Impact of an Educational Clinical Video Combined with Standard Helping Babies Breathe Training on Acquisition and Retention of Knowledge and Skills among Ethiopian Midwives.

Helping Babies Breathe (HBB) is an evidence-based neonatal resuscitation program designed for implementation in low-resource settings. While HBB reduces rates of early neonatal mortality and stillbirth, maintenance of knowledge and skills remains a challenge. The extent to which the inclusion of educational clinical videos impacts learners' knowledge and skills acquisition, and retention is largely unknown. We conducted a cluster-randomized controlled trial at two public teaching hospitals in Addis Ababa, Ethiopia. We randomized small training group clusters of 84 midwives to standard HBB vs. standard HBB training supplemented with exposure to an educational clinical video on newborn resuscitation. Midwives were followed over a 7-month time period and assessed on their knowledge and skills using standard HBB tools. When comparing the intervention to the control group, there was no difference in outcomes across all assessments, indicating that the addition of the video did not influence skill retention. Pass rates for both the control and intervention group on bag and mask skills remained low at 7 months despite frequent assessments. There is more to learn about the use of educational videos along with low-dose, high-frequency training and how it relates to retention of knowledge and skills in learners.

Cigarette Smoking Abstinence Among Pregnant Individuals Using E-Cigarettes or Nicotine Replacement Therapy.

Importance: Smoking cigarettes during pregnancy can impair maternal and child health, and pregnant individuals have increasingly used electronic cigarettes (e-cigarettes) for various reasons, including quitting smoking. Objective: To assess smoking abstinence rates among pregnant individuals who used e-cigarettes compared with those who used nicotine replacement therapy (NRT). Design, Setting, and Participants: This cohort study is a secondary data analysis of phase 8 of the US Pregnancy Risk Assessment Monitoring System, conducted between 2016 and 2020. Eligible participants included pregnant individuals who smoked combustible cigarettes within the 3 months before pregnancy and either used e-cigarettes or NRT during pregnancy. Data analysis was conducted from March 2022 to April 2023. Exposures: Combustible cigarette use within 3 months before pregnancy and use of either e-cigarettes or NRT during pregnancy. Main Outcomes and Measures: The primary outcome was the individual's self-reported smoking abstinence status during the last 3 months of pregnancy. Weighted percentages were reported and weighted multivariable logistic regression models were used to examine the association of e-cigarette use vs NRT with smoking abstinence. A propensity score was used to control for confounding by sociodemographics, pregnancy characteristics, prepregnancy smoking intensity, depression, behavioral support, and hookah use. Results: The cohort included 1329 pregnant individuals (759 ≥25 years [60.2%]; 766 non-Hispanic White individuals [79.8%]) of whom 781 had an education level of high school or lower (61.4%), and 952 had an annual household income of $48 000 or less (81.5%). Of the 1329 individuals, 890 (unweighted percentage, 67.0%) were existing e-cigarette users, 67 (unweighted percentage, 5.0%) were new e-cigarette users, and 372 (unweighted percentage, 28.0%) were NRT users. Compared with individuals who used NRT during pregnancy, individuals who used e-cigarettes had a higher rate of smoking abstinence in late pregnancy (456 individuals [50.8%] vs 67 individuals [19.4%]; propensity score adjusted odds ratio [OR], 2.47; 95% CI, 1.17-5.20; P = .02). In the secondary analysis stratified by the timing of e-cigarette use initiation, existing users of e-cigarettes who initiated before pregnancy had a higher smoking abstinence rate than NRT users (446 users [53.1%] vs 67 users [19.4%]; adjusted OR, 2.61; 95% CI, 1.23-5.51; P = .01). However, new e-cigarette users who initiated use during pregnancy had a similar smoking abstinence rate in late pregnancy when compared with NRT users (10 users [20.6%] vs 67 users [19.4%]; adjusted OR, 1.13; 95% CI, 0.22-5.87; P = .88). Conclusions and Relevance: These findings suggest that individuals who used e-cigarettes during pregnancy had a higher smoking abstinence rate in late pregnancy than individuals who used NRT, especially for those who initiated e-cigarette use before pregnancy, indicating that replacement of cigarettes with e-cigarettes during pregnancy may be a viable strategy for harm reduction.

Observational study comparing heart rate in crying and non-crying but breathing infants at birth.

BACKGROUND: Stimulating infants to elicit a cry at birth is common but could result in unnecessary handling. We evaluated heart rate in infants who were crying versus non-crying but breathing immediately after birth. METHODS: This was single-centre observational study of singleton, vaginally born infants at ≥33 weeks of gestation. Infants who were crying or non-crying but breathing within 30 s after birth were included. Background demographic data and delivery room events were recorded using tablet-based applications and synchronised with continuous heart rate data recorded by a dry-electrode electrocardiographic monitor. Heart rate centile curves for the first 3 min of life were generated with piecewise regression analysis. Odds of bradycardia and tachycardia were compared using multiple logistic regression. RESULTS: 1155 crying and 54 non-crying but breathing neonates were included in the final analyses. There were no significant differences in the demographic and obstetric factors between the cohorts. Non-crying but breathing infants had higher rates of early cord clamping <60 s after birth (75.9% vs 46.5%) and admission to the neonatal intensive care unit (13.0% vs 4.3%). There were no significant differences in median heart rates between the cohorts. Non-crying but breathing infants had higher odds of bradycardia (heart rate <100 beats/min, adjusted OR 2.64, 95% CI 1.34 to 5.17) and tachycardia (heart rate ≥200 beats/min, adjusted OR 2.86, 95% CI 1.50 to 5.47). CONCLUSION: Infants who are quietly breathing but do not cry after birth have an increased risk of both bradycardia and tachycardia, and admission to the neonatal intensive care unit. TRIAL REGISTRATION NUMBER: ISRCTN18148368.

Inadequate Bioavailability of Intramuscular Epinephrine in a Neonatal Asphyxia Model.

Background: Over half a million newborn deaths are attributed to intrapartum related events annually, the majority of which occur in low resource settings. While progress has been made in reducing the burden of asphyxia, novel approaches may need to be considered to further decrease rates of newborn mortality. Administration of intravenous, intraosseous or endotracheal epinephrine is recommended by the Newborn Resuscitation Program (NRP) with sustained bradycardia at birth. However, delivery by these routes requires both advanced skills and specialized equipment. Intramuscular (IM) epinephrine may represent a simple, low cost and highly accessible alternative for consideration in the care of infants compromised at birth. At present, the bioavailability of IM epinephrine in asphyxia remains unclear. Methods: Four term fetal lambs were delivered by cesarean section and asphyxiated by umbilical cord occlusion with resuscitation after 5 min of asystole. IM epinephrine (0.1 mg/kg) was administered intradeltoid after 1 min of positive pressure ventilation with 30 s of chest compressions. Serial blood samples were obtained for determination of plasma epinephrine concentrations by ELISA. Results: Epinephrine concentrations failed to increase following administration via IM injection. Delayed absorption was observed after return of spontaneous circulation (ROSC) in half of the studies. Conclusions: Inadequate absorption of epinephrine occurs with IM administration during asphyxial cardiac arrest, implying this route would be ineffective in infants who are severely compromised at birth. Late absorption following ROSC raises concerns for risks of side effects. However, the bioavailability and efficacy of intramuscular epinephrine in less profound asphyxia may warrant further evaluation.

Increased prevalence of severe neonatal hyperbilirubinaemia during social distancing.

AIM: Social distancing guidelines implemented with the COVID-19 pandemic impacted health-care utilisation and disrupted critical social supports. Resurgence of highly transmissible strains has resulted in revisiting restrictions with potential impacts on newborn health. With concerns for inadequate post-partum support, we sought to determine if social distancing correlated with increased rates of readmission for hyperbilirubinaemia. METHODS: Retrospective chart review identified all readmissions for hyperbilirubinaemia between 1/18 and 4/20 in Western New York. Infant/maternal demographics and data on hospital course were collected on control (1/1/18-31/1/20) and social distancing (1/2/20-30/4/20) cohorts. Nineteen outpatient clinics were surveyed regarding lactation support. RESULTS: Monthly readmissions for hyperbilirubinaemia nearly tripled during social distancing (0.90 ± 0.91 vs. 2.63 ± 2.29 per 1000 births during early COVID, P = 0.015). Comparable severity of disease at readmission was observed with no difference in the need for therapies (phototherapy, intravenous immunoglobulin or exchange transfusion) or length of hospital stay. Mothers were younger (25.8 ± 3.3 vs. 31.3 ± 4.7 years; P = 0.005) with higher rates of primiparity and exclusive breastfeeding than national norms, however not significantly higher than controls in our small cohort (62.5 vs. 37.0% for primiparity; 87.5 vs. 81.5% for breastfeeding). Of 19 clinics surveyed, only six confirmed a telemedicine option for lactation support. CONCLUSIONS: Rates of readmission for hyperbilirubinaemia increased during social distancing. Younger maternal age with high rates of primiparity and exclusive breastfeeding raise concern for inadequate social and/or lactation support. Proactive identification of mothers at risk and expansion of remote lactation services may be indicated with recurrent waves of the pandemic.

Changes in e-cigarette and cigarette use during pregnancy and their association with small-for-gestational-age birth.

BACKGROUND: Despite increased e-cigarette use, limited research has focused on changes in e-cigarette and combustible cigarette use around pregnancy and the subsequent effects on infant health. OBJECTIVE: This study aimed to characterize changes in e-cigarette and cigarette use from before to during pregnancy and examine their associations with small-for-gestational-age birth. STUDY DESIGN: This was a secondary data analysis of 2016-2018 data of the US Pregnancy Risk Assessment Monitoring System. We analyzed women aged ≥18 years who had a recent live birth (unweighted: n=105,438; weighted: n=5,446,900). Women were grouped on the basis of their self-reported e-cigarette and/or cigarette use 3 months before pregnancy (exclusive e-cigarette users, exclusive cigarette smokers, dual users, and nonusers) and change in e-cigarette and cigarette use during pregnancy (continuing use, quitting, switching, and initiating use). Small-for-gestational-age was defined as a birthweight below the 10th percentile for infants of the same sex and gestational age. We described the distributions of women's sociodemographic and pregnancy characteristics in both weighted and unweighted samples. We used multivariable log-binomial regression models to estimate the relative risks for the associations between changes in e-cigarette and cigarette use during pregnancy and risk of small-for-gestational-age, adjusting for significant covariates. RESULTS: The rates of cessation during pregnancy were the highest among exclusive e-cigarette users (weighted percentage, 80.7% [49,378/61,173]), followed by exclusive cigarette users (54.4% [421,094/773,586]) and dual users (46.4% [69,136/149,152]). Among exclusive e-cigarette users, continued users of e-cigarettes during pregnancy had a higher risk of small-for-gestational-age than nonusers (16.5% [1849/11,206]) vs 8.8% [384,338/4,371,664]; confounder-adjusted relative risk, 1.52 [95% confidence interval, 1.45-1.60]), whereas quitters of e-cigarettes had a similar risk of small-for-gestational-age with nonusers (7.7% [3730/48,587] vs 8.8% [384,338/4,371,664]; relative risk, 0.84 [95% confidence interval, 0.82-0.87]). Among exclusive cigarette users, those who completely switched to e-cigarettes during pregnancy also had a similar risk of small-for-gestational-age with nonusers (7.6% [259/3412] vs 8.8% [384,338/4,371,664]; relative risk, 0.83 [95% confidence interval, 0.73-0.93]). Among dual users before pregnancy, the risk of small-for-gestational-age decreased from 23.2% (7240/31,208) (relative risk, 2.53 [95% confidence interval, 2.47-2.58]) if continuing use to 16.9% (6617/39,142) (relative risk, 1.88 [95% confidence interval, 1.83-1.92]) if only quitting e-cigarettes or 15.1% (1254/8289) (relative risk, 1.61 [95% confidence interval, 1.52-1.70]) if only quitting cigarettes and further to 11.2% (7589/67,880) (relative risk, 1.23 [95% confidence interval, 1.20-1.25]) if both quitting e-cigarettes and cigarettes during pregnancy, compared with nonusers. CONCLUSION: Among exclusive e-cigarette users, quitting e-cigarettes during pregnancy normalized the risk of small-for-gestational-age. Among exclusive cigarette users, quitting smoking or completely switching to e-cigarettes normalized small for gestational age risk. Among dual users, smoking cessation has a greater effect than quitting e-cigarettes only, although discontinuing the use of both may lead to the greatest reduction in the risk of small-for-gestational-age.

Sustained Inflation Reduces Pulmonary Blood Flow during Resuscitation with an Intact Cord.

The optimal timing of cord clamping in asphyxia is not known. Our aims were to determine the effect of ventilation (sustained inflation-SI vs. positive pressure ventilation-V) with early (ECC) or delayed cord clamping (DCC) in asphyxiated near-term lambs. We hypothesized that SI with DCC improves gas exchange and hemodynamics in near-term lambs with asphyxial bradycardia. A total of 28 lambs were asphyxiated to a mean blood pressure of 22 mmHg. Lambs were randomized based on the timing of cord clamping (ECC-immediate, DCC-60 s) and mode of initial ventilation into five groups: ECC + V, ECC + SI, DCC, DCC + V and DCC + SI. The magnitude of placental transfusion was assessed using biotinylated RBC. Though an asphyxial bradycardia model, 2-3 lambs in each group were arrested. There was no difference in primary outcomes, the time to reach baseline carotid blood flow (CBF), HR ≥ 100 bpm or MBP ≥ 40 mmHg. SI reduced pulmonary (PBF) and umbilical venous (UV) blood flow without affecting CBF or umbilical arterial blood flow. A significant reduction in PBF with SI persisted for a few minutes after birth. In our model of perinatal asphyxia, an initial SI breath increased airway pressure, and reduced PBF and UV return with an intact cord. Further clinical studies evaluating the timing of cord clamping and ventilation strategy in asphyxiated infants are warranted.

Beyond Newborn Resuscitation: Essential Care for Every Baby and Small Babies.

Helping Babies Breathe (HBB) addresses a major cause of newborn mortality by teaching basic steps of neonatal resuscitation and improving survival rates of infants affected by intrapartum-related events or asphyxia. Addressing the additional top causes of mortality (infection and prematurity) requires more comprehensive education, including content on thermal and nutritional support, breastfeeding, and alternative feeding strategies, as well as recognition and treatment of infection. Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) use educational principles developed with HBB as a model for teaching basic newborn care. These programs complement the content provided with HBB, further integrate counseling of families, and advance the agenda of providing quality care to all infants at birth. ECEB and ECSB have further demonstrated that engagement of individuals through active participation in their education empowers providers at all levels. With added experience teaching and implementing ECEB and ECSB, the next generation of newborn educational programs will likely incorporate bedside teaching and clinical exposure, multimedia platforms for demonstrating clinical content, and added efforts toward quality improvement. Through ECEB and ECSB, the attention brought to the newborn health agenda with HBB has only grown. Although current global health issues pose new challenges in implementing this agenda, these programs together provide a critical framework to both educate and advocate for optimal care of every newborn.