Severe BPD and prolonged stay in NICU

[Mo7]

I apologise if this topic has already been covered. We’re currently discussing severe BPD cases, particularly infants who remain in the NICU beyond a corrected age of 44+0 weeks, with some even nearing six months. These prolonged stays bring unique challenges, such as the need for specialised training, appropriate equipment, and specific emergency protocols. For example, if a baby at a corrected age of four months experiences a collapse, should the team initiate resuscitation using an NLS/NRP approach, or should an APLS code be applied?

 

In my experience, only one unit had a clear policy to guide these situations. I’d be very interested to hear how your units handle such cases.

[Stefan Johansson]

This is indeed a tricky Q, I think there is a gradual shift over time from the neonatal to the pediatric code. But at four months corrected age, I would think most would go for  pediatric strategies.

[piatkat]

I recognize that you are asking about our units policies, but as I primarily do clinical research, I have stumbled upon these two papers regarding the topic of transitioning from NPT to PALS. So for everybody looking for current evidence, you don't have to google anymore- this is what is out there  

1) brief communication in Journal of Perinatology, 2021, team from Wisconsin describing their strategy of transitioning from NPR to PALS

"Utilization of PALS for infants was based on the following criteria: >44 weeks post menstrual age (PMA), previous non-PDA cardiac surgery or intervention, or obvious identified cardiac arrhythmia. Each week, the care team leader identified which patients qualified for PALS and ensured appropriate signage was posted in each patient’s room." https://pmc.ncbi.nlm.nih.gov/articles/PMC9617750/

 

2) "Considerations on the Use of Neonatal and Pediatric Resuscitation Guidelines for Hospitalized Neonates and Infants" from AAP, 2023 : "When Should Teams Transition From Neonatal to Pediatric Resuscitation Guidelines?
As the cardiopulmonary physiology of the newborn transitions to that of the neonate and infant, the evidence upon which the neonatal resuscitation guidelines are based becomes less applicable. Therefore, it makes sense to transition from neonatal to pediatric resuscitation guidelines at some point during the first days, weeks, or months after birth. (...) There are no scientific data to answer the question of when to transition from neonatal to pediatric resuscitation guidelines." However, they mention that studies are needed on optimal resuscitation protocols for infants with certain conditions, including BPD. https://publications.aap.org/pediatrics/article/153/1/e2023064681/196216/Considerations-on-the-Use-of-Neonatal-and

3) And actually, a similar topic has appeared here- almost 15 years ago. It seems these questions are still valid!

 

I haven't found a single answer regarding the NPR vs PALS management for infants with severe BPD though. 

[Mo7]

Thank you so much for these valuable resources. It’s quite telling that there aren’t many research or consensus papers on the topic. I believe it’s a logistical issue. Most NICU staff are trained in NRP/NLS, and it’s challenging to retrain everyone to a different resuscitation protocol. However, I’m curious to know: is there an age or condition after which NLS/NRP can cause harm?

[Gustaf Lernfelt]

Maybe @Pontus Johansson has something to add to this subject. He’s currently the chair of the pediatric section of the Swedish national resuscitation council. 

[Mo7]

Not the best sample size, but I’m surprised that those who answered chose APLS/PALS over continuing NLS/NRP.

 

Here are the results I obtained from Twitter. 

[Stefan Johansson]

@Mo7 interesting and unexpected resust!

[Mo7]

I’m not certain if evidence-based practice plays a role in this, but I believe it’s related to logistics. Most of the NICU staff will be trained in NLS/NRP, and I imagine that not many require training in APLS/PALS. However, there are other factors to consider, such as equipment (like a cuffed ETT) and drug dosages. In places where the NICU is part of a hospital that also includes pediatric services, if a child collapses, they call the pediatric crash team.