It is unknown if the lung deposition of surfactant administered via a catheter placed through a laryngeal mask airway (LMA) is equivalent to that obtained by bolus instillation through an ...endotracheal tube. We compare the lung deposition of surfactant delivered via two types of LMA with the standard technique of endotracheal instillation. 25 newborn piglets on continuous positive airway pressure support (CPAP) were randomized into three groups: 1—LMA-camera (integrated camera and catheter channel; catheter tip below vocal cords), 2—LMA-standard (no camera, no channel; catheter tip above the glottis), 3—InSurE (Intubation, Surfactant administration, Extubation; catheter tip below end of endotracheal tube). All animals received 100 mg·kg−1 of poractant alfa mixed with 99mTechnetium-nanocolloid. Surfactant deposition was measured by gamma scintigraphy as a percentage of the administered dose. The median (range) total lung surfactant deposition was 68% (10–85), 41% (5–88), and 88% (67–92) in LMA-camera, LMA-standard, and InSurE, respectively, which was higher (p < 0.05) in the latter. The deposition in the stomach and nasopharynx was higher with the LMA-standard. The surfactant deposition via an LMA was lower than that obtained with InSurE. Although not statistically significant, introducing the catheter below the vocal cords under visual control with an integrated camera improved surfactant LMA delivery by 65%.
Hypothermic neonates need to be promptly rewarmed but there is no strong evidence to support a rapid or a slow pace of rewarming. This study aimed to investigate the rewarming rate and its ...associations with clinical outcomes in hypothermic neonates born in a low-resource setting.
This retrospective study evaluated the rewarming rate of hypothermic inborn neonates admitted to the Special Care Unit of Tosamaganga Hospital (Tanzania) in 2019-2020. The rewarming rate was calculated as the difference between the first normothermic value (36.5-37.5°C) and the admission temperature, divided by the time elapsed. Neurodevelopmental status at 1 month of age was assessed using the Hammersmith Neonatal Neurological Examination.
Median rewarming rate was 0.22°C/h (IQR: 0.11-0.41) in 344/382 (90%) hypothermic inborn infants, and was inversely correlated to admission temperature (correlation coefficient -0.36,
< 0.001). Rewarming rate was not associated with hypoglycemia (
= 0.16), late onset sepsis (
= 0.10), jaundice (
= 0.85), respiratory distress (
= 0.83), seizures (
= 0.34), length of hospital stay (
= 0.22) or mortality (
= 0.17). In 102/307 survivors who returned at follow-up visit at 1 month of age, rewarming rate was not associated with a potential correlate of cerebral palsy risk.
Our findings did not show any significant association between rewarming rate and mortality, selected complications or abnormal neurologic exam suggestive of cerebral palsy. However, further prospective studies with strong methodological approach are required to provide conclusive evidence on this topic.
Deviations from normothermia affect early mortality and morbidity, but the impact on neurodevelopment of the survivors is unclear. We aimed to investigate the relationship between neonatal ...temperature at admission and the risk of cerebral palsy (CP) at one month of age in a low-resource setting.
This retrospective study included all inborn neonates admitted to the Special Care Unit of Tosamaganga Hospital (Tanzania) between 1 January 2019 and 31 December 2020. The neurological examination at one month of age was performed using the Hammersmith method. The relationship between the admission temperature and the risk of CP was investigated using logistic regression models, with temperature modeled as the non-linear term.
High/moderate risk of CP was found in 40/119 (33.6%) of the neonates at one month of age. A non-linear relationship between the admission temperature and moderate/high risk of CP at one month of age was found. The lowest probability of moderate/high risk of CP was estimated at admission temperatures of between 35 and 36 °C, with increasing probability when departing from such temperatures.
In a low-resource setting, we found a U-shaped relationship between the admission temperature and the risk of CP at one month of life. Expanding the analysis of the follow-up data to 12-24 months of age would be desirable in order to confirm and strengthen such findings.
Background: Training programs on resuscitation have been developed using simulation-based learning to build skills, strengthen cognitive strategies, and improve team performance. This is especially ...important for residency programs where reduced working hours and high numbers of residents can reduce the educational opportunities during the residency, with lower exposure to practical procedures and prolonged length of training. Within this context, gamification has gained popularity in teaching and learning activities. This report describes the implementation of a competition format in the context of newborn resuscitation and participants’ perceptions of the educational experience. Methods: Thirty-one teams of three Italian pediatric residents participated in a 3-day simulation competition on neonatal resuscitation. The event included an introductory lecture, familiarization time, and competition time in a tournament-like structure using high-fidelity simulation stations. Each match was evaluated by experts in neonatal resuscitation and followed by a debriefing. The scenarios and debriefings of simulation station #1 were live broadcasted in the central auditorium where teams not currently competing could observe. At the end of the event, participants received an online survey regarding their perceptions of the educational experience. Results: 81/93 (87%) participants completed the survey. Training before the event mostly included reviewing protocols and textbooks. Low-fidelity manikins were the most available simulation tools at the residency programs. Overall, the participants were satisfied with the event and appreciated the live broadcast of scenarios and debriefings in the auditorium. Most participants felt that the event improved their knowledge and self-confidence and stimulated them to be more involved in high-fidelity simulations. Suggested areas of improvement included more time for familiarization and improved communication between judges and participants during the debriefing. Conclusions: Participants appreciated the simulation competition. They self-perceived the educational impact of the event and felt that it improved their knowledge and self-confidence. Our findings suggest areas of improvements for further editions and may serve as an educational model for other institutions.
(1) Background: Our survey aimed to gather information on respiratory care in Neonatal Intensive Care Units (NICUs) in the European and Mediterranean region. (2) Methods: Cross-sectional electronic ...survey. An 89-item questionnaire focusing on the current modes, devices, and strategies employed in neonatal units in the domain of respiratory care was sent to directors/heads of 528 NICUs. The adherence to the "European consensus guidelines on the management of respiratory distress syndrome" was assessed for comparison. (3) Results: The response rate was 75% (397/528 units). In most Delivery Rooms (DRs), full resuscitation is given from 22 to 23 weeks gestational age. A T-piece device with facial masks or short binasal prongs are commonly used for respiratory stabilization. Initial FiO
is set as per guidelines. Most units use heated humidified gases to prevent heat loss. SpO
and ECG monitoring are largely performed. Surfactant in the DR is preferentially given through Intubation-Surfactant-Extubation (INSURE) or Less-Invasive-Surfactant-Administration (LISA) techniques. DR caffeine is widespread. In the NICUs, most of the non-invasive modes used are nasal CPAP and nasal intermittent positive-pressure ventilation. Volume-targeted, synchronized intermittent positive-pressure ventilation is the preferred invasive mode to treat acute respiratory distress. Pulmonary recruitment maneuvers are common approaches. During NICU stay, surfactant administration is primarily guided by FiO
and SpO
/FiO
ratio, and it is mostly performed through LISA or INSURE. Steroids are used to facilitate extubation and prevent bronchopulmonary dysplasia. (4) Conclusions: Overall, clinical practices are in line with the 2022 European Guidelines, but there are some divergences. These data will allow stakeholders to make comparisons and to identify opportunities for improvement.
Background: Cannulas with long and narrow tubing (CLNT) are increasingly being used as an interface for noninvasive respiratory support (NRS) in preterm neonates; however, their efficacy compared to ...commonly used nasal interfaces such as short binasal prongs (SBP) and nasal masks (NM) has not been widely studied. Material and Methods: Medline, Embase, CENTRAL, Health Technology Assessment Database, and Web of Science were searched for randomized clinical trials (RCTs) and observational studies investigating the efficacy of CLNT compared to SBP or NM in preterm neonates requiring NRS for primary respiratory and post-extubation support. A random-effects meta-analysis was used for data synthesis. Results: Three RCTs and three observational studies were included. Clinical benefit or harm could not be ruled out for the outcome of need for invasive mechanical ventilation (IMV) for CLNT versus SBP or NM relative risk (RR) 1.37, 95% confidence interval (CI) 0.61–3.04, certainty of evidence (CoE) low. The results were also inconclusive for the outcome of treatment failure RR 1.20, 95% CI 0.48–3.01, CoE very low. Oropharyngeal pressure transmission was possibly lower with CLNT compared to other interfaces MD −1.84 cm H20, 95% CI −3.12 to −0.56, CoE very low. Clinical benefit or harm could not be excluded with CLNT compared to SBP or NM for the outcomes of duration of IMV, nasal trauma, receipt of surfactant, air leak, and NRS duration. Conclusion: Very low to low CoE and statistically nonsignificant results for the clinical outcomes precluded us from making any reasonable conclusions; however, the use of CLNT as an NRS interface, compared to SBP or NM, possibly transmits lower oropharyngeal pressures. We suggest adequately powered multicentric RCTs to evaluate the efficacy of CLNT when compared to other interfaces.
Background: Kangaroo mother care (KMC) is a low-cost intervention that is indicated to be a highly effective practice for which adoption and implementation are lacking. We investigated the current ...provision of KMC in Vietnam and explored differences among levels of healthcare facility. Methods: A survey form was sent to 187 hospitals in Vietnam, representing the three levels (central, provincial and district) of public hospital-based maternity services. Results: Overall response rate was 74% (138/187 hospitals). Routine KMC implementation was estimated in 49% of the hospitals. Where KMC was implemented or was being introduced, half of the hospitals had a written protocol and a KMC-dedicated room, and held educational courses on KMC. KMC was mainly performed by the mother. Skin-to-skin contact was mostly performed for <12 h/day (55%), exclusive breastfeeding at discharge was very frequent (89%) and early discharge was considered in half of the hospitals (54%), while follow-up was not performed in 29% of the hospitals. Participants considered follow-up after discharge as the main barrier to KMC implementation, and indicated education (of both parents and health caregivers) and environment upgrades (KMC-dedicated room and equipment) as the most important facilitators. Conclusions: Our survey estimated a limited implementation of KMC in Vietnamese maternity hospitals, with marked variations across the different levels of maternity services. Areas of improvements include increasing the duration of skin-to-skin contact, arranging dedicated spaces for KMC, involving the relatives (especially at district level), extending the availability of a written protocol, improving the eligibility process, and implementing early discharge and follow-up monitoring.
BackgroundMonitoring of peripheral capillary oxygen saturation (SpO2) during neonatal resuscitation is standard of care in high-resource settings, but seldom performed in low-resource settings. We ...aimed to measure SpO2 and heart rate during the first 10 min of life in neonates receiving positive pressure ventilation (PPV) according to the Helping Babies Breathe (HBB) protocol and compare results with SpO2 and heart rate targets set by the American Heart Association (AHA).MethodsA cross-sectional study was conducted at Mulago National Referral Hospital, Kampala, Uganda, as a substudy of the NeoSupra Trial. SpO2 and heart rate were measured on apnoeic neonates (≥34 weeks) who received PPV according to HBB (room air). Those who remained distressed after PPV received supplemental oxygen (O2). All resuscitations were video recorded and data were extracted by video review at 1 min intervals until 10 min post partum. Data were analysed for all observations and separately for only observations before and during PPV.Results49 neonates were analysed. Median SpO2 at 5 min (n=39) was 67% (49–88) with 59% of the observations below AHA target of 80%. At 10 min median SpO2 (n=44) was 93% (80–97) and 32% were below AHA target of 85%. When only observations before and during PPV were analysed, median SpO2 at 5 min (n=18) was 52% (34–66) and 83% were below AHA target. At 10 min (n=15), median SpO2 was 72% (57–89) and 67% were below AHA target. Median heart rates were above AHA target of 100 beats/min at all time intervals.ConclusionsA high proportion of neonates resuscitated with PPV after birth failed to reach the AHA SpO2 target in this small sample, implying an increased risk of hypoxic-ischaemic encephalopathy. Further studies in low-resource settings are needed to evaluate baseline data and the need for supplemental O2 and optimal SpO2 during PPV.Trial registration numberThis is a substudy to the trial ‘Neonatal Resuscitation with Supraglottic Airway Trial (NeoSupra)’; ClinicalTrials.gov Registry (NCT03133572).
Extracorporeal membrane oxygenation (ECMO) implantation for neonates with severe cardiorespiratory life-threatening conditions is highly effective. However, since ECMO is a high-risk and complex ...therapy, this treatment is usually performed in centers with proven expertise.
A retrospective review of neonates, from January 2014 to January 2020, presenting with life-threatening conditions and treated by means of Hub and Spoke (HandS) ECMO in peripheral (spoke) hospitals. Data were retrieved from our internal ECMO registry. Protocols and checklists were revised and shared with all spoke hospitals located in North-Eastern Italy.
Eleven neonates receiving maximal respiratory and cardiovascular support at a spoke hospital underwent HandS ECMO management. All but three patients were affected by life-threatening meconium aspiration syndrome (MAS). The median ECMO support duration and hospitalization were four (range 2-32) and 30 days (range 8-50), respectively. All but two patients (with congenital diaphragmatic hernia), were weaned off ECMO and discharged home. At a mean follow up of 33.7 ± 29.2 months, all survivors were alive and well, without medications, and normal somatic growth. All but one had normal neuropsychological development.
HandS ECMO model for neonates with life-threatening conditions is effective and successful. A specialized multidisciplinary team and close cooperation between Hub and Spoke centers are essential for success.
Background: The poor quality of care received by mothers and neonates in many limited-resource countries represents a main determinant of newborn mortality. Small and sick hospitalized newborns are ...the highest-risk population, and they should be one of the prime beneficiaries of quality-of-care interventions. This study aimed to evaluate the impact on neonatal mortality of quality improvement interventions which were implemented at Tosamaganga Council Designated Hospital, Iringa, Tanzania, between 2016 and 2020. Methods: A retrospective comparison between pre- and post-intervention periods was performed using the chi-square test and Fisher’s exact test. Effect sizes were reported as odds ratios with 95% confidence intervals. Results: The analysis included 5742 neonates admitted to the Special Care Unit (2952 in the pre-intervention period and 2790 in the post-intervention period). A decrease in mortality among infants with birth weight between 1500 and 2499 g (overall: odds ratio 0.49, 95% confidence interval 0.27–0.87; inborn: odds ratio 0.50, 95% confidence interval 0.27–0.93) was found. The analysis of cause-specific mortality showed a decrease in mortality for asphyxia (odds ratio 0.33, 95% confidence interval 0.12–0.87) among inborn infants with birth weight between 1500 and 2499 g. Conclusions: A quality improvement intervention was associated with decreased mortality among infants with birth weight between 1500 and 2499 g. Further efforts are needed to improve prognosis in very-low-birth-weight infants.
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