This study compared high-flow nasal cannulae with nasal continuous positive airway pressure (CPAP) for noninvasive respiratory support of very preterm infants after extubation. The efficacy of ...high-flow nasal cannulae was similar to that of nasal CPAP.
In the United States, approximately 75,000 infants were classified as very preterm (gestational age, <32 weeks) in 2011.
1
Very preterm infants have substantially higher mortality and morbidity than term infants, partly because they are more prone to respiratory failure and often require mechanical ventilation through an endotracheal tube after birth. Once they recover from their acute breathing problems, the best way to achieve successful extubation from mechanical ventilation is controversial. Nasal continuous positive airway pressure (CPAP) is known to be superior to no positive-pressure support
2
and is the current standard of care for noninvasive respiratory support of very preterm infants. . . .
Summary Background Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and ...CHALICE) in a large sample of children. Methods In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury TBI, need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13–15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. Findings Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7–100·0; 38 patients identified of 38 with outcome 38/38) and PECARN in children 2 years and older (99·0%, 94·4–100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2–99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2–93·4; 125/141) and CHALICE (92·3%, 89·2–94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. Interpretation The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. Funding National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.
This multicenter trial comparing nasal high-flow therapy with CPAP as primary support for preterm infants with respiratory distress showed a significantly higher treatment-failure rate with high-flow ...therapy.
In 2014, there were more than 380,000 preterm births (i.e., births at a gestational age of <37 weeks) in the United States, accounting for approximately 10% of all births that year.
1
Preterm infants have a risk of the respiratory distress syndrome. The introduction of endotracheal ventilation has improved the survival rate among preterm infants but is associated with an increased risk of complications such as bronchopulmonary dysplasia.
2
Clinicians aim to use noninvasive respiratory support to minimize the risk of such complications. The most widely used noninvasive approach, nasal continuous positive airway pressure (CPAP), has been shown to be an effective . . .
The goal was to define reference ranges for pulse oxygen saturation (Spo(2)) values in the first 10 minutes after birth for infants who received no medical intervention in the delivery room.
Infants ...were eligible if a member of the research team was available to record Spo(2) immediately after birth. Infants were excluded if they received supplemental oxygen or any type of assisted ventilation. Spo(2) was measured with a sensor applied to the right hand or wrist as soon as possible after birth; data were collected every 2 seconds.
We studied 468 infants and recorded 61650 Spo(2) data points. The infants had a mean + or - SD gestational age of 38 + or - 4 weeks and birth weight of 2970 + or - 918 g. For all 468 infants, the 3rd, 10th, 50th, 90th, and 97th percentile values at 1 minute were 29%, 39%, 66%, 87%, and 92%, respectively, those at 2 minutes were 34%, 46%, 73%, 91%, and 95%, and those at 5 minutes were 59%, 73%, 89%, 97%, and 98%. It took a median of 7.9 minutes (interquartile range: 5.0-10 minutes) to reach a Spo(2) value of >90%. Spo(2) values for preterm infants increased more slowly than those for term infants. We present percentile charts for all infants, term infants of > or = 37 weeks, preterm infants of 32 to 36 weeks, and extremely preterm infants of <32 weeks.
These data represent reference ranges for Spo(2) in the first 10 minutes after birth for preterm and term infants.
Breastfeeding behaviour is multifactorial, and a wide range of socio-cultural and physiological variables impact on a woman's decision and ability to breastfeed successfully. An association has been ...reported between maternal obesity and low breastfeeding rates. This is of public health concern because obesity is rising in women of reproductive age and the apparent association with increased artificial feeding will lead to a greater risk of obesity in children. The aim of this paper is to examine the relationship between maternal overweight and obesity and breastfeeding intention and initiation and duration.
A systematic review was conducted in January and February 2007, using the following databases: Medline, CINAHL and the Australian Breastfeeding Association's Lactation Resource Centre. Studies which have examined maternal obesity and infant feeding intention, initiation, duration and delayed onset of lactation were tabulated and summarised.
Studies have found that obese women plan to breastfeed for a shorter period than normal weight women and are less likely to initiate breastfeeding. Of the four studies that examined onset of lactation, three reported a significant relationship between obesity and delayed lactogenesis. Fifteen studies, conducted in the USA, Australia, Denmark, Kuwait and Russia, have examined maternal obesity and duration of breastfeeding. The majority of large studies found that obese women breastfed for a shorter duration than normal weight women, even after adjusting for possible confounding factors.
There is evidence from epidemiological studies that overweight and obese women are less likely to breastfeed than normal weight women. The reasons may be biological or they may be psychological, behavioral and/or cultural. We urgently need qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.
Summary Background Infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia, admission to a neonatal intensive care unit (NICU), and not being exclusively breastfed. Many ...clinicians encourage women with diabetes in pregnancy to express and store breastmilk in late pregnancy, yet no evidence exists for this practice. We aimed to determine the safety and efficacy of antenatal expressing in women with diabetes in pregnancy. Methods We did a multicentre, two-group, unblinded, randomised controlled trial in six hospitals in Victoria, Australia. We recruited women with pre-existing or gestational diabetes in a singleton pregnancy from 34 to 37 weeks' gestation and randomly assigned them (1:1) to either expressing breastmilk twice per day from 36 weeks' gestation (antenatal expressing) or standard care (usual midwifery and obstetric care, supplemented by support from a diabetes educator). Randomisation was done with a computerised random number generator in blocks of size two and four, and was stratified by site, parity, and diabetes type. Investigators were masked to block size but masking of caregivers was not possible. The primary outcome was the proportion of infants admitted to the NICU. We did the analyses by intention to treat; the data were obtained and analysed masked to group allocation. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000217909. Findings Between June 6, 2011, and Oct 29, 2015, we recruited and randomly assigned 635 women: 319 to antenatal expressing and 316 to standard care. Three were not included in the primary analysis (one withdrawal from the standard care group, and one post-randomisation exclusion and one withdrawal from the antenatal expressing group). The proportion of infants admitted to the NICU did not differ between groups (46 15% of 317 assigned to antenatal expressing vs 44 14% of 315 assigned to standard care; adjusted relative risk 1·06, 95% CI 0·66 to 1·46). In the antenatal expressing group, the most common serious adverse event for infants was admission to the NICU for respiratory support (for three <1% of 317. In the standard care group, the most common serious adverse event for infants was moderate to severe encephalopathy with or without seizures (for three <1% of 315). Interpretation There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation. Funding Australian National Health and Medical Research Council.
Background Coadministration of a bacterial adjuvant with oral immunotherapy (OIT) has been suggested as a potential treatment for food allergy. Objective To evaluate a combined therapy comprising a ...probiotic together with peanut OIT. Methods We performed a double-blind, placebo-controlled randomized trial of the probiotic Lactobacillus rhamnosus CGMCC 1.3724 and peanut OIT (probiotic and peanut oral immunotherapy PPOIT) in children (1-10 years) with peanut allergy. The primary outcome was induction of sustained unresponsiveness 2 to 5 weeks after discontinuation of treatment (referred to as possible sustained unresponsiveness). Secondary outcomes were desensitization, peanut skin prick test, and specific IgE and specific IgG4 measurements. Results Sixty-two children were randomized and stratified by age (≤5 and >5 years) and peanut skin test wheal size (≤10 and >10 mm); 56 reached the trial's end. Baseline demographics were similar across groups. Possible sustained unresponsiveness was achieved in 82.1% receiving PPOIT and 3.6% receiving placebo ( P < .001). Nine children need to be treated for 7 to achieve sustained unresponsiveness (number needed to treat, 1.27; 95% CI, 1.06-1.59). Of the subjects, 89.7% receiving PPOIT and 7.1% receiving placebo were desensitized ( P < .001). PPOIT was associated with reduced peanut skin prick test responses and peanut-specific IgE levels and increased peanut-specific IgG4 levels (all P < .001). PPOIT-treated participants reported a greater number of adverse events, mostly with maintenance home dosing. Conclusion This is the first randomized placebo-controlled trial evaluating the novel coadministration of a probiotic and peanut OIT and assessing sustained unresponsiveness in children with peanut allergy. PPOIT was effective in inducing possible sustained unresponsiveness and immune changes that suggest modulation of the peanut-specific immune response. Further work is required to confirm sustained unresponsiveness after a longer period of secondary peanut elimination and to clarify the relative contributions of probiotics versus OIT.
In this randomized, controlled trial involving neonates in two Australian tertiary neonatal intensive care units, nasal high-flow therapy during neonatal endotracheal intubation increased the ...likelihood of successful intubation on the first attempt without physiological instability.
Background
Globally, the majority of newborns requiring resuscitation at birth are full term or late-preterm infants. These infants typically have their umbilical cord clamped early (ECC) before ...moving to a resuscitation platform, losing the potential support of the placental circulation. Physiologically based cord clamping (PBCC) is clamping the umbilical cord after establishing lung aeration and holds promise as a readily available means of improving early newborn outcomes. In mechanically ventilated lambs, PBCC improved cardiovascular stability and reduced hypoxia. We hypothesised that PBCC compared to ECC would result in higher heart rate (HR) in infants needing resuscitation, without compromising safety.
Methods and findings
Between 4 July 2018 and 18 May 2021, infants born at ≥32
+0
weeks’ gestation with a paediatrician called to attend were enrolled in a parallel-arm randomised trial at 2 Australian perinatal centres. Following initial stimulation, infants requiring further resuscitation were randomised within 60 seconds of birth using a smartphone-accessible web link. The intervention (PBCC) was to establish lung aeration, either via positive pressure ventilation (PPV) or effective spontaneous breathing, prior to cord clamping. The comparator was early cord clamping (ECC) prior to resuscitation. The primary outcome was mean HR between 60 to 120 seconds after birth, measured using 3-lead electrocardiogram, extracted from video recordings blinded to group allocation. Nonrandomised infants had deferred cord clamping (DCC) ≥120 seconds in the observational study arm.
Among 508 at-risk infants enrolled, 123 were randomised (
n =
63 to PBCC,
n
= 60 to ECC). Median (interquartile range, IQR) for gestational age was 39.9 (38.3 to 40.7) weeks in PBCC infants and 39.6 (38.4 to 40.4) weeks in ECC infants. Approximately 49% and 50% of the PBCC and ECC infants were female, respectively. Five infants (PBCC = 2, ECC = 3, 4% total) had missing primary outcome data. Cord clamping occurred at a median (IQR) of 136 (126 to 150) seconds in the PBCC arm and 37 (27 to 51) seconds in the ECC arm. Mean HR between 60 to 120 seconds after birth was 154 bpm (beats per minute) for PBCC versus 158 bpm for ECC (adjusted mean difference −6 bpm, 95% confidence interval (CI) −17 to 5 bpm,
P
= 0.39). Among 31 secondary outcomes, postpartum haemorrhage ≥500 ml occurred in 34% and 32% of mothers in the PBCC and ECC arms, respectively. Two hundred ninety-five nonrandomised infants (55% female) with median (IQR) gestational age of 39.6 (38.6 to 40.6) weeks received DCC. Data from these infants was used to create percentile charts of expected HR and oxygen saturation in vigorous infants receiving DCC. The trial was limited by the small number of infants requiring prolonged or advanced resuscitation. PBCC may provide other important benefits we did not measure, including improved maternal–infant bonding and higher iron stores.
Conclusions
In this study, we observed that PBCC resulted in similar mean HR compared to infants receiving ECC. The findings suggest that for infants ≥32
+0
weeks’ gestation who receive brief, effective resuscitation at closely monitored births, PBCC does not provide additional benefit over ECC (performed after initial drying and stimulation) in terms of key physiological markers of transition. PBCC was feasible using a simple, low-cost strategy at both cesarean and vaginal births. The percentile charts of HR and oxygen saturation may guide clinicians monitoring the transition of at-risk infants who receive DCC.
Trial registration
Australian New Zealand Clinical Trials Registry (ANZCTR)
ACTRN12618000621213
.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
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