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About 10% of newborns require some degree of assistance to begin their breathing, and 1% necessitates extensive resuscitation. Sick neonates are exposed to a number of invasive life-saving procedures as part of their management, either for investigation or for treatment. In order to support the neonates with the maximum possible benefits and reduce iatrogenic morbidity, health-care providers performing these procedures must be familiar with their indications, measurements, and potential complications. Hence, the aim of this review is to summarise ten of the main neonatal intensive care procedures with highlighting of their indications, measurements, and complications. They include the umbilical venous and arterial catheterizations and the intraosseous line which represent the principal postnatal emergency vascular accesses; the peripherally inserted central catheter for long-term venous access; the endotracheal tube and laryngeal mask airway for airway control and ventilation; chest tube for drainage of air and fluid from the thorax; and the nasogastric/orogastric tube for enteral feeding. Furthermore, lumber puncture and heel stick were included in this review as very important and frequently performed diagnostic procedures in the neonatal intensive care unit. [ABSTRACT FROM AUTHOR]

A current view that delayed cord clamping (DCC) results in greater haemodynamic stability at birth than immediate cord clamping (ICC) is based on comparison of DCC vs. ICC followed by an asphyxial (∼2 min) cord clamp-to-ventilation (CC–V) interval. More recent data suggest that relatively minor perinatal differences in heart rate and blood pressure fluctuations exist between DCC and ICC with a non-asphyxial (<45 s) CC–V interval, but it is unknown how ventricular output and central arterial blood flow effects of DCC compare with those of non-asphyxial ICC. Anaesthetized preterm fetal lambs instrumented with flow probes on major central arteries were ventilated for 97 (7) s (mean (SD)) before DCC at birth (n = 10), or underwent ICC 40 (6) s before ventilation (n = 10). Compared to ICC, initial ventilation and DCC was accompanied by (1) redistribution of a similar level of ascending aortic flow away from cephalic arteries and towards the aortic isthmus after ventilation; (2) a lower right ventricular output after cord clamping that was redistributed towards the lungs, thereby maintaining the absolute contribution of this output to a similar increase in pulmonary arterial flow after birth; and (3) a lower descending thoracic aortic flow after birth, related to a more rapid decline in phasic right-to-left ductal flow only partially offset by increased aortic isthmus flow. However, systemic arterial flows were similar between DCC and non-asphyxial ICC within 5 min after birth. These findings suggest that compared to non-asphyxial ICC, initial ventilation with DCC transiently redistributed central arterial flows, resulting in lower perinatal systemic arterial, but not pulmonary arterial, flows. [ABSTRACT FROM AUTHOR]

Aim: Heart rate (HR) is the most important parameter to evaluate newborns' clinical condition and to guide intervention during resuscitation at birth. The present study aims to compare the accuracy of NeoBeat dry‐electrode ECG for HR measurement with conventional ECG and pulse oximetry (PO). Methods: Newborns with a gestational age ≥32 weeks and/or birth weight ≥1.5 kg were included when HR evaluation was needed. HR was simultaneously measured for 10 min with NeoBeat, PO and conventional ECG. Results: A total of 18 infants were included (median (IQR) gestational age 39 (36–39) weeks and birth weight 3 150 (2 288–3 859) grams). Mean (SD) duration until NeoBeat obtained a reliable signal was 2.5 (9.0) s versus 58.5 (171.0) s for PO. Mean difference between NeoBeat and ECG was 1.74 bpm (LoA −4.987–8.459 and correlation coefficient 0.98). Paired HR measurements over 30‐s intervals revealed no significant difference between NeoBeat and ECG. The positive predictive value of a detected HR <100 bpm by NeoBeat compared with ECG was 54.84%, negative predictive value 99.99%, sensitivity 94.44%, specificity 99.99% and accuracy 99.85%. Conclusions: HR measurement with NeoBeat dry‐electrode ECG at birth is reliable and accurate. [ABSTRACT FROM AUTHOR]

Background: This study aimed to delineate the clinical phenotype of patients with 9p deletions, pinpoint the chromosomal breakpoints, and identify the critical region for trigonocephaly, which is a frequent finding in 9p terminal deletion. Methods: We investigated a cohort of nine patients with chromosome 9p terminal deletions who all displayed developmental delay, intellectual disability, hypotonia, and dysmorphic features. Of them, eight had trigonocephaly, seven had brain anomalies, seven had autistic manifestations, seven had fair hair, and six had a congenital heart defect (CHD). Results: Karyotyping revealed 9p terminal deletion in all patients, and patients 8 and 9 had additional duplication of other chromosomal segments. We used six bacterial artificial chromosome (BAC) clones that could identify the breakpoints at 17–20 Mb from the 9p terminus. Array CGH identified the precise extent of the deletion in six patients; the deleted regions ranged from 16 to 18.8 Mb in four patients, patient 8 had an 11.58 Mb deletion and patient 9 had a 2.3 Mb deletion. Conclusion: The gene deletion in the 9p24 region was insufficient to cause ambiguous genitalia because six of the nine patients had normal genitalia. We suggest that the critical region for trigonocephaly lies between 11,575 and 11,587 Mb from the chromosome 9p terminus. To the best of our knowledge, this is the minimal critical region reported for trigonocephaly in 9p deletion syndrome, and it warrants further delineation. [ABSTRACT FROM AUTHOR]

Aim: This study reviews clinical outcomes after initiating a routine policy of preterm respiratory stabilisation using nasal high flow (HF) in the delivery room (DR). Method: This was a retrospective observational cohort study in a single‐centre neonatal intensive care unit and included all neonates born before 32 weeks of gestation between 1 April 2015 and 31 March 2020. Stabilisation measures and outcomes were recorded including oxygen requirements, admission temperature, surfactant administration, invasive ventilation within 72 h of birth, bronchopulmonary dysplasia (BPD) and death. Results: There were 491 eligible babies during the 5‐year epoch. 292 were stabilised using HF in the DR. The median admission temperature in babies transferred on HF was 36.8°C, and the median FiO2 at admission was 25%. 45% of these infants received surfactant. At 72 postnatal hours, 78% were either sustained on HF or were either self‐ventilating in air (SVIA) or receiving low‐flow nasal cannula (LFNC) respiratory support. 27% were intubated within 7 days. At 36 weeks postmenstrual age, 36% of survivors had BPD. Conclusion: We have demonstrated that preterm babies <32 weeks can be effectively stabilised on HF in the DR. [ABSTRACT FROM AUTHOR]

Background: The neutral or sniffing position is advised for mask ventilation in neonates to avoid airway obstruction. As definitions are manifold and often unspecific, we wanted to investigate the reliability and reproducibility of angle measurements based on facial landmarks that may be used in future clinical trials to determine a hypothetical head position with minimal airway obstruction during mask ventilation. Methods: In a prospective single‐center observational study, 2D sagittal photographs of 24 near‐term and term infants were taken, with five raters marking facial landmarks to assess interobserver agreement of those landmarks and angle δ, defined as the angle between the line parallel to the lying surface and the line crossing Subnasale (Sn) and Porion' (P'). Angle δ was assessed in sniffing (δsniff) and physiologic (δphys) head position, the former based on a published, yet poorly defined head position where the tip of the nose aligns to the ceiling with the head in a supine, relaxed mid‐position. Results: Infants had a mean (SD) gestational age of 37.3 (2.3) weeks. Angle δ could be determined in all 48 images taken in either the sniffing or the physiological head position. Interobserver correlation coefficient was 98.6 for all measurements independent of head position. Angle δsniff was 90.5° (5.7) in the sniffing position. Conclusions: This study provides a new measuring technique using an angle that is reproducible and reliable and may be used in future studies to correlate head position with airway obstruction. [ABSTRACT FROM AUTHOR]

Aim: Neonatal intensive care unit (NICU) nurses provide tactile stimulation to terminate apnoea in preterm infants, but guidelines recommending specific methods are lacking. In this study, we evaluated current methods of tactile stimulation performed by NICU nurses. Methods: Nurses were asked to demonstrate and explain their methods of tactile stimulation on a manikin, using an apnoea scenario. All nurses demonstrated their methods three times in succession, with the manikin positioned either prone, supine or lateral. Finally, the nurses were asked how they decided on the methods of tactile stimulation used. The stimulation methods were logged in chronological order by describing both the technique and the location. The nurses' explanations were transcribed and categorised. Results: In total, 47 nurses demonstrated their methods of stimulation on the manikin. Overall, 57 different combinations of technique and location were identified. While most nurses (40/47, 85%) indicated they learned how to stimulate during their training, 15/40 (38%) of them had adjusted their methods over time. The remaining 7/47 (15%) stated that their stimulation methods were self‐developed. Conclusion: Tactile stimulation performed by NICU nurses to terminate apnoea was highly variable in both technique and location, and these methods were based on either prior training or intuition. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the relationship between clinical assessment of infant colour and oxygen saturation at birth in a low‐resource setting. Methods: Classification of infant colour (cyanotic, pink or unclear) by midwives was compared to pulse‐oximeter data at 60‐90‐120‐300 seconds after birth in 60 neonates. Results: Overall, oxygen saturation increased over time (P <.0001) and was different according to infant colour (P <.0001). Median oxygen saturation in pink infants was 87% at 60 seconds (n = 1), 90% (IQR 83‐91) at 90 seconds (n = 5), 86% (IQR 81‐94) at 120 seconds (n = 11) and 93% (IQR 90‐96) at 300 seconds (n = 20). Median oxygen saturation in cyanotic infants was 60% (IQR 45‐70) at 60 seconds (n = 52), 64% (IQR 52‐69) at 90 seconds (n = 42), 63% (IQR 56‐68) at 120 seconds (n = 35) and 66% (IQR 62‐74) at 300 seconds (n = 22). Median oxygen saturation in unclear‐coloured infants was 57% (IQR 56‐60) at 60 seconds (n = 7), 78% (IQR 71‐81) at 90 seconds (n = 13), 81% (IQR 79‐88) at 120 seconds (n = 14) and 80% (IQR 76‐84) at 300 seconds (n = 18). The proportion of infants with unclear colour ranged from 12% to 30%. Conclusion: The variability of oxygen saturation among pink and cyanotic infants, and the substantial proportion of unclear infant colour, suggest the possible benefit of the availability of pulse oximetry in low‐resource settings. [ABSTRACT FROM AUTHOR]

Aim: Oxygen saturation is frequently monitored with pulse oximetry to assess vital signs in critically ill patients. Optimally, pulse oximetry closely tracks arterial oxygen tension (PaO2 ), which provides guidance in oxygen titration. We investigated whether monitoring peripheral oxygen saturation (SpO2 ) could accurately guide oxygen titration in newborn infants.Methods: Twenty seven thousand two hundred thirty seven SpO2 readings were retrospectively paired with arterial oxygen saturation (SaO2 ) and PaO2 results from blood gas analyses performed in infants with arterial catheters in place.Results: SpO2 overestimated SaO2 readings by 2.9 ± 5.8%. When pulse oximetry readings were within the defined oxygen saturation target range, 7809 (20.9%) SaO2 values were below and 2830 (7.6%) exceeded the target range. In 57% of patients, PaO2 levels < 6 kPa was diagnosed while SpO2 readings were > 90%. PaO2  > 11 kPa was recorded in 19% of cases, when SpO2 readings were < 95%. Infants treated with supplemental oxygen showed a threefold increased risk of hypoxaemia compared to infants breathing room air. Sensitivity and specificity for detecting upper and lower target range limits were fair to good. For SpO2 values below 91%, ISO quality criteria were no longer fulfilled.Conclusions: Based on arterial blood gas analyses as reference, pulse oximetry readings did not fulfil the performance requirements for titrating oxygen in neonatal patients. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this review was to ascertain the impact of thermoregulation quality improvement initiatives (QIs) on the admission temperatures of premature/very‐low‐birth‐weight infants in neonatal intensive care units (NICUs). Methods: A systematic search of databases Cumulative Index to Nursing and Allied Health Literature, Medline, Embase, and the Cochrane library was carried out. Specific inclusion and exclusion criteria were adhered to, with no publication date limitations added. The chosen studies were examined for quality, data were extracted and analysed, before a narrative synthesis was performed. The last search occurred on January 7, 2019, with PRISMA flow diagrams completed for identified studies. Results: Ten studies of varying methodology design were included in this review. Variations of thermoregulation interventions were included in the 10 studies. Nevertheless, all of them demonstrated that admission temperature rates can be significantly improved by implementing a thermoregulation QI. The multidisciplinary team and ongoing education were seen as much needed components to the overall sustainability, and continuing success of the QI's. Practical Implications: This systematic review determines that thermoregulation QIs can positively impact the admission temperatures of premature/very‐low‐birth‐weight infants in the NICU. Prevention of hypothermia is aimed at reducing the risks of developing major neonatal morbidities. The pooling of the results from the 10 studies helps in the sharing of outcome measures and thus, improving quantitative synthesis. More frequent monitoring of the axillary temperature would help in preventing hypothermia and hyperthermia occurring. Ongoing education and staff training are essential for managing thermoregulation successfully. Examining the compliance rates to such quality initiatives, and the variations in interventions would benefit from further research to ensure better standardisation of clinical practice. [ABSTRACT FROM AUTHOR]

Aim: To investigate interinstitutional differences in preterm infant stabilisation between two European tertiary neonatal centres with particular focus on intubation timing, surfactant administration, caffeine therapy and neonatal morbidity and mortality.Methods: Retrospective (2012-2014) study of very low birth weight (VLBW) preterm infants admitted to John Radcliffe Hospital (UK centre) and Charité Medical Centre (German centre). Timing of intubation, surfactant and caffeine administration and respiratory outcomes were examined.Results: Gestational age, birth weight and five-minute Apgar scores of VLBW infants from the UK centre (n = 86) were comparable to those from the German centre (n = 96). Significant differences in antenatal steroid therapy, intubation timing and surfactant therapy were noted. Timing of caffeine initiation differed significantly between centres (median 0 [0-2.5] UK vs. 2 [1.5-4] days German centre); however, caffeine was discontinued at a similar corrected gestational age of 34.7 weeks. Mechanical ventilation was significantly longer at the UK centre, but there was no difference in bronchopulmonary dysplasia (BPD) (44% UK vs. 36% German centre) or mortality (15% UK vs. 13% German centre).Conclusion: Timing of primary intubation and caffeine therapy differed significantly between centres. However, earlier intubation and caffeine administration in the UK centre were not associated with a changed incidence of BPD. [ABSTRACT FROM AUTHOR]

The Japan Resuscitation Council joined the International Liaison Committee on Resuscitation (ILCOR) as a member of the Resuscitation Council of Asia in 2006. In 2007, the Japan Society of Perinatal and Neonatal Medicine (JSPNM), which is a member of an affiliated body, launched the Neonatal Cardiopulmonary Resuscitation (NCPR) program as an authorized project to ensure that all staff involved in perinatal and neonatal medicine can learn and practice neonatal cardiopulmonary resuscitation based on the Consensus on Science with Treatment Recommendations developed by ILCOR. The content of courses in the NCPR program is based on the NCPR guidelines. These guidelines are revised by the Japan Resuscitation Council according to the Consensus on Science with Treatment Recommendations, which is updated by ILCOR every 5 years. The latest updated edition in Japanese was published in 2016 and we translated these Japanese guidelines to English in 2018. Here, we introduce a summary of the NCPR guidelines 2015 in Japan. The NCPR 2015 algorithm has two flows, "lifesaving flow" and "stabilization of breathing flow" at the first branching point after the initial step of resuscitation. [ABSTRACT FROM AUTHOR]

Objective: To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress.Design: Prospective observational study.Setting: University hospital.Sample: CBG from 97 VDs and 124 CDs without fetal distress.Methods: Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs.Main Outcome Measures: Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO2 ), partial pressure of carbon dioxide (pCO2 ), pH, and postpartum haemorrhage.Results: Arterial cord blood pH, bicarbonate ( HCO3- , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO3-  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO3-  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO2 increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit.Conclusions: After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs.Tweetable Abstract: By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively. [ABSTRACT FROM AUTHOR]

Aim: Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks.Methods: A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations.Results: Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed.Conclusion: An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae. [ABSTRACT FROM AUTHOR]

Aim: This study compared how non-invasive respiratory support (NRS) was provided in neonatal units in Italy and the UK.Methods: An NRS questionnaire was sent to tertiary neonatal centres, identified by national societies, from November 2015 to May 2016.Results: Responses were received from 49/57 (86%) UK units and 103/115 (90%) Italian units. NRS was started in the delivery room by 61% of UK units and 85% of Italian units. In neonatal intensive care units, 33% of UK units used nasal high-flow therapy (HFT) as primary support, compared to 3% in Italy. Nasal continuous positive airway pressure (CPAP) was used in 57% of UK units and 90% of Italian units. The commonest starting flow rate on nasal HFT for term and preterm infants was 6 L/min in the UK, while Italian units mainly used this flow for term infants. In the UK, 67% of units decreased nasal HFT by 1 L/min per day. In Italy, infants on nasal CPAP were weaned by 1 cm H2 O per day in 39% of units.Conclusion: The way that NRS was managed for very preterm infants differed between the UK and Italy, reflecting a lack of evidence on optimal NRS and the use of local protocols. [ABSTRACT FROM AUTHOR]

Aim: The practice of providing advanced resuscitative measures to infants born at borderline viability (23-25+6 weeks gestation) varies among clinicians due to perception of futility. The aim of our study was to compare mortality and major morbidities in infants born at borderline viability who did not receive cardiopulmonary resuscitation (CPR) in the delivery room (No DR-CPR) as compared to those who did (DR-CPR).Methods: A retrospective analysis of prospectively collected data of infants born between 23 and 25+6 weeks gestation who were resuscitated at birth at the study centre or admitted to neonatal intensive care unit from peripheral hospitals, over 8 years (2007-2014). The primary outcome was survival, free of disability at 2 years corrected age and secondary outcomes were survival at discharge and neonatal morbidities.Results: Of 123 infants in the study cohort, 21 received DR-CPR. In unadjusted analysis, there was increased mortality rate in the DR-CPR group which was statistically insignificant (26.5 vs. 42.9%, P = 0.15). After adjustment for potential confounders, there was no significant difference in the mortality rate with odds ratio of 1.10 (confidence interval: 0.34-3.53, P = 0.86). Among infants who received DR-CPR for >2 min, the mortality rate was significantly higher (25.2 vs. 56.3%, P = 0.01). Survival free of disability was similar in two groups (50.9 vs. 47.6%, P = 0.78).Conclusions: Among infants born at borderline viability, the vast majority of infants did not receive CPR and, if CPR was prolonged for >2 min, mortality was increased. Among survivors of the small DR-CPR group, early neurodevelopmental outcomes were comparable to the No DR-CPR group. [ABSTRACT FROM AUTHOR]

Aim: This study investigated the different strategies used in 11 European countries to prevent hypothermia, which continues to affect a large proportion of preterm births in the region.Methods: We examined the association between the reported use of hypothermia prevention strategies in delivery rooms and body temperatures on admission to neonatal intensive care units (NICUs) in 5861 infants born at 22 + 0 to 31 +6 weeks of gestation. The use of plastic bags, wraps, caps, exothermic heat and mattresses was investigated.Results: The proportion of infants born in units that systematically used one or more hypothermia prevention strategies was 88.2% and 50.9% of those infants were hypothermic on admission to NICUs. Of the 9.6% born in units without systematic hypothermia prevention, 73.2% were hypothermic. Only 2.2% of infants were born in units with no reported prevention strategies. Lower gestational age increased the probability of hypothermia. No significant differences were found between the various hypothermia prevention strategies. Hyperthermia was seen in 4.8% of all admitted infants.Conclusion: Very preterm infants had lower risks of hypothermia on NICU admission if the unit used systematic prevention strategies. All the strategies had similar effects, possibly due to implementation rather than a strategy's specific efficacy. [ABSTRACT FROM AUTHOR]

Aim: This study analysed tactile stimulation during neonatal transition and resuscitation in preterm and term neonates born by Caesarean delivery. It examined the frequency, location and body region, duration and possible effects of stimulation on heart rate and arterial oxygen saturation (SpO2 ).Methods: Two independent investigators analysed video recordings of tactile stimulation on term and preterm neonates during neonatal transition from January 2012 to December 2014. They were recorded during a prospective observational study and randomised controlled trial at a tertiary centre, the Medical University of Graz, Austria. SpO2 and heart rate were continuously recorded. Data on the frequency, body region and duration of stimulation were collected. To investigate the possible effects of stimulation, SpO2 and heart rate were compared before and after stimulation.Results: Term infants received tactile stimulation more than once, and it tended to start later, last longer and be applied in more locations than in preterm infants. Only preterm infants showed a significant increase in SpO2 after stimulation and heart rates did not show any significant changes in either group.Conclusion: Tactile stimulation was applied in different ways to preterm and term infants during neonatal transition and SpO2 showed a significant increase in preterm infants. [ABSTRACT FROM AUTHOR]

Background: Approximately 5%-10% of newly born babies need intervention to assist transition from intra- to extrauterine life. All providers in the delivery ward are trained in neonatal resuscitation, but without clinical experience or exposure, training competency is transient with a decline in skills within a few months. The aim of this study was to evaluate whether neonatal resuscitations skills and team performance would improve after implementation of video-assisted, performance-focused debriefings.Methods: We installed motion-activated video cameras in every resuscitation bay capturing consecutive compromised neonates. The videos were used in debriefings led by two experienced facilitators, focusing on guideline adherence and non-technical skills. A modification of Neonatal Resuscitation Performance Evaluation (NRPE) was used to score team performance and procedural skills during a 7 month study period (2.5, 2.5 and 2 months pre-, peri- and post-implementation) (median score with 95% confidence interval).Results: We compared 74 resuscitation events pre-implementation to 45 events post-implementation. NRPE-score improved from 77% (75, 81) to 89% (86, 93), P < 0.001. Specifically, the sub-categories "group function/communication", "preparation and initial steps", and "positive pressure ventilation" improved (P < 0.005). Adequate positive pressure ventilation improved from 43% to 64% (P = 0.03), and pauses during initial ventilation decreased from 20% to 0% (P = 0.02). Proportion of infants with heart rate > 100 bpm at 2 min improved from 71% pre- vs. 82% (P = 0.22) post-implementation.Conclusion: Implementation of video-assisted, performance-focused debriefings improved adherence to best practice guidelines for neonatal resuscitation skill and team performance. [ABSTRACT FROM AUTHOR]

Aim: To collate and assess international clinical practice guidelines (CPG) to determine current recommendations guiding oxygen management for respiratory stabilisation of preterm infants at delivery.Methods: A search of public databases using the terms 'clinical practice guidelines', 'preterm', 'oxygen' and 'resuscitation' was made and complemented by direct query to consensus groups, resuscitation expert committees and clinicians. Data were extracted to include the three criteria for assessment: country of origin, gestation and initial FiO2 and target SpO2 for the first 10 minutes of life.Results: A total of 45 CPGs were identified: 36 provided gestation specific recommendations (<28 to <37 weeks) while eight distinguished only between 'preterm' and 'term'. The most frequently recommended initial FiO2 were between 0.21 and 0.3 (n = 17). Most countries suggested altering FiO2 to meet SpO2 targets recommended by expert committees, However, specific five-minute SpO2 targets differed by up to 20% (70-90%) between guidelines. Five countries did not specify SpO2 targets.Conclusion: CPG recommendations for delivery room oxygen management of preterm infants vary greatly, particularly in regard to gestational ages, initial FiO2 and SpO2 targets and most acknowledge the lack of evidence behind these recommendations. Sufficiently large and well-designed randomised studies are needed to inform on this important practice. [ABSTRACT FROM AUTHOR]

Aim: Asphyxiated neonates should be resuscitated with air, but it remains unclear if oxygen supplementation is needed in ineffectively ventilated newborn infants. We studied the return of spontaneous circulation (ROSC) with oxygen or air in an experimental model of inadequate ventilation.Methods: Asphyxia was induced in 16 newborn piglets until their heart rate was <60 bpm or mean arterial pressure (MAP) <30 mmHg. During the first 10 minutes of resuscitation, they received one breath per minute of oxygen (n = 8) or air (n = 8). Tidal volume was 7.5 mL/kg. If MAP was <30 mmHg for 15 seconds, closed-chest cardiac massage (CCCM) was performed for 45 seconds. From 10 minutes onward, all piglets received normal ventilation with air. ROSC was defined as a heart rate >150 bpm, MAP >40 mmHg and no subsequent CCCM.Results: Before resuscitation, the median arterial pH was 6.73. At 10 minutes, no piglets in the oxygen group needed CCCM, while all did in the air group (p < 0.001). The median time to ROSC was 60 seconds with oxygen and 845 seconds with air (p < 0.001). No brain tissue hyperoxia occurred.Conclusion: When ventilation was inadequate, one oxygen breath reduced time to ROSC in piglets with severe metabolic and respiratory acidosis. [ABSTRACT FROM AUTHOR]

To better understand the molecular functions of the master stress-response regulator AtfA in Aspergillus nidulans, transcriptomic analyses of the atfA null mutant and the appropriate control strains exposed to menadione sodium bisulfite- (MSB-), t-butylhydroperoxide- and diamide-induced oxidative stresses were performed. Several elements of oxidative stress response were differentially expressed. Many of them, including the downregulation of the mitotic cell cycle, as the MSB stress-specific upregulation of FeS cluster assembly and the MSB stress-specific downregulation of nitrate reduction, tricarboxylic acid cycle, and ER to Golgi vesicle-mediated transport, showed AtfA dependence. To elucidate the potential global regulatory role of AtfA governing expression of a high number of genes with very versatile biological functions, we devised a model based on the comprehensive transcriptomic data. Our model suggests that an important function of AtfA is to modulate the transduction of stress signals. Although it may regulate directly only a limited number of genes, these include elements of the signaling network, for example, members of the two-component signal transduction systems. AtfA acts in a stress-specific manner, which may increase further the number and diversity of AtfA-dependent genes. Our model sheds light on the versatility of the physiological functions of AtfA and its orthologs in fungi. [ABSTRACT FROM AUTHOR]

New Australian and New Zealand Neonatal Resuscitation guidelines reflect recent advances in neonatal resuscitation science, as critically appraised by the International Liaison Committee on Resuscitation. Substantial changes since the 2010 guidelines include: (i) updates to the Newborn Resuscitation Flowchart to include a greater emphasis on maintaining normal body temperature, and to emphasise the importance of beginning assisted ventilation by 1 min in infants who have absent or ineffective spontaneous breathing; (ii) updates to the physiology of the normal perinatal transition that resuscitation is trying to restore; (iii) recommendations for more frequent reinforcement of training, and for structured feedback for resuscitation training instructors; (iv) new guidance in relation to the timing of cord clamping for preterm newborn infants; (v) recommendation to monitor body temperature on admission to newborn units as a resuscitation quality indicator; (vi) suggestion to consider electrocardiographic (ECG) monitoring (as an adjunct to oximetry) to obtain more rapid and accurate estimation of heart rate during resuscitation; (vii) removal of previous suggestions to intubate meconium-exposed, non-vigorous term infants to suction the trachea; and (viii) suggestion to establish vascular access to enable administration of intravenous adrenaline (epinephrine) as soon as chest compressions are deemed to be needed. [ABSTRACT FROM AUTHOR]

Aim: To determine the neonatal incidence, indications and outcomes following transfusions with emergency uncross-matched O-negative blood.Methods: A five-year retrospective review in a single tertiary neonatal unit was conducted. The blood transfusion laboratory's database was analysed for all infants who had received an emergency released blood transfusion (ERBT) between January 2010 and December 2014.Results: We calculated a total ERBT rate of 0.91 per 1000 live births (39/42 657) and a rate of 0.43 per 1000 in infants >34 weeks' gestation (18/41 637). A rate of 0.14 per 1000 births (6/42 657) received an ERBT as part of newborn stabilisation despite almost half of our infant cohort having intrapartum haemorrhages (n = 18, 46%). One-third (13/39) of all infants who were transfused died. Outcome varied depending on underlying aetiology, gestation and birthweight. The highest mortality was in preterm infants weighing <1000 g, of whom 70% died.Conclusion: This study establishes an ERBT rate of <1 per 1000 births, and 0.14 per 1000 infants received an ERBT as part of newborn delivery room stabilisation. ERBTs are associated with a high mortality rate. This study highlights the need for further research and guidelines that clarify the role of ERBTs in newborn stabilisations. [ABSTRACT FROM AUTHOR]

Aim: We compared the performance of personnel in a low-resource setting when they used the I-gel cuffless neonatal laryngeal mask or a face mask on a neonatal airway management manikin.Methods: At Mulago Hospital, Uganda, 25 doctors, nurses and midwives involved in neonatal resuscitation were given brief training with the I-gel and face mask. Then, every participant was observed positioning both devices on three consecutive occasions. The success rate and insertion times leading to effective positive pressure ventilation (PPV) were recorded. Participants rated the perceived efficiency of the devices using a five-point Likert scale.Results: The I-gel achieved a 100% success rate on all three occasions, but the face mask was significantly less effective in achieving effective PPV and the failure rates at the first, second and third attempts were 28%, 8% and 20%, respectively. The perceived efficiency of the devices was significantly superior for the I-gel (4.7 ± 0.4) than the face mask (3.3 ± 0.8).Conclusion: The I-gel was more effective than the face mask in establishing PPV in the manikin, and user satisfaction was higher. These encouraging manikin data could be a stepping stone for clinical research on the use of the I-gel for neonatal resuscitation in low-resource settings. [ABSTRACT FROM AUTHOR]

Background: The Scandinavian society of anaesthesiology and intensive care medicine task force on pre-hospital airway management was asked to formulate recommendations following standards for trustworthy clinical practice guidelines.Methods: The literature was systematically reviewed and the grading of recommendations assessment, development and evaluation (GRADE) system was applied to move from evidence to recommendations.Results: We recommend that all emergency medical service (EMS) providers consider to: apply basic airway manoeuvres and airway adjuncts (good practice recommendation); turn unconscious non-trauma patients into the recovery position when advanced airway management is unavailable (good practice recommendation); turn unconscious trauma patients to the lateral trauma position while maintaining spinal alignment when advanced airway management is unavailable [strong recommendation, low quality of evidence (QoE)]. We suggest that intermediately trained providers use a supraglottic airway device (SAD) or basic airway manoeuvres on patients in cardiac arrest (weak recommendation, low QoE). We recommend that advanced trained providers consider using an SAD in selected indications or as a rescue device after failed endotracheal intubation (ETI) (good practice recommendation). We recommend that ETI should only be performed by advanced trained providers (strong recommendation, low QoE). We suggest that videolaryngoscopy is considered for ETI when direct laryngoscopy fails or is expected to be difficult (weak recommendation, low QoE). We suggest that advanced trained providers apply cricothyroidotomy in 'cannot intubate, cannot ventilate' situations (weak recommendation, low QoE).Conclusion: This guideline for pre-hospital airway management includes a combination of techniques applied in a stepwise fashion appropriate to patient clinical status and provider training. [ABSTRACT FROM AUTHOR]

In this report, we describe a female child with dysmorphic features and developmental delay. Chromosome microarray analysis followed by conventional karyotyping revealed a ring chromosome 9 with a 12 Mb deletion at 9pter-p23 and a 540 kb deletion at 9q34.3-qter. Four percent of the analyzed cells had monosomy 9. The patient has the features of both the Kleefstra syndrome and the chromosome 9p-syndrome, including trigonocephaly, long philtrum, hypertelorism, and retro-/micronagthia. The deletion of the patient overlaps with several of the proposed critical regions for the 9p deletion syndrome. © 2013 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

We report a patient with a maternally inherited unbalanced complex chromosomal rearrangement (CCR) involving chromosomes 4, 9, and 11 detected by microarray comparative genomic hybridization (aCGH) and fluorescence in situ hybridization (FISH). This patient presents with clinical features of 9p deletion syndrome and Silver-Russell syndrome (SRS). Chromosome analysis performed in 2000 showed what appeared to be a simple terminal deletion of chromosome 9p22.1. aCGH performed in 2010 revealed a 1.63 Mb duplication at 4q28.3, a 15.48 Mb deletion at 9p24.3p22.3, and a 1.95 Mb duplication at 11p15.5. FISH analysis revealed a derivative chromosome 9 resulting from an unbalanced translocation between chromosomes 9 and 11, a chromosome 4 fragment inserted near the breakpoint of the translocation. The 4q28.3 duplication does not contain any currently known genes. The 9p24.3p22.3 deletion region contains 36 OMIM genes including a 3.5 Mb critical region for the 9p-phenotype. The 11p15.5 duplication contains 49 OMIM genes including H19 and IGF2. Maternal aCGH was normal. However, maternal chromosomal and FISH analyses revealed an apparently balanced CCR involving chromosomes 4, 9, and 11. To the best of our knowledge, this is the first report of a patient with maternally inherited trans-duplication of the entire imprinting control region 1 (ICR1) among the 11p15.5 duplications reported in SRS patients. This report supports the hypothesis that the trans-duplication of the maternal copy of ICR1 alone is sufficient for the clinical manifestation of SRS and demonstrates the usefulness of combining aCGH with karyotyping and FISH for detecting cryptic genomic imbalances. © 2012 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Deletions of the short arm of chromosome 9 are associated with two distinct clinical entities. Small telomeric 9p24.3 deletions cause genital anomalies in male subjects, ranging from disorder of gonadal sex to genital differentiation anomalies, while large terminal or interstitial deletions result in 9p-malformation syndrome phenotype. The critical region for non-syndromic 46,XY sex reversal was assigned to a 1 Mb interval of chromosome 9p, extending from the telomere to the DMRT genes cluster. The 9p-syndrome was assigned to bands 9p22.3p24.1, but a phenotypic map has not been established for this condition, probably because of the lack of detailed molecular and/or phenotypic characterization, as well as frequent involvement of additional chromosome rearrangements. Here, we describe a unique patient with a small isolated 9p terminal deletion, characterized by array-CGH and FISH, who shows a complex phenotype with multiple physical anomalies, resembling the 9p-syndrome, disorder of sex development with gonadoblastoma, congenital heart defect and epilepsy. The observed deletion includes the 46,XY sex-reversal critical region, excluding the region so far associated with the 9p-syndrome. Genotype-phenotype correlations are tentatively established comparing our patient to seven other previously reported males with isolated terminal 9p deletions, finely defined at a molecular level. Our observations expand the 9p deletion clinical spectrum, and add significantly to the definition of a 9p-syndrome critical region. © 2012 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Delayed cord clamping (DCC) has already been established in healthy term infants,1 and there is growing evidence that DCC might also have beneficial effects in preterm infants.1-4 Current ERC guidelines recommend DCC for at least 30 seconds in preterm infants who do not need resuscitation.5 So far, approaches of incorporating DCC into stabilisation or resuscitation of preterm infants have not been widely established. However, assessment was heterogenous and the study was not sufficiently powered to allow for proper analyses of benefits and harms of DCC in preterm infants, thus hampering meaningful conclusions on outcome. [Extracted from the article]

Key Clinical Message Muscular dystrophy has been traditionally associated with common gastrointestinal symptoms such as reflux, constipation, and dysphasia. In myotonic dystrophy, there are rare reports of chronic intestinal pseudoobstruction ( CIPOS). We herein present a case of CIPOS requiring colectomy and with good results. [ABSTRACT FROM AUTHOR]

The article offers information on the study which focuses on the Hypoxic-ischaemic encephalopathy. Topics discussed include information on the need of appropriate documentation during resuscitation during reviewing the quality of emergency responses; discussions on the diagnosis for hypoxic-ischaemic encephalopathy and treatment for the neonates; and the information on the use of therapeutic hypothermia for the treatment.

The article reports on a study which examines the potential impact of the distance between the delivery room and neonatal intensive care unit (NICU) on the respiratory management of preterm infants. An overview of the study, which was conducted at the Padua University Hospital in Italy, is given. The study suggests that the distance to the NICU does not influence the delivery room respiratory management of extremely low birthweight infants.