The attitudes of neonatologists towards extremely preterm infants: a Q methodological study

The attitudes and biases of doctors may affect decision making within Neonatal Intensive Care. We studied the attitudes of neonatologists in order to understand how they prioritise different factors contributing to decision making for extremely preterm babies

Parental experience of interaction with healthcare professionals during their infant's stay in the neonatal intensive care unit.

OBJECTIVE: To explore the experiences of parents of infants admitted to the neonatal intensive care unit towards interaction with healthcare professionals during their infants critical care. DESIGN: Semi-structured interviews were conducted with parents of critically ill infants admitted to neonatal intensive care and prospectively enrolled in a study of communication in critical care decision making. Interviews were transcribed verbatim and uploaded into NVivo V.10 to manage and facilitate data analysis. Thematic analysis identified themes representing the data. RESULTS: Nineteen interviews conducted with 14 families identified 4 themes: (1) initial impact of admission affecting transition into the neonatal unit; (2) impact of consistency of care, care givers and information giving; (3) impact of communication in facilitating or hindering parental autonomy, trust, parental expectations and interactions; (4) parental perception of respect and humane touches on the neonatal unit. CONCLUSION: Factors including the context of infant admission, interprofessional consistency, humane touches of staff and the transition into the culture of the neonatal unit are important issues for parents. These issues warrant further investigation to facilitate individualised family needs, attachment between parents and their baby and the professional team

Cerebral blood flow and oximetry response to blood transfusion in relation to chronological age in preterm infants

OBJECTIVE: Preterm infants frequently receive blood transfusion (BT) and the aim of this study was to measure the effect of BT on cerebral blood flow and oxygenation in preterm infants in relation to chronological age. PATIENTS: Preterm infants undergoing intensive care recruited to three chronological age groups: 1 to 7 (Group 1; n=20), 8 to 28 (Group 2; n=21) & ≥29days of life (Group 3; n=18). METHODS: Pre and post-BT anterior cerebral artery (ACA) time averaged mean velocity (TAMV) and superior vena cava (SVC) flow were measured. Cerebral Tissue Haemoglobin Index (cTHI) and Oxygenation Index (cTOI) were measured from 15-20min before to 15-20min post-BT using NIRS. Vital parameters and blood pressure were measured continuously. RESULTS: Mean BP increased significantly, and there was no significant change in vital parameters following BT. Pre-BT ACA TAMV was higher in Group 2 and 3 compared to Group 1 (p<0.001). Pre-BT ACA TAMV decreased significantly (p≤0.04) in all 3 groups; pre-BT SVC flow decreased significantly in Group 1 (p=0.03) and Group 3 (p<0.001) following BT. Pre-BT cTOI was significantly lower in Group 3 compared to Group 1 (p=0.02). cTHI (p<0.001) and cTOI (p<0.05) increased significantly post-BT in all three groups. PDA had no effect on these measurements. CONCLUSION: Baseline cTOI decreases and ACA TAMV increases with increasing chronological age. Blood transfusion increased cTOI and cTHI and decreased ACA TAMV in all groups. PDA had no impact on the baseline cerebral oximetry and blood flow as well as changes following blood transfusion

Haemoglobin level at birth is associated with short term outcomes and mortality in preterm infants

Background Blood volume and haemoglobin (Hb) levels are increased by delayed umbilical cord clamping, which has been reported to improve clinical outcomes of preterm infants. The objective was to determine whether Hb level at birth was associated with short term outcomes in preterm infants born at ≤32 weeks gestation. Methods Data were collected retrospectively from electronic records: Standardised Electronic Neonatal Database, Electronic Patient Record, Pathology (WinPath), and Blood Bank Electronic Database. The study was conducted in a tertiary perinatal centre with around 5,500 deliveries and a neonatal unit admission of 750 infants per year. All inborn preterm infants of 23 to 32 weeks gestational age (GA) admitted to the neonatal unit from January 2006 to September 2012 were included. The primary outcomes were intra-ventricular haemorrhage, necrotising entero-colitis, broncho-pulmonary dysplasia, retinopathy of prematurity, and death before discharge. The secondary outcomes were receiving blood transfusion and length of intensive care and neonatal unit days. The association between Hb level (g/dL) at birth and outcomes was analysed by multiple logistic regression adjusting for GA and birth weight (BWt). Results Overall, 920 infants were eligible; 28 were excluded because of missing data and 2 for lethal congenital malformation. The mean (SD) GA was 28.3 (2.7) weeks, BWt was 1,140 (414) g, and Hb level at birth was 15.8 (2.6) g/dL. Hb level at birth was significantly associated with all primary outcomes studied (P <0.001) in univariate analyses. Once GA and BWt were adjusted for, only death before discharge remained statistically significant; the OR of death for infants with Hb level at birth <12 g/dL compared with those with Hb level at birth of ≥18 g/dL was 4.1 (95% CI, 1.4–11.6). Hb level at birth was also significantly associated with blood transfusion received (P <0.01) but not with duration of intensive care or neonatal unit days. Conclusions Low Hb level at birth was significantly associated with mortality and receiving blood transfusion in preterm infants born at ≤32 weeks gestation. Further studies are needed to determine the association between Hb level at birth and long-term neurodevelopmental outcomes

Blood transfusion in preterm infants improves intestinal tissue oxygenation without alteration in blood flow

BACKGROUND AND OBJECTIVE: The objective of the study was to investigate the splanchnic blood flow velocity and oximetry response to blood transfusion in preterm infants according to postnatal age. MATERIALS AND METHODS: Preterm infants receiving blood transfusion were recruited to three groups: 1–7 (group 1; n = 20), 8–28 (group 2; n = 21) and ≥29 days of life (group 3; n = 18). Superior mesenteric artery (SMA) peak systolic (PSV) and diastolic velocities were measured 30–60 min pre- and post-transfusion using Doppler ultrasound scan. Splanchnic tissue haemoglobin index (sTHI), tissue oxygenation index (sTOI) and fractional tissue oxygen extraction (sFTOE) were measured from 15–20 min before to post-transfusion using near-infrared spectroscopy. RESULTS: The mean pretransfusion Hb in group 1, 2 and 3 was 11, 10 and 9 g/dl, respectively. The mean (SD) pretransfusion SMA PSV in group 1, 2 and 3 was 0·63 (0·32), 0·81 (0·33) and 0·97 (0·40) m/s, respectively, and this did not change significantly following transfusion. The mean (SD) pretransfusion sTOI in group 1, 2 and 3 was 36·7 (19·3), 44·6 (10·4) and 41·3 (10·4)%, respectively. The sTHI and sTOI increased (P < 0·01), and sFTOE decreased (P < 0·01) following transfusion in all groups. On multivariate analysis, changes in SMA PSV and sTOI following blood transfusion were not associated with PDA, feeding, pretransfusion Hb and mean blood pressure. CONCLUSION: Pretransfusion baseline splanchnic tissue oximetry and blood flow velocity varied with postnatal age. Blood transfusion improved intestinal tissue oxygenation without altering mesenteric blood flow velocity irrespective of postnatal ages

An unusual cause of respiratory distress

Background: Respiratory distress is a very common presenting complaint in children and neonates, and is one that will regularly face healthcare professionals. A thorough clinical assessment and sound appreciation of the broad range of differential diagnoses is key to enabling effective and subsequent targeted investigation and management of the condition. Bronchogenic cysts, while rare, are one of the most common mediastinal masses encountered in the neonate. The clinical presentation of bronchogenic cysts is variable, however in the neonate they often present with respiratory distress shortly after birth. Radiological appearances are rarely conclusive, with histology required for a definitive diagnosis. Case: Presented here is a case of a term infant who developed respiratory distress shortly after birth that required intubation and ventilation. Antenatal ultrasound demonstrated a persistent posterior mediastinal cystic structure. Investigations: Chest radiographs obtained shortly after birth revealed a smooth, well-defined homogenous mediastinal mass, with left lung hyperinflation. Subsequent computed tomography confirmed that the mass was closely related to the trachea anteriorly and oesophagus posteriorly, displacing both of these structures to the right. Differential diagnosis: Differential diagnosis was of an oesophageal duplication cyst or bronchogenic cyst. Treatment: After stabilisation on the neonatal intensive care unit, the infant was transferred to a tertiary centre for definitive management. Thoracotomy was performed, and histopathology of the mass confirmed the diagnosis of a bronchogenic cyst. Outcome and follow up: The infant made an uneventful recovery, and was discharged 17 days post-operatively. She has since been discharged from formal follow up and displays no respiratory complications. Discussion: This case serves as a reminder to the reader that, although uncommon, bronchogenic cysts should be considered in the differential diagnosis, particularly when assessing the newborn infant with respiratory distress. As such, it provides an important educative value. It also serves to highlight the importance of careful radiographic imaging and interpretation. While often not diagnostic, when used in conjunction with good clinical assessment, imaging can help to narrow the differential diagnosis and subsequently focus the investigation and management

Could Near Infrared Spectroscopy (NIRS) be the new weapon in our fight against Necrotising Enterocolitis?

There is no ideal single gut tissue or inflammatory biomarker available to help to try and identify Necrotising Enterocolitis (NEC) before its clinical onset. Neonatologists are all too familiar with the devastating consequences of NEC, and despite many advances in neonatal care the mortality and morbidity associated with NEC remains significant. In this article we review Near Infrared Spectroscopy (NIRS) as a method of measuring regional gut tissue oxygenation. We discuss its current and potential future applications, including considering its effectiveness as a possible new weapon in the early identification of NEC