not differ by birth category. Compared with those born term and at appropriate size for gestational age, schooling attainment was 0.44 years lower (95% CI, 0.17-0.71 years) in those born preterm and 0.41 years lower (95% CI, 0.20-0.62 years) in those born term but SGA. Conclusion Being born preterm or term but SGA is associated with persistent deficits in adult height and schooling, but is not related to blood pressure or blood glucose level in low- and middle-income settings. Increased postnatal growth is associated with gains in height and schooling regardless of birth status, but not with increases in blood pressure or blood glucose level.

Screening for gestational diabetes mellitus: A prospective study in a tertiary care institution of North India

Aim:  The aim of this study was to determine the relevance of universal screening for gestational diabetes mellitus (GDM) in the patients attending the antenatal clinic of a tertiary institute of North India.

Mediastinal enteric duplication cyst containing aberrant pancreas

Objective : The purpose of the study is to report a unique association of clinical and pathological findings in a neonate. Foregut enteric duplication cysts-rare developmental anomalies that are associated with midline vertebral fusion anomalies.Methods : We had a neonate with foregut duplication cyst who presented at birth with respiratory distress. The child also had associated communicating hydrocephalus. The patient underwent excision of the duplication cyst alongwith a ventriculo-peritoneal shunt.Result : The excised specimen revealed a duplication cyst lined by aberrant pancreatic tissue.Conclusion : The present case demonstrates histologically the presence of both pancreatic and gastric tissue.