Archives of Disease in Childhood - Fetal and Neonatal Edition最新文献

Objective: Assess the relationship between applied face mask force and leak during simulated ventilation using different ventilating devices and mask holds.

Design: Randomised cross-over simulation study.

Setting: Quiet, non-clinical room in children's hospital.

Participants: Twenty-four experienced neonatal healthcare providers.

Interventions: Ventilate a manikin for 2 min per trial, each with three trial conditions: self-inflating bag (SIB) with one-hand hold, T-piece with one-hand hold, T-piece with two-hand hold.

Main outcome measures: Applied force (newtons (N)) measured under the head and at four locations on the manikin's face (nasal bridge, mentum, left and right zygomatic arches), force asymmetry applied to the mask rim, and mask leak.

Results: Under-head force was greatest using the SIB with one-hand hold (mean (SD) 20.53 (5.87) N) and least using the T-piece with one-hand hold (mean (SD) 17.58 (6.11) N). While mask leak was reduced with increasing force, leak-free ventilation was achieved by some participants in all trial conditions with low (<10 N) under-head force. Force asymmetry on the manikin's face was similar using a one-hand hold compared with a two-hand hold. With both holds, forces were greater on the side of the face corresponding to the operator's non-dominant hand.

Conclusion: Applied force and leak varied between devices and mask holds. Force asymmetry was present with both mask holds. Leak-free ventilation could be achieved with small forces using either an SIB or T-piece and either mask hold. Force feedback during training may improve the effectiveness and safety of neonatal ventilation.

Objectives: Extremely preterm children may have a prolonged neonatal intensive care unit (NICU) stay. Their parents interact with clinicians both before and after birth. There is little information about parental satisfaction with the information received and what they would want to improve. The objective of this study was to explore parental perspectives regarding their information needs.

Methods: Over 1 year, parents of children born at <29 weeks' gestational age (GA), who were aged between 18 months and 7 years old and came for their follow-up visit were invited to participate. They were asked to answer this question in their own words: "Knowing what you know now, what do you wish doctors would have told you about prematurity before and/or after your child's birth?" Mixed method analysis included thematic analysis performed by a multidisciplinary group, including parents, and logistic regression to compare parental responses.

Results: Among parents (n=248, 98% of parents coming to follow-up), 45% were satisfied. When parents had recommendations, the main themes invoked improving communication about (1) preparing for discharge and life after the NICU in a stepwise, personalised and practical manner (40%), (2) more practical and functional information about being a parent in the NICU during the whole clinical trajectory (35%) and (3) more optimistic conversations with clinicians about the function of babies/families (as opposed to diagnoses) (26%).

Conclusion: Although half the parents are satisfied with the information received, many recommended improvements in clinician-parent communication, mainly to make it more accessible, personalised, positive and practical.

Rationale: Stepwise positive end-expiratory pressure at birth (dynamic PEEP) reduces lung injury in preterm lambs; however, the impact of dynamic PEEP on pulmonary blood flow (PBF) during immediate (ICC) and deferred cord clamping (DCC) is unknown.

Objectives: To determine the impact of dynamic PEEP on PBF during DCC and ICC.

Methods: Preterm lambs (n=22) received a ventilation strategy with either dynamic PEEP (between 8 and 14 cmH₂O) or static PEEP (8 cmH₂O) after birth. Lambs were managed with either DCC or ICC (30 s clamp to ventilation) (n=5-6 per group). Left pulmonary artery flow was measured using echocardiography as a surrogate for PBF. Ventilation parameters and PBF were measured every 20 s until 180 s and at 5, 10 and 15 min from ventilation onset.

Results: There was no significant difference in PBF between dynamic and static PEEP applied during DCC (mean (SD) 183 (66) vs 125 (43) mL/kg/min, mean (SD) difference=-58 (103) mL/kg/min, p=0.09) or ICC (124 (26) vs 120 (31) mL/kg/min, mean difference=-4(184), p=0.94). PBF significantly increased over time (p<0.01; mixed effects) in all groups regardless of cord management. This was associated with an increase in the velocity time integral (p<0.01) but no difference in heart rate. Cerebral blood flow reduced over time during DCC (p<0.01) with no change observed during ICC. There was no difference in lung mechanics apart from higher respiratory system compliance in the ICC Dynamic PEEP group (mean difference 0.08 (0.05) mL/kg/cmH₂O, p<0.01).

Conclusions: Elective lung recruitment after birth using a dynamic PEEP does not impede PBF in preterm lambs.

Objective: To investigate the effect of gestational age on special education use at primary school age, and to examine specific groups with elevated risk.

Design, setting and patients: Population-based matched cohort study linking data from the Dutch national perinatal registry (PERINED) of all singleton surviving children without major congenital abnormalities, born between 25⁺⁰ and 42⁺⁶ weeks of gestation between 1999 and 2009, with data of the mandatory special education registry of Statistics Netherlands.

Main outcome measures: Use of special education at primary school age.

Results: 1 814 540 children were included. Overall prevalence of special education was 6.6%, with highest rates in children born at 25 weeks (34.7%) and lowest at 40 weeks (5.7%). Elevated adjusted ORs for special education compared with the reference of 40 weeks were found in all gestational age groups (25-29 weeks, 30-31 weeks, 32-36 weeks, 37-39 weeks and 41-42 weeks), with the highest adjusted OR (3.50 (95% CI, 3.26 to 3.77)) in children born at 25-29 weeks. Comparable ORs were obtained after 1 to 1 exact matching with controls born at 40 weeks. Low maternal education, male sex, small for gestational age and 5-min Apgar score<7 increased special education use at week 25 and above.

Conclusion: There is a strong inverse effect of gestational age on special education use in this complete nationwide, decennium birth cohort. Increased risk of special education use is still present in late preterms and those born at early-term or post-term.

Objective: To evaluate whether a perfusion-based approach (permissive hypotension, PH) for idiopathic low mean arterial blood pressure (MABP) during the first 72 hours after birth in preterm infants without overt sepsis affects neurodevelopmental outcome (NDO) at 24 months of age.

Design: Randomised controlled trial. Outcome assessors were blinded.

Setting: Single centre.

Patients: Infants <30 weeks gestational age (GA) with MABP in mm Hg

Intervention: Random assignment to PH, initiating treatment on signs of low perfusion and/or a MABP 5 mm Hg below their GA in weeks, or standard treatment (ST), initiating treatment when MABP was

Main outcome measures: Death, NDO at 24 months, and composite adverse outcome (death or cognitive and/or motor NDO below -1 SD).

Results: 86 infants were included, 57.3% of projected inclusions. Both cognitive NDO (PH-ST mean difference 0.8 (95% CI -5.6 to 7.3)) and motor NDO (mean difference 3.7 (-3.3 to 10.7)) were comparable. The relative risks for death (1.4 (0.6 to 3.7)) and composite adverse outcome (0.8 (0.5 to 1.3)) were comparable. The number of infants with inotropic support (n=19 (42.5%) vs 7 (15.2%), p=0.004) and duration of support (median 48.0 hours (IQR 26.8 to 77.5) vs 17.0 (14.0 to 37.0)) was lower in the PH group, with comparable MABPs.

Conclusion: A PH approach in preterm infants is feasible. It leads to comparable blood pressures with less inotrope administration. Though underpowered, we did not detect a major negative impact of PH on short-term or long-term outcomes.

Trial registration number: NCT01434251.

Objectives: We assessed whether an infusion of normal saline volume during chest compression resuscitation, compared with standard intravenous epinephrine, would increase diastolic blood pressure, achieve return of spontaneous circulation (ROSC) and maintain physiological stability after ROSC.

Methods: Near-term fetal lambs were asphyxiated until mean blood pressure reached 10-12 mm Hg and heart rate was <60 beats per minute. Resuscitation was commenced with ventilation and chest compressions. Lambs were randomly allocated to: standard care (20 µg/kg intravenous epinephrine; n=8) or volume infusion (20 mL/kg over 2 min; n=10). After two allocated treatment doses, rescue intravenous epinephrine was administered if ROSC was not achieved by 8 min. Lambs achieving ROSC were monitored for 60 min. Cerebral histology was assessed for micro-haemorrhages.

Results: Blood pressure and cerebral blood flow during chest compressions was higher in volume infusion lambs. ROSC occurred in 8/8 standard care lambs. Of the volume infusion lambs, 5/10 achieved ROSC in response to allocated treatment, and despite increased diastolic pressure, 3/10 required rescue epinephrine and 2/10 did not achieve ROSC. For 2 min after ROSC, blood pressure, heart rate and arterial partial pressure of arterial oxygen (PaO₂) was higher in standard care lambs compared with volume infusion lambs. The number of periventricular white matter micro-haemorrhages was higher in volume infusion lambs.

Conclusions: Volume infusion with saline improved blood pressure stability during and after cardiopulmonary resuscitation but was inferior to intravenous epinephrine in achieving ROSC and reducing cerebral micro-haemorrhages. The use of volume infusion during resuscitation in moderately asphyxiated euvolaemic newborns is unlikely to have clinical benefit.