Commentary on: Shankaran S, Bell EF, Laptook AR, Saha S, Newman NS, Kazzi SNJ, Barks J, Stoll BJ, Bara R, Gabrio J, Childs K, Das A, Higgins RD, Carlo WA, Sánchez PJ, Carlton DP, Pavageau L, Malcolm W, D'Angio CT, Ohls RK, Poindexter BB, Sokol GM, Van Meurs KP, Colaizy TT, Khmour A, Puopolo KM, Garg M, Walsh M for the Eunice Kennedy Shriver National Institute of Child Health, and Human Development Neonatal Research Network. J Pediatr 2019; 204:96–102.PMID 30337189 Preterm newborn infants need to be placed in incubators to maintain stable temperatures in order to prevent cold stress and associated increased mortality 1. However, there is accumulating evidence that compared to current practice, transfer of infants to an open crib at lower body weights is safe and does not lead to increased mortality, temperature instability or poor weight gain 2, 3. Due to the limited available data, there is a wide variation in clinical practice for weaning from an incubator. Institutional policies rely mainly on provider comfort or bedside nurses’ perceptions 4. Weaning earlier is considered beneficial in improving maternal–infant bonding, breastfeeding rates and neuro-development 5. The current study aimed to assess whether weaning from an incubator to a crib at a lower birth weight was associated with decreased length of hospital stay. Infants were randomized at 1500–1540 g to either group and weaned similarly in both cohorts by 1–1.5°C until 28°C in the isolette, maintaining axillary temperatures between 36.5 and 37.4°C. Infants were then weaned to a crib if stable for 8–12 hours at 28°C. Failure rates at first attempted weaning were higher in the lower weight neonates. Episodes of moderate and severe cold stress were more frequent in the lower weight group (10 infants out of 13 with moderate cold stress and 4 out of 5 with severe cold stress were in <1600 g); however, these were uncommon and not statistically significant. A study limitation is that blinding is not possible, which may introduce bias based on physician directive and healthcare providers perception of an adverse event with this population. Infants at lower weights have a higher likelihood of being moved back into an isolette and evaluated for infection with bradycardias and desaturation which possibly are associated with prematurity as opposed to weaning to a crib. Another limitation was that a large number of infants (~30%) were not included in secondary outcome analysis due to missing data. Interestingly, 36% of families refused to participate in the trial which was higher than other RCTs and observational studies 6, 2. The strength of this study lies in its focus on a specific population and its likely generalizability. Although the infants were not discharged earlier, the study is consistent with results from earlier and smaller trials 7, 6, 2. Weaning at 1600 vs 1800 g appears safe for these infants and may improve kangaroo care and parental involvement. Among providers, there was a higher perceived risk of cold stress and temperature instability in the more preterm infants. However, a small study by Heimler et al. 8 demonstrated that weaning at lower weights led to faster deposition of subcutaneous fat which may be advantageous for efficient weight gain and cold resistance. The question of whether faster fat deposition leads to slower organ weight gain has not been answered. This RCT adds to the existing data that weaning medically stable infants at lower weight of 1600 grams is feasible and safe but it does not decrease the length of hospital stay. https://ebneo.org/2019/03/incubator-crib-weaning/ The National Institutes of Health and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) provided grant support for the Neonatal Research Network's Trial on Incubator Weaning of Moderately Preterm Infants (NCT02160002) through cooperative agreements. No conflicts of interest.
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Sep 16, 2019
Yuki Matsushita + 11
