Although maternal antenatal transfer is the preferred option, some infants inevitably need urgent transport to a tertiary neonatal care facility after birth. This study aimed to investigate trends ...over time in patient characteristics and respiratory management in a large series of neonatal emergency transfers, in order to provide health caregivers an up-to-date profile of such patients and their therapeutic needs. Trends in patient characteristics and respiratory management were evaluated in 3337 transfers by the Eastern Veneto Neonatal Emergency Transport Service in 2000–2019. Joinpoint regression analysis was performed to evaluate trends and to estimate annual percentage changes (APCs). Proportions of preterm neonates increased (APC
2000–2012
2.25%), then decreased (APC
2012–2019
− 6.04%). Transfers at birth increased (APC
2000–2013
2.69%), then decreased (APC
2013–2019
− 5.76%). Proportion of neonates with cardiac and surgical diseases declined (APCs
2000–2019
− 6.82% and − 3.32%), while proportion of neonates with neurologic diseases increased (APC
2000–2019
8.62%). Use of nasal-continuous-positive-airway-pressure (APC
2000–2019
9.72%) and high-flow-nasal-cannula (APC
2007–2019
58.51%) at call, and nasal-continuous-positive-airway-pressure (APC
2000–2019
13.87%) and nasal-intermittent-mandatory-ventilation (APC
2000–2019
32.46%) during transfer increased. Mechanical ventilation during transfer decreased (APC
2014–2019
− 10.77%). Use of oxygen concentrations at 21% increased at call and during transfer (APCs
2000–2019
2.24% and 2.44%), while oxygen concentrations above 40% decreased at call and during transfer (APCs
2000–2019
− 3.93% and − 5.12%).
Conclusion
: Our findings revealed a shift toward a more “gentle” approach and the reduced use of oxygen in respiratory management. Equipment and team expertise should meet the requirements of such changing patients and their therapeutic needs.
What is Known:
•
Although antenatal transfer is the preferred option, some infants inevitably need urgent transport to a tertiary neonatal care facility after birth.
•
Trend studies investigating cohort information with appropriate statistical methods represent useful instruments to detect changes over time.
What is New:
•
Our findings revealed marked changes in patient characteristics and respiratory management in a large series of neonatal emergency transfers during the last two decades.
•
Equipment and team expertise should meet the requirements of such changing patients and their therapeutic needs.
Folic acid (FA) supplementation prevents neural tube defects (NTDs), but the effects on other reproductive outcomes are unclear. While common recommendation is 0.4 mg/day in addition to regular ...nutrition, the most appropriate dose of FA is still under debate. We investigated the effects of a higher dose of periconception FA on reducing adverse reproductive outcomes. In this multicenter double-blind randomized controlled trial (RCT), 1060 women (aged 18-44 years and planning a pregnancy) were randomly assigned to receive 4.0 mg or 0.4 mg of FA daily. The primary outcome was the occurrence of congenital malformations (CMs). A composite outcome including one or more adverse pregnancy outcomes was also evaluated. A total of 431 women had a natural conception within 1 year. The primary outcome occurred in 8/227 (3.5%) women receiving 4.0 mg FA and 9/204 (4.4%) women receiving 0.4 mg FA (RR 0.80; 95%CI 0.31 to 2.03). The composite outcome occurred in 43/227 (18.9%) women receiving 4.0 mg FA and 75/204 (36.8%) women receiving 0.4 mg FA (RR 0.51; 95%CI 0.40 to 0.68). FA 4.0 mg supplementation was not associated with different occurrence of CMs, compared to FA 0.4 mg supplementation. However, FA 4.0 mg supplementation was associated with lower occurrence of other adverse pregnancy outcomes.
Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid (MSAF) is supposed to delay initiation of positive pressure ventilation (PPV), but the magnitude of such ...delay is unknown. To compare the time of PPV initiation when performing immediate laryngoscopy with intubation and suctioning vs. performing immediate PPV without intubation in a manikin model. Randomized controlled crossover (AB/BA) trial comparing PPV initiation with or without endotracheal suctioning in a manikin model of non-vigorous neonates born through MSAF. Participants were 20 neonatologists and 20 pediatric residents trained in advanced airway management. Timing of PPV initiation was longer with vs. without endotracheal suctioning in both pediatric residents (mean difference 13 s, 95% confidence interval 8 to 18 s;
p
< 0.0001) and neonatologists (mean difference 12 s, 95% confidence interval 8 to 16 s;
p
< 0.0001). The difference in timing of PPV initiation was similar between pediatric residents and neonatologists (mean difference − 1 s, 95% confidence interval − 7 to 6 s;
p
= 0.85).
Conclusions
: Performing immediate laryngoscopy with intubation and suctioning was associated with longer—but not clinically relevant—time of initiation of PPV compared with immediate PPV without intubation in a manikin model. While suggesting negligible delay in starting PPV, further studies in a clinical setting are warranted.
Registration
: clinicaltrial.gov NCT04076189.
What is Known:
• Management of the non-vigorous newborn delivered through meconium-stained amniotic fluid remains still controversial.
• Tracheal suctioning in non-vigorous newborn delivered through meconium-stained amniotic fluid is supposed to delay initiation of positive pressure ventilation, but the magnitude of such delay is unknown.
What is New:
• Performing immediate ventilation without intubation was associated with shorter—but not clinically relevant—time of initiation of ventilation compared to immediate laryngoscopy with intubation and suctioning in a manikin model.
• Further studies in a clinical setting are warranted.
Meconium aspiration syndrome is a clinical condition characterized by respiratory failure occurring in neonates born through meconium-stained amniotic fluid. Worldwide, the incidence has declined in ...developed countries thanks to improved obstetric practices and perinatal care while challenges persist in developing countries. Despite the improved survival rate over the last decades, long-term morbidity among survivors remains a major concern. Since the 1960s, relevant changes have occurred in the perinatal and postnatal management of such patients but the most appropriate approach is still a matter of debate. This review offers an updated overview of the epidemiology, etiopathogenesis, diagnosis, management and prognosis of infants with meconium aspiration syndrome.
Fetuses with intrauterine growth restriction (IUGR) have significant aortic intima-media thickening (aIMT), which suggests that preclinical atherosclerosis might predispose the infants to ...hypertension. However, the natural course of aIMT in babies with IUGR remains an open question.The study enrolled 77 pregnant women between January 2007 and August 2009. The fetuses were classified as AGA (appropriate for gestational age) or IUGR, if the estimated fetal weight was between the 10th and 90th percentile or below the 10th percentile (with umbilical artery pulsatility index (PI) >2s.d.), respectively. Anthropometric parameters and aIMT were detected in each IUGR and AGA fetus at a mean gestational age of 32 weeks. The follow-up was performed in 25 IUGR and 25 AGA infants at a mean postnatal age of 18 months; the previous measurements were repeated, and blood pressure measurements were taken. The maximum aIMT was significantly higher in the IUGR fetuses and infants compared with the AGA infants, both in utero (2.05±0.43 vs. 1.05±0.19 mm, P<0.001) and at the follow-up (2.3±0.8 vs. 1.06±0.18 mm, P<0.0001), the resulting values significantly correlated (P=0.018) with one another. The systolic blood pressure was significantly increased in the IUGR subjects (123±16 vs. 104±8.5 mm Hg, P<0.0004), and it correlated with the prenatal and postnatal aIMT values (P<0.0156 and P<0.0054, respectively). The aortic wall thickening progression in IUGR fetuses and infants differed from AGA, which may predispose the infants to hypertension early in life and cardiovascular risk later in life.
A better understanding of the context-specific epidemiology, outcomes, and risk factors for death of critically ill parturients in resource-poor hospitals is needed to tackle the still alarming ...in-hospital maternal mortality in African countries. From October 2017 to October 2018, we performed a 1-year retrospective cohort study in a referral maternity hospital in Freetown, Sierra Leone. The primary endpoint was the association between risk factors and high-dependency unit (HDU) mortality. Five hundred twenty-three patients (median age 25 years, interquartile range IQR: 21-30 years) were admitted to the HDU for a median of 2 (IQR: 1-3) days. Among them, 65% were referred with a red obstetric early warning score (OEWS) code, representing 1.17 cases per HDU bed per week; 11% of patients died in HDU, mostly in the first 24 hours from admission. The factors independently associated with HDU mortality were ward rather than postoperative referrals (odds ratio OR: 3.21; 95% CI: 1.48-7.01;
= 0.003); admissions with red (high impairment of patients' vital signs) versus yellow (impairment of vital signs) or green (little or no impairment of patients' vital signs) OEWS (OR: 3.66; 95% CI: 1.15-16.96;
= 0.04); responsiveness to pain or unresponsiveness on the alert, voice, pain unresponsive scale (OR: 5.25; 95% CI: 2.64-10.94;
≤ 0.0001); and use of vasopressors (OR: 3.24; 95% CI: 1.32-7.66;
= 0.008). Critically ill parturients were predominantly referred with a red OEWS code and usually required intermediate care for 48 hours. Despite the provided interventions, death in the HDU was frequent, affecting one of 10 critically ill parturients. Medical admission, a red OEWS code, and a poor neurological and hemodynamic status were independently associated with mortality, whereas adequate oxygenation was associated with survival.
Objective To assess the effectiveness of supreme laryngeal mask airway (SLMA) over face mask ventilation for preventing need for endotracheal intubation at birth. Study design We report a ...prospective, randomized, parallel 1:1, unblinded, controlled trial. After a short-term educational intervention on SLMA use, infants ≥34-week gestation and/or expected birth weight ≥1500 g requiring positive pressure ventilation (PPV) at birth were randomized to resuscitation by SLMA or face mask. The primary outcome was the success rate of the resuscitation devices (SLMA or face mask) defined as the achievement of an effective PPV preventing the need for endotracheal intubation. Results We enrolled 142 patients (71 in SLMA and 71 in face mask group, respectively). Successful resuscitation rate was significantly higher with the SLMA compared with face mask ventilation (91.5% vs 78.9%; P = .03). Apgar score at 5 minutes was significantly higher in SLMA than in face mask group ( P = .02). Neonatal intensive care unit admission rate was significantly lower in SLMA than in face mask group ( P = .02). No complications related to the procedure occurred. Conclusions In newborns with gestational age ≥34 weeks and/or expected birth weight ≥1500 g needing PPV at birth, the SLMA is more effective than face mask to prevent endotracheal intubation. The SLMA is effective in clinical practice after a short-term educational intervention. Trial Registration Registered with ClinicalTrials.gov : NCT01963936.
Background Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of ...care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. Methods Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6-24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. Results The intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil. Conclusions The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs. Keywords: Acute malnutrition, Nutritional rehabilitation, Default
We assessed the effect of an adapted neonatal resuscitation program (NRP) course on healthcare providers' performances in a low-resource setting through the use of video recording.
A video recorder, ...mounted to the radiant warmers in the delivery rooms at Beira Central Hospital, Mozambique, was used to record all resuscitations. One-hundred resuscitations (50 before and 50 after participation in an adapted NRP course) were collected and assessed based on a previously published score.
All 100 neonates received initial steps; from these, 77 and 32 needed bag-mask ventilation (BMV) and chest compressions (CC), respectively. There was a significant improvement in resuscitation scores in all levels of resuscitation from before to after the course: for "initial steps", the score increased from 33% (IQR 28-39) to 44% (IQR 39-56), p<0.0001; for BMV, from 20% (20-40) to 40% (40-60), p = 0.001; and for CC, from 0% (0-10) to 20% (0-50), p = 0.01. Times of resuscitative interventions after the course were improved in comparison to those obtained before the course, but remained non-compliant with the recommended algorithm.
Although resuscitations remained below the recommended standards in terms of quality and time of execution, clinical practice of healthcare providers improved after participation in an adapted NRP course. Video recording was well-accepted by the staff, useful for objective assessment of performance during resuscitation, and can be used as an educational tool in a low-resource setting.
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