Parent experience of HIE and hypothermia: A call for trauma informed care

Purpose/Background: Therapeutic hypothermia (TH) is the standard treatment for hypoxic ischemic encephalopathy (HIE). We surveyed parents of infants treated with TH about their experiences of communication and parental involvement in the Neonatal Intensive Care Unit (NICU). Methods/Approach: A 29-question anonymous survey was posted on a parent support website (https://www.hopeforhie.org) and sent to members via e-mail. Responses from open-ended questions were analyzed using thematic analysis. Results: 165 respondents completed the survey and 108 (66%) infants were treated with TH. 79 (48%) respondents were dissatisfied/neutral regarding the quality of communication in the NICU, whereas 127 (77%) were satisfied/greatly satisfied with the quality of parental involvement in the NICU. 6 themes were identified: 1) Setting for communication: Parents preferred face to face meetings with clinicians. 2) Content and clarity of language: Parents valued clear language (use of layman’s terms) and being explicitly told the medical diagnosis of HIE. 3) Immediate and Longitudinal Emotional Support: Parents required support from clinicians to process the trauma of the birth experience and hypothermia treatment. 4) Clinician time and scheduling: Parents valued the ability to join rounds and other major conversations about infant care. 5) Valuing the Parent Role: Parents desired being actively involved in rounds, care times and decision making. 6) Physical Presence and Touch: Parents valued being physically present and touching their baby; this presence was limited by COVID-related restrictions. Conclusion: We highlight stakeholder views on parent involvement and parent-clinician communication in the NICU and note significant overlap with principles of Trauma Informed Care: safety (physical and psychological), trustworthiness and transparency, peer support, collaboration and mutuality, and empowerment, voice and choice. We propose that a greater understanding and implementation of these principles may allow the medical team to more effectively communicate with and involve parents in the care of infants with HIE in the NICU.

Ventilator-Free Days in Neonatal Ventilator-Associated Pneumonia

Objective To compare the ventilator-free days (VFDs) at day 28 and the short-term outcomes in neonates with and without ventilator-associated pneumonia (VAP and non-VAP groups). Study Design We performed a cohort study in a Thai neonatal intensive care unit between 2014 and 2020 to identify the VFDs in VAP and non-VAP neonates. Univariate and multivariate analyses were performed. Results The incidences of VAP rates were 5.76% (67/1,163 neonates) and 10.86 per 1,000 (92/8,469) ventilator days. The medians (interquartile ranges) of gestational age and birth weight in the VAP vs non-VAP groups were 31 (27–35) vs 34 (30–38) weeks, and 1,495 (813–2,593) vs 2,220 (1,405–2,940) grams (p < 0.001 both), respectively. The medians (interquartile ranges) of VFDs at 28 days in the VAP and non-VAP groups were 5 (0–16) and 24 (20–26) days (<i>p</i> < 0.001). From the univariate analysis, the lower VFDs, longer ventilator days, and higher rates of moderate to severe bronchopulmonary dysplasia (BPD), postnatal steroids for BPD, length of stay, and daily hospital cost in the VAP group were significantly higher than in the non-VAP group. From the multivariate analysis, the VAP group had significantly lower VFDs (regression coefficient = -10.99, standard error = 1.11, <i>p</i> < 0.001) and higher BPD (adjusted risk ratio 18.70; 95% confidence interval 9.17–39.5, <i>p</i> < 0.001) than the non-VAP group. <b>Conclusion</b> Neonatal VAP lead to lower VFDs and a higher frequency of BPD. A multimodal strategy with a VAP prevention bundle care should be used in indicated cases to reduce the occurrence of neonatal VAP.

Comparison of Three Different Cord Clamping Techniques Regarding Oxidative-antioxidative Capacity in Term Newborns

Objective As newborns are exposed to oxidative stress during delivery, cord clamping techniques play significant role on antioxidant status. In this study, we aimed to show the relationship between early cord clamping (ECC), delayed cord clamping (DCC) and cut umblical cord milking (C-UCM) techniques with total oxidant capacity (TOC), total antioxidant capacity (TAC) and peroxynitrite levels. Study Design Sixty-nine term infants were selected with APGAR score of 7 and above in the first and fifth minutes. The mothers of all infants had uncomplicated pregnancy, had no congenital anomaly, and delivered by cesarean section. Newborns were randomised to one of three groups: ECC (n: 23), DCC (n: 23) or C-UCM (n: 23). After all newborn babies were taken under radiant heater, blood samples were collected from the umbilical cord. The plasma samples were then frozen and stored at -80 °C until analysis and TOC, TAC and peroxynitrite levels were studied. Results The ages of the mothers participating in the study were between 17 and 42, with an average of 29.14 ± 6.28. 30 (43.5%) of the babies were girls and 39 (56.5%) were boys. The 5th minute APGAR score of the babies in early cord clamping group was significantly lower than the babies in delayed cord clamping and cut cord milking group (p = 0.034; p = 0.034; p <0.05). The TOC, OSI and Peroxynitrite measurements of three groups did not differ statistically. The TAC value of the C-UCM group was significantly higher than the patients with the ECC and DCC group (p = 0.002; p = 0.019; p <0.05). Conclusion C-UCM and DCC would be feasible methods by increasing antioxidant status and providing protective effect on the future health of the term newborns,

How do Clinicians View the Process of Shared Decision-Making with Parents Facing Extremely Early Deliveries? Results from an Online Survey

Objective The objective of this study was to better understand how neonatology (Neo) and maternal–fetal medicine (MFM) physicians approach the process of shared decision-making (SDM) with parents facing extremely premature (<25 weeks estimated gestational age) delivery during antenatal counseling. Study Design Attending physicians at U.S. centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. Preferences for conveying information are reported elsewhere. Here, we report clinicians' self-assessments of their ability to engage in deliberations and decision-making and perceptions of what is important to parents in the SDM process. Multivariable logistic regression analyzed respondents' views with respect to individual characteristics, such as specialty, gender, and years of clinical experience. Results In total, 74 MFMs and 167 Neos representing 94% of the 81 centers surveyed responded. Neos versus MFMs reported repeat visits with parents less often (<0.001) and agreed that parents were more likely to have made delivery room decisions before they counseled them less often (p < 0.001). Respondents reported regularly achieving most goals of SDM, with the exception of providing spiritual support. Most respondents reported that spiritual and religious views, risk to an infant's survival, and the infant's quality of life were important to parental decision-making, while a physician's own personal choice and family political views were reported as less important. While many barriers to SDM exist, respondents rated language barriers and family views that differ from those of a provider as the most difficult barriers to overcome. Conclusion This study provides insights into how consultants from different specialties and demographic groups facilitate SDM, thereby informing future efforts for improving counseling and engaging in SDM with parents facing extremely early deliveries and supporting evidence-based training for these complex communication skills. Key Points

Effect of Endotracheal Suctioning on Infants Born through Meconium-Stained Amniotic Fluid: A Meta-Analysis

Objective Meconium is a common finding in amniotic fluid and placental specimens, particularly in term and post-term pregnancies. The objective of this paper was to perform a meta-analysis to examine the impact of endotracheal suctioning on the occurrence of meconium aspiration syndrome (MAS), mortality, and complications. Study Design PubMed, EMBASE, and the Cochrane library were systematically searched for comparative studies. Odds ratios (ORs), weighted mean differences (WMDs), and corresponding 95% confidence intervals (CIs) were used to compare the outcomes. Results Twelve studies were included in the meta-analysis. There were no significant impacts of endotracheal suctioning on the occurrence of MAS (OR = 3.05, 95% CI: 0.48–19.56), mortality (OR = 1.25, 95% CI: 0.35–4.44), the need for mechanical ventilation (OR = 4.20, 95% CI: 0.32–54.72), the occurrence of pneumothorax (OR = 0.99, 95% CI: 0.34–2.85), persistent pulmonary hypertension of the newborn (PPHN), (OR = 1.31, 95% CI: 0.58–2.98), hypoxic-ischemic encephalopathy (HIE) (OR = 0.82, 95% CI: 0.52–1.30), and length of stay (WMD = −0.11, 95% CI: −0.99–0.77). Conclusion Routine endotracheal suctioning at birth is not useful in preventing MAS, mortality, mechanical ventilation, PPHN, HIE, and prolonged length of stay in neonates born through MSAF. Key Points

Neurodevelopmental outcomes following preterm birth and the association with postmenstrual age at discharge

Objective: To 1) define the prevalence of motor, cognitive, and language delays in preterm infants born < 32 weeks estimated gestational age (EGA) and 2) identify the relationship between the timing of discharge from the NICU and neurodevelopmental outcome in early childhood. Study Design: This retrospective study of 176 preterm infants born < 32 weeks EGA and hospitalized in a level IV NICU captured medical factors, including timing of discharge, from the NICU stay. Standardized developmental testing at 1-2 years corrected age was conducted in the newborn follow-up clinic. Results: At 1-2 years corrected age, the sample had an average cognitive composite score of 91.5 ± 17.4, language composite score of 84.5 ± 17.3, and motor composite score of 88.9 ± 18.4. Lower EGA at birth, necrotizing enterocolitis, patent ductus arteriosus, and oxygen requirement for > 28 days were independently associated with higher postmenstrual age (PMA) at NICU discharge. After controlling for known risk factors, higher PMA at discharge was associated with poorer cognitive outcome [p < 0.001, (-0.16, -0.07), β = -0.35], poorer language outcome [p = 0.049 (-0.10, 0.00), β = -0.15] and poorer motor outcome [p < 0.001, (-0.14, -0.05), β = -0.30]. Conclusion: Poorer cognitive, language, and motor outcomes were associated with longer hospitalization, even after controlling for medical risk factors known to be associated with poorer outcome. This provides further evidence for the potential role of the environment that may be impacting the developmental outcomes of infants hospitalized in the NICU.

COVID-19 associated multisystem inflammatory syndrome in a neonate with atypical coronary artery involvement.

Objective The study aimed to report a COVID-19 associated multisystem inflammatory syndrome in children (MIS-C) in a neonate found to have an atypical diffuse thickening in coronary artery walls, whose diagnosis required a multi-imaging approach. Study Design A neonate presented at birth with multiple organ involvement and coronary artery anomalies. A diagnosis of MIS-C associated to COVID-19 was supported by maternal Sars-CoV-2 infection during pregnancy, and by the presence of both IgG against Sars-CoV-2 and Spike-specific memory B cells response in the neonatal blood. Other plausible causes of the multiple organ involvement were excluded. Result At admission, a severe coronary artery dilatation was identified on echocardiography, supporting the diagnosis of MIS-C Kawasaki-like disease; however, coronary artery internal diameters were found to be normal using cardiac computed tomography angiography. At discharge, comparing the two imaging techniques each other, the correct diagnosis resulted to be an abnormal thickening in coronary arterial walls. These findings suggest that the inflammatory process affecting the coronary arterial wall in MIS-C could result not only in typical coronary artery lesions such as dilatation of the lumen or aneurysms development, but also in abnormal thickening of the coronary artery wall. Conclusion. Our case provides an alert for paediatric cardiologists about the complexity to assess coronary artery involvement in MIS-C, and raises the question of whether an abnormal vascular remodeling, with normal inner diameters, is to be considered like coronary artery dilatation for risk stratification.

Cord-blood derived chemistry reference values in preterm infants for sodium, chloride, potassium, glucose, and creatinine

Objectives: Guidelines recommend preterm infants be supported to maintain their serum electrolytes within “normal” ranges. In term babies, cord blood values differed in pathological pregnancies from healthy ones. Study design: We examined cord blood sodium, chloride, potassium, glucose, and creatinine to derive maturity-related reference intervals. We examined associations with gestational age, delivery mode, singleton versus multiple, and prenatal maternal adverse conditions. We compared preterm cord values to term, and to adult reference ranges. Results: There were 591 infants, 537 preterm and 54 term. Preterm cord glucose levels were steady (3.7+/-1.1mmol/l), while sodium, chloride and creatinine increased over GA by 0.17, 0.14 and 1.07 micromol/week respectively (p<0.003). Average preterm cord potassium and chloride were higher than term (p<0.05). Compared to adult reference intervals, cord preterm reference intervals were higher for chloride (100-111 vs 98-106 mmol/l), lower for creatinine (29-84 vs 62-115 micromol/l), more variable for potassium (2.7-7.9 vs. 3.5-5.0 mmol/l) and sodium (130-141 vs. 136-145 mmol/l). Cesarean section was associated with higher potassium and lower glucose; multiple births with higher chloride and creatinine and lower glucose; SGA with lower glucose. Conclusions: Cord blood values vary across the GA range with increases in sodium, chloride and creatinine while glucose remained steady. Average preterm reference values were higher than term values for potassium and chloride. Preterm reference values differed from published adults’ reference values. The varies across GA and by delivery mode, SGA, and being a multiple, which may have direct implications for neonatal care and fluid management.

Effectiveness of 17-OHP for Prevention of Recurrent Preterm Birth: A Retrospective Cohort Study

Objective 17-α-hydroxyprogesterone caproate (17-OHP) has been recommended by professional societies for the prevention of recurrent preterm birth, but subsequent clinical studies have reported conflicting efficacy results. This study aimed to contribute to the evidence base regarding the effectiveness of 17-OHP in clinical practice using real-world data. Study Design A total of 4,422 individuals meeting inclusion criteria representing recurrent spontaneous preterm birth (sPTB) were identified in a database of insurance claims, and 568 (12.8%) received 17-OHP. Crude and propensity score-matched recurrence rates and risk ratios (RRs) for the association of receiving 17-OHP on recurrent sPTB were calculated. Results Raw sPTB recurrence rates were higher among those treated versus not treated; after propensity score matching, no association was detected (26.3 vs. 23.8%, RR = 1.1, 95% CI: 0.9–1.4). Conclusion We failed to identify a beneficial effect of 17-OHP for the prevention of spontaneous recurrent preterm birth in our observational, U.S. based cohort. Key Points