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ObjectiveTo test the hypothesis that kangaroo mother care (KMC) initiated either at birth or at 1 hour after birth reduces moderate or severe hypothermia in term neonates at (A) 1 hour after birth and (B) at discharge when compared with standard thermoregulation care.MethodsTerm neonates born at a tertiary delivery centre in Zambia were randomised in two phases (phase 1: birth to 1 hour, phase 2: 1 hour to discharge) to either as much KMC as possible in combination with standard thermoregulation care (KMC group) or to standard thermoregulation care (control group). The primary outcomes were moderate or severe hypothermia (axillary temperature ResultsThe proportion of neonates with moderate or severe hypothermia did not differ between the KMC and control groups at 1 hour after birth (25% vs 27%, relative risk (RR)=0.93, 95% CI 0.59 to 1.4, P=0.78) or at discharge (7% vs 2%, RR=2.8, 95% CI 0.6 to 13.9, P=0.16). Hypothermia was not found among the infants who had KMC for at least 9 hours or 80% of the hospital stay.ConclusionsKMC practised as much as possible in combination with standard thermoregulation care initiated either at birth or at 1 hour after birth did not reduce moderate or severe hypothermia in term infants compared with standard thermoregulation care. The current study also shows that duration of KMC either for at least 80% of the time or at least 9 hours during the day of birth was effective in preventing hypothermia in term infants.Clinical trial registrationNCT02189759.

Despite major improvements in reducing childhood mortality worldwide, over 5 million pregnancies per year end in stillbirths or neonatal deaths. The vast majority of these deaths occur in low- and middle-income countries. Many of these deaths are preventable with readily available evidence-based care practices. This review focuses on educational programs developed to reduce preventable deaths in newborn infants in low- and middle-income countries, including Essential Newborn Care and Helping Babies Breathe, a simplified version of the Neonatal Resuscitation Program. Innovative pragmatic large-scale trials conducted in the Global Network for Women's and Children's Health Research of the National Institutes of Health in the USA have evaluated these programs in low-resource settings. The results of these studies and the implications for future programs designed to decrease childhood mortality are reviewed.

Objective To determine if postnatal transfer or birth in a non-tertiary hospital is associated with adverse outcomes. Design Observational cohort study with propensity score matching. Setting National health service neonatal care in England; population data held in the National Neonatal Research Database. Participants Extremely preterm infants born at less than 28 gestational weeks between 2008 and 2015 (n=17 577) grouped based on birth hospital and transfer within 48 hours of birth: upward transfer (non-tertiary to tertiary hospital, n=2158), non-tertiary care (born in non-tertiary hospital; not transferred, n=2668), and controls (born in tertiary hospital; not transferred, n=10 866). Infants were matched on propensity scores and predefined background variables to form subgroups with near identical distributions of confounders. Infants transferred between tertiary hospitals (horizontal transfer) were separately matched to controls in a 1:5 ratio. Main outcome measures Death, severe brain injury, and survival without severe brain injury. Results 2181 infants, 727 from each group (upward transfer, non-tertiary care, and control) were well matched. Compared with controls, infants in the upward transfer group had no significant difference in the odds of death before discharge (odds ratio 1.22, 95% confidence interval 0.92 to 1.61) but significantly higher odds of severe brain injury (2.32, 1.78 to 3.06; number needed to treat (NNT) 8) and significantly lower odds of survival without severe brain injury (0.60, 0.47 to 0.76; NNT 9). Compared with controls, infants in the non-tertiary care group had significantly higher odds of death (1.34, 1.02 to 1.77; NNT 20) but no significant difference in the odds of severe brain injury (0.95, 0.70 to 1.30) or survival without severe brain injury (0.82, 0.64 to 1.05). Compared with infants in the upward transfer group, infants in the non-tertiary care group had no significant difference in death before discharge (1.10, 0.84 to 1.44) but significantly lower odds of severe brain injury (0.41, 0.31 to 0.53; NNT 8) and significantly higher odds of survival without severe brain injury (1.37, 1.09 to 1.73; NNT 14). No significant differences were found in outcomes between the horizontal transfer group (n=305) and controls (n=1525). Conclusions In extremely preterm infants, birth in a non-tertiary hospital and transfer within 48 hours are associated with poor outcomes when compared with birth in a tertiary setting. We recommend perinatal services promote pathways that facilitate delivery of extremely preterm infants in tertiary hospitals in preference to postnatal transfer.

Ventilators, or more precisely, the modes they deliver, can be classified by the variables that are controlled (e.g., pressure or volume), as well as those that start (or trigger), sustain (or limit), and end (cycle) inspiration and those that maintain the expiratory support (or baseline pressure). Microprocessor and sensor technology has increased the quality and quantity of ventilator output feedback available (Fig. 10.1). These advances in technology have led to several different targeting schemes that warrant further classification (Chap. 44).

Alterations of pulmonary microbiome have been recognized in multiple respiratory disorders. It is critically important to ascertain if an airway microbiome exists at birth and if so, whether it is associated with subsequent lung disease. We found an established diverse and similar airway microbiome at birth in both preterm and term infants, which was more diverse and different from that of older preterm infants with established chronic lung disease (bronchopulmonary dysplasia). Consistent temporal dysbiotic changes in the airway microbiome were seen from birth to the development of bronchopulmonary dysplasia in extremely preterm infants. Genus Lactobacillus was decreased at birth in infants with chorioamnionitis and in preterm infants who subsequently went on to develop lung disease. Our results, taken together with previous literature indicating a placental and amniotic fluid microbiome, suggest fetal acquisition of an airway microbiome. We speculate that the early airway microbiome may prime the developing pulmonary immune system and dysbiosis in its development may set the stage for subsequent lung disease.

Objective To determine whether exposure to any antenatal corticosteroids is associated with a lower rate of death at each gestational age at which administration is currently recommended. Design Prospective cohort study. Settings 300 participating neonatal intensive care units of the Pediatrix Medical Group in the United States. Participants 117 941 infants 23 0/7 to 34 6/7 weeks’ gestational age born between 1 January 2009 and 31 December 2013. Exposure Any antenatal corticosteroids. Main outcomes measures Death or major hospital morbidities analyzed by gestational age and exposure to antenatal corticosteroids with models adjusted for birth weight, sex, mode of delivery, and multiple births. Results Infants exposed to antenatal corticosteroids (n=81 832) had a significantly lower rate of death before discharge at each gestation 29 weeks or less, 31 weeks, and 33-34 weeks compared with infants without exposure (range of adjusted odds ratios 0.32 to 0.55). The number needed to treat with antenatal corticosteroids to prevent one death before discharge increased from six at 23 and 24 weeks’ gestation to 798 at 34 weeks’ gestation. The rate of survival without major hospital morbidity was higher among infants exposed to antenatal corticosteroids at the lowest gestations. Infants exposed to antenatal corticosteroids had lower rates of severe intracranial hemorrhage or death, necrotizing enterocolitis stage 2 or above or death, and severe retinopathy of prematurity or death compared with infants without exposure at all gestations less than 30 weeks and most gestations for infants born at 30 weeks’ gestation or later. Conclusion Among infants born from 23 to 34 weeks’ gestation, antenatal exposure to corticosteroids compared with no exposure was associated with lower mortality and morbidity at most gestations. The effect size of exposure to antenatal corticosteroids on mortality seems to be larger in infants born at the lowest gestations.

To explore the association between administration-to-birth interval of antenatal corticosteroids (ACS) and survival in extremely preterm infants.Population-based prospective cohort study.All obstetric and neonatal units in Sweden from 1 April 2004 to 31 March 2007.All live-born infants (n = 707) born at 22-26 completed weeks of gestation.The relationship between time from first administration of ACS to delivery and survival was investigated using Cox proportional hazards regression analysis.Neonatal (0-27 days) and infant (0-365 days) survival, and infant survival without major neonatal morbidity (intraventricular haemorrhage grade ≥ 3, retinopathy of prematurity stage ≥ 3, periventricular leukomalacia, necrotising enterocolitis, or severe bronchopulmonary dysplasia).Five-hundred and ninety-one (84%) infants were exposed to ACS. In the final adjusted model, infant survival was lower in infants unexposed to ACS [hazard ratio (HR) = 0.26; 95% confidence interval 0.15-0.43], in infants born24 h [HR = 0.53 (0.33-0.87)] and7 days after ACS [HR = 0.56 (0.32-0.97)], but not in infants born 24-47 h after ACS [HR = 1.60 (0.73-3.50)], as compared with infants born 48 h to 7 days after administration. The findings were similar for neonatal survival. Survival without major neonatal morbidity among live-born infants was 14% in unexposed infants and 30-39% in steroid-exposed groups, indicating that any ACS exposure was valuable.Administration of ACS 24 h to 7 days before extremely preterm birth was associated with significantly higher survival than in unexposed infants and in infants exposed to ACS at shorter or longer administration-to-birth intervals.Timing of antenatal corticosteroids is important for extremely preterm infants' survival.