General Movements in preterm infants undergoing craniosacral therapy: a randomised controlled pilot-trial

BACKGROUND: The objective of this study was to investigate neurological short-term effects of craniosacral therapy as an ideal form of osteopathic manipulative treatment (OMT) due to the soft kinaesthetic stimulation. METHODS: Included were 30 preterm infants, with a gestational age between 25 and 33 weeks, who were admitted to the neonatal intensive care unit of the University Hospital of Graz, Austria. The infants were randomized either into the intervention group (IG) which received standardised craniosacral therapy, or the control group (CG) which received standard care. To guarantee that only preterm infants with subsequent normal neurodevelopment were included, follow up was done regularly at the corrected age (= actual age in weeks minus weeks premature) of 12 and 24 months. After 2 years 5 infants had to be excluded (IG; n = 12; CG: n = 13). General Movements (GMs) are part of the spontaneous movement repertoire and are present from early fetal life onwards until the end of the first half year of life. To evaluate the immediate result of such an intervention, we selected the General Movement Assessment (GMA) as an appropriate tool. Besides the global GMA (primary outcome) we used as detailed GMA, the General Movement Optimality Score (GMOS- secondary outcome), based on Prechtl’s optimality concept. To analyse GMOS (secondary outcome) a linear mixed model with fixed effects for session, time point (time point refers to the comparisons of the measurements before vs. after each session) and intervention (IG vs. CG), random effect for individual children and a first order autoregressive covariance structure was used for calculation of significant differences between groups and interactions. Following interaction terms were included in the model: session*time point, session*intervention, time point*intervention and session*time point*intervention. Exploratory post hoc analyses (interaction: session*time point*intervention) were performed to determine group differences for all twelve measurement (before and after all 6 sessions) separately. RESULTS: Between groups no difference in the global GMA (primary outcome) could be observed. The GMOS (secondary outcome) did not change from session to session (main effect session: p = 0.262) in the IG or the CG. Furthermore no differences between IG and CG (main effect group: p = 0.361) and no interaction of time*session could be observed (p = 0.658). Post hoc analysis showed a trend toward higher values before (p = 0.085) and after (p = 0.075) the first session in CG compared to IG. At all other time points GMOS were not significantly different between groups. CONCLUSION: We were able to indicate that a group of “healthy” preterm infants undergoing an intervention with craniosacral therapy (IG) showed no significant changes in GMs compared to preterm infants without intervention (CG). In view of the fact that the global GMA (primary outcome) showed no difference between groups and the GMOS (detailed GMA-secondary outcome) did not deteriorate in the IG, craniosacral therapy seems to be safe in preterm infants. TRIAL REGISTRATION: German Clinical Trials Register DRKS00004258

Full oral feeding is possible before discharge even in extremely preterm infants

Aim: This study described the steps needed to achieve full oral feeding before discharge in a group of very and extremely preterm (EPT) infants. We analysed the effects of oral feeding skills on discharge timing and on weight gain during their neonatal intensive care unit (NICU) stay. Methods: A prospective cross-sectional observational study of 100 infants who were <32 weeks of gestation (GA) was conducted at the Division of Neonatology, Graz, Austria, from March 2014 to February 2015. Patients were stratified into two groups: those who were <28 weeks at birth and those who were 28 weeks and over. Velocity of oral feeding skills attainment and weight gain were analysed. Results: All infants successfully acquired oral feeding skills during hospitalisation. The median GA at which full oral feeding skills were reached was 37 + 1 weeks in EPT and 34 + 5 weeks in very preterm infants. More immature neonates showed worse feeding performances and lower weight increments during oral feeding steps. Conclusion: Our study confirmed the role of GA in the development of oral feeding skills in the most premature babies. It also raises the question of whether expected daily weight gain should be targeted according to GA

Impact of bradycardia and hypoxemia on oxygenation in preterm infants requiring respiratory support at birth

Aim of the study: Analysis of the impact of bradycardia and hypoxemia on the course of cerebral and peripheral oxygenation parameters in preterm infants in need for respiratory support during foetal-to-neonatal transition. Methods: The first 15 min after birth of 150 preterm neonates in need for respiratory support born at the Division of Neonatology, Graz (Austria) were analyzed. Infants were divided into different groups according to duration of bradycardia exposure (no Bradycardia, brief bradycardia <2 min, and prolonged bradycardia 652 min) and to systemic oxygen saturation (SpO2) value at 5 min of life (<80% or 6580%). Analysis was performed considering the degree of bradycardia alone (step 1) and in association with the presence of hypoxemia (step 2). Results: In step 1, courses of SpO2 differed significantly between bradycardia groups (p = 0.002), while courses of cerebral regional oxygen saturation (crStO2) and cerebral fractional tissue oxygen extraction (cFTOE) were not influenced (p = 0.382 and p = 0.878). In step 2, the additional presence of hypoxemia had a significant impact on the courses of SpO2 (p < 0.001), crStO2 (p < 0.001) and cFTOE (p = 0.045). Conclusion: Our study shows that the degree of bradycardia has a significant impact on the course of SpO2 only, but when associated with the additional presence of hypoxemia a significant impact on cerebral oxygenation parameters was seen (crStO2, cFTOE). Furthermore, the additional presence of hypoxemia has a significant impact on FiO2 delivered. Our study emphasizes the importance of HR and SpO2 during neonatal resuscitation, underlining the relevance of hypoxemia during the early transitional phase

Feasibilty of Transcutaneous pCO2 Monitoring During Immediate Transition After Birth\u2014A Prospective Observational Study

Background: According to recommendations, non-invasive monitoring during neonatal resuscitation after birth includes heart rate (HR) and oxygen saturation (SpO2). Continuous transcutaneous monitoring of carbon dioxide partial pressure (tcpCO2) may further offer quantitative information on neonatal respiratory status. Objective: We aimed to investigate feasibility of tcpCO2 measurements in the delivery room during immediate neonatal transition and to compare the course of tcpCO2 between stable term and preterm infants. Methods: Neonates without need for cardio-respiratory intervention during immediate transition after birth were enrolled in a prospective observational study. In these term and preterm neonates, we measured HR and SpO2 by pulse oximetry on the right wrist and tcpCO2 with the sensor applied on the left hemithorax during the first 15 min after birth. Courses of tcpCO2 were analyzed in term and preterm neonates and groups were compared. Results: Fifty-three term (gestational age: 38.8 \ub1 0.9 weeks) and 13 preterm neonates (gestational age: 34.1 \ub1 1.5 weeks) were included. First tcpCO2 values were achieved in both groups at minute 4 after birth, which reached a stable plateau after the equilibration phase at minute 9. Mean tcpCO2 values 15 min after birth were 46.2 (95% CI 34.5\u201357.8) mmHg in term neonates and 48.5 (95%CI 43.0\u201354.1) mmHg in preterm neonates. Preterm and term infants did not show significant differences in the tcpCO2 values at any time point. Conclusion: This study demonstrates that tcpCO2 measurement is feasible during immediate neonatal transition after birth and that tcpCO2 values were comparable in stable term and preterm neonates

Clinical Implications of the General Movement Optimality Score:Beyond the Classes of Rasch Analysis

This article explores the clinical implications of the three different classes drawn from a Rasch analysis of the general movements optimality scores (GMOS) of 383 infants. Parametric analysis of the class membership examines four variables: age of assessment, brain injury presence, general movement patterns, and 2-year-old outcomes. GMOS separated infants with typical (class 3) from atypical development, and further separated cerebral palsy (class 2) from other neurodevelopmental disorders (class 1). Each class is unique regarding its quantitative and qualitative representations on the four variables. The GMOS has strong psychometric properties and provides a quantitative measure of early motor functions. The GMOS can be confidently used to assist with early diagnosis and predict distinct classes of developmental outcomes, grade motor behaviors, and provide a solid base to study individual general movement developmental trajectories

Physiological-based cord clamping versus immediate cord clamping for infants born with a congenital diaphragmatic hernia (PinC):study protocol for a multicentre, randomised controlled trial

Introduction Pulmonary hypertension is a majordeterminant of postnatal survival in infants with acongenital diaphragmatic hernia (CDH). The current careduring the perinatal stabilisation period in these infantsmight contribute to the development of pulmonaryhypertension after birth—in particular umbilical cordclamping before lung aeration. An ovine model ofdiaphragmatic hernia demonstrated that cord clampingafter lung aeration, called physiological-based cordclamping (PBCC), avoided the initial high pressures in thelung vasculature while maintaining adequate blood flow,thereby avoiding vascular remodelling and aggravationof pulmonary hypertension. We aim to investigate if theimplementation of PBCC in the perinatal stabilisation periodof infants born with a CDH could reduce the incidence ofpulmonary hypertension in the first 24 hours after birth.Methods and analysis We will perform a multicentre,randomised controlled trial in infants with an isolatedleft-sided CDH, born at ≥35.0 weeks. Before birth, infantswill be randomised to either PBCC or immediate cordclamping, stratified by treatment centre and severity ofpulmonary hypoplasia on antenatal ultrasound. PBCCwill be performed using a purpose- built resuscitationtrolley. Cord clamping will be performed when the infantis considered respiratory stable, defined as a heartrate >100 bpm, preductal oxygen saturation >85%,while using a fraction of inspired oxygen of <0.5. Theprimary outcome is pulmonary hypertension diagnosedin the first 24 hours after birth, based on clinical andechocardiographic parameters. Secondary outcomesinclude neonatal as well as maternal outcomes.Ethics and dissemination Central ethical approvalwas obtained from the Medical Ethical Committee ofthe Erasmus MC, Rotterdam, The Netherlands (METC2019-0414). Local ethical approval will be obtained bysubmitting the protocol to the regulatory bodies and localinstitutional review boards

Reply letter to: Intubation in neonatal resuscitation - compelling necessity or incalculable risk?

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