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.

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.