Resuscitation with Intact Cord Versus Clamped Cord in Late Preterm and Term Neonates: A Randomized Controlled Trial.

OBJECTIVE: To compare the effect of intact cord versus clamped cord resuscitation on the physiologic transition of neonates receiving positive-pressure ventilation (PPV) at birth. STUDY DESIGN: This open-label, parallel-group, randomized controlled superiority trial was conducted in a tertiary care hospital in India. Neonates born at ≥34 weeks of gestation after a complicated pregnancy or labor were randomized just before birth to receive resuscitation according to the Neonatal Resuscitation Program algorithm with either an intact cord (intact cord resuscitation group) or after early cord clamping (early cord clamping resuscitation group). The allocated study intervention was administered if the neonate needed PPV at birth. The primary outcome was expanded Apgar score at 5 minutes after birth. RESULTS: Birth weight, gestational age, and the incidence of pregnancy complications were similar in the 2 study groups. The proportion of neonates who received PPV was lower in the intact cord resuscitation group (28.7% vs 36.5%, P = .05; relative risk, 0.79; 95% CI, 0.61-1.01). Among neonates who received PPV, the expanded Apgar score at 5 minutes was significantly higher in the intact cord resuscitation group (median, 15 [IQR, 14-15] vs 14 [IQR, 13-15]; P < .001). The expanded Apgar score at 10 minutes, Apgar scores at 5 and 10 minutes, and oxygen saturation at 1, 5, and 10 minutes were also higher in the intact cord resuscitation group. CONCLUSION: In late preterm and term neonates, resuscitation with an intact cord results in better postnatal physiologic transition than the standard practice of resuscitation after immediate cord clamping. TRIAL REGISTRATION: Clinical Trial Registry of India (www.ctri.nic.in); trial registration no. CTRI/2020/02/023379.

Adapted Helping Babies Breathe approach to neonatal resuscitation in Haiti: a retrospective cohort study.

BACKGROUND: Helping Babies Breathe (HBB) is an American Academy of Pediatrics neonatal resuscitation program designed to reduce neonatal mortality in low resource settings. The 2017 neonatal mortality rate in Haiti was 28 per 1000 live births and an estimated 85 % of Haitian women deliver at home. Given this, the Community Health Initiative implemented an adapted HBB (aHBB) in Haiti to evaluate neonatal mortality. METHODS: Community Health Workers taught an aHBB program to laypeople, which didn't include bag-valve-mask ventilation. Follow-up after delivery assessed for maternal and neonatal mortality and health. RESULTS: Analysis included 536 births of which 84.3 % (n=452) were attended by someone trained in aHBB. The odds of neonatal mortality was not significantly different among the two groups (aOR=0.48 [0.16-1.44]). Composite outcome of neonatal health as reported by the mother (subjective morbidity and mortality) was significantly lower in aHBB attended births (aOR=0.31 [0.14-0.70]). CONCLUSION: This analysis of the aHBB program indicates that community training to laypersons in low resource settings may reduce neonatal ill-health but not neonatal mortality. This study is likely underpowered to find a difference in neonatal mortality. Further work is needed to evaluate which components of the aHBB program are instrumental in improving neonatal health.

Death after Birth Asphyxia in the Cooling Era.

In asphyxiated newborn infants treated with hypothermia, 31 of 50 (62%) deaths occurred in unstable infants electively extubated before completing hypothermia treatment. Later deaths occurred after consultation with palliative care (13/19) or clinical ethics (6/19) services, suggesting these decisions were challenging and required support, particularly if nutrition and hydration were withdrawn (n = 4).

Practical oxygen therapy for newborn piglets.

Aims: To evaluate the effect of a novel method of practical oxygen therapy on physiological parameters related to survival, weaning weight and preweaning mortality of neonatal piglets under commercial farm conditions. Methods: Piglets from hyperprolific sows born with signs of asphyxia, (n = 109; <6 on a score of respiration, meconium staining and activity) or very low birth weight (VLBW; n = 112; <1.05 kg) were selected for the study. Approximately half of each group (n = 55 VLBW piglets and n = 57 piglets with asphyxia) received 100% oxygen immediately after birth using a specially designed facemask for 45 seconds (VLBW) or 1 minute (asphyxiated). Physiological parameters (peripheral blood oxygen saturation (SpO2) blood glucose concentration and rectal temperature) were measured before oxygen treatment 5 minutes after birth (SpO2) and 24 hours later (SpO2, blood glucose concentration, temperature). Weight at birth, at 24 hours and at 21 days of age, preweaning mortality, and estimated colostrum intake were also recorded. Results: A significant treatment effect on SpO2 was observed (p = 0.013 and p < 0.001 for VLBW and asphyxiated piglets respectively). VLBW and asphyxiated piglets that received oxygen treatment had higher SpO2 after treatment (measured 5 minutes after birth, 97.7 and 97.8% respectively) compared to immediately after birth (93.3 and 86.8% respectively) while untreated piglets showed no variation. Blood glucose concentrations increased in all piglets between birth and 24 hours of age (p = 0.003 and p < 0.001 for asphyxiated and VLBW piglets respectively) and this was higher in asphyxiated piglets that received oxygen than those that did not (5.6 (SE 0.2) mmol/L; p < 0.05). Estimated colostrum intake was higher in asphyxiated (401.6 (SD 24.4) g/kg) and VLBW (374.9 (SE 23.4 g/kg) piglets that received oxygen than those that did not (273.2 (SE 24.1) g/kg; p < 0.001 and 249.0 (SE 22.5) g/kg; p < 0.001 respectively). Similarly weight at weaning was higher in asphyxiated (5.8 (SE 0.2) kg) and VLBW (4.9 (SE 0.2) kg) piglets that received oxygen therapy than control animals (4.9 (SE 0.2) kg; = 0.005 and 4.1 (SE 0.2) kg; p = 0.008 respectively). Furthermore, oxygen treatment markedly reduced preweaning mortality from 9/52 (17%) untreated to 1/57 (1.7%) oxygen-treated piglets suffering asphyxia at birth (p = 0.006). Conclusions: Oxygen therapy improves physiological and productive parameters in piglets born with signs of asphyxia or VLBW. The incorporation of this strategy as part of the farrowing routine enhances the advantages of rearing hyperprolific sows.

Características clínicas y del electroencefalograma de amplitud integrada en recién nacidos con encefalopatía hipóxico-isquémica bajo protocolo de hipotermia corporal total / Clinical and integrated amplitude electroencephalogram characteristics of newborns with hypoxic-ischemic encephalopathy under the protocol of total body hypothermia

RESUMEN La encefalopatía hipóxico-isquémica (EHI) es causa importante de mortalidad y discapacidad neurológica en neonatos. La evidencia sugiere que la terapia de hipotermia es capaz de impactar estos desenlaces. Este estudio se realizó con el objetivo de describir las características clínicas y las ayudas diagnósticas realizadas a recién nacidos con EHI sometidos a terapia de hipotermia corporal total con el uso de criterios preestablecidos de ingreso a la terapia, en una muestra de dos instituciones de la ciudad de Medellín. MÉTODOS: Se realizó un estudio descriptivo en el periodo 2017-2018, incluyendo la totalidad de pacientes con EHI ingresados a terapia de hipotermia. RESULTADOS: Se obtuvieron datos de 256 pacientes, con predominio masculino (182; 71,1%). Se evidenciaron fallas en el registro y subjetividad en la aplicación de los criterios de ingreso al protocolo de hipotermia en ambas instituciones. En 197 pacientes (77 %) no hubo reporte de evento centinela, y el expulsivo prolongado fue considerado por los clínicos un hallazgo significativo a la hora de definir el ingreso a la terapia. Hubo, además, pacientes ingresados que no cumplieron con el criterio de APGAR ≤ 5 a los 10 minutos (n = 136). Los resultados sugieren la necesidad de mejorar la adherencia al protocolo de ingreso a la terapia, pero al mismo tiempo señalan la importancia del concepto del clínico a la hora de abordar cada paciente de manera individual.

SUMMARY Hypoxic-ischemic encephalopathy (HIE) is an important cause of mortality in the neonatal population and neurological disability. The evidence shows that hypothermia therapy is capable of impacting these outcomes. This study was carried out with the objective of describing the clinical characteristics and the diagnostic aids made to newborns with HIE undergoing total body hypothermia therapy and the use of criteria for admission to therapy in a sample of two institutions in the city of Medellin. METHODS: A descriptive retrospective study was conducted, including all patients with HIE admitted to hypothermia therapy during 2017 and 2018. RESULTS: The data of 256 patients (males 182; 71.1 %) were obtained. There were flaws in the registry and subjectivity in the application of the entry criteria to the hypothermia protocol in both institutions. In 197 (77 %) patients there was no report of sentinel event and the prolonged labour was considered by the clinicians as a significant finding when defining the entrance to the therapy. There were also admitted patients who did not meet the criterion of APGAR ≤ 5 at 10 minutes (n = 136). The results suggest the need to improve adherence to the protocol for admission to therapy; but at the same time, it points out the importance of the clinician's concept when dealing with each patient individually.

Outcomes of preterm infants treated with hypothermia for hypoxic-ischemic encephalopathy.

BACKGROUND: Therapeutic hypothermia reduces the risk of death, or moderate to severe neurodevelopmental impairment (NDI) in term infants with hypoxic-ischemic encephalopathy (HIE). Reports of its safety and efficacy in preterm infants are scarce. OBJECTIVE: Report short and long-term outcomes of preterm infants with HIE who received therapeutic hypothermia. METHODS: A retrospective cohort analysis of all preterm infants <36 weeks' gestation with HIE who received whole body hypothermia in a single center from January 2007 to April 2015. The primary outcome was death or moderate to severe NDI defined by moderate or severe cerebral palsy, severe hearing or visual impairment, or cognitive score < 85 on the Bayley Scales of Infant Development III (BSID III) at 18-24 months' adjusted age. RESULTS: 30 infants with a median gestational age and birthweight of 35 weeks' (range; 33-35) and 2575 g (1850-4840) and a median first postnatal blood pH of 6.81 (6.58-7.14). Complications included coagulopathy (50%), early clinical seizures (43.3%), arterial hypotension (40%), persistent metabolic acidosis (37%) and thrombocytopenia (20%). Four infants died before or soon after discharge (18.2%). Eighteen surviving infants (69.2%) had follow up data; 7 of them had moderate to severe NDI (38.9%). Cognitive, motor and language mean composite BSID III scores were 84 (54-110), 83 (46-118), and 78 (46-112). Death or moderate to severe NDI occurred in 11/22 (50%) infants with known outcomes. CONCLUSION: Large randomized trials on efficacy and safety are needed in this highly vulnerable population as the incidence of complications and the combined outcome of death and NDI is concerning.

Efficacy of passive hypothermia and adverse events during transport of asphyxiated newborns according to the severity of hypoxic-ischemic encephalopathy / Eficácia da hipotermia passiva e eventos adversos durante o transporte de recém-nascidos asfixiados de acordo com a gravidade da encefalopatia hipóxico-isquêmica

Abstract Objective To determine if the efficacy of passive hypothermia and adverse events during transport are related to the severity of neonatal hypoxic-ischemic encephalopathy. Methods This was a retrospective study of 67 infants with hypoxic-ischemic encephalopathy, born between April 2009 and December 2013, who were transferred for therapeutic hypothermia and cooled during transport. Results Fifty-six newborns (84%) were transferred without external sources of heat and 11 (16%) needed an external heat source. The mean temperature at departure was 34.4 ± 1.4 °C and mean transfer time was 3.3 ± 2.0 h. Mean age at arrival was 5.6 ± 2.5 h. Temperature at arrival was between 33 and 35 °C in 41 (61%) infants, between 35 °C and 36.5 °C in 15 (22%) and <33 °C in 11 (16%). Infants with severe hypoxic-ischemic encephalopathy had greater risk of having an admission temperature < 33 °C (OR: 4.5; 95% CI: 1.1-19.3). The severity of hypoxic-ischemic encephalopathy and the umbilical artery pH were independent risk factors for a low temperature on admission (p < 0.05). Adverse events during transfer, mainly hypotension and bleeding from the endotracheal tube, occurred in 14 infants (21%), with no differences between infants with moderate or severe hypoxic-ischemic encephalopathy. Conclusion The risk of overcooling during transport is greater in newborns with severe hypoxic-ischemic encephalopathy and those with more severe acidosis at birth. The most common adverse events during transport are related to physiological deterioration and bleeding from the endotracheal tube. This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance during transport.

Resumo Objetivo Determinar se a eficácia da hipotermia passiva e eventos adversos durante o transporte estão relacionados à gravidade da encefalopatia hipóxico-isquêmica neonatal. Métodos Estudo retrospectivo de 67 neonatos com encefalopatia hipóxico-isquêmica (nascidos entre abril de 2009 e dezembro de 2013) transferidos para hipotermia terapêutica e resfriados durante o transporte. Resultados Foram transportados 56 recém-nascidos (84%) sem fontes externas de calor e 11 (16%) precisaram de uma fonte externa de calor. A temperatura média na saída foi de 34,4 ± 1,4 °C e o tempo médio de transporte foi de 3,3 ± 2,0 horas. A idade média na chegada foi de 5,6 ± 2,5 horas. A temperatura na chegada ficou entre 33-35 °C em 41 (61%) neonatos, entre 35°-36,5 °C em 15 (22%) e < 33 °C em 11 (16%). Neonatos com encefalopatia hipóxico-isquêmica grave apresentaram maior risco de temperatura < 33 °C na internação (RC 4,5; IC de 95% 1,1-19,3). A gravidade da encefalopatia hipóxico-isquêmica e o pH da artéria umbilical foram fatores de risco independentes para uma baixa temperatura na internação (p < 0,05). Eventos adversos durante o transporte, principalmente hipotensão e sangramento do tubo endotraqueal, ocorreram em 14 neonatos (21%), sem diferenças entre neonatos com encefalopatia hipóxico-isquêmica moderada ou grave. Conclusão O risco de super-resfriamento durante o transporte é maior em recém-nascidos com encefalopatia hipóxico-isquêmica grave e naqueles com acidose mais grave no nascimento. Os eventos adversos mais comuns durante o transporte estão relacionados a deterioração fisiológica e sangramento do tubo endotraqueal. Essa observação fornece informações úteis para identificar neonatos asfixiados que exigem maior vigilância clínica durante o transporte.

Efficacy of passive hypothermia and adverse events during transport of asphyxiated newborns according to the severity of hypoxic-ischemic encephalopathy.

OBJECTIVE: To determine if the efficacy of passive hypothermia and adverse events during transport are related to the severity of neonatal hypoxic-ischemic encephalopathy. METHODS: This was a retrospective study of 67 infants with hypoxic-ischemic encephalopathy, born between April 2009 and December 2013, who were transferred for therapeutic hypothermia and cooled during transport. RESULTS: Fifty-six newborns (84%) were transferred without external sources of heat and 11 (16%) needed an external heat source. The mean temperature at departure was 34.4±1.4°C and mean transfer time was 3.3±2.0h. Mean age at arrival was 5.6±2.5h. Temperature at arrival was between 33 and 35°C in 41 (61%) infants, between 35°C and 36.5°C in 15 (22%) and <33°C in 11 (16%). Infants with severe hypoxic-ischemic encephalopathy had greater risk of having an admission temperature<33°C (OR: 4.5; 95% CI: 1.1-19.3). The severity of hypoxic-ischemic encephalopathy and the umbilical artery pH were independent risk factors for a low temperature on admission (p<0.05). Adverse events during transfer, mainly hypotension and bleeding from the endotracheal tube, occurred in 14 infants (21%), with no differences between infants with moderate or severe hypoxic-ischemic encephalopathy. CONCLUSION: The risk of overcooling during transport is greater in newborns with severe hypoxic-ischemic encephalopathy and those with more severe acidosis at birth. The most common adverse events during transport are related to physiological deterioration and bleeding from the endotracheal tube. This observation provides useful information to identify those asphyxiated infants who require closer clinical surveillance during transport.

Recém-nascidos banhados em líquido amniótico meconial: atendimento em sala de parto e ocorrência de Síndrome da Aspiração Meconial / Meconium stained neonate: delivery room management and Meconium Aspiration Syndrome occurrence

As práticas para reanimação neonatal são fundamentadas em recomendações internacionais e no Brasil mantém-se a indicação de aspirar boca e nariz dos recém-nascidos banhados em mecônio, ainda que vigorosos. O objetivo deste estudo foi verificar o atendimento neonatal realizado na sala de parto em uma maternidade de atual conduta conservadora frente aos recém-nascidos a termo e vigorosos e a sua associação à ocorrência da Síndrome de Aspiração Meconial. Trata-se de um estudo observacional e transversal, com amostra de recém-nascidos a termo, cujas informações sobre os cuidados dispensados na sala de parto e as condições após o nascimento foram obtidas em registros de prontuários. Foram analisados 376 recém-nascidos, dos quais 70 (18,6%) nasceram banhados em mecônio. Destes, apenas 20 (28,6%) foram reanimados e 14 (70%) obtiveram Apgar no 1º minuto menor ou igual a 7. Às demais 50 crianças, o contato materno imediato foi estimulado e o cordão foi clampeado tardiamente. Dos 20 recém-nascidos banhados em mecônio e que foram reanimados ao nascer, 7 (35%) tiveram sua traqueia aspirada sob visualização direta, sendo que o escore médio de Apgar no 1º minuto destes indivíduos foi 4, enquanto o escore médio de Apgar no 1º minuto dos recém-nascidos que não foram submetidos à aspiração traqueal foi 8. Apenas um recém-nascido estudado desenvolveu Síndrome de Aspiração do Líquido Amniótico Meconial. A conduta expectando diante dos recém-nascidos vigorosos banhados em líquido amniótico meconial favorece o contato precoce com a mãe e a transferência sanguínea placentária e pode não aumentar a incidência de Síndrome da Aspiração Meconial.

The practices for neonatal reanimation are based on international recommendations and in Brazil the advised procedure is to aspirate the mouth and the nose of newborns that are born in meconiumstained amniotic fluid, even if they are vigorous. Thus, these children are separated from their mothers and their umbilical cord is immediately clamped. The objective of this study was to verify the neonatal assistance done in the labor room in conservative practice maternity towards vigorous and on-term newborns and its association with the occurrence of Meconium Aspiration Syndrome. This study is observational and transversal, with on-term newborns as samples, whose labor room care information and post-labor conditions were obtained through medical records. 376 newborns were analyzed, 70 of which (18,6%) were born through meconium-stained amniotic fluid. From these 70, only 20 (28,6%) were reanimated and 14 (70%) obtained first minute Apgar equal to or less than 7. Immediate maternal contact and late cord clamping was stimulated for the other 50 children. From the 20 newborns born in meconium that were reanimated at birth, 7 (35%) had their trachea aspirated under direct sight, being that the average first minute Apgar score of these individuals was 4, while the average first minute Apgar score of newborns not submitted to tracheal aspiration was 8. Only 1 newborn studied developed the Meconium Aspiration Syndrome. The expectant practice towards vigorous newborns through meconium-stained amniotic fluid favors the early contact with the mother and the placental blood transfusion and may not raise the incidence of Meconium aspiration Syndrome.

Evaluación neurológica en recién nacidos con asfixia al nacer / Neurogical Assessment in Newborn with Birth Asphyxia

Introducción: el daño asfíctico del cerebro del feto y neonato resultan de fenómenos hipóxicos e isquémicos que afectan en forma selectiva áreas vulnerables del encéfalo según el grado de madurez del cerebro en el momento de producirse la noxa. Objetivo: determinar la evaluación neurológica de pacientes con antecedentes de asfixia al nacer. Método: se realizó un estudio longitudinal en 25 neonatos con antecedentes de asfixia al nacer nacidos entre enero 2011-diciembre 2012 y valorados al año de edad. Resultados: las alteraciones neurológicas predominaron en los pacientes producto de parto por cesárea con el 44,5 %. El 62,5 % de los pacientes con cifras de pH menor de siete en la primera hora de vida fueron los que más presentaron alteraciones en su desarrollo psicomotor. El 90 % de los pacientes con ventilación prolongada fueron los más afectados, así como, la aparición de las convulsiones en las primeras 12 h de vida. Conclusiones: a mayor tiempo de ventilación y aparición temprana de las convulsiones peor pronóstico neurológico.

Introduction: the brain impairment by asphyxia in fetus and newborn is the consequence of hypoxic and ischemic phenomena that only affect certain vulnerable areas of the brain depending on the degree of the maturity of the brain at the moment of the noxa. Objective: to determine the neurological evaluation in patients with history of birth asphyxia. Method: a descriptive study in a series of neonates with history of birth asphyxia from January 2011 to December 2012 that were assessed at one year of age. Results: the neurological alterations prevailed in patients for cesarean delivery (45 %); 62.5 % of patients with PH below seven in the first hour of life were those of more psychomotor disorders, 90 % of patients with the extended time of ventilation as well as the beginning of the first twelve living hour convulsions. Conclusions: to a larger time of ventilation and on early apparition of convulsions a worse neurological prognosis.