Pain and Physiological Stress During Minimally Invasive Surfactant Therapy (MIST) in Very Preterm Infants

Objectives: To evaluate the pain or physiological stress caused during minimally invasive surfactant therapy (MIST) to very preterm neonates. Methods: In this prospective observational study conducted in a tertiary NICU, very preterm neonates were assessed for pain using Premature Infant Pain Profile-Revised (PIPP-R) score before, during and after MIST. Changes in the heart rate and oxygen saturation were also recorded during the procedure. Results: 23 neonates who received MIST were assessed for pain using PIPP-R. Mean (SD) PIPP-R score during MIST was 3.87(1.3), before; 12.83 (1.9), during; and 6.26 (1.0), after the procedure, respectively (all P<0.001). Heart rate and oxygen saturation were also significantly reduced during MIST (P<0.001). Conclusion: The high PIPP-R scores during surfactant administration suggest that MIST can cause moderate to severe pain/discomfort and significant physiological stress in very preterm infants.

Umbilical Cord Milking Reduces Duration of Inotrope Support in Preterm Infants Less than 32 Weeks of Gestation, Born with Cesarean Section in Comparison to Delayed Cord Clamping

Objective: Very preterm infants commonly need inotrope support. We aimed to demonstrate that umbilical cord milking (UCM)would reduce the need for inotropes in preterm infants born with cesarean section in comparison to delayed cord clamping (DCC).Study Design: We compared the need of inotrope support, in a pilot randomized controlled trial, among preterm infants<32 weeks’ gestation receiving UCM (n = 25) in comparison to those who underwent DCC (n = 24).Results: Baseline maternal and newborn characteristics were similar. There was a significant reduction in the total duration ofinotrope support (P = 0.004) and total duration of respiratory support (P = 0.021) in babies undergoing UCM when comparedto those undergoing DCC. Trend toward reduction in incidence of hemodynamically significant patent ductus arteriosus andintraventricular hemorrhage was noted in UCM group.Conclusion: UCM significantly improved respiratory and hemodynamic stability in preterm infants <32 weeks’ gestation withoutassociated complications.

Very Early (<2 h) Versus Early (12 h) Administration of Caffeine Citrate for Reducing Need for Mechanical Ventilation within 24 h of Life in Preterm Infants on Continuous Positive Airway Pressure

Background and Objective: In the caffeine for apnea of prematurity (CAP) trial, post hoc analyses have discovered reductionsin respiratory and neurologic morbidities associated with earlier caffeine initiation (within 3 days). This study aims to compare theeffects of early (<2 h) and late (12 h) initiation of caffeine in preterm neonates on continuous positive airway pressure (CPAP).Study Design: A total of 36 neonates <32 weeks gestational age were randomized to receive intravenous caffeine citrate(20 mg/kg) before 2 h (early n = 19) or at 12 h of age (late n = 17). This was a pilot randomized controlled trial to determine thepower needed to reduce the need for endotracheal intubation by 24 h of age. Other outcomes included the duration of respiratorysupport, duration of oxygen therapy, need for vasopressors, incidence of intraventricular hemorrhage, patent ductus arteriosusneeding treatment, necrotizing enterocolitis, bronchopulmonary dysplasia, retinopathy of prematurity, sepsis, and mortality.Results: There was no difference in the need for intubation (P = 0.615) or vasopressors (P = 0.455) by 24 h of age. Statisticallysignificant reduction was noted in the total duration of CPAP support (P = 0.003). However, total duration of respiratory support(P = 0.425), total duration of mechanical ventilation days (P = 0.237), and oxygen days (P = 0.145) were favoring early caffeinegroup, which were not statistically significant. None of the babies in both the groups had apnea of prematurity. There was nodifference in other outcomes.Conclusion: This pilot study demonstrated the feasibility of conducting such a trial in very preterm neonates. We found thatearly caffeine administration was associated with statistically significant reduction in the duration of non-inWvasive respiratorysupport. Larger studies are needed to determine whether early caffeine reduces intubation, intraventricular hemorrhage, durationof respiratory support, and related long-term outcomes.

Prefeeding Oromotor Stimulation Program for Improving Oromotor Function in Preterm Infants – A Randomized Controlled Trial

Objective: To determine effect of Premature Infant Oral Motor Intervention program on oro-motor function and time to full independent wati spoon feeds in preterm infants. Methods: 30preterm infants between 28-32 weeks of gestation on full gavage feeds of 150 mL/kg/daywere randomized to receive either pre-feed oro-motor stimulation using Premature InfantOral Motor Intervention (structured stimulation) or sham intervention (unstructuredstimulation). Results: Improvement in mean (SD) Neonatal Oro-Motor Assessment Scale(NOMAS) over 7 days from baseline was significantly higher in the study group infants ascompared to control group (9.25 (1.73) vs 4.79 (1.52), P=0.001). Infants in the study groupreached full independent wati spoon feeds significantly earlier than the infants in controlgroup (4.0 (0.8) d; vs 6.64 (1.0) d; P=0.001). There was significant increase in weight gainafter enrolment in infants in study group compared to those in control group. Conclusions:Oral stimulation program improves the oro-motor skills and growth velocity in 28-32 weekpreterm infants. There is decreased transition time from gavage to full independent feeds bymouth

Heated Humidified High Flow Nasal Cannula versus Nasal Continuous Positive Airway Pressure as Primary Mode of Respiratory Support for Respiratory Distress in Preterm Infants.

Objective: To compare the outcomes of preterm infants with respiratory distress initiated on either Heated Humidified High Flow Nasal Cannula or Nasal Continuous Positive Airway Pressure as a primary mode of respiratory support. Study Design: Prospective observational cohort study Setting : Tertiary care level III neonatal intensive care unit Participants : 88 preterm infants between 28 to 34 weeks of gestation with mild to moderate respiratory distress within 6 hours of birth. Intervention: Eligible infants were treated either with Heated Humidified High Flow Nasal Cannula (n=46) or Nasal Continuous Positive Airway Pressure (n=42). Primary outcome : Need for mechanical ventilation within 72 hrs of initiating support. Results: Baseline demographic characteristics were comparable between the two groups. There was no difference in the requirement of mechanical ventilation between Heated Humidified High Flow Nasal Cannula (19.5%) and Nasal Continuous Positive Airway Pressure (26.2%) groups [RD – 0.74 (95% CI 0.34-1.62; P =0.46)]. Moderate or severe nasal trauma occurred less frequently with Heated Humidified High Flow Nasal Cannula (10.9%) in comparison to Nasal Continuous Positive Airway Pressure (40.5%) (P= 0.004). Conclusion: Heated Humidified High Flow Nasal Cannula was comparable to Nasal Continuous Positive Airway Pressure as a primary respiratory support for preterm infants with respiratory distress, with lesser incidence of nasal trauma.

Nasal Mask Versus Nasal Prongs for Delivering Nasal Continuous Positive Airway Pressure in Preterm Infants with Respiratory Distress: A Randomized Controlled Trial.

Objective: To compare the effectiveness of nasal continuous positive airway pressure delivered by Nasal mask vs Nasal prongs with respect to continuous positive airway pressure failure. Study design: Randomized, controlled, open label, trial. Setting: Tertiary care level III neonatal unit. Participants: 118 preterm infants-gestational age (27-34 weeks) requiring nasal continuous positive airway pressure as a primary mode for respiratory distress, who were treated with either nasal mask (n=61) or nasal prongs (n=57) as interface. Primary outcome: Need for mechanical ventilation within 72 h of initiating support. Results: Nasal continuous positive airway pressure failure occurred in 8 (13%) of Mask group and 14 (25%) of Prongs group but was statistically not significant (RR 0.53, 95% CI 0.24-1.17) (P = 0.15). The rate of pulmonary interstitial emphysema was significantly less in the Mask group (4.9% vs. 17.5%; RR 0.28, 95% CI 0.08-0.96; P = 0.03). Incidence of moderate nasal trauma (6.5% vs 21%) (P=0.03) and overall nasal trauma (36% vs 58%) (P=0.02) were significantly lower in mask group than in the prongs group. Conclusion: Nasal continuous positive airway pressure with mask as interface is as effective as prongs but causes less nasal trauma and pulmonary interstitial emphysema.