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About this blog

I am a Neonatologist trained in Winnipeg, Manitoba and Edmonton, Alberta.  My current position is Section Head of Neonatology in Manitoba and over my career my interests have meandered from time to time.  I have been a past Program Director of Neonatology and Medical Director for a level II Intensive Care Unit prior to relocating to Winnipeg become a Section Head.

Welcome to my blog which I hope will provide a forum for discussion on topics that are of interest to Neonatologists, trainees, all health care professionals and in some cases parents of those we care for.  My intent is to post opinions and analysis on both items from the media and literature that pertain to neonates.  While I have many interests, my particular motivation is to find ways to reduce discomfort for the patients that we care for.  Whether it is through the use of non-invasive testing or finding a way to improve the patient experience this is where I find myself most energized.

I chose the picture for this site as since the inception of this site there is hardly a country that has not had an individual or many people view posts.  Moreover I have received comments from many people from so many different countries that have inspired me to think not just about the impact of these posts in North America but more globally as well.

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Entries in this blog

 

Time To Give Antenatal Steroids After 34 weeks

In April of this year the ALPS trial results were published in the New England Journal of Medicine (Antenatal Betamethasone for Women at Risk for Late Preterm Delivery) and I took the time to review the paper at the time Antenatal Steroids After 34 weeks. Believe the hype?  In the analysis I focused on an issue which was relevant at the time, being a shortage of betamethasone.  In a situation when the drug of choice is in short supply I argued that while the benefits of giving steroid to women at risk of delivery between 34 0/7 to 36 6/7 weeks was there, if I had to choose (as I did at the time) I would save the doses for those at highest risk of adverse outcome.  Since the blog post though a couple of things have come out in the literature that I believe are worth sharing as it could truly influence practice. Practice Advisory: Antenatal Corticosteroid Administration in the Late Preterm Period The American College of Obstetricians and Gynecologists, moved by the results of the ALPS trial issued the following recommendations (shortened in places). Betamethasone may be considered in women with a singleton pregnancybetween 34 0/7 and 36 6/7 weeks gestation at imminent risk of preterm birth within 7 days. Monitoring of late preterms for hypoglycemia (already being done) Do not give in the setting of chorioamnionitis. Tocolysis or delayed delivery for maternal indications should not be done in order to  to allow for administration of late preterm antenatal corticosteroids. Do not provide if the pregnancy was already exposed to antenatal corticosteroids. The exclusions above such as twins and triplets, diabetic pregnancies and previous receipt of steroids were included since the study had not included these patients.  As the ACOG states in the summary, they will be reviewing such indications in the future and providing recommendations.  I would imagine that if I were in a US based practice then this post might seem like old news since many centres would have started doing this.  Given that the readers of this blog are based in many different countries around the globe and at least in Canada this has not become commonplace I thought it would be worth the update! Antenatal corticosteroids for maturity of term or near term fetuses: systematic review and meta-analysis of randomized controlled trials I posted the abstract for this review on my Facebook page the other day and it certainly garnered a lot of interest.  Some of my readers indicated the practice is already underway. I was curious what a systematic review would reveal about the topic since the ACOG was so moved by the ALPS study in particular.  Perusing through the Society of Obstetricians and Gynecologists of Canada (SOGC) I can’t find any commentary on this topic and certainly there are no new clinical practice guidelines since the ALPS study landed on my desktop. Here are the pooled results from 6 trials: Lower risk of RDS (relative risk 0.74, 95% confidence interval 0.61 to 0.91) Mild RDS (0.67, 0.46 to 0.96) Moderate RDS (0.39, 0.18 to 0.89) Severe RDS (0.55, 0.33 to 0.91) Transient tachypnea of the newborn (0.56, 0.37 to 0.86) Shorter stay on a neonatal intensive care unit (−7.64 days, −7.65 to −7.64) So across the board patients who receive antenatal steroids after 34 weeks still continue to see a benefit but looked at a different way the real benefit of the intervention is easier to see and that is through looking at the number needed to treat (NNT).  For those of you who are not familiar with this analysis, this looks at how many patients one would need to treat in order to avoid the outcome in 1 patient. For the outcomes above as an example the NNT for RDS overall is about 59 while for TTN 31 patients.  Severe RDS which is less common after 34 weeks you might expect to require more patients to treat to help 1 avoid the outcome and you would be correct.  That number is 118 patients.  It is interesting to look at the impact of steroids in pregnancies below 34 weeks (taken from the Cochrane review on the subject) as the NNT there is 23!  If you were to break these benefits down from 23-27 weeks though where the risk of RDS is quite high the NNT would be even lower.  Steroids help, no question to reduce neonatal complications but as you can see even when there is a reduction in risk for various outcomes, the number of women you need to treat to get one good outcome is quite different. Some Discussion With Obstetrics Is Needed Here As you read through this post you may find yourself saying “Who cares? if there is a benefit at all most moms would say give me the steroids!”  The issue here has to do with long term outcome.  To put it simply, we don’t know for this type of patient.  We know clearly that for patients at high risk of adverse outcomes eg. 24 week infant, the reduction in risks of infection, NEC, PDA, BPD etc from receiving antenatal steroids translates into many long term benefits.  What about the patient who say is 35 weeks and would have none of those risks?  Yes we are avoiding some short term outcomes that let’s be honest can be scary for a new parent but what are we trading  this benefit for.  The concern comes from what we know about steroids impact on the developing brain.  Steroids lead to a developmental arrest but in very preterm infants there is no doubt that the protective effect on all of these other outcomes more than offsets whatever impact there is there.  Incidentally I wrote about this once before and the section of interest appears at the end of the relevant post Not just for preemies anymore? Antenatal steroids for elective c-sections at term.  In the absence of these other conditions could there be a long term impact in babies 34 – 36 6/7?  My suspicion is that the answer is no but discussion is needed here especially in the absence of an endorsement by our Canadian SOGC.  Having said all that I expect the future will indeed see an expansion of the program but then I do hope that someone takes the time to follow such children up so we have the answer once and for all.

AllThingsNeonatal

AllThingsNeonatal

 

Nitric oxide & Congenital Diaphragmatic Hernia; not so safe after all?

As a young resident I have a vivid memory of a baby with CDH having saturations of 60 – 65% despite HFOV, paralysis and alkalinization (yes we used to do that).  It was at that time that I pretty much threw my hands in the air and declared there was really nothing left that we could do.  One of my mentors, a very wise Neonatologist Dr. Henrique Rigatto looked at me and said “why don’t we try inhaled nitric oxide?”  Being the resident immersed in the burgeoning field of evidence based medicine I questioned him on this stating “But the evidence shows no benefit of iNO in CDH in any trials”.  He looked back at me and asked “Are you prepared to let this baby die without even trying it?”.  When put that way I answered shyly that I would order the iNO and… it worked.  Whether it was coincidence or not I cannot say but I felt he had a point which I have shared many times with students over the years.  A drug may not show a benefit in a clinical RCT so at a population level it should not be our ” go to” drug of choice but on an individual level as a last resort sometimes these medications for an individual patient may make a difference.  Looking at it from a different standpoint one might say it falls into the “can’t hurt but might help” category of therapy. Or is it safe in CDH? The Congenital Diaphragmatic Hernia Study Group (CDHSG) of which we are a contributing centre recently published a retrospective analysis of the registry (now including over 9000 patients!) in an attempt to answer whether iNO use in babies with CDH is indeed safe. Evaluation of Variability in Inhaled Nitric Oxide Use and Pulmonary Hypertension in Patients With Congenital Diaphragmatic Hernia. The study looked at 2047 patients treated with iNO most of whom received 20 ppm of iNO.  Interestingly about 15% of the patients treated with iNO did not have pulonary hypertension on ECHO.  The study found a positive association between centres using iNO and mortality. Moreover as the number of centres increased over time that used iNO so did the overall mortality in the study cohort.   Beyond just looking at the trend in mortality with increasing use the authors took this one step further and used the statistical technique of propensity scoring to determine the attributable risk to mortality of using iNO in patients with CDH. Propensity scoring is an interesting technique that one can use to estimate risk when it is unlikely that a randomized controlled trial will be available and this is one of those cases.  The technique uses an approach which strives to balance the variables that determined why different patients received a treatment so when comparing the outcomes of the two groups you manage to isolate the effect to just the treatment that is being studied.  In this case the technique indicates that the estimate of harm is estimated to be 15% meaning that there is an estimated 15% increase in mortality for patients with CDH treated with iNO regardless of the indication. So what to do with our next patient? I can’t help but think back to the words of one of my mentors and ask myself what I would do if I was confronted with a patient who had CDH and was saturating poorly.  I think what this study adds perhaps is that one should tread carefully with iNO in the setting of CDH. Maybe the overall message is that one should not jump to use iNO early in treatment. Optimizing  ventilation, use of analgesics and sedation and even paralysis may be a better approach to controlling oxygenation than early iNO.  When all those have been tried though and the patient is still not responding I think those wise words from long ago carry a lot of weight. “Are you prepared to let this baby die without even trying it?” When mortality is already a strong possibility I believe at least for me the answer will remain no.  I think it is important to keep iNO in your back pocket but to let a patient die without trying would leave me forever asking “what if”.  That is a question I am certainly not comfortable asking at all.

AllThingsNeonatal

AllThingsNeonatal

 

Free parking to increase parental visitation

This is a title that I hope caught your eye.  In the nearly twenty years I have been in the field of Pediatrics the topic of parking being a barrier to parental visitation has come up again and again.  A few years ago the concern about the cost of parking was so great that I was asked if I could find a pool of donors to purchase parking passes to offset the burden to the family.  The theory of course is based on the idea that if parking were free in the NICU parents would visit more.  If parents visit more they will be more involved in the care of their baby, more likely to breastfeed and with both of these situations in play the infant should be discharged earlier than other infants whose parents don’t visit.  Try as I might it was a tough sell for donors who tend to prefer buying something more tangible that may bear their name or at least something they can look at and say “I bought that”.  This is quite tough when it comes to a parking stall and as such I am still looking for that elusive donor.  Having said that, is there any basis to believe that free parking is the solution that will deliver us from minimal visitation by some parents? A Study May Help Answer The Question Northrup TF et al published an article that was sent my way and to be honest I couldn’t wait to read it.  A free parking trial to increase visitation and improve extremely low birth weight infant outcomes. This is like the holy grail of studies.  A study that gets right to the point and attempts to answer the exact question I and others have been asking for some time.  The study took place in Houston, Texas and was set up as an RCT in which families were randomized into two groups.  Inclusion criteria were birth weight ⩽1000 g, age 7 to 14 days and deemed likely to survive.  Seventy two patients were enrolled in the free parking group while 66 were placed in the usual care.  Interestingly the power calculation determined that they would need 140 to show a difference so while 138 is close it wasn’t enough to truly show a difference but let’s see what they found. The Results Free parking made absolutely no difference for the whole group. Specifically there was no difference in the primary outcome of length of stay or hours spent per visit.  Some interesting information though that may not be that surprising was found to be of importance in the table below.   It may not seem like a surprise but the patients who were more affluent and those who had less children tended to visit more.  The latter makes a lot of sense as what are many people to do when they have one or more other children to care for at home especially in the face of little support?  Would free parking make one iota of difference if the barrier has nothing to do with the out of pocket cost? The conclusion was that the strategy didn’t work that well but as you may have picked up I think the study was flawed.  By applying the strategy to all they were perhaps affected by choosing the wrong inclusion criteria.  Taken to an extreme, would a 50 million dollar Powerball winner care one bit about parking vouchers?  It wouldn’t make any difference to whether they were going to come or not.  Similarly a single mother with 5 other kids who lives below the poverty line and has little support is not going to come more frequently whether they have a voucher or not. What if the study were redone? I see a need to redo this study again but with different parameters.  What if you randomized people with a car or access to one who lived below a certain income level and had a committed support person who could assure that team that they could care for any other children the family had when called upon?  Or one could look at families with no other children and see if offering free parking led to more frequent visitation and then from there higher rates of Kangaroo Care and breastfeeding.  I for one haven’t given up on the idea and while I was truly excited to be sent this article and sadly initially dismayed on first read, I am hopeful that this story has not seen it’s end. It is intuitive to me that for some parents parking is a barrier to visiting. Finding the right population to prove this though is the key to providing the evidence to arm our teams with evidence to gain support from hospital administrations.  Without it we truly face an uphill battle to get this type of support for families.  Stay tuned…

AllThingsNeonatal

AllThingsNeonatal

 

Autopilot Non-Invasive Ventilation

I had a chance recently to drive a Tesla Model S with autopilot. Taking the car out on a fairly deserted road near my home I flicked the lever twice to activate the autopilot feature and put my hands behind my head while the vehicle took me where I wanted to go.  As I cruised down the road with the wheel automatically turning with the curves in the road and the car speeding up or slowing down based on traffic and speed limit notices I couldn’t help but think of how such technology could be applied to medicine.  How far away could the self driving ventilator or CPAP device be from development? I have written about automatic saturation adjustments in a previous post but this referred to those patients on mechanical ventilation.  Automatic adjustments of FiO2. Ready for prime time? Why is this goal so important to attain?  The reasoning lies in the current design trends in modern NICUs.  We are in the middle of a large movement towards single patient room NICUs which have many benefits such as privacy which may lead to enhanced breastfeeding rates and increased parental visitation.  The downside, having spoken to people in centres where such designs are already in place is the challenge nursing faces when given multiple assignments of babies on O2.  If you have to go from room to room and a baby is known to be labile in their O2 saturations it is human nature to turn the O2 up a little more than you otherwise would to give yourself a “cushion” while you are out of the room.  I really don’t fault people in this circumstance but it does pose the question as to whether in a few years we will see a rise in oxygen related tissue injury such as CLD or ROP from such practice.  In the previous post I wrote about babies who are ventilated but these infants will often be one to one nursed so the tendency to overshoot the O2 requirements may be less than the baby on non- invasive ventilation. A System For Controlling O2 Automatically For Infants on Non-Invasive Ventilation This month in Archives Dr. Dargaville and colleagues in Australia provide two papers, the first demonstrating the validation of the mathematical algorithm that they developed to control O2 and the second a clinical report outlining how well the system actually performed on patients.  The theoretical paper Development and preclinical testing of an adaptive algorithm for automated control of inspired oxygen in the preterm infant. is a challenge to comprehend although validates the approach in the end while the clinical paper at least for me was easier to digest Clinical evaluation of a novel adaptive algorithm for automated control of oxygen therapy in preterm infants on non-invasive respiratory support. The study was really a proof of concept with 20 preterm infants (mean GA 27.5 weeks, 8 days of age on average) included who each underwent two hours of manual control by nursing to keep saturations between 90-94% and then 4 hours of automated control (sats 91 – 95%) then back to manual for two hours.  The slightly shifted ranges were required due to the way in which midpoint saturations are calculated. The essential setup was a computer equipped with an algorithm to make adjustments in FiO2 using an output to a motor that would adjust the O2 blender and then feedback from an O2 saturation monitor back to the computer.  The system was equipped with an override to allow nursing to adjust in the event of poor signal or lack of response to the automatic adjustment. The results though demonstrate that the system works and moreover does a very good job!  The average percentage of time that the saturations were in the target range were significantly better with automated control (81% automated, 56% manual).  As well as depicted in the following figure the amount of time spent in both hypoxic and hyperoxic ranges was considerable with manual control but non-existent on either tail with automated control (defined as < 85% or > 98% where black bars are manual control and white automatic). From the figure you can see that the amount of time the patients are in target range are much higher with automatic control but is this simply because in addition to automatic control, nurses are “grabbing the wheel” and augmenting the system here?  Not at all. “During manual control epochs, FiO2 adjustments of at least 1% were made 2.3 (1.3–3.4) times/hour by bedside staff. During automated control, the minimum alteration to FiO2 of 0.5% was being actuated by the servomotor frequently (9.9 alterations/min overall), and changes to measured FiO2 of at least 1% occurred at a frequency of 64 (49–98) /hour. When in automated control, a total of 18 manual adjustments were made in all 20 recordings (0.24 adjustments/hour), a reduction by 90% from the rate of manual adjustments observed during manual control (2.3/hour).” From the above quote from the paper it is clear that automated control works to keep the saturation goal through roughly 7 X the number of adjustments than nursing makes per hour.  It is hard to keep up with that pace when you have multiple assignments but that is what you need I suppose!  The use of the auto setting here reduced the amount of nursing interventions to adjust FiO2 by 90% and yields tighter control of O2 saturations. Dare to Dream Self driving oxygen administration is coming and this proof of concept needs to be developed and soon into a commercial solution.  The risk of O2 damage to developing tissues is too great not to bring this technology forward to the masses.  As we prepare to move into a new institution I sincerely hope that this solution arrives in time but regardless I know our nurses and RRTs will do their best as they always do until such a device comes along.  When it does imagine all of the time that could be devoted to other areas of care once you were able to move away from the non-invasive device!

AllThingsNeonatal

AllThingsNeonatal

 

Stop guessing when the NICU team is needed at a delivery

The other day I met with some colleagues from Obstetrics and other members from Neonatology to look at a new way of configuring our delivery suites.  The question on the table was which deliveries which were always the domain of the high risk labour floor could be safely done in a lower acuity area.  From a delivery standpoint they would have all the tools they need but issues might arise from a resuscitation point of view if more advanced resuscitation was needed.  Would you have enough space for a full team, would all the equipment you need be available and overall what is in the best interests of the baby and family? We looked at a longstanding list of conditions both antenatal and intrapartum and one by one tried to decide whether all of these were high risk or if some were more moderate.  Could one predict based on a condition how much resuscitation they might need?  As we worked our way through the list there was much discussion but in the end we were left with expert opinion as there was really no data to go by.  For example, when the topic of IUGR infants came up we pooled our collective experience and all agreed that most of the time these babies seem to go quite well.  After a few shoulder shrugs we were left feeling good about our decision to allow them to deliver in the new area.  Now several days later I have some concern that our thinking was a little too simple.  You see, conditions such as IUGR may present as the only risk factor for an adverse outcome but what if they also present with meconium or the need for a instrument assisted delivery.  We would presume the risk for advanced resuscitation (meaning intubation or chest compressions and/or medication need) would be increased but is there a better way of predicting the extent of this risk? Indeed there might just be An interesting approach to answer this question has been taken by an Argentinian group in their paper Risk factors for advanced resuscitation in term and near-term infants: a case–control study.  They chose to use a prospective case control study matching one case to 4 control infants who did not require resuscitation.  The inclusion criteria were fairly straightforward.  All babies had to be 34 weeks gestational age or greater and free of congenital malformations.  By performing the study in 16 centres they were able to amass 61953 deliveries and for each case they found (N=196) they found 784 deliveries that were matched by day of birth.  The idea here was that by matching consecutive patients who did not require resuscitation you were standardizing the teams that were present at delivery. The antepartum and intrapartum risk factors that were then examined to determine strengths of association with need for resuscitation were obtained from the list of risks as per the NRP recommendations. A Tool For All of Us? What came out of their study was a simple yet effective tool that can help to predict the likelihood of a baby needing resuscitation when all factors are taken into account.   By resuscitation the authors defined this as intubation, chest compressions or medications.  This is pretty advanced resuscitation!  In essence this is a tool that could help us answer the questions above with far better estimation than a shoulder shrug and an “I think so” response.  The table can be found by clicking on this link to download but the table looks like this. By inserting checks into the applicable boxes you get a calculated expected need for resuscitation.  Let’s look at the example that I outlined at the start of the discussion which was an IUGR infant. It turns out that IUGR itself increases the background risk for infants 34 weeks and above from 6% to 55% with that one factor alone.  Add in the presence of fetal bradycardia that is so often seen with each contraction in these babies and the risk increases to 97%!  Based on these numbers I would be hesitant to say that most of these kids should do well.  The majority in fact would seem to need some help to transition into this world. Some words of caution The definition here of resuscitation was intubation, chest compressions or medications.  I would like to presume that the practioners in these centres were using NRP so with respect to chest compressions and medication use I would think this should be comparable to a centre such as ours.  What I don’t know for sure is how quickly these centres move to intubate.  NRP has always been fairly clear that infants may be intubated at several time points during a resuscitation although recent changes to NRP have put more emphasis on the use of CPAP to establish FRC and avoid intubation.  Having said that this study took place from 2011 – 2013 so earlier than the push for CPAP began.  I have to wonder what the effect of having an earlier approach to intubating might have had on these results.  I can only speculate but perhaps it is irrelevant to some degree as even if in many cases these babies did not need intubation now they still would have likely needed CPAP.  The need for any respiratory support adds a respiratory therapist into the mix which in a crowded space with the additional equipment needed makes a small room even smaller.  Therefore while I may question the threshold to intubate I suspect these results are fairly applicable in at least picking out the likelihood of needing a Neonatal team in attendance. Moreover I think we might have a quick tool on our hands for our Obstetrical colleagues to triage which deliveries they should really have us at.  A tool that estimates the risk may be better than a shoulder shrug even if it overestimates when the goal is to ensure safety.

AllThingsNeonatal

AllThingsNeonatal

 

Does High Flow Really Have A Place in the NICU At All?

This may sound familiar as I wrote about this topic in the last year but the previous post was restricted to infants who were under 1000g.  High Flow Nasal Cannula be careful out there had a main message that suggested the combined outcome of BPD or death was more prevalent when HFNC is used alone or with CPAP than when CPAP is used alone.  The question remains though whether this applies to larger infants.  Without looking at the evidence for that combined outcome most people would say there is unlikely to be a difference.  Larger more mature babies have a much lower risk of BPD or death so proponents of HFNC would say it is simpler to use and helps prevent nasal breakdown as well.  The question remains as to whether all outcomes are the same in larger infants and that is the point of this post. A Non-Inferiority Trial First off it is important to understand what this type of trial is.  The first requirement is that the two treatments have both been compared to a placebo and found to be both effective.  Once you establish that you have a choice between two treatment options then you eliminate the placebo and compare them head to head.  What you are looking for in this type of trial is to determine not whether one is better than the other but that there is no difference in a clinical outcome of interest.  If you find no difference then the next step is to look at other outcomes that might be of interest and see if there are any benefits to picking one versus the other.  In the case of CPAP vs HNFC, if a non-inferiority trial showed no difference in an important outcome such as length of stay but nasal breakdown was less with HFNC it might lead a unit to use HFNC for their infants.  Okay, now that we have that cleared up we can move on to an actual study examining this very subject. Nasal High-Flow Therapy for Primary Respiratory Support in Preterm Infants. This was an interesting study with a great name (The HIPSTER trial) that enrolled infants > 28 weeks and 0 days with none of the infants receiving surfactant but either being randomized to HFNC or CPAP after delivery.  These infants were your typical modern day cohort of babies who may avoid intubation and surfactant by establishing FRC early with positive pressure applied to the nose through one of these devices.  The end point for the study was treatment failure within 72 hours.  If an infant failed in the HFNC they could have a trial of CPAP whereas in the CPAP group they were intubated.  For each infant in the HFNC group flow was set from 6-8 l/min and for CPAP 6-8 cmH2O. Treatment was considered to have failed if an infant receiving maximal support (high-flow therapy at a gas flow of 8 liters per minute or CPAP at a pressure of 8 cm of water) met one or more of the following criteria: FiO2 of 0.4 or higher Arterial or free flowing cap gas with a pH of 7.2 or less plus a pCO2 > 60 mm Hg obtained at least 1 hour after starting treatment Two or more episodes of apnea requiring positive-pressure ventilation within a 24-hour period or six or more episodes requiring any intervention within a 6-hour period. Infants with an urgent need for intubation and mechanical ventilation. So what happened? The trial randomized 583 infants (278 HFNC, 286 CPAP) but was halted by the data and safety monitoring committee after an analysis of the first 515 revealed that the outcome was worse in the HFNC group (25.5% failure rate vs 13.3 for CPAP).  Interestingly treatment failures were more common in babies below and above 32 weeks so it was not just the smallest infants who failed. Another interesting finding was that the most common reason for treatment failure was criteria 1 (FiO2 > 40%) while intubation was higher for all infants but did not reach statistical significance.  Curiously what did reach a significant difference was criteria #4 (18.4% urgent intubations in the CPAP group vs 5.6% in the HFNC group). You might be tempted to therefore ponder which is worse, a little O2 or being intubated but you need to recall the trial design which was set up to provide this kind of result.  If you failed HFNC you were placed on CPAP whereas if you failed CPAP you were intubated.  In the HFNC group, 78 infants were deemed to have failed but 28 of them were in fact “rescued by CPAP”.  It therefore isn’t a fair comparison when it comes to urgent intubation since if you failed CPAP there wasn’t another option. Not a total loss Nasal trauma was indeed much lower in the HFNC group, occurring only 8.3% vs 18.5% of the time with CPAP.  Pneumothorax was also found to be significantly different with none of the patients in the HFNC group having that complication vs 2.1% in the CPAP group.  What this study tells us is that as a primary modality to treat newborns with RDS who have not received surfactant it is preferable to use CPAP in the first 72 hours.  Some of you may say it might not say that at all but consider the impact of having more babies exposed to high FiO2.  We know from other studies that high FiO2 can be quite damaging to preterm infants and this study was certainly not powered to look at all those important outcomes such as ROP, PVL and BPD.  The authors report them and found no difference but without adequate power to show a difference I wouldn’t take much comfort in those findings. I think were things may settle out though is what to do in more mature infants.  There is no question that for those on chronic respiratory support there is some risk of nasal breakdown.  Although I don’t have much experience with HFNC I would think that for the older patient who either already has BPD at 36 weeks or is close to that point but reliant on +4 or +5 CPAP that HFNC might help “give them a break”.  As such I don’t see this as a total loss but rather an option to try when CPAP for whatever reason is not tolerated. As a primary therapy for non-invasive management RDS I will keep my CPAP for all babies thank you.

AllThingsNeonatal

AllThingsNeonatal

 

Informed Refusal at 22 weeks

While we draw the line at 22 5/7 weeks for offering active resuscitation where I work, what does one do when the family requests resuscitation prior to that point.  While I am a clear fan of social media, one consequence of having such widely available information at our fingertips is that families may already know before you come to speak with them that were they only to have been born in another place like Montreal, the cutoff would have been lower.  When faced with such demands what does one do?  Well, in the case of my own experience it was to give in to the demands of the parents.  While I certainly discourage such heroic attempts, what is one to say when the family having received your opinion states “I want everything done”.  Informed consent is a tricky one in that if you approach a family for informed consent and they refuse to accept your desired direction of care where does that leave you?  It leaves you with informed refusal and if we are being fair to our families we have to accept that informed refusal is just as important as informed consent. Nothing New? The truth is informed refusal has been recognized as being critically important to decisions in patient care for many years.  Previous papers on the subject include a nice review by Ridley DT, Informed consent, informed refusal, informed choice–what is it that makes a patient’s medical treatment decisions informed?  What this really comes down to is a patient’s right to personal autonomy and self determination.  Does a parent in this case have the right to do what they want even in the face of dismal odds?  Furthermore where are we placing the importance of values?  Is it physician or patient centric?  In the physician centric world, after we impart our experience and wisdom we expect the patient to generally follow through with what we are steering them towards in cases such as this.  Informed consent of course is meant to be free of coercion but let’s face it, when we truly believe something is fairly futile are we honestly playing an impartial role or using our tone, body language and choice of words to direct families down the path that fits with our own beliefs and values?  I would offer that in most cases when we seek informed consent what we are really doing is seeking to pass along the justification for what we are wanting to do and then moving forward once obtained. What do we do though when after hearing the pros and cons the family still opts to move forward and worse yet is in disagreement with our preferred plan.  Well there you arrive at informed refusal.  If after hearing our best transfer of information the family still wants to proceed what does one do?  As a physician if I believe something is completely futile and I find myself in this position then I am truly at fault.  Seeking informed consent in this situation was completely inappropriate.  One should have simply said there is nothing that can be done. The Montreal Example Getting back to the example that started this piece, if a family knows that there are places in Canada (or let’s be honest, if I know there are survivors in Canada at 22 weeks) that resuscitate and have survivors then it isn’t really futile is it.  I know many of you would say “but the odds are so stacked against the baby” and “they don’t know what they are getting themselves into” but what does one say in this circumstance when despite your best attempts the family still wants to resuscitate? Therein lies the challenge.  If we approach this as an opportunity for informed consent we need to accept that we may find ourselves face to face with “informed refusal”.  Now I need to be careful here.  I am not advocating a wide open optimistic approach to resuscitation at 22 weeks.  What I am suggesting though is that if you find yourself coming into a unit somewhere in the next few months and find yourselves looking at a 22 week infant don’t jump to conclusions!  Did the family despite all the warnings want this?  Don’t leap to the thought that the Neonatologist is pushing for this but rather it may indeed be a case of a family advocating for their child against all odds.  It may not be something that we agree with in many cases but are we thinking from the perspective of the family or our own value system?

AllThingsNeonatal

AllThingsNeonatal

 

Hold Their Hand

Each day the number of people following these sites grows and at the time of this post, the largest following on Facebook has over 8200 people who receive the feed on a daily basis.  That is nothing short of remarkable and I hope that each of you gets something out of my writings and postings. I recognise that each post may not “light it up” in your mind but if you get at least a few “a ha” moments along the way then I am very happy that you have found these sites! What This Is Not! As I begin hinting at money, many of you may be thinking “here we go”, he is finally asking for some payment for this site!  To be clear I have no interest in personal financial gain from this hobby I have developed, but rather find my joy in sharing ideas, getting your feedback and helping to generate interest overall in topics pertaining to Neonatology.  I have no intention of ever asking for such payment but that doesn’t mean that I might not want to help someone else.  For those of you who make philanthropy a part of your lives you will know the joy that comes from helping others.  Being able to help others need not take tremendous dollars per donor when you have many people banding together to help a cause.  This is the power that I am hoping to harness through this initiative and make a difference in care to our babies in hospital. For the past year and a half, I have put my fingers to the keyboard to hopefully share my knowledge and expertise with you about an industry I am so passionate about. My Philanthropic Side When I am not busy finding content for the sites or being a Neonatologist, I am quite dedicated to philanthropy. One thing people may not realise about our province/country is that the government helps out the best they can financially but with the heavy demands of our province, they can’t meet all the needs. That’s why I’m proud of my partnership with the Children’s Hospital Foundation of Manitoba. The Foundation’s donors have helped bridge the gap so our hospital doesn’t go without the specialised items they need. From ultrasounds, starting a breast milk depot, specialised pediatric equipment and funding a position to support Quality Improvement in our unit to a soon to be announced Family Support coordinator position and so much more. But now, I turn to you to help us make the next difference in our unit. The other day as the Facebook page hit 8,000 followers a thought struck me. What if I asked everyone on the page to just give $1 towards the purchase of a piece of equipment for babies in our units? Hold Their Hand In the Neonatal Intensive Care Unit (NICU), they are watched closely to make sure they are getting the right balance of fluids and nutrition. Incubators or special warmers help babies maintain their body temperature. This reduces the energy the babies have to use to stay warm and allow them to use that energy elsewhere. Premature babies need to receive good nutrition so they grow at a rate close to that of babies still inside the womb. Babies born under 38 weeks have different nutritional needs than babies born at full term (after 38 weeks). They often have problems feeding from a bottle or a breast. This is because they are not yet mature enough to coordinate sucking, breathing, and swallowing. Many NICUs will give donor milk from a milk bank to high-risk babies who cannot get enough milk from their own mother. But because the baby must be kept at a certain temperature to stay warm, so does their milk.  Thanks to the generous support of donors to the Children’s Hospital Foundation of Manitoba, 12 milk warmers have been purchased. However, we need 24 more warmers to keep up with demand. Each one costs $2,000 and will make a huge impact. An impact to help our babies get the nutrition they need at the temperature they require to survive and thrive. So let’s hold their hand and let’s do it together! Has this journey of learning been worth at least $1 to you?  If it has, then please help make a difference by giving at least $1.  Giving more will only increase the power of this campaign!  If you aren’t able to donate $1 or more, I ask that you share this post and challenge your friends to help make a difference to the over 1,000 patients we see a year. Click the link below to donate and make your difference today. chfm.convio.net/help-hold-their-hand

AllThingsNeonatal

AllThingsNeonatal

 

Could this be the perfect home apnea monitor?

A question that we are asked from time to time is whether a home apnea monitor should be purchased after discharge from the hospital.  The typical parent is one who has experienced the ups and downs of apnea of prematurity and is faced with the disturbing notion of coming off monitors and going home.  “What if he has an event at home and I don’t know”?  This leads to a search on the web for home monitors which finds numerous options to choose from.  This is where things get interesting from a North American perspective. In the two centres I have worked at in Canada our answer to such a question is to save your money and not buy one.  Contrast this with two families I know in the US who were sent home by the hospital with home apnea monitors.  How can the advice between the two nations be so different?  I suspect the great risk of a lawsuit in the US is responsible at least in part but it may have to do with risk tolerance as well. What does the evidence say? First off, one might surmise that the use of a home apnea monitor helps hospitals move patients to the home faster than those centres that don’t prescribe them.  A 2001 Cochrane systematic review on the subject noted that this was not the case and determined that out of nearly 15000 neonates studied the greatest predictor of sending such babies home on monitors was physician preference. In the largest home monitoring study of its kind, the Collaborative Home Infant Monitoring Evaluation (CHIME) demonstrated some very important information.  First off, ex-preterm infants have events and some of them quite significant after discharge.  What the study which followed discharged infants at risk of SIDS in the home environment found though was that term infants also have events although less severe.  Does this mean that everyone should run out and buy such monitoring equipment though?  No!  The main reason was that while the study did show that events may continue after discharge, it failed to show that these events had any relation to SIDS.  The apneic events noted in hospital disappeared long before the arrival of a risk for SIDS.  They really are separate entities. The other issue with such monitors pertains to false alarms which can lead to sleepless nights, anxiety in parents and eventual abandonment of such technology.  This led the AAP in 2005 to declare that they did not endorse such practice.  Having said that, it is clear from my own experience with two US ex-preterm infants that this practice remains alive and well. Could this be the solution? One of my followers sent me this tonight and I have to say at the very least I am intrigued.  The device is called the Owlet and was featured in this article  The Sock That Could Save Your Babies Life.  Watch the video here. This monitor has me a little excited as it brings the home apnea monitor into the modern era with smart phone connectivity and at the same time helps the developers of this technology use data collected every two seconds to get a clearer picture on breathing patterns in infants that have been sent home.  The saturation monitor in a sock is at the core of this technology which is meant to keep the probe in a relatively stable location.  It brings another angle to the concept of wearable tech!    What I find most interesting is the claim by the manufacturer that the device has a false alarm rate similar to that of a hospital saturation probe which would make it quite reliable. I note though that the product has not received FDA approval yet (at least on the source I looked at) but is being worked on.  The challenge though is whether this will truly make a difference.  It may well have an excellent detection rate and it may in fact detect true apnea leading to bradycardia and cyanosis.  What it won’t do though is change the natural history of these events once home.  It may capture them very well but I suspect the four events that the mother in the video describes may have been self resolving if she hadn’t intervened.  We know from the CHIME study that the events seen in the home did not lead to death from SIDS so I see no reason why these would be different. Is it useless? I suppose that depends on your perspective.  From a data collection point, obtaining data every two seconds in a cloud based storage environment will allow this company to describe the natural history of respiratory patterns in ex-preterm infants better than I suspect has ever been done before.  From a population standpoint I suppose that is something!  At an individual level I suppose it depends on your strength of “needing to know”.  This may well be the best monitor out there and it may one day be the most reliable.  Will it save your baby’s life?  I doubt it but might it give you piece of mind if it false alarms very infrequently?  I think it just might but based on the low likelihood of it changing the outcome of your baby you won’t see me recommending it.  If I come across one make no mistake about it, I will want to play with it myself!

AllThingsNeonatal

AllThingsNeonatal

 

Walk but don’t run to reduce apnea of prematurity

Now that I have caught your attention it is only fair that I explain what I mean by such an absurd title.  If you work with preterm infants, you have dealt with apnea of prematurity.  If you have, then you also have had to manage such infants who seemingly are resistant to everything other than being ventilated.  We have all seen them.  Due to increasing events someone gives a load of methylxanthine and then starts maintenance.  After a couple days a miniload is given and the dose increased with the cycle repeating itself until nCPAP or some other non-invasive modality is started.  Finally, after admitting defeat due to persistent episodes of apnea and/or bradycardia, the patient is intubated.  This, in the absence of some other cause for apnea such as sepsis or seizures is the methylxanthine resistant preterm infant.  Seemingly no amount of treatment will amount to a reduction in events and then there is only so much that CPAP can do to help. What Next? Other strategies have been attempted to deal with such infants but sadly none have really stood the test of time.  Breathing carbon dioxide might make sense as we humans tend to breathe quickly to excrete rising CO2 but in neonates while such a response occurs it does not last and is inferior to methylxanthine therapy.  Doxapram was used in the past and continues to be used in Europe but concerns over impacts on neurodevelopment have been a barrier in North America for some time.  Stimulating infants through a variety of methods has been tried but the downside to using for example a vibrating mattress is that sleep could be interfered with and there are no doubt impacts to the preterm infant of having weeks of disturbed sleep states on developmental outcomes. What if we could make our preterm infants walk? This of course isn’t physically practical but two researchers have explored this question by using vibration at proprioceptors in the hand and foot.  Such stimulation may simulate limb movement and trick the brain into thinking that the infant is walking or running.  Why would we do this?.  It has been known for 40 years that movement of limbs as in walking triggers a respiratory stimulatory effect by increasing breathing.  This has been shown in adults but not in infants but this possibility is the basis of a study carried out in California entitled Neuromodulation of Limb Propriceptive Afferents Decreases Apnea of Prematurity and Accompanying Intermittent Hypoxia and Bradycardia.  This was a small pilot study enrolling 19 patients of which 15 had analyzable data.  The design was that of alternating individual preterm infants born between 23 – 35 weeks to receive either vibratory stimulation or nothing and measuring the number and extent of apnea and bradycardia over these four periods.  In essence this was a proof of concept study. The stimulation is likened to that felt when a cell phone vibrates as this was the size of device used to generate the sensation.  The authors note that during the periods of stimulation the nurses noted no signs of any infant waking or seeming to be disturbed by the sensation.  The results were quite interesting especially when noting that 80% of the infants were on caffeine during the time of the study so these were mostly babies already receiving some degree of stimulation Should we run out and buy these? The stimulation does appear to work but with any small study we need to be careful in saying with confidence that this would work in a much larger sample.  Could there have been some other factor affecting the results?  Absolutely but the results nonetheless do raise an eyebrow.  One thing missing from the study that I hope would be done in a larger sample next time is an EEG.  The authors are speculating that by placing the vibration over the hand and foot the brain is perceiving the signal as limb movement but it would have been nice to see the motor areas of the brain “lighting up” during such stimulation.  As we don’t have that I am left wondering if the vibration was simply a form of mild noxious stimulus that led to these results.  Of course in the end maybe it doesn’t matter if the results show improvement but an EEG could also inform us about the quality of sleep rather than relying on nursing report of how they thought the baby tolerated the stimulus.  I know our nursing colleagues are phenomenal but can they really discern between quiet and active sleep cycles?  Maybe some but I would guess most not.  There will also be the naysayers out there that will question safety.  While we may not perceive a gentle vibration as being harmful, with such a small number of patients can we say that with certainty?  I am on the side of believing it is probably insignificant but then again I tend to see the world through rose coloured glasses. Regardless of the filter through which you view this world of ours I have to say I am quite excited to see where this goes.  Now we just have to figure out how to manage the “real estate” of our infant’s skin as we keep adding more and more probes that need a hand or a foot for placement!

AllThingsNeonatal

AllThingsNeonatal

 

Can Parental Administered Physiotherapy Lead to Better Outcome in Preemies?

Posted on August 10, 2016 by winnineo I don’t know about your place of work but our centre is busy and by busy I mean our resources and staff are almost always working at full capacity.  There is a shift afoot though in modern Neonatal care to shift some of the responsibility for care to the parents.  You might say it always should have been this way but as with any speciality we grow, learn and evolve over time. The most recent stage of evolution is the development of the FiCare philosophy.  This is not the first time (and likely not the last) that I will reference this strategy.  For more information on what it is and what it takes to practice this concept you can click on the FiCare website from Mt. Sinai Hospital in Toronto here.  The gist of it though is that with education and support from nursing in particular some of the traditional functions that are carried out by health care staff can be transferred to the parents.  Something as basic as identifying their baby can be a start with progression to providing part of the daily report, participating in handling of their infant during times of stress and performing skin to skin care for many hours a day.  The parents are asked to commit to a significant number of hours per day to make this work and the benefits of having close contact are obvious as well. Can Physiotherapy Be Taught To Parents? As someone who has been involved in the FiCare project I took particular interest in an article this past month which in essence is related to the teachings of FiCare.  T. Ustad from Norway and colleagues published the following Early Parent-Administered Physical Therapy for Preterm Infants: A Randomized Controlled Trial.  As someone who values the contribution of our physiotherapists I was curious as to what could be transferred given the demands on an individual PT’s time.  Add to this that during surges when many babies under 29 weeks are born and the number of patients they need to see may become overwhelming.  What if parents though could take over some of this workload?  Well that is what they did in three centres in Norway in a RCT single blinded intervention. What did they do? All babies were born < 32 weeks and underwent the intervention between 34 – 36 weeks with final evaluation at 37 week.  Parents were taught to perform 10 minutes of manipulation with the goal of improving postural control, head control, and midline orientation.  Teaching was done through videos, photos, booklets and direct teaching by the PT on day 1 and then on day 2 return demonstration with correction by the PT occurred. It was single blinded in that the parent and the PT who did the teaching knew of course which baby received what treatment but the PT doing the standardized evaluation after the two week period was over was blind to treatment assignment.  The authors used the TIMP scoring system for spontaneous movements which as it can take up to 30 minutes in some cases may stress the infants so for those a scoring system consisting of half the items was developed called the TIMPSI.  This has beee shown previously to correlate well with the larger more involved test. Sample size calculations were based on finding a difference at 2 years of 0.5 SD between groups which meant they needed 63 infants to show such a difference. They enrolled 153 but after some withdrew the groups were 63 in the intervention and 76 in conventional care. On to the results Just so we are clear, this was only designed to be a two week intervention but it was meant to be twice daily for ten minutes at a time.  Graphically, using thez-scores for the TIMP scores we have the following graph.  Clicking on the highlighted link will tell you more about z-scores but it measures simply how many standard deviations above or below a population mean a score is. So in this case the absolute difference after the two week period with evaluation one week later is 0.42.  This falls short of the 0.5 at two years the sample size calculation was looking for.  As with many differences in outcome the results tend to improve with time.  Think about the CAP study as an example in which those babies who received caffeine initially had better developmental outcome measures than those who did not but by school age there was no longer a differenced. If the difference is less then one needs many more patients to show a difference than the original sample size would allow.  In the end one also needs to think about whether the difference in scores is of statistical interest or if it has true clinical impact. Some things to consider though The parents in the intervention group did keep a journal and what they actually did was not what was designed in the study. The average number of sessions per day was only 1.3 with a length of 9 minutes per session.  The goals again were 2 for 10 minutes each.  The second thing to think about is that by looking at the difference in results from this short intervention it is an exciting mental exercise to think about a couple things.  The first is what might the differences look like if the families had been able to do two sessions each per day instead of being closer to 1.  The extra minute may not have made such a difference but the extra session might have. The next thing to consider is how short a time period this really was.  What if the plan had been rather than only two weeks, providing the intervention till discharge which for some born at 24 weeks might have been a corrected age at 40 – 44 weeks when they finally went home.  Would a much longer exposure have made a bigger difference? It is always fun to speculate and while I cautioned that the difference seen at two years may narrow further I wonder what the impact on the families will be after the intervention and post discharge.  They were taught a new set of techniques to support motor development.  Would they simply revert back to the control group afterwards or informally continue on which is what I suspect to some degree they would.  The log book doesn’t count the impact of these “extra sessions”.  The authors plan an interim analysis along the way so that will be interesting to see. What the study does show though and what I think is exciting is that it is not just nursing that can transfer some functions to parents.  Clearly the parents in this study learned something about handling of patients from the perspective of a PT.  I would hope that this study might inspire PTs and other disciplines as the FiCARE approach widens to consider equipping parents with some of their skills sets that are traditionally owned by those specialties alone.  What we are discovering with time is that parents are capable of doing more than we have had them do in the past.  To make it family centred care truly make them part of the team!

AllThingsNeonatal

AllThingsNeonatal

 

The Art of Doing Nothing

There may be nothing that is harder in medicine.  We are trained to respond to changes in patients condition with a response that more often than not suggests a new treatment or change in management.  Sometimes the best thing for the patient is in fact to do nothing or at least resist a dramatic response to the issue in front of you.  This may be the most common issue facing the new trainee who is undoubtedly biased towards doing something.  Take for instance the situation in which the trainee who is new to the service finding out that their 26 week infant has a PDA.  Their mind races as they digest this information from morning signover.  There is less than 2 hours until they come face to face with their attending who no doubt will ask them the dreaded question.  “What are you going to do about it?”.  When having to choose a path, if they state “I want to sit tight and watch” they fear the thought of the attending thinking they don’t know what to do. Conversely they could stick their neck out and choose to treat with a variety of approaches but then might they be seen as too aggressive?!  The likely path is suggesting treatment but in fact the more I think about it the option of benign neglect may be the best approach or at least one in which if you treat and it doesn’t work the first time you just shrug your shoulders and say “I’ll deal with it till it closes on it’s own”. This post really is a follow-up to a previous one entitled The Pesky PDA.  A Puzzle After All These Years.  What triggered this writing was another before and after comparison of two periods in which the management of PDAs for a unit took a 180 degree turn. Know When to Hold Em And No When to Fold Em This is the essence of the issue for one unit.  Sung SI et al published a paper this month entitled Mandatory Closure Versus Nonintervention for Patent Ductus Arteriosus in Very Preterm Infants.  They describe a before and after comparison of 81 infants from 2009-11 and 97 infants from 2012-14.  All babies were born between 23-26 weeks gestational age.  In the first time period their unit had a mandatory PDA closure policy.  That is they gave one course of indomethacin and if possible a second course followed by surgical ligation.  A significant PDA was defined as one that had a left to right shunt and was at least 2 mm in diameter and the patient had to be ventilated.  Any patient who had been extubated regardless of need for CPAP did not have to have their PDA closed.  In the second time period the group attempted to avoid indomethacin and ligation at all costs and in fact in this cohort none received either. So What Happened? In the first time period 52 (64%) received indomethacin but only 29% responded and a full 37/52 (71%) went on to receive surgical ligation.  Of the 29 that did not receive indomethacin due to contraindications they underwent primary ligation for a total of 82% receiving surgical ligation.  The average day of closure for period 1 was 12.9 days. In period 2 a number of interesting findings occurred. The average day of closure was at 44.2 days.  Five infants were discharged with a PDA with 3 experiencing spontaneous closure after discharge and the remaining infants undergoing transcatheter occlusion.  In period 2 there were more diuretics and fluid restriction employed.  Comparing the two periods for a number of other outcomes reveals some other intriguing findings. Even with such differing approaches there is no difference in mortality, severe IVH, ROP, PVL, NEC or sepsis.  What is different though is the diagnosis of BPD yet there is no difference in total ventilation. In period 2 there is a shift towards more of this ventilation being HFOV less CPAP use at the same time. What Might It All Mean? It is retrospective and therefore we cannot be certain that there are not other variables that are not affecting the results that would have had a better chance of being evened out in an RCT.  Having said that it is intriguing that having a PDA has been associated with BPD in the past but in this study having a PDA for a longer time is associated with a reduction in BPD.  We know that longer periods of invasive mechanical ventilation increase the risk of developing BPD so it is intriguing that that there is no difference in mechanical ventilation yet there is more BPD when you are aggressive with the PDA.  You might postulate that the need for surgery leads to greater need for ventilatory support and therefore damages the lungs but the needs for HFOV was higher in the second phase which at least hints that in terms of aggressiveness, Period 2 infants had a tougher go. The culprit may be the heart.  In period 1 there was a significantly increased rate of myocardial dysfunction and need for inotropes following ligation.  It could well be that left ventricular dysfunction led to pulmonary edema such that in the 24-28 hours after the surgery ventilator requirements were increased and damaged the lung.  The lack of a difference in overall ventilation days supports this possibility.  Looking at the other common risk factors for BPD such as chorioamnionitis and lack of antenatal steroids these are no different between groups.  Although not statistically significant there are more male infants in period 2 which would usually tip the scales towards worse outcome as well.  It does need to be stressed as well that the rate of surgical ligation is higher than any study I have come across so the contribution of the surgery itself to the disparate outcome needs to be seriously considered. What would I do? Despite this study and some others that have preceded it I am not at the point of saying we shouldn’t treat at all.  Our own approach is to give prophylactic indomethacin to such babies and then for the most part if a PDA remains treat one more time but at all costs try and avoid ligation.  An RCT sounds like it is in the works though comparing the two approaches so that will certainly be interesting to see.  It is tough to say what the future holds but to any young trainees who are reading this, the next time you are asked what to do about a PDA you are well within your rights to suggest “Maybe we should do nothing”!

AllThingsNeonatal

AllThingsNeonatal

 

When should blood be given prior to surgery?

A 28 week preterm infant now two weeks of age develops bilious emesis and abdominal distension.  An x-ray reveals an intestinal perforation and surgery is consulted. Arrangements are made to go to the operating room for a laparotomy and due to apnea and hypotension the baby is both intubated and placed on dopamine.  The resident on service ensures that blood is available in the operating room and an hour after presentation the baby is found to have a HgB of 102 g/L with a HcT of 35%. I don’t know about you but if I am then asked whether we should give blood now or in the OR I might say at that level with the degree of illness to give blood or I might say wait till the baby gets to the OR if perhaps they were fairly stable on the support.  You the reader might be more convinced of your actions but if I manipulate the numbers a little bit to say 105 g/l and HcT of 37% might you feel different?  What about 110 g/L and 39%?  You get the picture.  Where is that magic cutoff where we say prior to an OR that a baby needs blood or can wait?  In our heads of course we conjure up the equation for delivery of O2 to tissues Cardiac output X (1.39 X HgB X Sat +0.003*pO2) and realize that the delivery of oxygen is critically dependent on HgB level but how much is enough?  The truth is I don’t think we really know but we do a good job of coming up with some markers such as lactate or more recently near infrared spectroscopy to give us an idea of how much O2 the tissues are seeing. How much HgB does a baby need before surgery? Although this may seem like something that is well known, the truth is we don’t really know.  We may have an inkling though based on a recent paper entitled Association of Preoperative Anemia With Postoperative Mortality in Neonates by S. Goobie et al. They performed a retrospective review of a US surgical quality database to examine mortality after operations and identified 2764 neonates out of 114395 children who underwent surgery.  Similar to previous studies the neonatal postoperative mortality rate was higher at 3.4% than the rest of childhood at 0.6%.  When examining the effect of low hematocrit prior to surgery they further identified a cutoff of 40% below which the risk of mortality increased.  Of the neonatal group that survived 31% had a preop hematocrit of 40% or more while of those who died 72% had a hematocrit < 40%. Hematocrit was not the only factor predicting mortality though as ASA class 3 – 5 (an anesthesiology risk score where these scores indicate severe systemic disease or emergencies), weight < 2 kg, preoperative ventilation and inotropic support.  Put simply, sicker small patients have worse outcomes which I suppose should not surprise anyone. So how do we interpret this data? One important point that this article does not control for is the specific type of condition that the patient had.  Clearly all conditions of the newborn are not the same as for example an umbilical flap closure of gastroschisis compared to fulminant necrotizing enterocolitis.  The authors do try and control somewhat for this by demonstrating that the ASA categories demonstrate if you have severe systemic disease you are worse off but where does this leave the hematocrit?  The other possible explanation is that the anemia is simply a reflection of the critical nature of the patient.  Sicker patients are more likely to be anemic and also patients who present later are as well.  A baby needing a colostomy for a bowel obstruction diagnosed after birth is likely to have low risk of mortality and also have a normal HgB.  Contrast this with the baby who develops NEC at 3 weeks of age who is likely anemic or close to being so when they present and in the presence of shock and DIC becomes even more so.    Is the low HcT just a proxy for severity of disease? I suspect for the otherwise well infant who is electively intubated for surgery, having a hematocrit alone below 40% is not dangerous.  What do we do though with the baby who is on inotropes for example.  To truly answer this question we need a randomized controlled trial comparing transfusing patients with a hematocrit below 40% vs choosing a higher threshold of say 50% to say whether it makes a difference.  That doesn’t help us though in the here and now.  This gold standard for studies won’t tell me what to do for a few years but right now I have to decide what to do for a patient in front of me. Not everyone may agree with me on this but I think in such circumstances I would transfuse based on this publications results.  To the naysayers out there I would suggest that whether I choose to give the blood or not before the operation, they will be getting it after they enter the OR.  Why not give them a boost before they undergo the knife?  It is not a question of whether they will be transfused or not it is a difference in time. If I have the chance I will “top them up” but what will you do?  

AllThingsNeonatal

AllThingsNeonatal

 

IV Intermittent Flushing or Continuous Infusions. Which is better for longevity?

As with many things in Neonatology, changes in practice come and go.  Such is the case with how best to manage an IV.  During my career I have seen advocates for both continuous infusions and intermittent flushing.  Sometimes with heparin and at other times none.  The issue at hand is how best to preserve the precious IV.  Based on opinion only I would have said that having a continuous flow through a plastic catheter should help avoid clot formation and prolong the life of an IV but what is the actual evidence to support one method or the other. Why might flushing be better? Clotting may not be the biggest issue to contend with.  When I think about the IVs that are “lost” I am more commonly approached by nurses with concerns that the site is looking “red” and ultimately becomes indurated as the catheter extravasates.  Far less common, is a concern that the catheter has simply obstructed or is reading high resistance these days.  While we flush IVs with isotonic saline, infusions of dextrose are both hypotonic and acidic which may lead to endothelial damage.  In theory then phlebitis should be lessened with intermittent flushes but could blockage due to clots still be an issue if there is no flow at the tip and lumen of the catheter? What does the evidence show? In 2012 Perez A et al looked at this in their paper Intermittent flushing improves cannula patency compared to continuous infusion for peripherally inserted venous catheters in newborns: results from a prospective observational study. As with the few recent papers out there on the subject, the study was small and performed over one year as an observational cohort. Out of 53 patients with 86 cannula insertions 25 had continuous dextrose infusions vs 28 who received at least one flush with NS per day.  The findings in this study were that the mean cannula patency was 62.1 hr in the continuous group vs 92.8 hrs in the flushing group.  Given the size of the study it might not be too surprising that practice did not change but that is where a more recent study may add some strength. A more recent paper by Stok and Wieringa adds to this discussion by looking exclusively at the use for durations of antibiotics (Continuous infusion versus intermittent flushing: maintaining peripheral intravenous access in newborn infants).  As with the previous study this was an observational cohort in which a shift in practice occurred from use of continuous 5% dextrose infusions to flushing six times per day with NS through a 24 gauge IV.  The primary outcome was duration of catheter patency but several other important outcomes were followed as well in particular the time required by nursing to deal with IV issues. A total of 115 newborns were recruited with 98 completing the analysis after excluding some patients.  Of these newborns 71 fell into the continuous infusion vs 62 cannulas in the flushing cohort.  Interestingly the main outcome was found to be no different between groups (55.42 hrs flushing vs 57.48 hrs continuous) regardless of placement site.  Also interesting is that the median number of cannula placements were no different as well. With respect to complications the results indicate that this is more of an issue with continuous infusions and is shown in the table below.  The differences in complication rates were significant between the two groups.  Consistent with endothelial damage being more common from dextrose infusions, the incidence of phlebitis and infiltration were both higher in the continuous group.  Arguably this was not a blinded study so the diagnosis of phlebitis could be subject to bias but infiltration should have been more objective. The amount of time nursing spent addressing IV related activities was significantly shorter with 8.8 minutes per shift vs 5.5 minutes in the continuous vs flushing groups respectively.  Statistically significant but perhaps not that clinically relevant.  Then again the extra three minutes of aggravation might be quite significant! Finally, it may be surprising that the length of IV patency was no different between the groups but the majority of the IVs were utilized for less than 48 hours so one can only speculate what would have happened if a different target population was looked at such as babies being treated with peripheral IVs for 7 days of antibiotics as an example.  Given the differing rates of complications I would think that with longer use a difference in mean durations of patency would in fact present itself. What does the future hold? This is hard to say.  Opinions run strong on this topic with most members of the medical team favouring continuous infusions as they “don’t want to lose the IV”.  I suspect the way to truly look at this will not be through a randomized trial but rather a quality project in which a formal PDSA cycle is utilized to first collect our own numbers and then implement a formal change to using flushing only for those who only have an IV for antibiotics.  Certainly something to discuss with our group and perhaps your own.  If you have already done such a project and wish to share the results I would love to hear from you though!

AllThingsNeonatal

AllThingsNeonatal

 

At the Edge of Viability Does Every Day Count?

Preterm infants born between 22 to 25 weeks gestational age has been a topic covered in this blog before. Winnipeg hospital now resuscitating all infants at 22 weeks! A media led case of broken telephone. Is anything other than “perfect practice” acceptable for resuscitating infants from 22 – 25 weeks? Winnipeg Hospital About to Start Resuscitating Infants at 23 weeks! I think it is safe to say that this topic stirs up emotions on both sides of the argument of how aggressive to be when it comes to resuscitating some of these infants, particularly those at 22 and 23 weeks.  Where I work we have drawn a line at 23 weeks for active resuscitation but there are those that would point out the challenge of creating such a hard-line when the accuracy of dating a  pregnancy can be off by anywhere from 5 – 14 days.  Having said that, this is what we have decided after much deliberation and before entertaining anything further it is critical to determine how well these infants are doing not just in terms of survival but also in the long run.  In the next 6 months our first cohort should be coming up for their 18 month follow ups so this will be an informative time for sure. Do Days Matter? This is the subject of a short report out of Australia by Schindler T et al.  In this communication they looked at the survival alone for preterm infants in a larger study but broke them down into 3 and four-day periods from 23  to 25 weeks as shown below. The asterisk over the two bars means that the improvement in survival was statistically significant between being born in the last half of the preceding week and the first half of the next week. In this study in other words days make a difference.  A word of caution is needed here though.  When you look at the variation in survival in each category one sees that while the means are statistically different the error bars show some overlap with the previous half week.  At a population level we are able to say that for the average late 23 week infant survival is expected to be about 30% in this study and about 55% at 24 +0-3 days.  What do you say to the individual parent though?  I am not suggesting that this information is useless as it serves to provide us with an average estimate of outcome.  It also is important I believe in that it suggests that dating on average is fairly accurate.  Yes the dates may be off for an individual by 5 – 14 days but overall when you group everyone together when a pregnancy is dated it is reasonably accurate for the population. Don’t become a slave to the number The goal of this post is to remind everyone that while these numbers are important for looking at average outcomes they do not provide strict guidance for outcome at the individual level.  For an individual, the prenatal history including maternal nutrition, receipt of antenatal steroids, timing of pregnancy dating and weight of the fetus are just some of the factors that may lead us to be more or less optimistic about the chances for a fetus.  Any decisions to either pursue or forego treatment should be based on conversations with families taking into account all factors that are pertinent to the decision for that family.  Age is just a number as people say and I worry that a graph such as the one above that is certainly interesting may be used by some to sway families one way or another based on whether the clock has turned past 12 AM.  At 23 weeks 3 days and 23 hours do we really think that the patient is that much better off than at 24 weeks 4 days and 1 hour?

AllThingsNeonatal

AllThingsNeonatal

 

No more intubating for meconium? Not quite.

After the recent CPS meeting I had a chance to meet with an Obstetrical colleague and old friend in Nova Scotia.  It is easy to get lost in the beauty of the surroundings which we did. Hard to think about Neonatology when visits to places like Peggy’s Cove are possible. Given out mutual interest though in newborns our our conversation eventually meandered along the subject of the new NRP.  What impact would the new recommendations with respect to meconium have on the requirements for providers at a delivery.  This question gave me reason to pause as I work in a level III centre and with that lens tend to have a very different perspective than those who work in level I and II centres (I know we don’t label them as such anymore but for many of you that has some meaning).  Every delivery that is deemed high risk in our tertiary centre has ready access to those who can intubate so the changes in recommendations don’t really affect our staffing to any great degree.  What if you are in a centre where the Pediatrician needs to be called in from home?  Do you still have to call in people to prepare for a pending delivery of a baby through meconium stained fluid?   What does the new recommendation actually say? These recommendations are from the American Heart Association and are being adopted by the NRP committees in the US and Canada.  The roll-out for this change is coming this fall with all courses required to teach the new requirements as of September 2017. “However, if the infant born through meconium-stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice. (Class IIb, LOE C-LD)“ The rationale for the change is that is that there is a lack of evidence to demonstrate that routine suctioning will reduce the incidence of meconium aspiration syndrome and its consequences.  Rather priority is placed on the establishment of adequate FRC and ventilation thereby placing a priority on teaching of proper bag-valve mask or t-piece resuscitator.  Better to establish ventilation than delay while atempting to intubate and run the risk of further hypoxia and hypercarbia causing pulmonary hypertension. Does this mean you don’t need to have a person skilled in intubation at such deliveries? This question is the real reason for the post.  At least from my standpoint the answer is that you do in fact still require such people.  This may seem to be in conflict with the new position but if you move past that recommendation above you will see there is another line that follows afterwards that is the basis for my argument. “Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each individual infant. This may include intubation and suction if the airway is obstructed.” While we should not routinely perform such intubations there may be a time and a place.  If one has intiated PPV with a mask and is not obtaining a rising heart rate, MRSOPA should be followed and attempts made to optimize ventilation.  What if that is unsuccessful though and heart rate continues to be poor.  You could have a plug of meconium distal to the vocal cords and this is the reason that intubation should be considered.  In order to remove such a plug one would need to have an intubator present. Where do we go from here? As much as I would like to tell my colleague that he doesn’t need to have this skill set at a delivery for meconium I am afraid the skill still needs to be present.  It will be interesting to see how instructors roll this out and answer such questions.  It is a little concerning to me that in our world of wanting the “skinny” or “Coles’ Notes” version of things, the possibility of still needing the intubator on short notice may be lost.  Having someone on call who is only “5 minutes away” may seem to be alright but at 3 AM I assure you the 5 minutes will become 15 as the person is woken, dresses, gets to the car and parks.  Whether it is 5 or 15 minutes each centre needs to ask themselves if the baby is in need of urgent intubation are you willing to wait that amount of time for that to happen? I hope not.

AllThingsNeonatal

AllThingsNeonatal

 

A little cream may go a long way in reducing BPD

Breast milk has many benefits and seems to be in the health care news feeds almost daily.  As the evidence mounts for long term effects of the infant microbiome, more and more centres are insisting on providing human milk to their smallest infants.  Such provision significantly reduces the incidence of NEC, mortality and length of stay.  There is a trade-off though in that donor milk after processing loses some of it’s benefits in terms of nutritional density.  One such study demonstrated nutritional insufficiencies with 79% having a fat content < 4 g/dL, 56% having protein content< 1.5 g/dL, and 67% having an energy density < 67 kcal/dL (< 20 Kcal/oz).  It is for this reason that at least in our unit many infants on donor milk ultimately receive a combination of high fluid volumes, added beneprotein or cow’s milk powders to achieve adequate caloric intake.  Without such additions, growth failure ensues.  Such growth failure is not without consequence and will be the topic of a future post.  One significant concern however is that failure of our VLBW infants to grow will no doubt impact the timing of discharge as at least in our unit, babies less than 1700g are unlikely to be discharged.  With the seemingly endless stream of babies banging on the doors of the NICU to occupy a bed, any practice that leads to increasing lengths of stay will no doubt slow discharge and cause a swelling daily patient census. What if increasing volume was not an option? Such might be the case with a baby diagnosed with BPD.  Medical teams are often reluctant to increase volumes in these patients due to concerns of water retention increasing respiratory support and severity of the condition.  While diuretics have not been shown to be of long term benefit to BPD they continue to be used at times perhaps due to old habits or anecdotal experiences by team members of a baby who seemed to benefit.  Such use though is not without it’s complications as the need to monitor electrolytes means more needle sticks for these infants subjecting them to painful procedures that they truly don’t need.  Alternatively, another approach is to restrict fluids but this may lead to hunger or create little room to add enough nutrition again potentially compromising the long term health of such infants. Amy Hair and colleagues recently published the following study which takes a different approach to the problem Premature Infants 750–1,250 g Birth Weight Supplemented with a Novel Human Milk-Derived Cream Are Discharged Sooner This paper is essentially a study within a study.  Infants taking part in an RCT of Prolacta cream (Prolacta being the subject of a previous post) were randomized as well to a cream supplement vs no cream.  The cream had a caloric density of 2.5 Kcal/mL and was added to donor milk or mother’s own milk when the measured caloric density was less than 19 Kcal/oz.  The study was small (75 patients; control 37, cream 38) which should be stated upfront and as it was a secondary analysis of the parent study was not powered to detect a difference in length of stay but that was what was reported here.  The results for the groups overall were demonstrated an impact in length of stay and discharge with the results shown below.   Control  (N=37) Cream (N=38) p PDA ligation % 8.1 2.6 0.36 PDA treated medically % 27 29 0.85 Sepsis % 5.4 7.9 1 NEC% 0 0 – BPD% 32.4 23.7 0.4 Death % 0 0 – Length of stay, days 86+/-39 74+/-22 0.05 PMA at discharge, weeks 39.9+/-4.8 38.2+/-2.7 0.03 What about those with sensitivity to fluid? Before we go into that let me state clearly that this group comparison is REALLY SMALL (control with BPD=12 vs cream with BPD=9).  The results though are interesting.     BPD control (N=12) BPD cream N=9 p Length of stay, days 121 +/-49 104+/-23 0.08 PMA at discharge, weeks 44.2+/-6.1 41.3+/-2.7 0.08 So they did not reach statistical significance yet one can’t help but wonder what would have happened if the study had been larger or better yet the study was a prospective RCT examining the use of cream as a main outcome.  That of course is what no doubt will come with time.  I can’t help but think though that the results have biologic plausibility.  Providing better nutrition should lead to better growth, enhanced tissue repair and with it earlier readiness for discharge. One interesting point here is that the method that was used to calculate the caloric density of milk was found to overestimate the density by an average of 1.2 Kcal/oz when the method was compared to a gold standard.  Given that fortification with cream was only to be used if the caloric density of the milk fell below 19 Kcal/oz where average milk caloric density is 20 Kcal/oz there is the distinct possibility that the eligible infants for cream were underestimated.  Could some of the BPD be attributable to infants being significantly undernourished in the control group as they actually were receiving <19 Kcal/oz but not fortified?  Could the added fortification have led to faster recovery from BPD? Interesting question’s in need of answers.  I look forward to seeing where this goes.  I suspect that donor milk is not enough, adding a little cream may be needed for some infants especially those who have trouble tolerating cow’s milk fortification.

AllThingsNeonatal

AllThingsNeonatal

 

Parental stress in the NICU; effect of parental presence on rounds.

To many of you the answer is a resounding yes in that it reduces stress.  Why is that though?  Is it because you have had a personal experience that has been favourable, it is the practice in your unit or it just seems to make sense?  It might come as a surprise to you who have followed this blog for some time that I would even ask the question but a social media friend of mine Stefan Johansson who runs 99NICU sent an article my way on this topic. Having participated in the FiCare study I realised that  I have a bias in this area but was intrigued by the title of the paper.  The study is Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion by Abdel-Latif ME et al from New Zealand and was performed due to the lack of any RCTs on the subject specifically in the NICU. Before I go on though I have to disclose a few biases.  I love parents being on rounds so I can speak with them directly and have them ask me any questions they may have after hearing about their infants condition. Our unit encourages the practice. We are rolling out the principals of FiCare after being part of the study which encourages parental presence at the bedside for far more than just rounds.For information on implementing FiCare click here While this study is the only reported RCT on the subject in the NICU, the FiCare results will be published before long. What is the problem with having families on rounds? The detractors would say that sensitive information may be more difficult to discuss out in the open for fear that the family will take offence or be hurt.  Another concern may be that teaching will be affected as the attending may not want to discuss certain aspects of care in order to prevent creating fear in the parents or awkwardness in the event that the management overnight was not what they would have done.  Lastly, when patient volumes and acuity are high, having parents ask questions on rounds may lead to excessive duration of this process and lead to fatigue and frustration by all members of the team. So what does this study add? This particular study enrolled 72 families of which 63 completed the study.  The study required 60 families to have enough power to detect the difference in having parents on rounds or not.The design was interesting in that the randomisation was a cross over design in which the following applied.  One arm was having parents on rounds and the other without.  The unit standard at the time was to not have parents on rounds. ≤30 weeks 1 week in one arm, one week washout period then one week in the other arm >30 weeks 3 days in one arm, three day washout and then three days in the other arm The primary outcome was to see if there would be a significant difference in the Parental Stressor Scale.   Surprisingly there was no difference across any domains of measuring parental stress.  When we look at questions though pertaining to communication in the NICU we see some striking differences. The families see many benefits to the model of being on rounds.  They appear to have received more information, more contact with the team, contributed more to the planning of the course of their babies care and been able to ask more questions.  All of these things would seem to achieve the goals of having parents on rounds. So why aren’t parents less stressed? This to me is the most interesting part of this post.  The short answer is I am not sure but I have a few ideas.  The study could not be blinded.  If the standard of care in the unit was to not have parents on rounds, what kind of conversations happened after rounds?  Were staff supportive of the families or were they using language that had a glass is half empty feel to it?  Much like I am biased towards having parents on rounds and thanking them for their participation were there any negative comments that may have been unintentional thrown the families way. Is a little knowledge a dangerous thing?  Perhaps as families learn more details about the care of their baby it gives them more things to worry about.  Could the increase in knowledge while in some ways being pleasing to the family be offset by the concern that new questions raise. Was the intervention simply too short to detect a difference?  This may have been a very important contributor.  This short period of either a week or two leaves the study open to a significant risk that an event in either week could acutely increase stress levels.  What if the infant had to go back on a ventilator after failing CPAP, needed to be reloaded with caffeine or developed NEC?  With such short intervals one cannot say that while communication was better the parents were not stressed due to something unrelated to communication.  In an RCT these should balance out but in such a small study I see this as a significant risk. So where do we go from here? I applaud the authors for trying to objectively determine the effect of parental presence on rounds in the NICU.  Although I think they did an admirable job I believe the longer time frame of the FiCare study and the cluster randomised strategy using many Canadian centres will prove to be the better model to determine effectiveness.  What the study does highlight though in a very positive way is that communication is enhanced by having parents on rounds and to me that is a goal that is well worth the extra time that it may take to get through rounds.  Looking at it another way, we as the Neonatologists may need to spend less time discussing matters after rounds as we have taken care of it already.  In the end it may be the most efficient model around!

AllThingsNeonatal

AllThingsNeonatal

 

High Flow Nasal Cannula: Be Careful Out There

As the saying goes the devil is in the details.  For some years now many centres worldwide have been publishing trials pertaining to high flow nasal cannulae (HFNC) particularly as a weaning strategy for extubation.  The appeal is no doubt partly in the simplicity of the system and the perception that it is less invasive than CPAP.  Add to this that many centres have found less nasal breakdown with the implementation of HFNC as standard care and you can see where the popularity for this device has come from. This year a contact of mine Dominic Wilkinson@NeonatalEthics on twitter (if you don’t follow him I would advise having a look!) published the following cochrane review, High flow nasal cannula for respiratory support in preterm infants.  The review as with most cochrane systematic reviews is complete and comes to a variety of important conclusions based on 6 studies including 934 infants comparing use of HFNC to CPAP. 1.  No differences in the primary outcomes of death (typical RR 0.77, 95% CI 0.43 to 1.36; 5 studies, 896 infants) or CLD. 2.  After extubation to HFNC no difference in the rate of treatment failure(typical RR 1.21, 95% CI 0.95 to 1.55; 5 studies, 786 infants) or reintubation(typical RR 0.91, 95% CI 0.68 to 1.20; 6 studies, 934 infants). 3.  Infants randomised to HFNC had reduced nasal trauma (typical RR 0.64, 95% CI 0.51 to 0.79; typical risk difference (RD) -0.14, 95% CI -0.20 to -0.08; 4 studies, 645 infants). 4. Small reduction in the rate of pneumothorax (typical RR 0.35, 95% CI 0.11 to 1.06; typical RD -0.02, 95% CI -0.03 to -0.00; 5 studies 896 infants) in infants treated with HFNC but the RR crosses one so this may be a trend at best. If one was to do a quick search for the evidence and found this review with these findings it would be very tempting to jump on the bandwagon.  Looking at the review a little closer though there is one line that I hope many do not miss and I was happy to see Dominic include it. “Subgroup analysis found no difference in the rate of the primary outcomes between HFNC and CPAP in preterm infants in different gestational age subgroups, though there were only small numbers of extremely preterm and late preterm infants.” In his conclusion he further states: Further evidence is also required for evaluating the safety and efficacy of HFNC in extremely pretermand mildly preterm subgroups, and for comparing different HFNC devices. With so few ELBW infants included and with these infants being at highest risk of mortality and BPD our centre has been reluctant to adopt this mode of respiratory support in the absence of solid evidence that it is equally effective to CPAP in these smallest infants.  A big thank you to our Respiratory Therapy Clinical Specialist for harping on this point over the years as the temptation to adopt has been strong as other centres turn to this strategy. Might Not Be So Safe After All Now do not take what I am about to say as a slight against my twitter friend.  The evidence to date points to exactly what he and his other coauthors concluded but with the release of an important paper in May by Taka DK et al, I believe caution is needed when it comes to our ELBW infants. High Flow Nasal Cannula Use Is Associated with Increased Morbidity and Length of Hospitalization in Extremely Low Birth Weight Infants This paper adds to the body of literature on the topic as it truly focuses on the outcome of infants < 1000g.  While this study is retrospective in nature it does cover a five year period and examines important outcomes of interest to this population. The primary outcome in this case was death or BPD and whether HFNC was used alone or with CPAP, this was more frequent than when CPAP was used alone.  Other important findings were the need for multiple and longer courses of ventilation in those who received at least some HFNC.  In these times of overburdened health care systems with goals of improving patient flow, it is also worth noting that there was a significant prolongation of length of stay with use of HFNC or HFNC and CPAP. One interesting observation was that the group that fared the worst across the board was the combination of CPAP and HFNC rather than HFNC alone.   CPAP (941) HFNC (333) HFNC +/- CPAP (1546) CPAP d (median, IQR) 15(5-28)   7 (1-19) HFNC d (median, IQR) 14(5-25) 13 (6-23) HFNC +/- CPAP 15 (5-28) 14(5-25) 26 (14-39) BPD or death % 50.40% 56.80% 61.50% BPD % 42.20% 52.20% 59.00% Multiple ventiation courses 51.10% 53.10% 64.70% More than 3 vent courses 17.60% 21.00% 29.40% Ventilator d (median, IQR) 18(5-42) 25 (6-52) 30 (10-58) I believe the finding may be explained by the problem inherent with retrospective studies.  This is not a study in which patients were randomized to either CPAP, HFNC or CPAP w/HFNC.  If that were the case one would expect lung pathologies and severity of illness to even ou,t such that differences between groups might be explained by the difference in treatments.  In this study though we are looking though the rearview mirror so to speak.  How could we account for the combination being worse than the HFNC alone?  I suspect it relates to the severity of lung disease.  The babies who were placed on HFNC and did well on it might have had less severe chronic changes.  What might be said about those that had the combination?  Well, one could postulate that there might be some who were extubated to HFNC and collapsed needing escalation to CPAP and then failing that therapy were reintubated.  Another explanation could be those babies who were placed on CPAP after extubation and transitioned before their lungs were ready to HFNC may have failed and lost FRC thereby going back to CPAP and possibly intubation.  Exposure in either circumstance to HFNC would therefore put them at risk of further positive pressure ventilation and subsequent further lung injury.  The babies who could tolerate transition to HFNC without CPAP might be intermediary in their outcomes (as they were found to be) as they lost FRC but were able to tolerate it but consumed more calories leaving less for growth and repair of damaged tissue leading to prolonged need for support. Either way, the use of HFNC was found to lead to worse outcomes and in the ELBW infant should be avoided as routine practice pending the results of a prospective RCT on the subject. Is it a total ban though? As with many treatments that one should not consider standard of care there may be some situations where there may be benefit.  The ELBW infant with nasal breakdown from CPAP that despite excellent nursing and RRT attention continues to demonstrate tissue damage is one patient that could be considered.  The cosmetic implications and potential for surgical correction at a later date would be one reason to consider a trial of HFNC but only in the patient that was close to being able to come off CPAP.  In the end I believe that if a ELBW infant needs non invasive pressure support then it should be with CPAP but as there saying goes there may be a right time and a place for even this modality.

AllThingsNeonatal

AllThingsNeonatal

 

Point of Care Ultrasound: Changing Practice For The Better in NICU

It has been some time since I wrote on the topic of point of care ultrasound (POC). The first post spoke to the benefits of reducing radiation exposure in the NICU but was truly theoretical and also was really at the start of our experience in the evolving area.  Here we are a year later and much has transpired. We purchased an ultrasound for the NICU in one of our level III units and now have two more on the way; one for our other level III and one for our level II unit.  The thrust of these acquisitions have been to reduce radiation exposure for one but also to shorten the time to diagnosis for a number of conditions.  No matter how efficient x-ray technologists are, from the time a requisition is placed  to the arrival of the tech, placement of the baby and then processing of the film, it is much longer than using a POC at the bedside.  Having said that though is it accurate?  There are many examples to choose from but when thinking about times when one would like an answer quickly I can’t think of anything much better than a pneumothorax. Chest X-ray vs POC for Diagnosis of Pneumothorax The diagnosis of a pneumothorax is easily diagnosed by ultrasound when there is an absence of lung sliding as seen in this video.  In the majority of cases employing POC we are looking at ultrasound artifacts.  In the case of pleural sliding which is best described as ants marching, it’s absence indicates the presence of a pneumothorax.  The “lung point” sign as shown in thisvideo marks the transition from pleural sliding to none and in a mode called “M” appears as a bar code when the pneumothorax is present. Using such signs Raimondi F et al as part of the LUCI (Lung Ultrasound in the Crashing Infant) group compared traditional x-ray diagnosis as the gold standard to POC for diagnosis of pneumothorax.  This study is important as it demonstrated two very important things in the 42 infants who were enrolled in the study.  The first was the accuracy of POC.  In this study each patient had both an ultrasound and an x-ray and the results compared to determine how accurate the POC was.  Additionally in cases where there was no time for an x-ray to confirm the clinical suspicion the accuracy of the study was determined based on the finding of air with decompression along with abrupt clinical improvement.  In case people are wondering infants as small as 24 weeks were included in the study with an average weight of 1531 +/-832 g for included infants. The accuracy was stunning with a sensitivity and specificity of 100% each.  Comparing this with clinical evaluation (transillumination, assessment of breath sounds) was far less accurate with a sensitivity of 84% (65-96) and specificity 56% (30-80). Adding to the accuracy of the test is the efficiency of the procedure. “After clinical decompensation, lung ultrasound scans were completed in a mean time of 5.3 +/- 5.6 minutes vs a mean time of 19 +/- 11.7 minutes required for a chest radiograph (P < .001).” In short, it is very accurate and can be done quickly.  In an emergency, can you think of a better test? If efficiency weren’t enough what about the reduction in radiation exposure? This was the focus of a recent paper by Escourrou G & Deluca D entitled Lung ultrasound decreased radiation exposure in preterm infants in a neonatal intensive care unit. The authors in this study chose to examine retrospecitively the period from 2012 – 2014 as in 2013 they rolled out a program of teaching POC ultrasound to clinicians.  The purpose of this paper was to see if practitioners educated in interpretation of ultrasound would actually change their practice and use less ionizing radiation. Their main findings are indicated in the table Test 2012 2014 p Min 1 x-ray during admission 81% 70% <0.001 Total x-rays 1976 1476   Mean x-rays per patient 4.9+/-1.5 2.6+/-1.0 <0.001 Mean radiation dose (microGy) 183+/-78 68+/-30 <0.001 As they predicted use of ionizing radiation dropped dramatically.  I should also mention that they tracked outcomes such as IVH, mortality and BPD to name a few and found no change over time.  In conclusion the use of ultrasound did not affect major outcomes but did spare each neonate ionizing radiation. Now before anyone hits the panic button I still think the amounts of radiation here are safe for the most part.  In Canada the maximum allowed dose for the public per year is 1 mSv which is the equivalent of 1000 microGy.  This was obtained from the Nuclear Safety agency in Canada in case you are interested in finding out more about radiation safety limits. Back in 2012 at least in this study, 2 standard deviations from the mean would have put the level received at a little over a third of what the annual limit is but it is the outliers we need to think of.  What about kids getting near daily x-rays while on high frequency ventilation or for monitoring pleural fluid collections?  There certainly are many who could receive much higher dosages and it is for those kids that I believe this technology is so imperative to embrace. It will take time to adopt and much patience.  With any new roll out there is a learning curve.  Yes there will be learners who will need to handle patients and yes there will be studies done at times to obtain the skills necessary to perform studies in an efficient and correct manner but I assure you it will be worth it.  If we have a way of obtaining faster and accurate diagnoses and avoiding ionizing radiation don’t we owe it to our patients and families to obtain such skill?  I look forward to achieving a centre of excellence utilizing such strategies and much like this last study it will be interesting to look back in a year an see how things have changed.

AllThingsNeonatal

AllThingsNeonatal

 

Just Text Me! Enhancing Communication With Families

When you mention electronic medical records to some physicians you get mixed responses.  Some love them and some…well not so much.  These tech heavy platforms promise to streamline workflows and reduce error with drop down menus, some degree of artificial intelligence in providing warnings when you stray too far from acceptable practice but for some who are not so tech savvy they are more of a pain.  I have to admit I am in the camp of believing they are a good thing for patient care as I work in one centre with expanded EMR services and one without and I do find a number of benefits to working with a more robust EMR platform but I respect that not all do. The cell phone on the other hand is everywhere and even the most tech fearful often carry one including most of the parents we care for.  What caught my eye this month was the article by Globus O The use of short message services (SMS) to provide medical updating to parents in the NICU in which an EMR system is described that sends parents a text message at a pre-specified time regarding their infants condition.  I had a visceral reaction at first thought thinking “would I want my cell phone number sent to families?”, “how much time out of the day would all of this take?” and to be a little old fashioned “can’t we just talk on the phone?”.  I am sure there are many other questions that others would have as well.  Having said that as I read through the paper I warmed to the concept and by the end questioned whether we could do the same! The Intervention It turns out the SMS message comes from the EMR and not the personal cell phone of the bedside nurse and is sent out at 9 AM each day.  Each nurse requires only 30 seconds of their day to populate a few questions during the night shift and then the information goes out to the parents. “The text message includes one-sentence prefaces and conclusions and provides updated information that includes the location of the infant’s crib (room and position), the infant’s current weight and whether medical procedures, such as head ultrasound, cardiac echocardiogram or eye examination, were performed. Information regarding acute events or deterioration of the infant’s medical condition are not included in the SMS, but are delivered personally to the parents in real time.” This last sentence is important.  The SMS service will not notify the family that their infant is receiving chest compressions but is there to give them “updates”.  The sceptics out there will likely comment that this should be the job of both nursing and medicine to regularly update the families but thinking about it, how many parents are not there everyday and when they are out of sight how many physicians regularly call them to provide them updates?  No doubt there are some but I would think they are not in the majority. But is it effective? The measurement in this case was through surveys of nursing and families both pre-implementation and afterwards.  Provided in the table below are the scores (means +/- SD) in the pre and post implementation phases of the program. Statement Pre-SMSi N=91 Post SMSi N=87 P-value The physician was available when needed 4.1+/-0.9 4.4+/-0.7 0.002 The physician was patient in answering my questions 4.6+/-0.7 4.9 +/-0.4 0.002 I felt comfortable approaching the physicians 4.3+/-1.0 4.7+/-0.6 0.001 I felt comfortable approaching the nurses 4.4+/-0.8 4.6+/-0.6 0.02 I regularly received information from the physicians regarding my infant’s medical status 3.7+/-1.3 4.1+/-1.1 0.03 These are some pretty powerful outcomes.  The use of what many consider an impersonal form of communication (how many times have I looked at people texting furiously and thought JUST PICK UP THE PHONE!) actually appears to have improved the approachability of the staff in the unit and facilitated information transfer more easily. One other important finding was that when surveyed pre-intervention staff were somewhat sceptical that this would help and moreover were concerned that it would interfere too much with work flow in the day.  Evaluations afterwards did not support these fears and many felt it was an improvement.  In the end the total time spent on this by nursing was estimated to be no more than 30 seconds of each day!  From the parent’s standpoint they certainly saw this as an improvement. The Future At least in our centre we are moving slowly but steadily towards a fully functioning EMR.  Will we have this capability in the software that we use?  After reading this I hope so.  I can see how receiving a daily morning message would prime the family to interact with staff on rounds.  The added benefit is that by knowing that the information would be ready at 9 AM, families could be present with questions already formulated in their minds.  How often do we encourage families to be on rounds and have them listen to a tremendous amount of information and then turn to them with the standard “any questions?”.  While I am sure many of us try and explain matters in lay terms, giving parents a change to mull over the issues first could well enhance the interaction they have with our team in a meaningful way. Time to look into whether this is possible…

AllThingsNeonatal

AllThingsNeonatal

 

How many preterm infants can we safely care for at once?

We have been seemingly under siege over the last year or so by a relentless flow of preterm infants through our units in the city.  Peaks and valleys for patient census come and go for the most part but this almost unwavering tendency to be filled to the rafters so to speak is unusual.  Much has been said and will continue to be acknowledged that we are all doing incredible work, that we are dedicated and putting patients first but where is the breaking point?  When does fatigue lead to errors no matter how well intentioned and selfless we are.  In those cases when it is not a matter of being selfless but we are mandated to come in fatigue is no less an issue. Like many units in North America and in other parts of the world, rates of neonatal sepsis have been on the decline but during a recent peak in both acuity and volume in the region we saw a spike in the rate of culture proven sepsis.  At a time when we were at our busiest our sepsis rate worsened which raised many eyebrows as to what could be contributing.  It is tempting to blame it on patient volumes but what is the actual evidence to support such a claim.  This is the thrust of this piece and I hope you find the topic of some relevance to you as we continue on this journey of a higher state of patient volumes in the city. Nurse to Patient Ratio is Likely Important This has to be important right?! NICUs come in many shapes and sizes but if you can staff appropriately with 1:1, 1:2 and 1:3 ratios based on patient acuity if you had enough nurses would your sepsis rates be ok?  To answer this a useful study is by Jeannie P. Cimiott et al entitled Impact of staffing on bloodstream infections in the neonatal intensive care unit.  The study group was actually from an RCT on hand hygiene and this study was a reanalysis of the data to determine for infants with confirmed sepsis what impact nursing hours had in the context of a patient with their first positive blood culture.   In her study there were 2675 infants in two New York level III NICUs that had 224 positive blood cultures.  The impact of nursing hours on risk of infection was dramatic. The NICU with greater nursing coverage had a significantly decreased risk (HR, 0.21; 95% CI, 0.06-0.79) of bloodstream infection. Moreover, the more RN hours per nursing intensity weight was associated with a 79% reduction in the risk of bloodstream infection in the unit with greater nursing work hours.  Looking also at the impact of greater nursing hours on time to infection demonstrated the following curve. From the graph one can see that two patients both of which develop an infection at 100 days of life have markedly different chances of survival based on the staffing level.  The Neonatologist, RRT, dietician could all be the same but if the nursing hours are lacking the patient is more likely to die.  A very significant concern indeed! What Effect Does The Percentage of Preterm Babies In The Unit Have On The Rate of Infections? The next question may be answered by looking at a study from this year by Goldstein et al entitled Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?  This study looked retrospectively at a 17 year period between 1997 and 2014 to determine the risk of systemic infection from two standpoints; occupancy and percentage of infants < 32 weeks.  In other words they were looking at whether the presence of many smaller babies in the units increases such risk of infection specifically.  This was a rather large study population of 19810 infants of which 446 had confirmed late onset sepsis.  Not surprisingly 70% of the cases of sepsis were with CONS. The authors examined hazard ratios to determine whether occupancy or proportion of infants < 32 weeks had an effect on risk and determined that the average occupancy did not correlate with risk of infection but did for the category of infants < 32 weeks.  Interestingly the HR for this was 1.03 with a CI that touches 1 so I am not sure how they make this claim but in the end they conclude: "For each additional percentage of infants <32 weeks gestation in the unit, neonates had an increased late-onset sepsis hazard of 2% (HR 1.02, 95% CI: 1.00, 1.03) over their NICU hospitalization." For arguments sake let's say this is a real effect.  I do have to call into question the diagnosis of sepsis.  I could not find mention of the definition of sepsis in this cohort and with so many CONS infections I do worry that some of these were in fact contaminants.  Did they draw one or two blood cultures in each instance?  How many of these if they had would have had one positive and the other negative?  Having just a few of these labelled as contaminants may have negated any effect seen. What About The Nurses? You also can't ignore the fact that while they looked at occupancy they made no attempt to control for the amount of staff.  To not do so I think misses a very important point.  Whether your unit is functioning at 60, 70, 80 or more occupancy while giving a measure of patient volumes tells you nothing about the coverage for such patients.  In a well staffed unit with adequate nurse to patient ratios there might be minimal risk of error.  If assignments though that are ideally 2:1 are stretched to 3 or 4: 1 that is likely where the errors start to come in. Coming back to our situation that likely mirrors many other centres across the globe I believe all of this comes down to ensuring a safe environment to care for our patients.  A safe environment means having enough staff to cover the number of patients and that includes medical, RRTs, dieticians and others.   The message from all of this is that to do our best we need the right amount of staff to do it.  We can handle the volume, just provide us with the resources to handle it.  If it is money that we are hoping to save consider the amount of dollars that could be saved by avoiding prolonged stays from infection and all the associated morbidities that follow. Then there is the increase in mortality to consider and I for one will not even begin to put a price on that.

AllThingsNeonatal

AllThingsNeonatal

 

Is It Time To Use Sustained Lung Inflation In NRP?

As I was preparing to settle in tonight I received a question from a reader on my Linkedin page  in regards to the use of sustained inflation (SI) in our units.  We don't use it and I think the reasons behind it might be of interest to others.  The concept of SI is that by providing a high opening pressure of 20 - 30 cm H2O for anywhere from 5 to 15 seconds one may be able to open the "stiff" lung of a preterm infant with RDS and establish an adequate functional residual capacity.  Once the lung is open, it may be possible in theory to keep it open with ongoing peep at a more traditional level of 5 - 8 cm of H20. The concept was tested 25 years ago by Vyas et al in their article Physiologic responses to prolonged and slow-rise inflation in the resuscitation of the asphyxiated newborn infant.  In this study, 9 newborn infants were given a relatively short 5 second sustained inflation and led to earlier and larger lung volumes with good establishment of FRC.  Like many trials in Neonatology though sceptics abound and here we are 25 years later still discussing the merits of this approach. As I have a warm place in my heart for the place that started my professional career whenever I come across a paper published by former colleagues I take a closer look.  Such is the case with a systematic review on sustained inflation by Schmolzer et al.  The inclusion criteria were studies of infants born at <33 weeks. Their article provides a wonderful assessment of the state of the literature on the topic and I would encourage you to have a look at it if you would like a good reference to keep around on the topic.  What it comes down to though is that there are really only four randomized human studies using the technique and in truth they are fairly heterogeneous in their design.  They vary in the length of time an SI was performed (5 - 20 seconds), the pressures used (20 - 30 cm H2O), single or multiple SIs and lastly amount of oxygen utilized being 21 - 100%.  In fact three of the four studies used either 100% or in one case 50% FiO2 when providing such treatments. What Did They Show? This is where things get interesting.  SI works in the short term by reducing the likelihood that an infant will need mechanical ventilation at 72 hours with a number needed to treat of only 10!  In medicine we normally would embrace such results but sadly the results do not translate into long term benefits as the rate of BPD, mortality and the combined outcome do not remain significant.  Interestingly, the incidence of a symptomatic PDA needing treatment with either a medical or surgical approach had a number needed to harm of 11; an equally impressive number but one that gives reason for concern.  As the authors speculate, the increased rate of PDA may be in fact related to the good job that the SI does in this early phase.  By establishing an open lung and at an earlier time point it may well be that there is an accentuation in the relaxation of the pulmonary vasculature and this leads to a left to right shunt that by being hemodynamically significant helps to stent the ductus open at a time when it might otherwise be tending to close.  This outcome in and of itself raises concern in my mind and is the first reason to give me reason to pause before adopting this practice. Any other concerns? Although non-significant there was a trend towards increased rates of IVH in the groups randomized to SI.  There is real biologic plausibility here.  During an SI the increased positive pressure in the chest could well simulate a similar effect to a pneumothorax and impede the passive drainage of blood from the head into the thorax.  In particular, longer durations and/or frequent SIs could increase such risk.  Given the heterogeneous nature of these studies it is difficult to know if they all had been similar in providing multiple SIs could we have seen this cross over to significant? I believe the biggest concern in all of this though is that I would have a very hard time applying the results of these studies to our patient population.  The systematic review addresses the question about whether SI is better than IPPV as a lung recruitment strategy in the preterm infant with respiratory distress.  I have to say though we have moved beyond IPPV as an initial strategy in favour of placement of CPAP on the infant directly after birth.  The real question in my mind is whether providing brief periods of SI followed by CPAP of +6 to +8 is better than placement on CPAP alone as a first strategy to establish good lung volumes. If I am to be swayed by the use of SI someone needs to do this study first.  The possibility of increasing the number of hemodynamically significant PDAs and potentially worsening IVH without any clear reduction in BPD is definitely placing me firmly in the camp of favouring the CPAP approach.  Having said all that, the work by the Edmonton group is important and gives everyone a glimpse into what the current landscape is for research in this field and opens the door for their group or another to answer my questions and any others that may emerge as this strategy will no doubt be discussed for years to come.

AllThingsNeonatal

AllThingsNeonatal

 

What if we criminalized drug use in pregnancy?

I don't know if you missed it but I did until tonight.  We don't have this in Canada but there have been some US states that have been doing so for the past while.  You may find the following link very interesting that explains the positions of each state in regards to drug use in pregnancy. The intentions were good to protect the unborn child but the consequences to mother's who tested positive were of great concern. As this article from March 4th indicates the practice has been ongoing in Tennessee for at least a year and a pilot project was planned for Indiana this year.  According to the article the situation in Tennessee came with some significant risk to the mother if found to have a positive screen. "Lawmakers in Tennessee last year increased drug screenings of expectant mothers and passed a law allowing prosecutors to charge a woman with aggravated assault against her unborn baby if she was caught using illicit drugs. The penalty is up to 15 years in prison." The law may seem harsh and in my eyes is but it came in response to the tidal wave of drug addiction and neonatal withdrawal in the US as was identified in the article from the NEJM in 2015 entitled Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs.  The impact on neonatal ICUs in the US can be seen in the following graphs which demonstrate not only the phenomenal rise in the incidence of the problem but in the second graph the gradually prolonging length of stay that these patients face.  Aside from the societal issues these families face and the problems their infants experience, the swelling volume of patients NICUs have to contend with are quite simply overwhelming resources with time. Although I reside in Canada, it is the trend shown that likely motivated some states to adopt such a draconian approach to these mother-infant dyads. There are so many questions that would arise from such an approach.  What if a mother refuses testing as is the option in Indiana.  Would Child and Family services be called simply on the suspicion? What if a mother received prescription opioids for chronic back pain or used an old prescription in the days before she was tested after a fall to ease her pain? Then there is the Sharapova situation where a mother could conceivably take a medication that she is unaware is on a list of "banned substances".  What about Naturopathic or herbal supplements that might test positive? Then what about false positive tests?   The ramifications of any of the above situations on the family unit could be devastating.  Interestingly this year the courts in Indiana passed a law that prevents health care providers from releasing the results of such toxicology screens to police without a court order so indeed there would need to be suspicion.  In the end though is it right? Tennessee Sings a New Tune As surprised as I was to hear about the situation in Tennessee just now I was equally surprised to come across a U.S. Supreme Court ruling handed down March 21st, 2001 that has ruled that subjecting mothers to such testing in hospitals is unconstitutional.  This may disclose my ignorance of US law but I would have thought if the US Supreme Court says you cannot do something the states would follow along but at least in Tennessee that was not the case...until now. March 23rd the law in Tennessee is changing as the state has chosen not to renew the legislation after a two year trial period saw about 100 women arrested.  For more information on this decision see Assault Charges for Pregnant Drug Users Set to Stop in Tennessee. Where do we possibly go from here? I found this whole storyline shocking but I am taking some solace in knowing that this was a very limited experiment in one state.  Neonatal abstinence is a problem and a big one at that.  Criminalizing mothers though is not an effective solution and to me the solution to this problem will need to involve a preventative approach rather than one of punishment.  A first step in the right direction will be to stem the tide of liberal use of prescription opioids in pregnancy as was suggested in the BMJ news release in January of this year.  In the end if we as medical practitioners are freely prescribing such medications to the mothers we care for perhaps we should look in the mirror when pointing fingers to determine fault.  So many of the mothers and the infants we care for may well be victims of a medical establishment that has not done enough to prevent the problem. .

AllThingsNeonatal

AllThingsNeonatal

 

Detecting Congenital Heart Defects After Home Birth

As evidence mounts for the use of pulse-ox screening to detect congenital heart defects a few key points have arisen.  The evidence comes from many publications but one of the best which summarizes the body of evidence is the systematic review by  Thangaratinam S which included over 200000 asymptomatic newborns.  The key here is to note that as this is a screening test if there are symptoms of congenital heart disease one should be referring to a specialist to rule out a significant CHD rather than spending time with such screening tests.  The four points to highlight though are: Comparing preductal to postductal saturations enhances sensitivity Performing such testing after 24 hours decreases false positive results from conditions leading to desaturation that are not CHD such as TTN. The false positive rate is 0.14% if the first two criteria are applied using the cutoffs of < 95% in any limb or > 3% difference between pre and post ductal locations. Pulse-ox screening does not detect ALL CHD but rather the ones that are deemed critical or immediately life threatening if not identified in the newborn period. Examples of CCHD Lesions Detectable with Pulse Oximetry Screening Most consistently cyanotic May be cyanotic Hypoplastic left heart syndrome (HLHS) Pulmonary atresia with intact septum (PA IVS) Total anomalous pulmonary venous return (TAPVR) Tetralogy of Fallot (TOF) Transposition of the great arteries (TGA) Tricuspid atresia Truncus arteriosus Coarctation of the aorta (COA) Double outlet right ventricle (DORV) Ebstein anomaly Interrupted aortic arch (IAA) Single ventricles   Is there a danger in screening too early? As you screen closer to birth the risk of detecting conditions leading to desaturation which are not CHD rises.  Common conditions such as TTN or mild pulmonary hypertension may mimic CHD and lead to a false positive finding.  Thinking of the hospital environment, how many patients are sent to triage beds on a daily basis with tachypnea and mild desaturation? This month the first real assessment of screening in the home environment was completed by Cawsey MJ entitled Feasibility of pulse oximetry screening for critical congenital heart defects in homebirths. This study describes in a retrospective fashion the results of applying a pulse-ox screening protocol in the UK to 90 babies screened at 2 hours of age.  This study is important as the typical early discharge of patients from birth centres or could potentially benefit as well by having the results of such work available.  Out of the 90 patients screened 4 had abnormal results and after rescreening two were normal but 2 were persistently abnormal and required admission for further workup.  Neither of the two had CHD but were diagnosed with congenital pneumonia. This yields a false positive rate of 2% or about 16 times as high as screening after 24 hours. How do we apply the results? As the saying goes "something is better than nothing".  In the home or birthing centre environment, waiting until after 24 hours to perform the screen may not be possible either due to the midwife leaving after the delivery or in the case of a birth centre the couple leaving before 6 hours as is the case in our local centre.  As I see it all is not lost in doing screening in such circumstances early as one may detect TTN, pneumonia or another vascular condition such as PPHN before it becomes symptomatic.  Intervening earlier in the course of the illness may actually result in better outcomes for the infant.  We have to be careful though when looking at the ability of this screen to detect CHD.  The truth is there are not enough patients screened in this study to really draw any conclusions.  With an incidence of about 1:100 births a sample of 90 patients would be lucky to find one patient so the absence of any detected patients is not surprising. The study though does draw attention to a couple important points.  First as mentioned above, the midwife has the opportunity by screening early to detect ANY cause of desaturation and then plan for further management.  Secondly, it does raise the question with a 2% false positive rate whether screening programs regardless of home or birth centre should include follow-up by a midwife after 24 hours to do testing.  My vote would be a resounding yes.  If applied to a population there would certainly be kids detected with CHD over time and reducing the false positive rate is important in terms of the downstream consequences of overwhelming our Cardiology colleagues who would ultimately need to see such patients to rule in or out significant CHD. I am not a midwife, nor do I attend home or birthing centre deliveries but I would ask that the consideration of such screening programs consider the timing of testing as sending 2 per 100 deliveries vs 1 in 1000 deliveries for further assessment to rule out CHD is something that our overwhelmed health care systems need to consider strongly.
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