Stabilization of very low birth weight

infants after delivery

Zbynek Stranak

Institute for the Care of Mother and Child, Prague

3rd Medical Faculty, Charles University, Prague

Czech Republic

Priority in Extremely Low Birth Weight Infants

• Decrease incidence of intraventricular haemorrhage

• Optimal treatment of acute respiratory insufficiency

• Minimalize circulatory dysfunction

• Avoid early and late onset infection including NEC

• Decrease chronic respiratory insufficiency rate

• Appropriate solving of metabolic disturbances

• Facilitate nutrition and growth

PVH-IVH RDS Circulatory Dysfunction EOS/LOS/NEC BPD/CLD Metabolic Disturbances Nutrition and Growth

GOLDEN HOURS: the difference in life and death

LOW-TECH and LOW-COST Interventions

Pre-conception Folic acid supplementation

Antenatal Syphylis screening and treatment

Pre-eclapmsia and eclampsia prevention

Tetanus toxoid immunization

Preventive treatment of malaria

Detection and treatment of bacteriuria

Intrapartum (birth) Antibiotics - PROM

Steroids for preterm labor

Detection and management for breech

Clean delivery practices

Postnatal Resuscitation of newborn babies

Breasfeeding

Prevention and management of hypotermia

Kangaroo, skin to skin

Factors May Injure Preterm Lung During Resuscitation P

regn

ancy

• Infection

• Steroids

• Delayed cord clamping

DR

/NIC

U M

anag

emen

t • High VT

• Oxygen

• Cold Gas

• Dry Gas

• No PEEP

• T Control

• Surfactant Post

nat

al C

are

• MV Strategy

• Infection

• Oxygen

• Nutrition

• PDA

Months Minutes/Hours Months

Background:

• Resuscitation is one of the most frequently performed procedures in the neonatal period

• Since the most recent guidelines from the ILCOR appeared in 2005. Revision: 2010

• Experimental and clinical research has introduced changes regarding the different components of the procedure, with the common denominator being the least aggressive to the baby

Validity of Newborn Examination at DR

Inaccurate value of Apgar score, skin perfusion and heart rate can lead to inappropriate treatment.

Oxygen: how much is too much?

Vento et al: Pediatrics 2009, Aug 10

The SpO2 value in preterm newborn in DR

Kamlin et al. Peduatrics 2006

Intubation

• When is indicated?

• How we are successful?

• Who is best?

Carbine et al., Pediatr.106, 2000 O Donnell et al., Pediatr., 117, 2006

Intubation at Delivery Room (elective, selective, prophylactic, urgent….)

78

90 9085

78

100

53

3943

18

54

29 27

58

23 24 25 26 27

VON 98-00 DR Trial 02-03 Columbia 99-02

CURPAP Trial: Secondary outcomes

Prophylactic Surfactant (N = 105)

nCPAP (N = 103)

Risk Ratio

95% Confidence

Interval

ROP: n(%) Stage > 3: n(%)

30 (28.6) 7 (6.7)

30 (29.1) 7 (6.8)

0.98 0.98

0.65-1.48 0.36-2.70

NEC : n(%) 7 (6.7) 9(8.7) 0.76 0.30-1.90

Sepsis : n(%) 45 (42.9) 43 (41.7) 1.02 0.75-1.40

Mild BPD in survivors: n/N(%) 11 /98 (11.2)

12 /94 (12.8) 0.89 0.41-1.93

Moderate and Severe BPD in survivors: n/N(%)

14/98 (14.3)

11/94 (11.7)

1.22 0.58-2.50

Use of systemic steroids: n(%) 14

(13.3) 11

(10.7) 1.25 0.59-2.62

Sandri F, Stranak Z et al. Pediatrics 2010, June 125

CURPAP Trial: Secondary outcomes

Prophylactic Surfactant (N = 105)

nCPAP (N = 103)

Risk Ratio

95% Confidence

Interval

Pneumothorax: n(%) 7 (6.7) 1 (1.0) 6.82 0.86-53.75

Pulmonary interstitial emphysema: n(%)

3 (2.9) 4 (3.9) 0.74 0.17-3.21

Pulmonary hemorrhage: n(%) 3 (2.9) 2 (1.9) 1.47 0.25-8.76

PVH-IVH: n(%) Grade 3-4: n(%)

21 (20.0) 6 (5.7)

19 (18.4) 8 (7.8)

1.08 0.73

0.62-1.89 0.27-2.03

PDA: n(%) Medically treated Surgically ligated

43 (41.0)

28 (26.7) 6 (5.7)

51 (49.5)

35 (34.0) 3 (2.9)

0.83 0.62-1.10

Sandri F, Stranak Z et al. Pediatrics 2010, June 125

CURPAP Trial: Primary outcome - need for mechanical

ventilation within 5 days

Prophylactic Surfactant (N = 105)

nCPAP (N = 103)

Risk Ratio 95%

Confidence Interval

Gestational age 25-28+6 wk - n (%) 33 (31.4%) 34 (33.0%) 0.95 0.64-1.41

Gestational age 25-26 wk - n (%) 15 (47%) 12 (39%) 1.21 0.68-2.16

Gestational age 27-28+6 wk - n (%) 18 (24.7%) 22 (30.6%) 0.81 0.47-1.37

Sandri F, Stranak Z et al. Pediatrics 2010, June 125

Our Patients are Resilient, Fortunately……

• Most infants need only stabilisation and/or adaptation

• A little or Oxygen/Air is all that is needed for infants needing the help

Doctor, please do not harm !!! Adapted from Jobe A, Ipokrates - Prague 2009

CONCLUSION

The Golden Hour of Thermoregulation: Prevention of

Delivery Room-Associated Hypothermia

DR - Associated Hypothermia is any body temperature less than 36.50 degrees on admission to the NICU for inborn babies!

WHO - Background

• Prevention and management of hypothermia is one of the key interventions for reducing neonatal mortality and morbidity.

• According to UNICEF, such interventions can help reduce neonatal mortality or morbidity by 18%–42%.

• Improvement in Infant Mortality Rate last 10 years

– 24 weeks: improved survival rate from 25% to 40%

– 25 weeks: improved survival rate from 40% to 60%

– No improvement in DR - associated mortality (Still impacts ~ 15% of the live-born)

•No improvement in morbidity

Annual Summary of Vital Statistics: 2006. Pediatrics, April 1, 2008

Intrauterine Thermal Homeostasis

Is the uterus a “bun-warmer” or an air conditioner?

Factors which impact heat

balance in utero:

Uterine wall temperature Maternal-fetal blood temperature

gradient Placental vessel temperature Amniotic fluid temperature Fetal core ~ 0.5 ºC > maternal

core temperature Graphic ©2002 Nucleus Communications

Bhatt, D. et al. PAS 2007; E-PAS2007:617933.23

Admission Temperatures Across Birth-weight

Birthweight, g # < 36.5C

< 750 g, n (%) 15/15 (100%)

751-1000 g, n (%) 20/25 (80%)

1001-1250 g, n (%) 23/28 (82%)

1251-1500 g, n (%) 16/22 (73%)

1501-2500 g, n (%) 71/164 (43%)

> 2500 g, n (%) 57/258 (22%)

Laptook, A. R. et al. Pediatrics 2007;119:e643-e649

Admission Temperatures - All Gestations

GA, Weeks N BW (M+SD),

Grams < 35C, % < 36C, %

<24 187 598 + 118 43.9 71.1

24 397 655 + 100 33.8 64.2

25 468 751 + 130 20.5 57.1

26 539 840 + 163 13.2 44.2

27 609 977 + 182 10.7 41.5

28 643 1088 + 201 9.6 38.3

For each 1°C decrease in admission temperature, chances of survival are decreased by 10%! (Nedrelow) For each 1°C decrease in admission temperature, late-onset sepsis is increased by 11% & odds of death are increased by 28%! (Laptook)

DR – Associated Hypothermia Consequences

Clinical Consequences of Heat Loss

Potential risks of heat loss in infants

• Depletion of surfactant • Hypoxia • Hypoglycaemia • Metabolic disorders • Increased utilisation of calorific reserves • Acidosis • Increased neonatal morbidity

• Warm resuscitation surface • Warm transportation equipment

• Plastic bags

What is “Normal” Temperature? •A single, discrete value is mythical! •Definition of “normal” :

– Normal range: 36.5 - 37.5oC – Potential cold stress: 36.0 to 36.5oC

• Have concern

– Moderate hypothermia: 32.0 to 36.0oC • Danger, immediately warm infant

– Severe hypothermia: < 32.0oC • Outlook grave • Skilled care urgently needed

World Health Organization, 1997

Delayed cord clamping/milking

• Rationale: – Improve circulatory parameters during transitional period

• For uncompromised babies, a delay in cord clamping of at least 1min from the complete delivery of the infant, is now recommended

• As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who are severely compromised at birth

Reactions to Cold

Voluntary

• None • Adding clothing layers

• Posture:

Rubbing hands

Curling up

Crossing arms across chest

Involuntary

• Limited non-shivering thermogenesis

• “Goose-pimples”

• Shivering

• Peripheral vasoconstriction

• Non-shivering thermogenesis

INFANT ADULT

Thermal Balance at the Beginning of Life

Convection Radiation

Conductive Heat Loss

Evaporation

Why are Newborns Prone to Heat Loss?

•Increased insensible water loss •Thin epidermis in preterms •Large surface area compared to body mass •Lack of insulating and brown fat •Extended posture •Non-shivering thermogenesis may be insufficient to compensate for heat loss •Sick, hypoxic babies will have limited ability to increase heat production

FROM BIRTH TO THE NEONATAL UNIT: A COLD JOURNEY?

Mannheim Study - Rationale

•Compared Giraffe OmniBed to traditional transport incubator

– Admission temperature

– Number of transfers between beds

– Time from DR to NICU

– Physiological/behavioral stress of subjects

Permissions on File

Mannheim Study - Demographic characteristics

Characteristic (Range)

Traditional Transport

(N=50)

Giraffe OmniBed Transport

(N=50) Gender (M/F)

22/28

24/26

Average Gestational Age (weeks)

33+2 w (24+1to 41+4)

34+1 (24+3 to 41+1)

Average Weight (grams)

1780.2 g (530 to 4120)

1934.5 (470 to 3890)

Prematurity

28/50

31/50

Diaphragmatic Hernia (CDH)

18/50

17/50

Congenital Cystic Adenomatoid Malformation

(CCAM)

1/50

2/50

Other Diagnoses

3/50

0/50

Mannheim Study - Summary

Characteristic (Range)

Traditional Transport

(N=50)

Giraffe OmniBed Transport

(N=50)

Total Transport Time (minutes,m) Team to

DR; Returns with Baby

56.3 m (Preterms)

42.7 m (Preterms) *

62.1 m (Others)

46.8 m (Others) *

Birth to NICU Admission Time

(minutes. m)

33.9 m (Preterms)

25.3 (Preterms) *

29.1 m (Others)

27.7 m (Others)

*p<0.0001, Welch-Satterthwaite t-test

Hypothermia - Conclusion

•Hypothermia is preventable!

•Know your facility data

•Adopt actions that attenuate admission hypothermia

– Raise the room temperature

– Place occlusive wrap @ point of delivery • Consider chemical blankets, if staff stuggles with polyethylene wrap

– Use developmental care from birth • Swaddling, appropriate handling

– Consider use of a single device from DR to NICU to further improve thermal stability

Resuscitation of babies at birth: ILCOR 2010

• „For uncompromised babies, a delay in cord clamping of at least 1min from the complete delivery of the infant, is now recommended.“

• „As yet there is insufficient evidence to recommend an appropriate time for clamping the cord in babies who are severely compromised at birth.“

• „For term infants, air should be used for resuscitation at birth. If, despite effective ventilation, oxygenation (ideally guided by oximetry) remains unacceptable, use of a higher concentration of oxygen should be considered.“

Resuscitation of babies at birth: ILCOR 2010

• „Preterm babies less than 32 weeks gestation may not reach the same transcutaneous oxygen saturations in air as those achieved by term babies. Therefore blended oxygen and air should be given judiciously and its use guided by pulse oximetry. If a blend of oxygen and air is not available use what is available“

Delivery room management in 24-30 wks

„Well being“ infants

INSURE

„Bad“ infants

Spontaneously breathing

NCPAP

PPV with PEEP

INSURE

CPAP failure criteria for Early Surfactant

Success on NCPAP

Active weaning

Arteficial Ventilation

15 min

DR

NICU

75-80% patients 20-25% patients

Strategy of Arteficial Ventilation

0

1

2

3

4

5

6

7

PTV+VG PTV IPPV

HFV

1970 1980 1990 2000

LLV HLV OLV

PEEP

Tidal Volume

SURFACTANT

Optimal Lung Volume and Trigger Ventilation

Ventilatory Induced Lung Injury:

Role of Tidal Volume

Severe Respiratory Morbidity

58

47

12

4,4

0

10

20

30

40

50

60

70

2002-2005 2006-2009

BPD/CLD Air leak

Ventilatory Strategy:

•NCPAP

•SIMV+VG

•A/C, SIMV

•HFOV •INO

Singapore Med 2008; 49(3) : 199

Resuscitation of babies at birth: ILCOR 2010

• „Preterm babies of less than 28 weeks gestation should be completely covered up to their necks in a food-grade plastic wrap or bag, without drying, immediately after birth. They should then be nursed under a radiant heater and stabilised. They should remain wrapped until their temperature has been checked after admission. For these infants delivery room temperatures should be at least 26 ◦C.“

Resuscitation of babies at birth: ILCOR 2010

• „If adrenaline is given then the intravenous route is recommended using a dose of 10–30 μg/kg. If the tracheal route is used, it is likely that a dose of at least 50–100 μg/kg will be needed to achieve a similar effect to 10 μg/kg intravenously.“

Resuscitation of babies at birth: ILCOR 2010

• Detection of exhaled carbon dioxide in addition to clinical assessment is recommended as the most reliable method to confirm placement of a tracheal tube in neonates with spontaneous circulation

• Newly born infants born at term or near-term with evolving moderate to severe hypoxic–ischaemic encephalopathy should, where possible, be treated with therapeutic hypothermia. This does not affect immediate resuscitation but is important for postresuscitation care

Necrotizing Enterocolitis

Early use of colostrum (3-6 hrs) after delivery in ELBW.

14

7

0

2

4

6

8

10

12

14

16

2002-2007 2008-2009

N=266 vs N=134

Conclusion I • Babies should be kept warm, avoiding suctioning as a

general rule

• Adjusting pressure, volume and oxygen to the minimum to achieve stabilisation without causing harm to the airways or oxidative stress

• Applying all the available technology in the delivery room before transportation to the neonatal intensive care unit

• The response to ventilation should primarily be assessed by the heart rate

Vento et al. Semin Fetal Neonatal Med. 2010 May 5

Conclusion II • Babies of gestational age ≥ 32 weeks should be

ventilated initially with 21% oxygen

• Babies of gestational age and if <32 weeks should be ventilated initially with 21-30% oxygen

• Intubation, chest compressions, use of drugs or volume therapy are rarely needed in term or near term babies in need of resuscitation

• The first minutes of life are decisive, and what we do during these minutes will have unequivocal influence later on

Vento et al. Semin Fetal Neonatal Med. 2010 May 5

Common serious complications in preemies

PVH-IVH/CP BPD/CLD/ROP Sepsis/NEC

Thank you for your attention…