Whole-body vibration in neonatal transport: a review of current knowledge and future research challenges.

Interfacility transport to tertiary care for high-risk neonates has become an integral part of equitable access to optimal perinatal healthcare. Excellence in clinical care requires expertise in transport medicine and the coordination of safe transport processes. However, concerns remain regarding environmental stressors involved in the transportation of sick high-risk neonates, including noise and vibration. In order to mitigate the potential deleterious effects of these physical stressors during transport, further knowledge of the burden of exposure, injury mechanisms and engineering interventions/modifications as adjuncts during transport would be beneficial. We reviewed the current literature with a focus on the contribution of new and emerging technologies in the transport environment with particular reference to whole-body vibration. This review intends to highlight what is known about vibration as a physical stressor in neonates and areas for further research; with the goal to making recommendations for minimizing these stressors during transport.

Defining Significant Events for Neonatal and Pediatric Transport: Results of a Combined Delphi and Consensus Meeting Process.

Objective To develop standardized definitions for a list of indicators that represent significant events during pediatric transport, which were previously identified by a national Delphi study. Methods We designed a three-phase consensus process that applied Delphi methodology to a combination of electronic questionnaires and a live consensus meeting. Results Thirty-one pediatric transport experts evaluated a total of 59 indicators. Twenty-four indicators represented events or interventions that did not require definition. One indicator was removed from the list. Definitions for the remaining 34 indicators were developed. Conclusion This standardized indicator list is intended for application to quality improvement and clinical research initiatives.

High-fidelity simulator technology may not be superior to traditional low-fidelity equipment for neonatal resuscitation training.

OBJECTIVE: Despite completing accredited resuscitation training, neonatal trainees often feel unprepared to deal with real-life clinical emergencies. High-fidelity simulator (HFS) technology offers the potential of recreating a realistic stressful clinical environment to aid training and evaluation. To date, there are limited data examining the physiological impact of this training modality in comparison to less costly alternatives. The objective of this study was to compare the effects of low-fidelity simulator (LFS) versus HFS technology on performance levels, objective and subjective measures of stress in neonatal trainees. STUDY DESIGN: Sixteen neonatal fellows were invited to participate in a prospective randomized study. Subjects were divided into pairs and randomized to LFS or HFS for completion of scenario I. After an interval of 1 month, fellow teams crossed over to complete scenario II using the alternative simulator technology. Technical and non-technical skills were assessed using validated resuscitation scoring tools. Participants recorded subjective stress at sequential time points before and after each simulation. Buccal cortisol was measured at each corresponding time point and comparison between HFS and LFS groups was made. RESULT: The mean overall resuscitation performance score was 75.8%±10, but there was no difference in performance between HFS and LFS groups. There was also no significant difference in non-technical skills performance between groups. Salivary cortisol increased over the duration of the simulated experience, but there were no differences between the two groups (P=0.001, two-way repeated measures analysis of variance). We also identified changes in subjective measures of stress (P<0.001, analysis of variance) over time, but again there were no differences between groups. CONCLUSION: Simulated neonatal resuscitations induce a significant stress response in neonatal trainees; however, we were unable to identify any difference in stress measures between HFS and LFS. These data suggest that HFS technology offers no additional stress-inducing benefit.

Improved procedural performance following a simulation training session may not be transferable to the clinical environment.

OBJECTIVE: Neonatal intubation is a life-saving procedural skill required by pediatricians. Trainees receive insufficient clinical exposure to develop this competency. Traditional training comprises a Neonatal Resuscitation Program (NRP) complemented by clinical experience. More recently, simulation is being used in procedural skills training. The objective of this study is to examine the impact of a simulation session, which teaches the skill of neonatal intubation by comparing pre- and post-intervention performance, and examining transferability of skill acquisition to the clinical setting. STUDY DESIGN: First-year pediatric residents with NRP training, but no previous neonatal experience, attended a 2-h intubation education session conducted by two experienced respiratory therapists. Individual components of the skill were taught, followed by practice on a high-fidelity infant mannequin with concurrent feedback. Skills were assessed using a validated neonatal intubation checklist (CL) and a five-point global rating scale (GRS), pre- and immediately post-intervention, using the mannequin. Clinical intubations performed in the subsequent 8-week neonatal intensive-care unit (NICU) rotation were evaluated by documenting success rates, time taken to intubate, and CL and GRS scores. Performance was also compared with similar data collected on intubations performed by a historical cohort of first-year residents who did not receive the training intervention. Data were analyzed using descriptive statistics, Student's t-test and χ (2)-test as appropriate, and analysis of variance. RESULT: Thirteen residents participated in the educational session. Mean pre-intervention CL score was 65.4 ± 18% (s.d.) and GRS was 3 ± 0.7 (s.d.). Performance improved following the intervention with post-training CL score of 93 ± 5% (P<0.0001) and GRS of 3.92 ± 0.4 (P=0.0003). These trainees performed 40 intubations during their subsequent NICU rotation, with a success rate of 67.5% compared with 63.15% in the cohort group (NS). However, mean CL score for the study trainees during the NICU rotation was 64.6 ± 20%, significantly lower than their post-training CL score (P<0.001), and significantly lower than the historical cohort score of 82.5 ± 15.4% (P=0.001). In the intervention group, there were no significant differences between the pre-intervention and real-life CL scores of 65 ± 18% and 64.63 %, respectively, and the pre-intervention and real-life GRS of 3.0 ± 0.7 and 2.95 ± 0.86, respectively. CONCLUSION: Trainees showed significant improvement in intubation skills immediately post intervention, but this did not translate into improved-clinical performance, with performance returning to baseline. In fact, significantly higher CL scores were demonstrated by the cohort group. These data suggest that improved performance in the simulation environment may not be transferable to the clinical setting. They also support the evidence that although concurrent feedback may lead to improved performance immediately post training intervention, this does not result in improved skill retention overall.

Failure of pediatric and neonatal trainees to meet Canadian Neonatal Resuscitation Program standards for neonatal intubation.

OBJECTIVE: Neonatal intubation skills are initially taught through the Neonatal Resuscitation Program (NRP) and thereafter complemented by further practical clinical training. The aim of this study is to compare the ability of NRP trained individuals to successfully complete a neonatal intubation. STUDY DESIGN: A prospective observational study was performed at an inborn high-risk level 3 perinatal center. Participants were postgraduate years 1 and 3 pediatric residents, neonatal-perinatal medicine subspecialty residents and fellows, and neonatal intensive care unit (NICU) respiratory therapists (RTs) with earlier NRP training. Intubations were scored on a checklist as well as a global assessment scale. Characteristics of the intubation attempt were recorded for each patient. RESULT: Fifty neonatal intubations were assessed, of which 73% of the attempts were deemed successful. A higher proportion of endotracheal tubes were successfully placed by RTs (100%, P<0.05), compared with both NICU fellows (69%) and pediatric residents (63%). The overall mean time for successful neonatal intubation was 51+/-28 s, which is greater than twice the time currently recommended by the NRP and American Heart Association guidelines. Attempts by pediatric residents and NICU fellows were longer (P<0.05, analysis of variance) and received lower global assessment scale (P<0.05, analysis of variance) and checklist (P<0.05, analysis of variance) scores, when compared with RTs. CONCLUSION: The success rate and overall quality of neonatal intubations performed by neonatal and pediatric trainees in Canada did not meet NRP standards; in particular, the time taken to intubate by pediatric residents and neonatal fellows is concerning. Re-evaluation of training methods and the volume of formalized exposure to neonatal intubation in Canadian residency programs are required.

Prophylactic antibiotics in the prevention of catheter-associated bloodstream bacterial infection in preterm neonates: a systematic review.

OBJECTIVE: To evaluate the efficacy of prophylactic antibiotics in preventing infection associated with central venous catheters in preterm neonates. STUDY DESIGN: The search strategy of the Cochrane Neonatal Review Group was used. The following databases were searched: Medline, Cochrane Central Register of Controlled Trials, CINAHL and EMBASE. In addition, we hand-searched abstracts of Pediatric Academic Societies annual meetings published in Pediatric Research (1990 to July 2007) and Canadian Pediatric Society annual meeting proceedings (1990 to July 2007). No language restrictions were applied. Included were randomized controlled trials of antibiotics given prophylactically to prevent infection in preterm infants (<37 completed weeks) less than 1-month old admitted to neonatal intensive care units. Both centrally or peripherally inserted central venous catheters were included. Assessment of methodological quality and extraction of data for included trials was undertaken independently by two authors. When suitable, data from trials were combined in a meta-analysis. RESULT: A total of three studies were found which addressed the role of prophylactic antibiotics to prevent catheter-related infection in neonates. Two studies used vancomycin as the prophylactic antibiotic and one study used amoxicillin. The meta-analysis of studies that used vancomycin had shown an absolute risk reduction of infection from 23 to 2.4%, which yields a number needed to treat equal to 5 (P=0.0001). Total duration of catheter stay and mortality, were both similar in the vancomycin and control groups. In the amoxicillin study, catheter-related sepsis was not significantly different between the treatment and control groups (P=0.40). The rate of colonization, however, was significantly higher in the control group (relative risk 0.48; 95% CI 0.12, 1.35). The incidence of necrotizing enterocolitis, intracranial hemorrhage, thrombosis and deaths were not statistically significant between groups. CONCLUSION: Prophylactic vancomycin appeared to be effective in preventing catheter-related sepsis in preterm neonates. The potential risks, however, of the emergence of resistance because of prophylactic antibiotics, and their continued effectiveness, need further evaluation, before routine use can be recommended.

Dedicated neonatal retrieval teams improve delivery room resuscitation of outborn premature infants.

BACKGROUND: Morbidity related to ineffective resuscitation and stabilization of premature infants is increased when delivery occurs outside tertiary perinatal centers. The regional neonatal transport team received extensive training to expand their scope of practice to include delivery room resuscitation allowing them to attend high-risk deliveries in community hospitals when maternal transfer was not possible. OBJECTIVE: Compare the resuscitation and stabilization of premature infants when a specialized neonatal retrieval team (SNRT) is in attendance at delivery with immediate resuscitation and stabilization performed by the referral hospital team (RHT). STUDY DESIGN: We assessed the impact of a specially trained neonatal transport team by comparing the initial resuscitation process, airway and vascular access skills, illness severity and patient stabilization in both groups. RESULTS: Neonates resuscitated by the RHT were more likely to receive oxygen, mask CPAP, bag and mask ventilation and cardiac compressions for a significantly longer time period. Neonates resuscitated by the SNRT were intubated more promptly (8.5 minutes {1 to 22} vs 16 minutes {1 to 90}, p=0.035) following a fewer number of attempts. The endotracheal tube was correctly positioned on radiological assessment in 72% of cases in the SNRT group vs 38.1% in the RHT group (p<0.001). Many neonates had no vascular access (31%) and were profoundly hypothermic (38.5%) on arrival of the SNRT. Although there was no significant difference in maximum FiO(2) or oxygenation index, babies with respiratory distress syndrome resuscitated by the RHT were less likely to receive surfactant therapy (76.6 vs 34.4%, p=0.001). There was no difference in transport-related mortality between the groups CONCLUSIONS: The presence of a highly skilled transport team at a high-risk preterm delivery improves the quality of neonatal resuscitation by increasing intubation success rates and achieving earlier vascular access. Neonates resuscitated by dedicated neonatal retrieval teams were less likely to become significantly hypothermic. Although the severity of RDS was similar neonates in the RHT were less likely to receive surfactant.

The relationship between periventricular brain injury and deficits in visual processing among extremely-low-birthweight (< 1000 g) children.

OBJECTIVE: To examine the relationship between neonatal, periventricular brain damage and visuomotor performance in extremely-low-birthweight (ELBW) children of normal intelligence whose birthweights were appropriate for gestational age (AGA). METHODS: Seventy-eight ELBW and 23 control children, all six years of age, completed two "motor-free" tests of visual spatial ability and three tests requiring visuomotor control. RESULTS: Full-term control children outperformed ELBW children with periventricular brain damage on all three tests requiring visuomotor guidance. No group differences were found on two "motor-free" tests of visual spatial ability. ELBW children without periventricular brain damage performed in a manner indistinguishable from controls on all tests included in this study. CONCLUSIONS: The findings indicate that the presence and severity of periventricular brain injury are important factors to consider in predicting visuomotor development in ELBW children.

Development of a paperless, Y2K compliant exposure tracking database at Los Alamos National Laboratory.

The Industrial Hygiene and Safety Group at Los Alamos National Laboratory (LANL) developed a database application known as IH DataView, which manages industrial hygiene monitoring data. IH DataView replaces a LANL legacy system, IHSD, that restricted user access to a single point of data entry needed enhancements that support new operational requirements, and was not Year 2000 (Y2K) compliant. IH DataView features a comprehensive suite of data collection and tracking capabilities. Through the use of Oracle database management and application development tools, the system is Y2K compliant and Web enabled for easy deployment and user access via the Internet. System accessibility is particularly important because LANL operations are spread over 43 square miles, and industrial hygienists (IHs) located across the laboratory will use the system. IH DataView shows promise of being useful in the future because it eliminates these problems. It has a flexible architecture and sophisticated capability to collect, track, and analyze data in easy-to-use form.

Outcome of infants 23-26 weeks' gestation pre and post surfactant.

To describe mortality and neurodevelopmental outcome before and after the introduction of rescue therapy with natural surfactant in two neonatal units in Toronto, Canada, a retrospective cohort study of 891 liveborn 23-26 wk gestational age infants, 421 presurfactant (1982-1987) and 470 postsurfactant (1990-1994) was performed. Overall mortality was stable over time (41% vs 35%, p = 0.077), but declined for inborn 24 (71% vs 43%, p = 0.03) and 26 wk (26% vs 13%, p = 0.01) gestational age infants and was higher in surfactant-treated infants (p < 0.0001). Chronic lung disease (61% vs 34%, p < 0.0001) and bilateral blindness (8% vs 4%, p = 0.004) declined over time, with stable rates of cerebral palsy (12% vs 15%), cognitive deficit (27% vs 26%) and aided sensorineural hearing loss (5% vs 4%). Sixty-five percent of surviving infants in both eras were free from neurodevelopmental impairment, and severe impairment declined over time (p = 0.035). This study shows no secular change in overall mortality in a large cohort of 23-26 wk gestational age infants since the introduction of rescue therapy with natural surfactant. However, it does suggest that maternal transfer to and delivery of all extremely preterm infants in high risk perinatal centres is justified.

Neonatal meningitis and multiple brain abscesses due to Citrobacter diversus.

We report a fatal sporadic case of neonatal Citrobacter diversus meningitis with rapid clinical progression. At autopsy, multiple brain abscesses and abscesses in the spinal cord had complicated purulent meningitis. Septic omphalitis was identified as the most likely portal of entry.

Early somatosensory evoked potentials in preterm infants: their prognostic utility.

We hypothesized that somatosensory evoked potentials (SEPs) recorded early in the course of a preterm infant life would be predictive of long-term neurodevelopmental outcome. We recorded unilateral, median nerve SEPs in 88 preterm infants twice in the first 3 weeks of life (SEP1 and SEP2). We found both SEP1 and SEP2 to be significantly associated with the presence of periventricular leukomalacia on head ultrasound (p = 0.04 and p = 0.02 for SEP1 and SEP2, respectively). Both SEP1 and SEP2 were predictive of later cerebral palsy (CP) (p = 0.03 and p = 0.003, respectively). False-positive results were frequent (13 of 17 for SEP1 and 20 of 28 for SEP2). A normal SEP, even when there was periventricular echogenicity on head ultrasound, was associated with a normal outcome in all but 1 instance. SEP1 and SEP2 were less accurate than head ultrasound findings of periventricular leukomalacia in the prediction of later CP (73, 69 and 93%, respectively). SEPs done in the first 3 weeks of life may provide additional prognostic information, particularly when the test is normal. Abnormal SEPs in this period must be interpreted cautiously.

Visual evoked potentials for prediction of neurodevelopmental outcome in preterm infants.

Visual evoked potentials (VEPs) have proved to be accurate predictors of outcome in term infants with hypoxic-ischemic encephalopathy. Parallels between term asphyxia and hypoxic-ischemic injury in the preterm brain suggested the hypothesis that VEPs may predict the development of periventricular leukomalacia (PVL) and later cerebral palsy. 123 infants less than 32 weeks' gestational age were enrolled in the study. VEPs were done in the first 3 weeks of life (usually first week). VEPs did show a statistically significant association with PVL (p < 0.04) although false-positive recordings were twice as frequent as true-positive recordings. VEPs were not associated with grade III-IV intraventricular hemorrhage (p = 1.0). Unlike asphyxiated term infants, VEPs were not predictive of abnormal neurodevelopmental outcome in the preterm population.

Secular changes in the outcomes to eighteen to twenty-four months of age of extremely low birth weight infants, with adjustment for changes in risk factors and severity of illness.

OBJECTIVES: To analyze secular changes in the rates of death and of major impaired outcome in surviving outborn infants who weighted < or = 800 gm at birth and were admitted in 1980 to 1989, with adjustment for changes in risk factors and severity of illness around the time of birth; and to identify changes in these factors that might explain changes in outcomes. DESIGN: Retrospective cohort study with follow-up to a minimum of 18 months of postterm age. After preliminary screening, multivariate models of association between risk/severity of illness factors and outcomes were constructed, validated, and used to adjust outcomes (death and major impairment to 18 to 24 months of age). SETTING: Regional neonatal intensive care unit for referral of "outborn" infants. PATIENTS: Two hundred eighty-seven consecutively admitted infants who weighted < or = 800 gm at birth (97% follow-up). RESULTS: The death rate during the 1980s did not fall significantly (p adjusted for risk factors = 0.115). The major impairment rate fell (odds ratio, 0.24 (95% confidence interval, 0.10, 0.60); p = 0.002, adjusted for delivery route and respiratory failure measures), mainly because of a reduced rate of blindness, not attributable to cryotherapy. The risk factors that improved and were possibly related to the reduced impairment rate were blood pH and glucose concentration, and serum sodium concentration in the first 48 hours of life. CONCLUSIONS: Despite an increasing selection for referral of less mature and more severely ill outborn babies near the "limit of viability," and despite more aggressive care, the rate of major impairment fell significantly during the 1980s. This trend was enhanced by adjustment for severity of illness. The fall was attributable to a reduced rate of blindness, and was associated with evidence of improved control of physiologic balance after birth.

Acute digoxin overdose in a newborn with renal failure: use of digoxin immune Fab and peritoneal dialysis.

Digitalis intoxication is a common problem, mainly because of the narrow margin of safety of digoxin. These patients may have concomitant renal failure. In patients who have renal failure and who have been treated with digoxin-Fab, the elimination of the digoxin-Fab complex is significantly delayed, and there is a risk of dissociation of the complex with rebound of free digoxin and recurrence of toxicity. The high molecular weight of digoxin and digoxin-Fab complex prevents its elimination by hemodialysis or continuous arteriovenous hemofiltration. A 3-day-old newborn with digoxin overdose and acute renal failure was treated with digoxin immune Fab and peritoneal dialysis. Low levels of total digoxin were measured in the dialyzate, indicating poor elimination of the digoxin-Fab complex through peritoneal dialysis.

Developmental outcome of infants treated with extracorporeal membrane oxygenation (ECMO) in the neonatal period: is the evidence all in?

The North American literature was reviewed regarding the developmental outcome of infants treated with ECMO therapy versus those infants who received conventional medical therapy for treatment of persistent pulmonary hypertension of the newborn. The literature reviewed included all ECMO follow-up investigations published in medical journals cited in CD-ROM between January 1980 and July 1992, as well as abstracts presented at the Society for Pediatric Research 1990-1992. The literature was examined with respect to the incidence, prevalence and nature of morbidity, with particular attention paid to the neuroevelopmental domains assessed, test measures used, age at assessment and criteria for normal and abnormal outcome. Rough comparison of the published outcome statistics for the cohorts of infants who received neonatal ECMO therapy or conventional medical therapy (CMT) suggest equivalent amounts of morbidity within the first few years of life. Without appropriate systematic comparison at the same ages on the same measures and in infants with equivalent severity of illness, the current observations remain tentative at best. Longitudinal investigations are needed in order to identify specific medical and developmental markers in infancy of good and poor long-term outcome in this population, together with comparisons of outcome in the group treated with ECMO versus the group treated with CMT. Fine-grained, sensitive measures must be employed that record transient or permanent delays and/or qualitative deficits in specific skills.

Ocular sequelae in premature infants.

OBJECTIVE: The authors report on the incidence of myopia and strabismus at 12 and 24 months postterm in a cohort of 190 premature infants with birth weights of less than 1251 g born in 1986 and 1987. METHODS: The neonatal and follow-up eye charts of a cohort of 190 premature infants were retrospectively reviewed. All 138 children who survived the neonatal period had at least one eye examination between day 28 and 42 of life that documented the presence and staging of retinopathy of prematurity (ROP) according to the International Classification of ROP. No infants received cryotherapy. Eye examinations conducted at 12 and 24 months postterm included assessment of vision, fundus, ocular motility, anterior segment abnormality, and refractive error. Eyes were refracted using cycloplegic retinoscopy. Strabismus was detected using the Hirschberg and cover tests. Eye reports were available for 80% (n = 110) at 12 months and 36% (n = 50) at 24 months. RESULTS: Fifty-three percent of the cohort exhibited ROP in the neonatal period; 12% of these progressed to stage 3 or 4 ROP. Myopia was observed in 16% (18/110) of the cohort at 12 months of age; 4.5% (5/110) measured more than 4.0 diopters of myopia. Children with birth weights of less than 751 g were 3.2 times more likely than those with birth weights between 751 and 1000 g and 10 times more likely than those with birth weights between 1001 and 1250 g to develop myopia in the first year of life. The likelihood of myopia at 12 months doubled with each increment in ROP stage. Of the 50 children reexamined at 24 months postterm, more than 80% demonstrated deteriorating vision. The incidence of myopia increased to 38% (19/50) overall, with 24% (12/50) of the cohort showing severe myopia. Astigmatism and anisometropia were highly correlated with severe myopia. Strabismus was seen with increasing frequency through the second year of life. All children with grade III or IV intraventricular hemorrhage in the neonatal period developed esotropia. CONCLUSION: This study emphasizes the significant roles of low birth weight, ROP, and intraventricular hemorrhage in the development of myopia and strabismus. Follow-up to 2 years of life is recommended given the demonstrated deterioration in our cohort.

Changing survival and impairment rates at 18-24 months in outborn very low-birth-weight infants: 1984-1987 versus 1980-1983.

Outcomes at 18-24 months corrected age of very low-birth-weight infants admitted to our Neonatal Intensive Care Unit in 1984-1987 (period 2) were compared with the outcomes of infants admitted in 1980-1983 (period 1) (total 1357 infants). In the 500-750-g birth-weight subgroup, the survival rate increased from 32 to 54% (p = 0.002). Rates of moderate and severe impairment at 18-24 months (neurosensory deficit, or Bayley corrected mental developmental index < or = 68) in this subgroup decreased from 41 to 15% (p = 0.005), and in those without severe impairment, mean mental Bayley scores in periods 1 and 2 were 84 +/- 18 and 90 +/- 16, respectively (p = 0.20). Analysis after exclusion of small-for-gestational-age infants gave similar results. In the small-for-gestational-age infants of birth weight 500-750 g, the survival rate increased but the impairment rate was unchanged between periods. It is concluded that outcomes improved in 1984-1987 compared with 1980-1983 only for infants with birth weight of 500-750 g.

Extreme immaturity: outcome of 568 pregnancies of 23-26 weeks' gestation.

OBJECTIVE: To provide guidelines to the perinatologist regarding extremely premature infants based on the experience of the University of Toronto Newborn Service (two high-risk perinatal units and one outborn neonatal intensive care unit), with a catchment area of 60,000 deliveries annually. METHODS: The study included all births or admissions in the Newborn Service from January 1, 1982 to June 30, 1987 with gestational age determined by the best obstetric estimate of gestational age, ranging from 23-26 completed weeks. The obstetric records were reviewed and the surviving infants followed prospectively for a minimum of 2 years after delivery. RESULTS: Analysis of the neonatal and 2-year follow-up data on 568 infants born between 23-26 weeks' gestation revealed a 39% mortality rate, which increased with decreasing gestation. The highest mortality rates occurred following complicated pregnancies, including fetal growth restriction. Intact survival increased with increasing gestational age, from 11% at 23 weeks to 50% at 26 weeks. There was a marked improvement in both mortality and morbidity by 25 completed weeks. CONCLUSIONS: The results suggest that an aggressive approach before 24 completed weeks' gestation is not warranted. From a total of 60,000 live births per year, only one child born at 23 weeks' gestation and three at 24 weeks were free of major handicap at 2 years.