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Aim It takes several minutes for infants to become pink after birth. Preductal oxygen saturation (SpO2) measurements are used to guide the delivery of supplemental oxygen to newly born infants, but pulse oximetry is not available in many parts of the world. We explored whether the pinkness of an infant's tongue provided a useful indication that supplemental oxygen was required. Methods This was a prospective observational study of infants delivered by Caesarean section. Simultaneous recording of SpO2 and visual assessment of whether the tongue was pink or not was made at 1-7 and 10 min after birth. Results The 38 midwives and seven paediatric trainees carried out 271 paired assessments on 68 infants with a mean ( SD) birthweight of 3214 (545) grams and gestational age of 38 (2) weeks. When the infant did not have a pink tongue, this predicted SpO2 of <70% with a sensitivity of 26% and a specificity of 96%. Conclusion Tongue colour was a specific but insensitive sign that indicated when SpO2 was <70%. When the tongue is pink, it is likely that an infant has an SpO2 of more than 70% and does not require supplemental oxygen. [ABSTRACT FROM AUTHOR]

Aim To compare heart rate ( HR) measurements from Masimo and Nellcor pulse oximeters ( POs) against HR measured via a three lead electrocardiograph ( ECG) ( HRECG). We also compared peripheral oxygen saturation ( Sp O2) measurements between Nellcor and Masimo oximeters. Method Term infants born via elective caesarean section were studied. ECG leads were placed on the infant's chest and abdomen. Masimo and Nellcor PO sensors were randomly allocated to either foot. The monitors were placed on a trolley, and data from each monitor screen captured by a video camera. HR, Sp O2 measurements and signal quality were extracted. Bland- Altman analysis was used to determine agreement between HR from the ECG and each oximeter, and between Sp O2 from the oximeters. Results We studied 44 infants of whom 4 were resuscitated. More than 8000 pairs of observations were used for each comparison of HR and Sp O2. The mean difference (±2 SD) between HRECG and HRNellcor was −0.8 (±11) beats per minute (bpm); between HRECG and HRMasimo was 0.2 (±9) bpm. The mean (±2 SD) difference between Sp O2Masimo and Sp O2Nellcor was −3 (±15)%. The Nellcor PO measured 20% higher than the Masimo PO at Sp O2 <70%. Conclusion Both oximeters accurately measure HR. There was good agreement between SpO2 measurements when Sp O2 ≥70%. At lower Sp O2, agreement was poorer. [ABSTRACT FROM AUTHOR]

Aim: To identify the optimal sensor application method that gave the quickest display of accurate heart rate (HR) data using the Nellcor OxiMax N-600x pulse oximeter (PO). Methods: Stable infants who were monitored with an electrocardiograph were included. Three sensor application techniques were studied: (i) sensor connected to cable, then applied to infant; (ii) sensor connected to cable, applied to investigator's finger, and then to infant; (iii) sensor applied to infant, then connected to cable. The order of techniques tested was randomized for each infant. Time taken to apply the PO sensor, to display data and to display accurate data (HRPO = HRECG ± 3 bpm) were recorded using a stopwatch. Results: Forty infants were studied [mean (SD) birthweight, 1455 (872) g; gestational age, 31 (4) weeks; post-menstrual age, 34 (4) weeks]. Method 3 acquired any data significantly faster than methods 1 (p = 0.013; CI, −9.6 to −3.0 sec) and 2 (p = 0.004; CI, −5.9 to −1.2 sec). Method 3 acquired accurate data significantly faster than method 1 (p = 0.016; CI, −9.4 to −1.0 sec), but not method 2 (p = 0.28). Conclusion: Applying the sensor to the infant before connecting it to the cable yields the fastest acquisition of accurate HR data from the Nellcor PO. [ABSTRACT FROM AUTHOR]

Background: Postnatal corticosteroid therapy has been proved in randomized controlled trials to reduce ventilator dependence and the rate of chronic lung disease in preterm infants with few serious short-term side effects. However, there are other consequences that might follow postnatal corticosteroid therapy that are more important, including mortality or cerebral palsy.Objectives: To review the evidence from reported randomized controlled trials on the effects of postnatal corticosteroid on long-term mortality and motor dysfunction, including cerebral palsy.Methods: The methods involved a meta-analysis of reported randomized controlled trials, following guidelines of the Cochrane Collaboration, including calculation of event rate differences (ERD) and 95% confidence intervals (CI).Results: The mortality rate difference was non-significant both statistically and clinically (ERD - 0.1% favouring corticosteroids, 95% CI -2.9% to 2.8%). There were no subgroups in which a beneficial effect of postnatal corticosteroids on survival could be demonstrated. The rate of motor dysfunction in survivors was significantly higher in survivors from the postnatal corticosteroid group (ERD 11.9% favouring controls, 95% CI 4.6% to 19.2%). The rate of survival, free of motor dysfunction, was significantly lower in the postnatal corticosteroid group (ERD 7.8% favouring controls, 95% CI 0.5% to 15.1%).Conclusions: Although postnatal corticosteroids have short-term benefits, they do not increase the survival rate, and they may cause motor dysfunction in survivors. A large-scale, placebo-controlled randomized trial, with survival free of sensorineural impairments and disabilities as the major endpoint, is urgently needed. [ABSTRACT FROM AUTHOR]

Objectives: Methylxanthines, including theophylline, have been used extensively and successfully to treat apnoea in preterm infants. However, long-term consequences of such therapy are largely unknown. The aim of this study was to determine the relationship between theophylline therapy and outcome at 14 years of age in surviving preterm children of birthweight < 1501 g.Methodology: The subjects of this study were 154 consecutive survivors with birthweights < 1501 g born from 1 October 1980 to 31 March 1982; 130 (84.4%) were assessed at 14 years of age. Outcomes included motor function, psychological test scores, and growth.Results: Of the 130 children assessed, 69 (53.1%) had been exposed to theophylline; 13.0% had cerebral palsy, significantly higher than 1.6% in the 61 children not exposed to theophylline (P < 0.02). This difference remained statistically significant after adjusting for potential confounding variables including the presence of cerebroventricular haemorrhage. In contrast, after adjusting for known confounding variables, children who had received theophylline achieved higher psychological test scores. There was no association between theophylline therapy and growth.Conclusions: Theophylline therapy in the newborn period is associated with some evidence of harmful, but also helpful sensorineural effects at 14 years of age. [ABSTRACT FROM AUTHOR]

Objectives: Illicit drug taking in Australia, with its attendant social and medical consequences, is increasing and the effects extend to maternity hospitals where infants born to addicted mothers have more health problems in the neonatal period. The aims of this study were to evaluate (1) the patterns of illness of such infants and (2) the burden imposed on the neonatal department of a large tertiary maternity centre.Methodology: An audit was conducted of all Chemical Dependency Unit (CDU) mothers and babies delivered at the Royal Women's Hospital, Melbourne, Australia during 1997. Data were compared with those from a concurrent control group of mothers and babies randomly generated from the hospital's obstetric database.Results: Ninety-six infants born to CDU mothers were compared with a control group of 200 infant/mother pairs. The majority of women in the CDU clinic were treated for narcotic addiction with methadone (90%) but most continued to use heroin during pregnancy (68%). Infants born to CDU mothers were significantly less mature and lighter than control infants. Fifty-three (55%) CDU infants required admission to the Special Care Nursery either because of neonatal abstinence syndrome (n = 29) or other medical reasons (n = 24). The median length of hospital stay was significantly longer in CDU compared with control infants (8 vs 3 days, P < 0.01).Conclusions: Infants born to drug dependent mothers have more neonatal problems requiring specialized medical and nursing expertise, compared with control infants. These infants are large consumers of scarce health resources. [ABSTRACT FROM AUTHOR]

Aim: Systemic postnatal corticosteroids are used to treat or prevent bronchopulmonary dysplasia (BPD) in extremely preterm (EP) or extremely low birth weight (ELBW) infants but are associated with long-term harm. We aimed to assess the relationship between cumulative postnatal corticosteroid dose and neurodevelopmental outcomes., Methods: Longitudinal cohort study of all EP/ELBW livebirths in Victoria, Australia 2016-2017. Perinatal data were collected prospectively. Neurodevelopmental assessment was performed at 2 years' corrected age. Linear and logistic regression were used to determine relationships between cumulative corticosteroid dose and neurodevelopment, adjusted for gestational age, birth weight, sex and major intraventricular haemorrhage., Results: Seventy-six EP/ELBW infants received postnatal corticosteroids to treat or prevent BPD, 62/65 survivors were seen at 2 years. Median (IQR) cumulative postnatal corticosteroid dose was 1.36 (0.92-3.45) mg/kg dexamethasone equivalent. Higher cumulative corticosteroid dose was associated with increased odds of cerebral palsy, adjusted OR (95% CI) 1.47 (1.04, 2.07). Higher cumulative corticosteroid dose was also associated with lower cognitive and motor developmental scores, however, this weakened after adjustment for confounding variables: cognitive composite score adjusted coefficient (95% CI) -1.3 (-2.7, 0.1) and motor composite score adjusted coefficient (95% CI) -1.3 (-2.8, 0.2)., Conclusion: Higher cumulative postnatal corticosteroid dose in EP/ELBW infants is associated with increased odds of cerebral palsy at 2 years' corrected age. Adequately powered studies are needed to assess the independent effects of cumulative steroid dose on neurodevelopmental outcomes., (© 2023 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation., Methods: The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019., Results: The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial., Conclusion: Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit., (© 2022 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: To examine the association between Apgar score at 5 min and childhood developmental and educational outcome., Methods: A population-based data linkage study of births ≥37 weeks' gestation linked to developmental outcomes at preparatory school and educational outcomes at school grades 3, 5 and 7 in Victoria, Australia. Multivariable logistic regressions and generalised estimating equations were used., Results: There were 167,126 singleton infants with developmental results and 392,933 singleton infants with at least one educational result. There was an inverse relationship between Apgar score at 5 min and poor developmental and educational outcomes, with the worst outcomes among Apgar scores of 0-3. Apgar scores of 7, 8 and 9 were all associated with poorer developmental outcomes (aOR = 1.31, 95% CI: 1.12-1.54; aOR = 1.17, 95% CI: 1.05-1.29; aOR = 1.08, 95% CI: 1.02-1.13 respectively), while Apgar scores of 7 and 8 were associated with poorer educational outcomes at grades 3, 5, and 7. With progression through grades 3, 5, and 7, the extent of the difference in educational outcomes diminished (e.g. for Apgar scores of 0-3: aOR = 3.33, 95% CI: 1.85-6.00 in grade 3 and aOR = 1.49, 95% CI: 0.75-2.96 in grade 7)., Conclusion: Apgar scores below 10 at 5 min are associated with poorer developmental and educational outcomes in school., (© 2022 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Fetal scalp blood sampling for lactate measurement (FBSLM) is sometimes used to assist in identification of the need for expedited birth in the presence of an abnormal cardiotocograph (CTG). However, there is no randomised controlled trial evidence to support this., Aim: To determine whether adding FBSLM reduces the risk of birth by emergency caesarean section in labours complicated by an abnormal CTG, compared with CTG without FBS., Material and Methods: Labouring women at a tertiary maternity hospital in Melbourne, Australia with a singleton, cephalic presentation, at ≥37 weeks gestation with an abnormal CTG pattern were randomised to the intervention (n = 61), with intermittent FBSLM in addition to CTG monitoring, or control (CTG without FBS, n = 62). The primary outcome was rate of birth by caesarean section. Secondary outcomes included overall operative birth and fetal and neonatal safety endpoints., Trial Registration: ACTRN12611000172909., Results: The smaller than anticipated sample was unable to demonstrate an effect from adding FBSLM to CTG monitoring on birth by caesarean section vs monitoring by CTG without FBS (25/61 and 28/62 respectively, P = 0.64, risk ratio 0.91, 95% confidence intervals 0.60-1.36). One newborn infant in the CTG group met the criteria for the composite neonatal outcome of death or serious outcome, neonatal encephalopathy, five-minute Apgar score < 4, neonatal resuscitation, admission to neonatal intensive care unit for 96 h or more., Conclusion: We were unable to provide robust evidence of the effectiveness of FBSLM to improve the specificity of the CTG in the assessment of fetal wellbeing., (© 2021 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aim: To develop a Neonatal Intervention Score (NIS) to describe the clinical trajectory of a neonate throughout their neonatal intensive care unit (NICU) admission., Methods: The NIS was developed by modifying the Neonatal Therapeutic Intervention Scoring System (NTISS) to reflect illness severity, dependency on life-sustaining interventions and overall life trajectory on a longitudinal basis, rather than illness burden. Validity for longitudinal use within the NICU was tested by calculating the score for 99 preterm babies born less than 28 weeks at predetermined time points throughout their admission to tertiary level care at two institutions., Results: A total of 1333 NISs were analysed, ranging from 0 to 32.5 (mean 9.77, SD 5.4). Internal consistency (Cronbach alpha) reached 0.8. NIS moderately correlated to both SNAPPE-II and SNAP-II (Spearman's rho = 0.47, p =< 0.001) within the first 24 hours., Conclusion: The NIS is a useful and reliable descriptive tool of relative illness severity and degree of medical interventions throughout a baby's admission. Integrating a longitudinal description of medical dependency of a patient may assist both clinical and ethical decision-making and empirical research by providing an objective account of a baby's clinical trajectory. Establishment of validity within individual institutions is required., (©2019 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Our aim was to report perinatal characteristics of very preterm births before arrival (BBAs) at a hospital, and perinatal and infant mortality rates up to one year, comparing BBAs with births in a hospital., Materials and Methods: A population-based cohort study of 22-31 weeks' gestation births in the state of Victoria, Australia from 1990-2009. BBAs were defined as unintentional births at home or on route to hospital. Perinatal data were obtained from the Department of Health and Human Services, Victoria. Perinatal and infant mortality data comparing BBAs with births in hospitals were analysed by logistic regression, adjusted for gestational age, birthweight and sex., Results: One hundred and thirty-three BBAs were recorded: 51 (38%) stillbirths and 82 (62%) livebirths. Compared with births in a hospital, BBAs were less mature (26.3 weeks (SD 2.9) vs 27.7 weeks (SD 2.8), P < 0.001) and a higher proportion were born to teenagers: 13% versus 5% (adjusted odds ratio (aOR) 2.86, P < 0.001). BBAs were significantly more likely to be stillborn (aOR 2.13, 95% confidence interval (CI) 1.41, 3.23, P < 0.001) die within 28 days of livebirth (aOR 2.97, 95% CI 1.54, 5.73, P = 0.001) or die within a year of livebirth (aOR 2.87, 95% CI 1.51, 5.46, P = 0.001) compared with hospital births. Overall, 54 BBAs survived to one year (41% all BBAs, 67% liveborn BBAs), compared with 69% of hospital births (87% of livebirths)., Conclusions: Very preterm birth before arrival is more common in teenagers and is associated with significantly increased risks of perinatal and infant mortality compared with birth in a hospital., (© 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aim: To describe cerebral oxygenation during gavage feeding of preterm infants during incubator and skin-to-skin care., Methods: Further analysis of data from two crossover studies comparing cerebral oxygenation, heart rate and oxygen saturation during skin-to-skin care with incubator care. Data were analysed in three epochs; 10 minutes prefeed, during-feed and 10 minutes postfeed. Measurements from infants fed during incubator care were compared with those obtained during skin-to-skin care., Results: In 39 infants [median (IQR) 27.8 (26.1-30.0) weeks' gestation], there was no difference in cerebral oxygenation between pre-, during- and postfeed. Heart rate increased by three beats per minute postfeed compared with during-feed. Twenty infants received two gavage feeds, one feed in the incubator and another during skin-to-skin care. There was no difference in cerebral oxygenation and heart rate; peripheral oxygen saturation decreased by 3% during feeding whilst skin-to-skin care compared with feeding in the incubator., Conclusion: Cerebral oxygenation remained stable before, during and after gavage feeding in an incubator and during skin-to-skin care. The small decrease in oxygen saturation whilst receiving gavage feeding during skin-to-skin care is unlikely to be clinically important, providing reassurance that preterm infants maintain physiological stability during skin-to-skin care., (©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: To determine the rate of nonpublication and discontinuation of randomised controlled trials (RCTs) in newborns., Methods: This was a retrospective, cross-sectional study of RCTs registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) between 2008 and 2012., Results: Fifty trials were identified, of which 23 (46%) were retrospectively registered. Thirty trials (60%) were published. After a median follow-up of 8.0 (range 4.6-17.4) years from Research Ethics Committee approval, 15 of 41 completed trials (37%) remained unpublished, representing 5422 neonatal trial participants. Nine trials (18%) were discontinued, including four that were published. The most frequent reason for discontinuation was poor recruitment (n = 4). Sample size discrepancies between registration and publication were found in 17 (65%) of the 26 completed, published trials. In nine (35%) of these trials, the calculated sample size in the method section of the published article differed from the planned sample size in the trial registry (relative difference -20% to +33%)., Conclusion: Nonpublication and discontinuation of RCTs conducted in newborns is common. Additional efforts are needed to minimise the number of neonatal trial participants that are exposed to interventions without subsequent publication., (©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Heart rate (HR) is a vital sign for assessing the need for resuscitation. We performed a systematic review of studies assessing novel methods of measuring HR in newborns and infants in the neonatal unit. Two investigators completed independent literature searches. Identified papers were independently evaluated, and relevant data were extracted and analysed., Conclusion: This systematic review identified seven new technologies, including camera-based photoplethysmography, reflectance pulse oximetry, laser Doppler methods, capacitive sensors, piezoelectric sensors, electromyography and a digital stethoscope. Clinicians should be aware of several of these, which may become available for clinical use in the near future., (©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: This study determined current international clinical practice and opinions regarding initial fractional inspired oxygen (FiO2 ) and pulse oximetry (SpO2 ) targets for delivery room resuscitation of preterm infants of less than 29 weeks of gestation., Methods: An online survey was disseminated to neonatal clinicians via established professional clinical networks using a web-based survey programme between March 9 and June 30, 2015., Results: Of the 630 responses from 25 countries, 60% were from neonatologists. The majority (77%) would target SpO2 between the 10th to 50th percentiles values for full-term infants. The median starting FiO2 was 0.3, with Japan using the highest (0.4) and the UK using the lowest (0.21). New Zealand targeted the highest SpO2 percentiles (median 50%). Most respondents agreed or did not disagree that a trial was required that compared the higher FiO2 of 0.6 (83%), targeting the 50th SpO2 percentile (60%), and the lower FiO2 of 0.21 (80%), targeting the 10th SpO2 percentile (78%). Most (65%) would join this trial. Many considered that evidence was lacking and further research was needed., Conclusion: Clinicians currently favour lower SpO2 targets for preterm resuscitation, despite acknowledging the lack of evidence for benefit or harm, and 65% would join a clinical trial., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: This study investigated whether chorioamnionitis was associated with increased inflammation, dyslipidaemia and adverse cardiovascular phenotypes in the immediate postnatal period., Methods: This prospective case-control study included preterm infants (30(+0) -35(+6) weeks gestational age, GA) whose mothers did not have pregnancy-related conditions that may influence outcomes. Chorioamnionitis was diagnosed by placental histology, and infants were divided retrospectively into cases (chorioamnionitis-exposed) and controls (unexposed). Serum high-sensitivity C-reactive protein (hsCRP), lipid profile, far-wall abdominal aortic intima-media thickness (aIMT) and blood pressure (BP) were measured in the first week of life., Results: There were 20 (16 male, mean GA 32.4 weeks) cases and 31 (12 male, mean GA 32.6 weeks) controls. Histological chorioamnionitis was associated with a significant increase in hsCRP and a non-significant trend towards an adverse lipid profile. There was no evidence of differences in aIMT or BP., Conclusion: Preterm infants exposed to chorioamnionitis have greater postnatal inflammation. There were no early postnatal differences in aIMT or BP. The inflammatory stimulus of chorioamnionitis late in gestation may be of insufficient intensity and duration to result in immediate postnatal alterations to arterial structure. Cardiovascular follow-up of infants exposed to chorioamnionitis may identify differential risk trajectories and subsequent inflammatory responses., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aim: We tested whether operators using manometers attached to self-inflating bags could accurately deliver set targeted peak inspiratory pressures (PIPs) compared to the Neopuff(™) T-piece resuscitator (TPR)., Methods: Participants provided positive pressure ventilation to a leak-free neonatal test lung at a rate of 60 inflations/min and a flow of 8 L/min. Participants used three manometers attached to self-inflating bags and a Neopuff(™) TPR to target PIPs of 20, 30 and 40 cmH2 O on each device. Mean PIPs delivered with each manometer were compared to the 'gold standard' Neopuff(™) TPR., Results: In total, 13 991 inflations delivered by 20 participants were analysed. At all target PIPs, the mean PIP delivered using the Mercury Medical manometer attached to a Laerdal self-inflating bag was significantly higher by 5 cmH2 O (p < 0.01) than the Neopuff(™) TPR. The PIP delivered using both the Ambu(™) and Parker Healthcare manometers attached to their respective devices was similar to that delivered by the Neopuff(™) TPR at all targeted PIPs., Conclusion: Accurately targeted PIPs can be achieved when a manometer specifically designed for use on a self-inflating bag is used during manual ventilation. This may be useful in settings where access to a Neopuff(™) TPR or a gas flow source is limited., (©2016 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Background: Parent counselling and decision-making regarding the management of preterm labour and birth are influenced by information provided by healthcare professionals regarding potential infant outcomes., Aim: The aim of this study was to determine whether perinatal healthcare providers had accurate perceptions of survival and major neurosensory disability rates of very preterm infants born in non-tertiary hospitals ('outborn') and tertiary perinatal centres ('inborn')., Materials and Methods: A web-based survey was distributed to midwives, nurses, obstetricians and neonatologists working in non-tertiary and tertiary maternity hospitals, and the perinatal/neonatal emergency transport services in Victoria, Australia., Main Outcome Measures: Estimates of survival rates at 24 and 28-weeks' gestation were compared with actual survival rates of a population-based cohort of 24 and 28-weeks' gestation infants, born free of lethal anomalies in Victoria in 2001-2009. Estimates of major neurosensory disability rates in 24 and 28-week survivors were compared with actual disability rates in 24 and 28-week children born in Victoria averaged over three eras: 1991-1992, 1997 and 2005., Results: Response rates varied as follows: 83% of non-tertiary midwives, 4% of obstetricians, 55% of tertiary centre staff and 68% of transport team staff responded (total of 30%). Overall, respondents underestimated survival and overestimated major neurosensory disability rates in both outborn and inborn 24 and 28-week infants. Outborn infants were perceived to have much worse prospects for survival and for survival with major disability compared with inborn peers., Conclusion: Many clinicians overestimated rates of adverse outcomes. These clinicians may be misinforming parents about their child's potential for a favourable outcome., (© 2016 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Very preterm infants born in non-tertiary hospitals ('outborn') are known to have higher mortality rates compared with infants 'inborn' in tertiary centres., Aim: The aim of this study was to report changes over time in the incidence of outborn livebirths, 22-31 weeks and infant mortality rates for outborn compared with inborn births., Methods: We conducted a population-based cohort study of consecutive livebirths, 22-31 weeks' gestation in Victoria from 1990 to 2009. The relationship between birthplace, gestational age, birthweight, sex and infant mortality were analysed by logistic regression., Results: There were 13,760 livebirths, 22-31 weeks: 14% were outborn. The proportion of outborn livebirths fell from 19% in 1991 to a nadir of 9% in 1997, but climbed to 17% by 2009. At all times, outborns had higher mortality rates compared with inborns. The overall infant mortality rate was 250.6 per 1000 outborn compared with 113.3 per 1000 inborn livebirths (adjusted odds ratio (aOR) 2.76 (95% CI 2.32, 3.27, P < 0.001). There were no differences between outborn and inborn mortality risks for 22-week livebirths (OR 7.04, 95% CI 0.87, 56.8, P = 0.067), but there were at 23-27 weeks (aOR 3.16, 95% CI 2.52, 3.96, P < 0.001) and at 28-31 weeks (aOR 1.66, 95% CI 1.19, 2.31, P = 0.003). Over time, mortality rates fell for inborn 23-27 week infants. Mortality rates fell for outborn 23-27 week infants in 1990-2005, but rose in 2006-2009., Conclusions: Outborn livebirths at 22-31 weeks' gestation occur too frequently and are associated with a significantly increased risk of mortality. Strategies to reduce outborn livebirths are required., (© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Ventilator frequency is one of the determinants of tidal volume delivery during high-frequency ventilation. Clinicians increasingly use data on ventilator displays to inform their decisions., Aim: To measure the frequencies delivered by the Dräger Babylog 8000plus ventilator when used in high-frequency mode., Methods: Ventilator waveforms using a test lung were recorded at the full range of settings 5-20 Hz using Spectra software at 1000 Hz. The changes in frequency produced by a 1-Hz change in set frequency were calculated. Actual and displayed frequencies were compared., Results: For settings up to 12 Hz, median (range) difference between set and delivered frequencies was 0 (-0.4 to +0.1) Hz. Above 12 Hz, delivered frequency varied by -0.3 (-1.9 to +0.3) Hz. For 1-Hz changes in frequency settings, in the range 5-12 Hz, 1-Hz changes produced a change in delivered frequency of 1.0 (0.6-1.4) Hz. Above 12 Hz, the corresponding changes were 0.7 (0-2.9) Hz. The ventilator displays the set frequency during operation rather than the delivered frequency., Conclusion: At 12 Hz and below, the differences between set and delivered frequencies were relatively small compared with those at 13 Hz and higher. Above 13 Hz, the difference between set and delivered frequencies was up to 2.9 Hz. Some frequency setting changes did not result in a change in delivered frequency., (© 2010 The Author(s)/Acta Paediatrica © 2010 Foundation Acta Paediatrica.)

Aim: Neonatal resuscitation is a common and important intervention. International consensus statements advise how newborns should be resuscitated and suggest equipment to be used. Use of equipment not specifically recommended in these guidelines has been advocated. We wished to determine how widely this supplementary equipment is used in a geographically defined region., Methods: Each of the 25 tertiary perinatal centres with on-site deliveries in Australia and New Zealand was surveyed. The questionnaire asked about the use of the following items during delivery room resuscitation: pulse oximetry, exhaled carbon dioxide detection, polyethylene wrapping, oxygen blenders, laryngeal mask and oropharyngeal airways., Results: Data were obtained from all centres. Pulse oximetry is used at 12 (48%) centres. Exhaled CO2 detection is used to confirm endotracheal tube placement at three (12%) of the centres. Polyethylene wrapping is used to prevent heat loss in very-low-birthweight infants at delivery at 11 (44%) centres. Oxygen blenders are used to modify the amount of oxygen delivered at nine (36%) centres. Laryngeal mask airways are infrequently used at two (8%) centres. Oropharyngeal airways are infrequently used at five (20%) centres., Conclusion: There is considerable variation in the equipment and techniques used to resuscitate newly born infants. Use of equipment not specifically recommended in international consensus statements is widespread. These are potentially effective tools to improve resuscitation. The evidence supporting their use is, however, limited. Urgent evaluation of their efficacy and safety is required before even more widespread use occurs.

Background: The equipment used to provide positive pressure ventilation to newborns needing resuscitation at delivery varies between institutions. Devices were reviewed and their use surveyed in a sample of neonatal centres worldwide., Aim: To determine which equipment is used to resuscitate newborns at delivery in a sample of teaching hospitals around the world., Methods: A questionnaire was sent via e-mail to a neonatologist at each of 46 NICUs in 23 countries on five continents, asking which resuscitation equipment they used. If it was not returned, follow-up was by e-mail., Results: Data were obtained from 40 (87%) centres representing 19 countries. Round face masks are used at 34 (85%) centres, anatomically shaped masks are used exclusively at six (15%) and a mixture of types are used at 11 (28%). Straight endotracheal tubes are used exclusively at 36 (90%) centres: shouldered tubes are used infrequently at three of the four centres that have them. The self-inflating bag is the most commonly used manual ventilation device (used at 33 (83%) centres), the Laerdal Infant Resuscitator the most popular model. Flow-inflating bags are used at 10 (25%) centres. The Neopuff Infant Resuscitator is used at 12 (30%) centres. Varying oxygen concentrations are provided during neonatal resuscitation at half of the centres, while 100% oxygen is routinely used at the other half., Conclusions: This survey shows considerable variation in practice, reflecting this lack of evidence and consequent uncertainty among clinicians. Comparison of the two most popular manual ventilation devices, the Laerdal Infant Resuscitator and the Neopuff Infant Resuscitator, is urgently required.

Aim: To determine whether nasal intermittent positive pressure ventilation (NIPPV) is more effective in preterm infants than nasal continuous positive airway pressure (NCPAP) in reducing the rate of extubation failure following mechanical ventilation, and reducing the frequency of apnoea of prematurity and subsequent need for endotracheal intubation., Methods: Randomized trials of NIPPV versus NCPAP were sought and their data extracted and analysed independently by the authors using the methodology of the Cochrane Collaboration. The analysis used relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence intervals., Results: The three studies identified, comparing NIPPV with NCPAP in the postextubation period, all used synchronized NIPPV (SNIPPV), which was more effective than NCPAP in preventing failure of extubation [RR 0.21 (0.10, 0.45), RD -0.32 (-0.45, -0.20), NNT 3 (2, 5)]. Two studies compared NIPPV versus NCPAP for the treatment of apnoea of prematurity. Although meta-analysis was not possible one trial showed a reduction in apnoea frequency with NIPPV and the other a trend favouring NIPPV., Conclusion: SNIPPV is an effective method of augmenting the beneficial effects of NCPAP in preterm infants in the postextubation period. Further research is required to delineate the role of NIPPV in the management of apnoea of prematurity.