Tertiary Neonatal Intensive Care Unit Research Articles

If We Cannot Use Nitric Oxide for Newborn Persistent Pulmonary Hypertension, is Oral Sildenafil Therapeutic? A Single-center Experience

Background: Persistent pulmonary hypertension is still an issue in newborn period with different treatment strategies. In this study, we aimed to evaluate the three-year experience of a neonatal intensive care unit on use of sildenafil citrate for treating newborns with persistent pulmonary hypertension. Methods: Twenty-nine newborn patients with the diagnosis of persistent pulmonary hypertension solely treated by sildenafil citrate (2 mg/kg per dose, orally, three times a day) in intensive care unit of a private hospital between 2018 and 2021 were retrospectively analyzed. Results: The newborns that underwent sildenafil treatment and the newborns that received no treatment had statistically similar length of hospital stay (p = 0.188). The premature newborns had significantly lower systolic and diastolic blood pressure than the term newborns on their first day of sildenafil treatment (p = 0.001 for both). The premature newborns had significantly lower systolic, diastolic, and right ventricular systolic pressure than the term newborns on their day of hospital discharge (p = 0.003, p = 0.013 and p = 0.001 respectively). The premature newborns had significantly lower systolic, diastolic, and right ventricular systolic pressure on their day of hospital discharge than their first day of sildenafil treatment (p = 0.039, p = 0.041 and p = 0.043 respectively). The term newborns had also significantly lower systolic, diastolic, and right ventricular systolic pressure on their day of hospital discharge than their first day of sildenafil treatment (p = 0.001 for each). Conclusions: Sildenafil citrate can be considered as an efficient and safe alternative for the treatment of persistent pulmonary hypertension in newborn at the in tertiary neonatal intensive care units without nitric oxide and devices.

Racial identification represents significant risk factor for healthcare disparity among patients with severe bronchopulmonary dysplasia treated with tracheostomy

ObjectivesTo characterize the patient population with severe bronchopulmonary dysplasia (BPD) requiring tracheostomy in a large tertiary level 4 neonatal intensive care unit (NICU) and to identify potential targets for improvement in the delivery of high-quality healthcare. MethodsAn IRB-exempt but IRB-registered retrospective review of medical records. Study inclusion criteria: patients treated for severe BPD with tracheostomy under 2 years of age in our tertiary referral center NICU. Control group criteria: 4-year aggregate NICU patient demographics. Basic demographics, maternal history, clinical data points, and outcomes variables were collected. ResultsThere was a statistically significant difference between the two groups in only one variable: racial identification (p-value = 0.036). All data points were then analyzed against racial identification, and statistically significant differences appeared in 4 categories: 1) illicit drug use, 2) birth head circumference and length, 3) days to readmission, and 4) child opportunity index scores. There was not a statistically significant difference in any other maternal characteristics or medical comorbidities, NICU length of stay, age at tracheostomy, or decannulation status. ConclusionThe incidence of our tracheostomy in infants with severe BPD was significantly higher (p = 0.036) in the subjects whose families identified as racially African American or Black, a marked contrast to our general NICU population and our overall tracheostomy population. The timing of the first readmission to the hospital was shorter for Caucasian or White infants compared to African American or Black infants. COI demonstrated statistically significantly poorer resources for African American or Black infants compared to White infants with tracheostomy. All other perinatal and outcome measurements did not differ significantly between the two racial groups. This suggests that this racial disparity is present and needs further investigation to better assess its impact on risk and outcomes as we develop pathways for high-quality healthcare delivery.

Breastfeeding rates at discharge for very low birthweight neonates and their determinants: An observational study from a tertiary care neonatal intensive care unit in India.

Mother's milk is the best milk for neonates. Preterm very low birthweight (VLBW) neonates face many challenges leading to low rates of breastfeeding at discharge. (i) To determine the proportion of <32 weeks preterm VLBW neonates who are exclusively breastfed (EB) at discharge and (ii) determinants of exclusive breastfeeding (EBF) at discharge. An observational study was conducted for a duration of 1 year, from May 2019 to April 2020 in a tertiary care neonatal intensive care unit (NICU) in North India. Consecutive <32 weeks preterm VLBW neonates admitted within 72 h of birth and on full enteral feeds (FEF) within 10 days of birth were included in this study and followed up till discharge. Forty-four of 97 (45.4%) preterm VLBW neonates were exclusively breastfed and 31/97 (32%) received more than 80% mother's own milk (MOM) at discharge. Male sex (P=0.03), those whose first feed had any amount of MOM (P=0.038) or exclusive MOM in their first feed or when initiated on first FEF (P=0.002), and neonates with longer duration of hospital stay (P=0.035) had an increased chance of being exclusively breastfed at discharge. Preterm VLBW neonates who receive any amount of MOM in their first feed or first FEF, male infants and those who stay longer in hospital are more likely to be exclusively breastfed at discharge.

Parental perceptions on the impact of visiting restrictions during COVID-19 in a tertiary neonatal intensive care unit.

AimDuring the first wave of coronavirus disease 2019 (COVID‐19), visiting guidelines in neonatal units changed to maintain the health and safety of staff, neonates, and families. In the neonatal intensive care unit/special care nursery (NICU/SCN), restrictions were placed on parental contact and extended family excluded. Our team was interested in evaluating the effect of these restrictions on parental stress and discharge confidence.MethodsA prospective descriptive study utilising survey methodology was undertaken. The survey was developed and previously used by the NICU research group to evaluate parental knowledge and understanding, parental role, communication, and parental stress (admission/discharge). We have also included a section regarding COVID19 visiting restrictions (ETH.2020.LRE.00124). The survey used a five‐level Likert scale. Statistical analysis was completed using SPSS version 21.ResultsNotably, 33 surveys were returned. Results showed visiting restrictions reduced social contact between partners 26/33 (84%), with their other children 14/16 (87.5%) and extended family 28/33 (84.8%). Parents indicated that they had high levels of confidence in understanding their babies' medical needs (78–93%) and gaining hands‐on experience caring for their baby (87–100%). However, 11/33 (33%) of parents reported concerns with discharge processes and gaining consistent information as challenges during their baby's admission. Notably, 17/33 (51.5) stated their NICU/SCN experience had been very to extremely stressful. Parents openly described how the restrictions had affected their mental/emotional health identifying the need to treat parents as one unit, and a gap in the psychological support available for families.ConclusionSupport services and consistency of communication with NICU/SCN families need to be enhanced and prioritised during periods of restrictions, especially peri‐discharge.

Neonatal Staphylococcus Aureus Sepsis: a 20-year Western Australian experience

ObjectivesThe purpose of this study was to characterise neonatal Staphylococcus aureus (SA) sepsis in Western Australia (WA) between 2001 and 2020 at the sole tertiary neonatal intensive care unit (NICU), examine risk factors for sepsis in the cohort, and compare short- and long-term outcomes to control infants without any sepsis.MethodsRetrospective cohort study at the Neonatal Directorate at King Edward Memorial Hospital (KEMH) and Perth Children’s Hospital, using electronic databases and patient medical records.ResultsThe overall incidence of SA sepsis was 0.10 per 1000 live births (62/614207). From 2001 to 2010 the incidence was 0.13/1000 live births, reducing to 0.07/1000 live births from 2011 to 2020. SA was most frequently isolated from endotracheal aspirates, and infants with SA sepsis had longer median duration of ventilatory support than those without any sepsis (31 days vs 18 days respectively, p < 0.001). In our cohort, SA sepsis was associated with worse neurodevelopmental outcomes compared to infants without any sepsis.ConclusionsThe incidence of neonatal SA sepsis has reduced over the last 20 years, suggesting potential effectiveness of the preventative interventions implemented. Endotracheal tube (ETT) colonisation and prolonged ventilation may be under-recognised as potential sources of SA infection. Our study suggests SA sepsis may negatively impact neurodevelopmental outcomes.

Organizational Risk Factors and Clinical Impacts of Unplanned Extubation in the Neonatal Intensive Care Unit

To assess the association between organizational factors and unplanned extubation events in the neonatal intensive care unit (NICU) and to evaluate the association between unplanned extubation event and bronchopulmonary dysplasia (BPD) among infants born at <29weeks of gestational age. This is a retrospective cohort study of infants admitted to a tertiary care NICU between 2016 and 2019. Nursing provision ratios, daily nursing overtime hours/total nursing hours ratio, and unit occupancy were compared between days with and days without unplanned extubation events. The association between unplanned extubation events (with and without reintubation) and the risk of BPD was evaluated in infants born at <29weeks who required mechanical ventilation using a propensity score-matched cohort. Multivariable logistic regression analysis was used to assess the association between exposures and outcomes while adjusting for confounders. On 108 of 1370days there was ≥1 unplanned extubation event for a total of 116 unplanned extubation event events. Higher median nursing overtime hours (20hours vs 16hours) and overtime ratios (3.3% vs 2.5%) were observed on days with an unplanned extubation event compared with days without an unplanned extubation event (P=.01). Overtime ratio was associated with higher adjusted odds of a unplanned extubation event (aOR, 1.09; 95% CI, 1.01-1.18). In the subgroup of infants born at <29weeks, those with an unplanned extubation event who were reintubated had a longer postmatching duration of mechanical ventilation (aOR, 13.06; 95% CI, 4.88-37.69) and odds of BPD (aOR, 2.86; 95% CI, 1.01-8.58) compared with those without an unplanned extubation event. Nursing overtime ratio is associated with an increased number of unplanned extubation events in the NICU. In infants born at <29weeks of gestational age, reintubation after an unplanned extubation event is associated with a longer duration of mechanical ventilation and increased risk of BPD.

Validation of a non-invasive pressure–time index of the inspiratory muscles in spontaneously breathing newborn infants

To validate the pressure–time index of the inspiratory muscles as a non-invasive index of inspiratory muscle function in spontaneously breathing infants by comparing it against the gold-standard pressure–time index of the diaphragm. Prospective observational cohort study of consecutive infants breathing unsupported in room air in a tertiary neonatal intensive care unit, studied prior to discharge from neonatal care. The invasive pressure–time index of the diaphragm was calculated using a transdiaphragmatic dual-pressure catheter that measured transdiaphragmatic pressure by subtraction of the oesophageal from the gastric pressure. The non-invasive pressure–time index of the inspiratory muscles was calculated using pressure measurements at the level of the mouth via a differential pressure transducer connected to a face mask. Both indices were calculated as the product of the ratio of the mean inspiratory pressure divided by the maximum inspiratory pressure and the ratio of the inspiratory time divided by the total time of a respiratory cycle. One hundred and thirty infants (79 male) were included with a mean (SD) gestational age of 35.2 (3.2) weeks, studied at a median (IQR) postnatal age of 9 (6–20) days. The mean (SD) pressure–time index of the diaphragm was 0.063 (0.019) and the mean (SD) pressure–time index of the inspiratory muscles was 0.065 (0.023). The correlation coefficient for the two indices was 0.509 (p < 0.001). The mean (SD) absolute difference between the pressure–time index of the inspiratory muscles and pressure–time index of the diaphragm was 0.002 (0.021). In convalescent infants, the non-invasive pressure–time index of the inspiratory muscles had a moderate degree of correlation with the invasively derived pressure time index of the diaphragm measured with a transdiaphragmatic catheter.

Postnatal Cytomegalovirus Infection: Is it Important? A 10-Year Retrospective Case-control Study of Characteristics and Outcomes in Very Preterm and Very Low Birth Weight Infants.

To determine the characteristics and outcomes of postnatal cytomegalovirus (pCMV) infection in preterm infants in a neonatal intensive care unit (NICU). A retrospective, matched case-control study in a tertiary NICU. Infants born between January 2009 and December 2019, <32 weeks' gestational age (GA) and/or birth weight (BW) <1500 g with pCMV infection were matched 1:1 with cytomegalovirus-(CMV)-negative infants by year of admission, gender, GA and BW. Primary outcome was death ≤36 weeks' postmenstrual age or bronchopulmonary dysplasia (BPD). Secondary outcomes were length of ventilation (LOV), length of stay (LOS) and neurodevelopmental impairment (NDI) at corrected age 1 and 2 years. Forty-eight pCMV-positive infants (median GA 25.3 weeks, BW 695 g, age 58 days) were identified from 1659 infants (incidence 2.9%). The most common symptoms of pCMV infection were abdominal distension (43.8%), sepsis-like syndrome (29.2%), thrombocytopenia (60.5%) and conjugated hyperbilirubinemia (60.9%). Compared with controls, there were no significant differences in the composite outcome of death or BPD (56.3% vs. 37.5%; P = 0.1) or NDI at 1 and 2 years (51.9% vs. 44%; P = 0.8; 71.4% vs. 50%; P = 0.4). pCMV-positive infants had a significantly longer median LOV (23.5 vs. 12 days)* and LOS (140 vs. 110.5 days)*. Eleven (22.9%) infants received antivirals. Ten improved and 1 died. Two untreated infants died (1 from pCMV infection). Clinically identifiable pCMV infections are significant and associated with increased respiratory support and prolonged hospital stay in vulnerable infants. pCMV screening and preventive measures against transmission merit consideration.*P < 0.05.

Persistent Coagulase-Negative Staphylococcal Bacteremia in Neonates: Clinical, Microbiological Characteristics and Changes within a Decade.

Atypical outbreaks of persistent coagulase-negative staphylococci (CoNS) bacteremias, defined as three or more consecutive positive blood cultures with the same CoNS species, at least 48 h apart, have been reported in neonatal intensive-care units (NICUs). Our aim was to describe the profile of these cases in our NICU over a two-year period with the objective of assessing possible changes within a decade. Demographics, clinical and microbiological data were recorded for all CoNS bacteremias in our tertiary NICU during 2016–2017 and compared with the results of the same study in 2006–2007. Fifty-six cases of CoNS sepsis were recorded. Fourteen (25%) of them were persistent. There were no significant differences in demographic and clinical characteristics between cases with persistent vs. non-persistent bacteremia. Staphylococcus epidermidis was the most common species. In logistic regression analysis, biofilm production (β = 2.464, p = 0.04) was the most significant determinant for the development of persistent CoNS bacteremia. Our isolates were less likely to produce biofilm and carry ica operon as compared to those of 2006–2007. The cases of persistent CoNS sepsis have decreased within a decade, which could be attributed to the implementation of intensive infection control practices. Biofilm production remains the most important risk factor.

Fungal Sepsis in a Tertiary Neonatal Intensive Care Unit: A Cross-sectional Study

Fungal Sepsis in a Tertiary Neonatal Intensive Care Unit: A Cross-sectional Study

Electrographic Seizures in Neonates with a High Risk of Encephalopathy.

Background: Neonatal encephalopathy is caused by a wide variety of acute brain insults in newborns and presents with a spectrum of neurologic dysfunction, such as consciousness disturbance, seizures, and coma. The increased excitability in the neonatal brain appears to be highly susceptible to seizures after a variety of insults, and seizures may be the first clinical sign of a serious neurologic disorder. Subtle seizures are common in the neonatal period, and abnormal clinical paroxysmal events may raise the suspicion of neonatal seizures. Continuous video electroencephalographic (EEG) monitoring is the gold standard for the diagnosis of neonatal seizures. The aim of this study was to identify the prevalence of electrographic seizures and the impact of monitoring in neonates with a high risk of encephalopathy. Methods: We conducted this prospective cohort study in a tertiary neonatal intensive care unit over a 4-year period. Neonates with a high risk of encephalopathy who were receiving continuous video EEG monitoring were eligible. The patients were divided into 2 groups: (1) acute neonatal encephalopathy (ANE) and (2) other high-risk encephalopathy conditions (OHRs). The neonates’ demographic characteristics, etiologies, EEG background feature, presence of electrographic seizures and the impact of monitoring were analyzed. Results: A total of 71 neonates with a high risk of encephalopathy who received continuous video EEG monitoring were enrolled. In this consecutive cohort, 42 (59.2%) were monitored for ANE and 29 (40.8%) were monitored for OHRs. At the time of starting EEG monitoring, 54 (76.1%) of the neonates were term infants. The median gestational age at monitoring was 39 weeks (interquartile range, 37–41 weeks). The median total EEG monitoring duration was 64.7 h (interquartile range, 22.2–72.4 h). Electrographic seizures were captured in 25 of the 71 (35.2%) neonates, of whom 20 (80%) had electrographic-only seizures without clinical correlation. Furthermore, of these 20 neonates, 13 (65%) developed electrographic status epilepticus. Electrographic seizures were most commonly found in the ANE group (17, 40.5%) than in the OHRs group (8, 27.6%) (p = 0.013). Besides, normal/mild abnormality and inactive EEG background were less electrographic seizure than moderate and major abnormality EEG background (2 of 30, 6.7% vs. 23 of 41, 56.1%, p < 0.001). Finally, continuous video EEG monitoring excluded the diagnosis of electrographic seizures in two-thirds of the monitored neonates who had paroxysmal events mimicking seizures and led to a change in clinical management in 39.4% of the neonates. Conclusions: Our findings showed that monitoring could accurately detect seizures, and that it could be used to guide seizure medication management. Therefore, continuous video EEG monitoring has important clinical management implications in neonates with a high risk of encephalopathy.

Variations in practices and outcomes of neonates with hypoxic ischemic encephalopathy treated with therapeutic hypothermia across tertiary NICUs in Canada

To characterize variations in practices and outcomes for neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia (TH) across Canadian tertiary Neonatal Intensive Care Units (NICUs). Retrospective study of neonates admitted for HIE and treated with TH in 24 tertiary NICUs from the Canadian Neonatal Network, 2010-2020. The two primary outcomes of mortality before discharge and MRI-detected brain injury were compared across NICUs using adjusted standardized ratios (SR) with 95% CI. Of the 3261 neonates that received TH, 367 (11%) died and 1033 (37%) of the 2822 with MRI results had brain injury. Overall, rates varied significantly across NICUs for mortality (range 5-17%) and brain injury (range 28-51%). Significant variations in use of inotropes, inhaled nitric oxide, blood products, and feeding during TH were identified (p values < 0.01). Significant variations exist in practices and outcomes of HIE neonates treated with hypothermia across Canada.

Risk factors for prolonged mechanical ventilation in neonates following gastrointestinal surgery.

BackgroundProlonged mechanical ventilation (MV) should be avoided in neonates. Noninvasive ventilation (NIV) can facilitate weaning from MV but has risks for patients immediately following foregut surgery due to the potential risk of anastomotic leak. We evaluated the risk factors for prolonged MV following intestinal surgery in neonates.MethodsWe retrospectively reviewed 253 neonates undergoing intestinal surgery in 2017-2018 to identify risk factors for prolonged MV, and determine the correlation between NIV and anastomotic leak in a tertiary neonatal intensive care unit that performs the greatest number of neonatal surgeries in Ontario.ResultsThe most common diagnoses were necrotizing enterocolitis/spontaneous intestinal perforation (NEC/SIP) 21%, intestinal atresia 16%, esophageal atresia/tracheoesophageal fistula 14%, ano-rectal malformation 13%, malrotation/volvulus 11%, gastroschisis 9% and omphalocele 4%. The median (IQR) duration of MV post-surgery was 3 (1–8) days with 25.7 % (n=65) of neonates on MV for >7 days. Compared to infants on MV post-surgery for ≤7 days, those with MV>7 days were of lower gestational age, birth weight and weight at surgery, but a higher proportion underwent stoma creation, had a longer duration of opioid administration and higher rates of moderate to severe bronchopulmonary dysplasia (BPD) and mortality (P<0.05). Generalized linear regression analysis showed lower gestational age (GA) and longer opioid administration were associated with longer duration of MV (P<0.001), but indication for surgery, weight at surgery and stoma creation didn’t correlate with longer duration of MV (P>0.05). Of the 122 patients handled by one-stage resection with primary anastomosis, 22.1% (n=27) received NIV with 74.1% (n=20) commenced on NIV after 7 days post-surgery, anastomotic leak was detected in 2.5 % (3/122) patients and didn’t correlate with NIV.ConclusionsLower GA and longer opioid administration were risk factors for prolonged MV in neonates following intestinal surgery. Further research is needed to investigate modifiable practices around pain assessment/ventilation in these patients, and the correlation between NIV and anastomotic leak.

Early initiation of broad-spectrum antibiotics in premature infants.

Neonatal sepsis remains one of the main reasons for mortality among premature infants, and the early initiation of empirical broad-spectrum antibiotics could increase the risk of complications, including late-onset sepsis. This study aimed to investigate the complications related to the use of empirical broad-spectrum antibiotics in the first week of life. A retrospective study of 365 neonates with gestational age ≤32 weeks and birth weight <1500 g who survived and had no confirmed sepsis in the first week of life from July 2015 to June 2018 was performed in a large tertiary Neonatal Intensive Care Unit. The primary outcome of this study was the incidence of a composite outcome consisting of late-onset sepsis, necrotizing enterocolitis, and mortality. The secondary outcomes were the incidences of late-onset sepsis, necrotizing enterocolitis, bronchopulmonary dysplasia, and infant mortality. Of the 365 premature infants, 75 (20.5%) received broad-spectrum antibiotics. Multivariate regression analysis revealed that administration of broad-spectrum antibiotics in infants was independently associated with adverse outcomes. The composite outcome (late-onset sepsis, necrotizing enterocolitis, and death) had an odds ratio of 3.03 with 95% confidence interval of 1.41-6.49. Administration of empirical broad-spectrum antibiotics in the first week of life is associated with severe adverse outcomes. Thus, the restricted use of broad-spectrum antibiotics in the first week of life is recommended.

Implementation of a temperature bundle improves admission hypothermia in very-low-birth-weight infants in China: a multicentre study

BackgroundHypothermia is a common problem that is associated with increased mortality and morbidity among preterm infants, especially in China. The objective of this study was to evaluate the efficacy of...

Platelet parameters as a diagnostic marker in early diagnosis of neonatal sepsis- Seeking newer answers for older problems.

ABSTRACTBackground:Early identification and intervention of neonatal sepsis can improve the clinical outcome. Blood cultures remain the gold standard for diagnosis but are not easily available and require time. There is a need to identify and validate newer easily available cost-effective investigations, which would help in the diagnosis of neonatal sepsis.Aim:To test the hypothesis that whether platelet parameters, i.e., total platelet count (TPC), mean platelet volume (MPV), and the ratio of MPV/TPC can serve as diagnostic markers in neonatal sepsis.Methods:It is was a prospective study conducted in a tertiary care neonatal intensive care unit (NICU). The platelet parameters, i.e., TPC, MPV, and MPV/TPC of blood culture-positive septic neonates were compared with those of non-septic neonates admitted to the NICU. The diagnostic accuracy of the platelet indices was assessed by receiver operating characteristics (ROC) curves and sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).Result:During the study period, 43 blood culture-positive sepsis neonates were compared with 54 cases of non-septic neonates. There was a significant difference in the mean of TPC, MPV, and MPV/TPC ratio between septic groups and non-septic groups. The sensitivity, specificity, PPV, NPV values of MPV (cut-off >9 fL) were 63.40%, 53.8%, 52.0%, and 65.11% respectively. The sensitivity, specificity, PPV, NPV of MPV/TPC ratio (>7.2) were 48.8%, 96.22%, 90.9%, and 70.42% respectively. The area under the curve (AUC) values for TPC, MPV, and MPV/TPC in the ROC analysis were 0.797, 0.641, and 0.809, respectively.Conclusion:Platelet indices MPV and MPV/TPC ratio can be useful in the early diagnosis of neonatal sepsis.

Nasal High-Flow Therapy during Neonatal Endotracheal Intubation

BackgroundNeonatal endotracheal intubation often involves more than one attempt, and oxygen desaturation is common. It is unclear whether nasal high-flow therapy, which extends the time to desaturation during elective intubation in children and adults receiving general anesthesia, can improve the likelihood of successful neonatal intubation on the first attempt.MethodsWe performed a randomized, controlled trial to compare nasal high-flow therapy with standard care (no nasal high-flow therapy or supplemental oxygen) in neonates undergoing oral endotracheal intubation at two Australian tertiary neonatal intensive care units. Randomization of intubations to the high-flow group or the standard-care group was stratified according to trial center, the use of premedication for intubation (yes or no), and postmenstrual age of the infant (≤28 or >28 weeks). The primary outcome was successful intubation on the first attempt without physiological instability (defined as an absolute decrease in the peripheral oxygen saturation of >20% from the preintubation baseline level or bradycardia with a heart rate of <100 beats per minute) in the infant.ResultsThe primary intention-to-treat analysis included the outcomes of 251 intubations in 202 infants; 124 intubations were assigned to the high-flow group and 127 to the standard-care group. The infants had a median postmenstrual age of 27.9 weeks and a median weight of 920 g at the time of intubation. A successful intubation on the first attempt without physiological instability was achieved in 62 of 124 intubations (50.0%) in the high-flow group and in 40 of 127 intubations (31.5%) in the standard-care group (adjusted risk difference, 17.6 percentage points; 95% confidence interval [CI], 6.0 to 29.2), for a number needed to treat of 6 (95% CI, 4 to 17) for 1 infant to benefit. Successful intubation on the first attempt regardless of physiological stability was accomplished in 68.5% of the intubations in the high-flow group and in 54.3% of the intubations in the standard-care group (adjusted risk difference, 15.8 percentage points; 95% CI, 4.3 to 27.3).ConclusionsAmong infants undergoing endotracheal intubation at two Australian tertiary neonatal intensive care units, nasal high-flow therapy during the procedure improved the likelihood of successful intubation on the first attempt without physiological instability in the infant. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Registry number, ACTRN12618001498280.)

Noninvasive High-Frequency Oscillatory Ventilation vs Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation as Postextubation Support for Preterm Neonates in China

Several respiratory support techniques are available to minimize the use of invasive mechanical ventilation (IMV) in preterm neonates. It is unknown whether noninvasive high-frequency oscillatory ventilation (NHFOV) is more efficacious than nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) in preterm neonates after their first extubation. To test the hypothesis that NHFOV is more efficacious than NCPAP or NIPPV in reducing IMV after extubation and until neonatal intensive care unit discharge among preterm neonates. This multicenter, pathophysiology-based, assessor-blinded, 3-group, randomized clinical trial was conducted in 69 tertiary referral neonatal intensive care units in China, recruiting participants from December 1, 2017, to May 31, 2021. Preterm neonates who were between the gestational age of 25 weeks plus 0 days and 32 weeks plus 6 days and were ready to be extubated were randomized to receive NCPAP, NIPPV or NHFOV. Data were analyzed on an intention-to-treat basis. The NCPAP, NIPPV, or NHFOV treatment was initiated after the first extubation and lasted until discharge. Primary outcomes were total duration of IMV, need for reintubation, and ventilator-free days. These outcomes were chosen to describe the effect of noninvasive ventilation strategy on the general need for IMV. A total of 1440 neonates (mean [SD] age at birth, 29.4 [1.8] weeks; 860 boys [59.7%]) were included in the trial. Duration of IMV was longer in NIPPV (mean difference, 1.2; 95% CI, 0.01-2.3 days; P = .04) and NCPAP (mean difference, 1.5 days; 95% CI, 0.3-2.7 days; P = .01) compared with NHFOV. Neonates who were treated with NCPAP needed reintubations more often than those who were treated with NIPPV (risk difference: 8.1%; 95% CI, 2.9%-13.3%; P = .003) and NHFOV (risk difference, 12.5%; 95% CI, 7.5%-17.4%; P < .001). There were fewer ventilator-free days in neonates treated with NCPAP than in those treated with NIPPV (median [25th-75th percentile] difference, -3 [-6 to -1] days; P = .01). There were no differences between secondary efficacy or safety outcomes, except for the use of postnatal corticosteroids (lower in NHFOV than in NCPAP group; risk difference, 7.3%; 95% CI, 2.6%-12%; P = .002), weekly weight gain (higher in NHFOV than in NCPAP group; mean difference, -0.9 g/d; 95% CI, -1.8 to 0 g/d; P = .04), and duration of study intervention (shorter in NHFOV than in NIPPV group; median [25th-75th percentile] difference, -1 [-3 to 0] days; P = .01). Results of this trial indicated that NHFOV, if used after extubation and until discharge, slightly reduced the duration of IMV in preterm neonates, and both NHFOV and NIPPV resulted in a lower risk of reintubation than NCPAP. All 3 respiratory support techniques were equally safe for this patient population. ClinicalTrials.gov Identifier: NCT03181958.

Risk prediction model for 24-hour mortality in preterm infants using lactate and blood gas analysis: A machine learning approach and retrospective cohort study

Background: This study aimed to evaluate the performance of machine learning algorithms using lactate and arterial blood gas parameters to predict the imminent risk of death in extremely low birth weight infants. Methods: A retrospective cohort study analyzing preterm infants with birth weight less than 1000 grams in a single-center tertiary neonatal intensive care unit in São Paulo, Brazil, between 2012 and 2017 was carried out. We included all infants with at least one arterial blood gas analysis with paired serum lactate. To assess 24-hour mortality risk, we conducted three machine learning algorithms (Logistic Regression, Extreme Gradient Boosting, and AutoML Tables). Results: We analyzed 1932 blood gas samples with matched lactate measurements. Our study population had a median gestational age of 27.1 (26 – 29.1) weeks and a median birth weight of 746 (600 – 880) grams. The Extreme Gradient Boosting model with lactate achieved the highest area under the receiver operating characteristic (AUROC) of 0.898. Base excess, lactate, and pH were, in order of importance, the most important features associated with 24-hour mortality. Conclusions: Incorporating lactate and blood gas samples into real-time mortality predictive models may aid to identify those preterm infants with a higher risk of death.

Longitudinal Analysis of Amplitude-Integrated Electroencephalography for Outcome Prediction in Hypoxic-Ischemic Encephalopathy

To investigate the prognostic accuracy of longitudinal analysis of amplitude-integrated electroencephalography (aEEG) background activity to predict long-term neurodevelopmental outcome in neonates with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia. This single-center observational study included 149 neonates for derivation and 55 neonates for validation with moderate-severe HIE and of gestational age ≥35weeks at a tertiary neonatal intensive care unit. Single-channel aEEG background pattern, sleep-wake cycling, and seizure activity were monitored over 84hours during therapeutic hypothermia and rewarming, then scored for each 6-hour interval. Neurodevelopmental outcome was assessed using the Bayley Scales of Infant Development, Second Edition. Favorable outcome was defined as having both a Mental Development Index (MDI) score and Psychomotor Development Index (PDI) score ≥70, and adverse outcome was defined as either an MDI or a PDI <70 or death. Regression modeling for longitudinal analysis of repeatedly measured data was applied, and area under the receiver operating characteristic curve (AUC) was calculated. Longitudinal aEEG background analysis combined with sleep-wake cycling score had excellent predictive value (AUC, 0.90; 95% CI, 0.85-0.95), better than single aEEG scores at any individual time point. The model performed well in the independent validation cohort (AUC, 0.87; 95% CI, 0.62-1.00). The reclassification rate of this model compared with the conventional analysis of aEEG background at 48hours was 18% (24 patients); 14% (18 patients) were reclassified correctly. Our results were used to develop a user-friendly online outcome prediction tool. Longitudinal analysis of aEEG background activity and sleep-wake cycling is a valuable and accurate prognostic tool.