Category: Delivery room care

T-piece versus self inflating bag for resuscitation of VLBW infants

In a prospective multi-center observational study from Brazil of almost 2000 infants with a birth weight less than 1500 grams, compared to infants who received positive pressure at birth with a self-inflating bag (with no PEEP valve), those who received…

Placental transfusion in newborns needing resuscitation

A narrative review summarizes the current evidence on three different methods of placental transfusion in preterm and term infants who need resuscitation – delayed cord clamping, milking of the uncut umbilical cord, and milking of the cut umbilical cord. The…

Review – congenital diaphragmatic hernia

In a comprehensive, well-illustrated review the authors summarize the current literature on congenital diaphragmatic hernia (CDH). Prenatally, severity can be assessed by the lung to head ratio (LHR) and position of the liver. Delivery at term is preferred, and management at birth includes…

High-flow nasal cannula for initial respiratory support

A multicenter randomized trial compared the use of high-flow nasal cannula (HFNC) versus nasal CPAP for respiratory support in preterm infants greater than 28 weeks gestation with respiratory distress who had not received surfactant. Treatment failure was defined as an…

Multiple intubation attempts and IVH

A single-center retrospective study of over 300 infants less than 1500 grams birth weight found that infants with severe IVH had a higher number of intubation attempts in the first four days of life than infants with mild or no…

Delayed cord clamping improves motor function

A randomized trial of women delivering singleton fetuses before 32 weeks gestation compared the effects of delayed cord clamping (30-45 seconds) versus immediate (less than ten seconds) cord clamping. There were no differences in rates of intraventricular hemorrhage or late-onset…

Signs of CPAP failure after birth

An observational study from one center used the results of pulmonary function testing in 32 preterm infants stabilized on CPAP immediately after birth to compare patterns in infants who failed CPAP versus those who succeeded. Respiratory interventions were recorded starting…

LISA for RDS

A multicenter randomized controlled trial from Germany in infants 23 – 26 weeks with respiratory distress syndrome compared traditional surfactant administration following endotracheal intubation and positive pressure ventilation, versus less invasive surfactant administration (LISA) where surfactant was administered through a thin…

Heart rate assessment immediately after birth

A systematic review that included eighteen studies of heart rate assessment after birth found that palpation and auscultation were the least accurate methods of heart rate detection during resuscitation, that pulse oximetry was superior, and that the electrocardiogram was the…

The Apgar Score

A recent statement by the AAP and ACOG emphasizes the following about the Apgar score: It does not predict mortality or neurologic outcome in an individual infant. It alone should not be used to diagnose asphyxia – it is not…

Interventions to reduce neonatal and child mortality

A comprehensive overview of nearly 150 published systematic reviews of experimental and observational studies assessed interventions to prevent perinatal/neonatal and child mortality and classified them as effective, promising or ineffective. Effective interventions were: antenatal corticosteroids to prevent neonatal respiratory distress syndrome in…

Is resuscitation of preterm infants with room air risky?

In a retrospective cohort study of infants less than 27 weeks gestation from 17 Canadian NICUs, when compared to infants resuscitated with 100% oxygen, infants resuscitated with less than 100% (typically 21-40%) oxygen had a higher rate of severe neurologic injury or death (adjusted…

Vindication for the SUPPORT trial

Investigators of the SUPPORT trial have been criticized and accused (by parents and by the Office of Human Research Protection) of causing harm to babies enrolled in the trial even though this study was approved by multiple institutional review boards.…

Measuring heart rate during resuscitation

A simulation study compared the accuracy and time to detection of various heart rates detected either by umbilical palpation, listening to tapping of heart rate, or auscultation. While these methods were fairly accurate and timely in detection of heart rates…

The effect of rudeness on team performance

A randomized trial in a simulated setting assessed the effects of rudeness on performance of a NICU team that had to respond to a case scenario of a preterm infant with acute deterioration due to necrotizing enterocolitis. A putative external…

CPAP for Preterm Infants

A review article summarizes the available evidence on nasal CPAP and discusses implications for developing countries. Key points of this review are: In preterm infants less than 28 weeks gestation whose mothers have received antenatal steroids, CPAP is the preferred…

The ideal admission temperature in preterm infants < 33 weeks of gestation

Submitted by: Krithika Lingappan, MD A retrospective observational study of nearly 10,000 neonates neonates  <33 weeks of gestation from 29 NICUs in the Canadian Neonatal Network sought to estimate the admission temperature associated with lowest rates of adverse outcomes. The…

Delay in increase of delivered oxygen during resuscitation

During neonatal resuscitation, when positive pressure ventilation is delivered through a T-piece resuscitator and the fraction of inspired oxygen is increased at the oxygen blender, it may take some time before the infant actually receives the increased FiO2.  In a…

Sustained lung inflation at birth

A randomized trial of babies 25 – 28 weeks gestation compared two methods of initial stabilization after birth – nasal CPAP alone versus sustained lung inflation followed by nasal CPAP. Infants receiving the sustained lung inflation had a lower incidence of mechanical…

Risk factors for morbidity in term neonates

A prospective two-year cohort study of term neonates without major congenital anomalies determined the antepartum and intrapartum factors associated with a composite measure of neonatal morbidity, defined as one or more of the following: hypoxic ischemic encephalopathy, meconium aspiration with pulmonary…

Heart rate at birth measured by pulse oximetry versus electrocardiography

Concurrent readings of heart rate immediately after birth as detected by pulse oximetry and EKG electrodes were compared in 53 neonates (both term and preterm infants were included). The leads or sensor were applied as soon as possible after birth…

Occlusive wrap to prevent heat loss at birth

A multicenter randomized study in 39 NICUs (the largest trial of its kind) compared the effects of applying polyethylene occlusive wrap to preterm infants between 24 – 27 weeks gestation immediately after birth. The study was stopped early when 50%…

Benefits of umbilical cord milking

A systematic review and meta-analysis of seven randomized trials of umbilical cord milking compared to control conditions found the following benefits in preterm infants less than 33 weeks gestation – a higher hemoglobin and hematocrit, reduction in oxygen requirement at…

Lung-protective respiratory support in preterm infants

Lung injury in preterm infants receiving respiratory support can be decreased by avoiding: (1) Atelectrauma by promoting alveolar stability, (2) Volutrauma by limiting tidal volume to prevent alveolar overdistension, and (3) Oxitrauma by minimizing oxygen toxicity by improving ventilation-perfusion matching.…

Periviable birth: Workshop summary

The findings of a Joint Workshop held by leading organizations in obstetric and pediatric/neonatal care were recently published in multiple journals and contains summaries and recommendations about obstetric and neonatal management. Highlights of this report: The term perviable birth was…

Umbilical cord milking versus immediate cord clamping

A randomized trial of infants born at less than 32 weeks gestation compared the effects of umbilical cord milking versus immediate cord clamping. Thirty infants were assigned to each arm. Infants who underwent umbilical cord milking had a higher serum hemoglobin,…

Intranasal midazolam for delivery room intubation

A case series from France reports on the use of intranasal midazolam as pre-medication for intubation of preterm infants to administer surfactant soon after birth. Twenty-seven infants with a median gestation of 29 weeks were studied. Infants were monitored using pain…

Operation Toasty Tot – An intervention to reduce hypothermia

A quality improvement project to reduce admission hypothermia in inborn very-low-birth-weight infants used a bundle of interventions to prevent heat loss from conduction, convection, radiation and evaporation. The interventions did not include increasing delivery room temperature or exothermic mattresses. Over…

Stylets for intubation

An unblinded randomized study from Australia compared endotracheal intubations (by residents or fellows in the delivery room or in the NICU) performed with and without a stylet. The overall success rate on the first attempt was between 50 – 60%.…

Nasal tube resuscitation of preterm infants

A randomized (unblinded) study compared the effects of resuscitating infants 24 – 29 weeks at birth with either a face mask or a nasal tube to provide positive pressure ventilation. Both these devices were connected to a T-piece resuscitator. Resuscitation…

Dilemmas in the care of extremely preterm infants – an essay

An essay written by a neonatologist describes the dilemmas faced by NICU teams when faced with decisions about resuscitation of extremely preterm infants. In the ‘Gray Zone’. Suresh 2013 Listen to the podcast Tweet

Music to improve neonatal CPR

In the world of adult CPR, listening to specific music pieces (Staying Alive, Nellie the Elephant, Disco Science) while performing CPR has been shown to improve the quality of CPR. A pilot study evaluated the effect of ‘Radetzkymarsch’ (110 beats…

Cord milking prior to umbilical cord clamping vs immediate clamping

A single-center randomized trial compared the effects of immediate umbilical cord clamping after birth with clamping after active cord milking in infants 24 – 28 weeks gestation. In the latter group, around 20 cms of the cord was actively milked…

Exothermic mattresses to prevent admission hypothermia

A randomized trial from Ireland compared preterm infants less than 31 weeks gestation who underwent temperature management at birth with or without an exothermic mattress. All infants received radiant heat and were placed in a polyethylene bag as well. The trial…

Surfactant administration with a thin catheter inserted into the trachea

A randomized trial tested a new method of administering surfactant to preterm infants that avoids positive pressure ventilation. In spontaneously breathing infants surfactant was administered through a thin catheter is inserted into the trachea under laryngoscopy. Infants treated this way had…

Presenting information to help parents decide: how much detail and what order ?

When volunteers were presented a hypothetical scenario of a 23 week gestation infant and asked to choose either intensive care or comfort care, they chose similarly, irrespective of whether they were presented information in more detail or less, and whether…