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Radiation exposure rates and radiation doses were measured in 174 locations in the Western Desert. Exposure rates were measured 1m above the ground with NaI (Tl) scintillation detector. Total radiation doses due to external exposure to the ambient gamma ray in the same previous locations were measured with FAG-FH 40 F2. The radioactivity concentrations of 238U, 232Th and 40K in selected soil and rocks samples were measured using gamma spectroscopy system based on high purity Germanium detector. Then, absorbed doses due to presence of 238U, 232Th and 40K in the samples were estimated. The exposure rates ranged between (5.0-71.7) ىR/h, while the average of radiation dose due to the exposure to ambient gamma ray ranged between (0.7-3.32) mSv/y. Doses due to expose to the concentrations of 238U, 232Th and 40K in the soil and rocks of the Western Desert were calculated. The average of these exposure doses ranged between (0.03-1.84)mSv/y.

Objective: Maintaining normothermia is crucial for neonatal survival, especially in preterm infants prone to temperature instability. This study evaluates the correlation and variability between axillary and rectal temperatures at Neonatal Intensive Care (NICU) admission across gestational age ranges of 23-28, 29-32, 33-36, and ≥ 37 weeks, aiming to inform improved neonatal thermal management strategies., Methods: This cross-sectional study was conducted at King Abdulaziz Medical City, Riyadh, from October 2023 to April 2024, involving 160 infants. Admission temperatures were measured using digital thermometers. Data analysis included ANOVA/Kruskal-Wallis for continuous variables, Chi-square tests for categorical data, Bland-Altman method for agreement assessment, and Pearson correlation coefficients to evaluate temperature correlations., Results: Mean axillary temperature increased from 36.4 °C in the 23-28 weeks gestational group, to 36.5 °C in the 29-32 weeks group, and to 36.7 °C in the 33-36 weeks and ≥ 37 weeks groups, (p = 0.033). Rectal temperature increased from 36.5 °C in the 23-28 weeks group, to 36.6 °C in the 29-32 weeks group, and reached 36.8 °C in both the 33-36 weeks and ≥ 37 weeks groups (p = 0.006). Notable differences between measurement methods were observed in the 33-36 and ≥ 37 weeks groups (p < 0.001), with less pronounced differences in the 23-28 and 29-32 weeks groups. While temperature differences between rectal and axillary measurements remained consistent across all groups at 0.1 °C (p = 0.779), neonatal outcomes varied significantly across gestational age groups, with younger infants exhibiting lower survival rates (p < 0.001), higher incidences of hypoglycemia (p < 0.001) and sepsis (p < 0.001), and extended durations of ventilation (p < 0.001) and hospital stay (p < 0.001). Strong correlations between rectal and axillary temperature were found across all age ranges (Pearson coefficients: 0.953 for 23-28 weeks, 0.762 for 29-32 weeks, 0.910 for 33-36 weeks, and 0.761 for ≥ 37 weeks; all p < 0.001). Bland-Altman analysis indicated higher variability in agreement for younger preterm groups, showing limits of agreement ranging from - 0.5 to 0.65 °C for 23-28 weeks and - 0.5 to 0.69 °C for 29-32 weeks, improving in older groups with - 0.2 to 0.4 °C for 33-36 weeks and similarly narrow ranges for ≥ 37 weeks., Conclusion: Both rectal and axillary temperatures showed variation across different age groups, exhibiting a substantial overall correlation. Notable differences between the two methods were observed in the 33-36 weeks and ≥ 37 weeks groups. Younger preterm infants demonstrated greater variability, with enhanced agreement observed in older infants., Competing Interests: Declarations Ethics approval and consent to participate All procedures performed in studies involving human participants adhered to the ethical standards of the institutional and/or national research committee. They also complied with the 1964 Helsinki Declaration and its subsequent amendments or comparable ethical standards. King Abdullah International Medical Research Centre (KAIMRC) ethics committee approved the project with IRB number: NRC23R/336/04. Informed written consent was obtained from the parents. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Objective: To explore the relationship between Oxygenation Index (OI) and Oxygen Saturation Index (OSI) among infants with Congenital Diaphragmatic Hernia (CDH), both within the first 24 h after birth and in extended observations in those who survived until their surgical intervention., Methods: Seven- years retrospective review of CDH cases at a single Level III neonatal intensive care unit. The correlations of various combinations of OI-OSI pairs were assessed using the Spearman's rho Correlation Coefficient. Additionally, during the initial 24 h, the correlations between admission (first), best (lowest), highest, and mean OI and OSI values were determined. The predictive ability of the first 24 h oxygen and oxygen saturation indices for mortality and other adverse outcomes were assessed using the Area Under the Curve (AUC) analysis., Results: Thirty-seven infants with CDH were included in the analysis. A strong correlation was observed between all pairs of OI/OSI (2,289) (Spearman's rho = 0.843), matched pairs of Postductal OI/OSI (1,232 pairs) (Spearman's rho = 0.835) and the unmatched pairs of Postductal OI and Preductal OSI (1,057 pairs) (Spearman's rho = 0.852). Using the regression equations for all pairs, matched and unmatched OI/OSI pairs, we deduced that for clinically pertinent OI thresholds of 10, 15, 20 and 40, the corresponding OSI values were 5, 8, 11, and 23, respectively. Furthermore, in the first 24 h, strong correlations were evident between OI/OSI: at admission (Spearman's rho = 0.783), best OI/OSI (Spearman's rho = 0.848), and highest OI/OSI (Spearman's rho = 0.921). The most robust correlation was observed between the mean OI/OSI with a Spearman's rho of 0.928. First (AUC = 0.849), best (AUC = 0.927), highest (AUC = 0.942) and mean day 1 OI (AUC = 0.946) were all predictive of mortality. Similarly, first (AUC = 1.00), best (AUC = 0.989), highest (AUC = 1.00) and the mean OSI in day 1 (AUC = 0.978) were all predictive of mortality. All of the OIs and OSIs in day 1 except for the admission OSI (AUC = 0.683) were predictive of pulmonary hypertension. Additionally, all of OI and OSI indices in the first 24-hour except for the best day 1 OI (AUC = 0.674) were predictive of the need for rescue HFOV., Conclusion: There were a strong correlation between the OI and OSI in infants with CDH. Oxygenation indices and OSI in the first 24 h were predictive of mortality and other adverse outcomes in infants with CDH., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Ali, Algarni, Alotaibi, Aljuaid, Ghazwani, Alshreedah, Alotaibi, Alanazi, Almutairi, Althubaiti, Alsehli, Alwatban and Alsaif.)

Objectives: The purpose of this research was to evaluate the differences between rectal and axillary temperature measurements in preterm infants who were born less than 32 weeks' gestation using digital thermometers upon their admission to the Neonatal Intensive Care Unit (NICU)., Methods: Prospective, observational, single centre study. Rectal and axillary temperatures measurements were performed using a digital thermometer. The study examined various maternal and neonatal factors to describe the study group, including the use of prenatal corticosteroids, the occurrence of maternal diabetes and hypertension, a history of maternal prolonged rupture of membranes (PROM), maternal chorioamnionitis, the mode of delivery, along with the neonate's gender, birth weight, and gestational age. The Pearson correlation coefficient (R) was calculated to ascertain the linear relationship between the temperatures taken at the rectal and axillary sites. The concordance between the two sets of temperature data was analyzed using the Bland-Altman method., Results: Eighty infants with a mean gestational age of 28.4 weeks (SD = 2.9) and a mean birth weight of 1,229 g (SD = 456) were included in the study. The mean axillary temperature was 36.4 °C (SD = 0.7), which was lower than the mean rectal temperature of 36.6 °C (SD = 0.6) ( p  = 0.012). Rectal temperatures surpassed axillary measurements in 59% of instances, while the reverse was observed in 21% of cases. Rectal and axillary temperatures had a strong correlation (Pearson correlation coefficient of 0.915, p  < 0.001). Bland-Altman plot showed a small mean difference of 0.1C between the two temperatures measurements but the limits of agreement were wide (+0.7 to -0.6 °C). For hypothermic infants, the mean difference between rectal and axillary temperatures was 0.27 °C, with a wide limit of agreement ranging from -0.5 °C to +1 °C. Conversely, for normothermic infants, the mean difference was smaller at 0.1 °C, with a narrower limit of agreement from -0.4 °C to +0.6 °C., Conclusions: While there is a good correlation between axillary and rectal temperatures, the wider limits of agreement indicate variability, particularly in hypothermic infants. For a more accurate assessment of core body temperature in hypothermic infants, clinicians should consider using rectal measurements to ensure effective thermal regulation and better clinical outcomes., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Halabi, Almuqati, Al Essa, Althubaiti, Alshareef, Mahlangu, Homedi, Alsehli, Alsaif and Ali.)

Objective . To describe heated humidified high-flow nasal cannulas (HHHFNC) utilization in level III neonatal intensive care units (NICUs) in Saudi Arabia. Methods . A prospective cross-sectional study using an electronic web-based questionnaire. The survey targeted level III NICUs hospitals using HHHFNCs, covering HHHFNC availability, protocols, patient characteristics, and indications. It also collected opinions on the benefits of HHHFNCs compared to nasal continuous positive airway pressure (nCPAP). Results . Out of 47 government-level III neonatal intensive care units, 35 (74%) responded to the survey. Among the included units, 46% had guidelines for HHHFNC use. Additionally, 51% reported using HHHFNC in infants of all gestational ages. The primary indication for HHHFNC use was weaning off nCPAP (34%), with 60% of the respondents noting its advantages for kangaroo care and breastfeeding. Conclusion . HHHFNC are increasingly prevalent in NICUs in Saudi Arabia. However, there remain no clear policies or guidelines regarding their use in preterm infants., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Objective. To compare mortality and major neonatal morbidities between singleton preterm infants and preterm infants of multiple gestations born <33 weeks' gestation. Method. Case-control study of preterm multiples and singletons <33 weeks' born at King Abdul-Aziz Medical City Riyadh (KAMC-R) between January 2017 and December 2020. Out-born infants and infants with lethal congenital abnormalities were excluded from the study. Mortality and major neonatal morbidities including bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), sepsis and surgical necrotizing enterocolitis (NEC) were compared between preterm singletons and multiples. Results. A total of 803 preterm infants were included: 567 (70.6%) were singletons, 158 (19.6%) were twins and 36 (4.5%) infants were higher multiples. Adjusted mortality before hospital discharge was significantly higher among preterm infants of multiple gestations compared to preterm singletons (12.3% vs 7.9%; P  = .003; AOR, 2.2; 95% CI, 1.3-3.7). Retinopathy of prematurity (ROP) needing treatment was significantly higher among preterm infants of multiple pregnancies compared to preterm singletons (11% vs 6.5%, P  = .033, AOR 1.1, 95% CI, 1.04-2.99). In addition, the incidence of bronchopulmonary dysplasia (BPD) at 36 weeks post menstrual age (PMA) (29.7% vs 20.5%; P = .003; AOR, 1.7; 95% CI, 1.2-2.5) and culture positive sepsis (24.2% vs 17.5%; P  = .044; AOR, 1.5; 95% CI, 1.01-2.2) were significantly higher among preterm infants of multiple pregnancy. There were no differences in mortality and adverse neonatal outcomes between twins and higher multiples. Conclusion. Preterm infants of multiple gestations suffered higher mortality and neonatal morbidities compared to preterm singleton infants despite a higher utilization of maternal antenatal steroids and better antenatal care., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: With the advances in neonatal intensive care, the survival rate of extremely preterm infants is increasing. However, bronchopulmonary dysplasia (BPD) remains a major cause of morbidity among infants in this group. This study examined the changes in respiratory support modalities, specifically heated humidified high-flow nasal cannula (HHHFNC), and their association with BPD incidence among preterm infants born at < 29 weeks of gestation., Method: This population-based retrospective cohort study included infants born at < 29 weeks of gestation between 2016 and 2020. Data regarding the use and duration of respiratory support modalities were obtained, including mechanical ventilation, continuous positive airway pressure, HHHFNC, and low-flow oxygen therapy. Additionally, the incidence of BPD was determined in the included infants. Trend analysis for each respiratory support modality and BPD incidence rate was performed to define the temporal changes associated with changes in BPD rates. In addition, a logistic regression model was developed to identify the association between BPD and severity grade using HHHFNC., Results: Three Hundred and sixteen infants were included in this study. The use and duration of HHHFNC therapy increased during the study period. Throughout the study period, the overall incidence of BPD was 49%, with no significant trends. The BPD rate was significantly higher in the infants who received HHHFNC than in those who did not (52% vs. 39%, P = 0.03). Analysis of BPD severity grades showed that both grade 1 BPD (34% vs. 21%, P = 0.03) and grade 2 BPD (12% vs. 1%, P < 0.01) were significantly more common among infants who received HHHFNC than among those who did not. In contrast, the incidence of grade 3 BPD was lower in infants who received HHFNC (6% vs. 17%, P < 0.01). The duration in days of HHHFNC was found to significantly predict BPD incidence (OR 1.04 [95%CI: 1.01-1.06], P < 0.01) after adjusting for confounding variables., Conclusion: The use of HHHFNC in extremely preterm infants born at < 29 weeks of gestation is increasing. There was a significant association between the duration of HHHFNC therapy and the development of BPD in extremely preterm infants born at < 29 weeks of gestation., (© 2023. The Author(s).)

Objective: This study aimed to investigate the association between admission hypothermia (AH), neonatal mortality and major neonatal morbidities in preterm infants <33 weeks' gestation. An additional aim of the study was to examine changes in the prevalence of admission hypothermia after the initiation of a thermoregulation quality improvement (QI) project., Method: This is a retrospective cohort study of preterm infants < 33 weeks' gestation born at King AbdulAziz Medical City Riyadh (KAMC-R) between January 2017 to December 2020., Results: Eight-hundred infants were born during the study period. Four hundred and one infants (50.1%) had an admission temperature of <36.5 °C and a further 399 (49.9%) had an admission temperature of >36.5 °C. The mortality before discharge was 15.7% in infants with AH compared to 4.8% among those with an admission temperature above 36.5 °C. This remained statistically significant after adjustments for gestational age and maternal PET status on a multivariate analysis ( P  = .001, OR 2.7,95%CI 1.5-4.7). The need for mechanical ventilation ( P  = .005) and incidence of surgical NEC ( P  = .030) were significantly different between the two temperature groups. Mean (SD) admission temperature increased from 36.3 °C to 36.6 °C following the thermoregulation intervention program ( P <.001). Admission temperature <36 °C is associated with higher mortality in the first week ( P  = .001, OR 3.3,95% CI (1.7-6.6)) and increased incidence of cystic PVL ( P  = .04, OR 2.1, CI (1.03-4.3))., Conclusion: Preterm infants with AH suffered higher mortality and greater neonatal morbidities., (© 2022 Publishing services provided by Elsevier B.V. on behalf of King Faisal Specialist Hospital & Research Centre (General Organization), Saudi Arabia.)

Objectives: To determine the incidence, trends, maternal and neonatal risk factors of severe intraventricular hemorrhage (IVH) among infants born 24-32 weeks and/or < 1500 g, and to evaluate the impact of changing of hospital policies and unit clinical practice on the IVH incidence., Study Design: Retrospective chart review of preterm infants with a gestational age (GA) of 24-32 6  weeks and/or weight of < 1500 g born at King Abdulaziz Medical City-Riyadh (KAMC-R), Saudi Arabia, from 2016 to 2018. Multivariate logistic regression model was constructed to determine the probability of developing severe IVH and identify associations with maternal and neonatal risk factors., Results: Among 640 infants, the overall incidence of severe IVH was 6.4% (41 infants), and its rate decreased significantly, from 9.4% in 2016 to 4.5% and 5% in 2017 and 2018 (p = 0.044). Multivariate analysis revealed that caesarian section delivery decreased the risk of severe IVH in GA group 24-27 weeks (p = 0.045). Furthermore use of inotropes (p = 0.0004) and surfactant (p = 0.0003) increased the risk of severe IVH. Despite increasing use of inotropes (p = 0.024), surfactant therapy (p = 0.034), and need for delivery room intubation (p = 0.015), there was a significant reduction in the incidence of severe IVH following the change in unit clinical practice and hospital policy (p = 0.007)., Conclusion: Cesarean section was associated with decreased all grades of IVH and severe IVH, while use of inotropes was associated with increased severe IVH. The changes in hospital and unit policy were correlated with decreased IVH during the study period.

Objectives Extubation failure is common in infants and associated with complications. Methods A prospective study was undertaken of preterm and term born infants. Diaphragm electromyogram (EMG) was measured transcutaneously for 15-60 min prior to extubation. The EMG results were related to tidal volume (Tve) to calculate the neuroventilatory efficiency (NVE). Receiver operating characteristic curves (ROC) were constructed and areas under the ROCs (AUROC) calculated. Results Seventy-two infants, median gestational age 28 (range 23-42) weeks were included; 15 (21%) failed extubation. Infants successfully extubated were more mature at birth (p=0.001), of greater corrected gestational age (CGA) at extubation (p<0.001) and heavier birth weight (p=0.005) than those who failed extubation. The amplitude and area under the curve of the diaphragm EMG were not significantly different between those who were and were not successfully extubated. Those successfully extubated required a significantly lower inspired oxygen and had higher expiratory tidal volumes (Tve) and NVE. The CGA and Tve had AUROCs of 0.83. A CGA of >29.6 weeks had the highest combined sensitivity (86%) and specificity (80%) in predicting extubation success. Conclusions Although NVE differed significantly between those who did and did not successfully extubate, CGA was the best predictor of extubation success.

Wireless sensor networks (WSNs) are often deployed in hostile environments, where an adversary can physically capture some of the sensor nodes. The adversary collects all the nodes' important credentials and subsequently replicate the nodes, which may expose the network to a number of other security attacks, and eventually compromise the entire network. This harmful attack where a single or more nodes illegitimately claims an identity as replicas is known as the node replication attack. The problem of node replication attack can be further aggravated due to the mobile nature in WSN. In this paper, we propose an extended version of multi-level replica detection technique built on Danger Theory (DT), which utilizes a hybrid approach (centralized and distributed) to shield the mobile wireless sensor networks (MWSNs) from clone attacks. The danger theory concept depends on a multi-level of detections; first stage (highlights the danger zone (DZ) by checking the abnormal behavior of mobile nodes), second stage (battery check and random number) and third stage (inform about replica to other networks). The DT method performance is highlighted through security parameters such as false negative, energy, detection time, communication overhead and delay in detection. The proposed approach also demonstrates that the hybrid DT method is capable and successful in detecting and mitigating any malicious activities initiated by the replica. Nowadays, crimes are vastly increasing and it is crucial to modify the systems accordingly. Indeed, it is understood that the communication needs to be secured by keen observation at each level of detection. The simulation results show that the proposed approach overcomes the weaknesses of the previous and existing centralized and distributed approaches and enhances the performance of MWSN in terms of communication and memory overhead.

Aims: To compare the mean oxygenation index on day1 (MOId1) with the best OI on day1 (BOId1) in predicting 30-day mortality in congenital diaphragmatic hernia (CDH). In addition, to determine whether serial OIs in the first 48 h after birth and preoperative OI (PreOp-OI), were associated with optimal timing of surgery, ventilation requirement and hospital stay in infants with CDH., Methods: The medical records of infants with antenatally diagnosed CDH during 2009-2015 were retrospectively reviewed. Receiver operator characteristic curves were constructed to identify MOId1 and BOId1 cutoff levels to predict 30-day mortality. In those who underwent surgery, the mean OI on each of the first two days (MOId1, MOId2) and PreOp-OI were correlated using Spearman (rs) with the age at surgery, the duration of ventilation and length of stay. Statistical significance was P < 0.05* and < 0.001**., Results: Survivors (n = 44) and nonsurvivors (n = 24) were comparable in gestational age, birth weight and defect laterality. Nonsurvivors had higher median BOId1 (15.4 vs 2.9; P < 0.01) and MOId1 (48 vs 7.5; p < 0.01) than survivors. Mortality was best predicted by two cutoffs [BOId1 > 6 (sensitivity 92%, specificity 89%); and MOId1 > 17 (sensitivity 96%, specificity 96%)]. Forty-four infants underwent surgery at a median postnatal age of five (range 2-19) days. MOId1 and MOId2 both correlated significantly with the age at surgery (rs = 0.4**, rs 0.5**) but not ventilation period and length of stay. PreOp-OI correlated significantly with age at surgery, duration of ventilation and length of stay (rs = 0.32*, rs = 0.47**, rs = 0.37*). A PreOp-OI <3 was predictive of optimal timing for surgery with improved duration of ventilation (8 vs 22, P = 0.001) and length of stay (26 vs 47, P = 0.004). However, 11/44 (25%) patients would not achieve a PreOp-OI < 3 by day 7+ of life and might still require surgery, one of them died., Conclusion: Both MOId1 and BOId1 are highly predictive of mortality in CDH. Oxygenation indices in the first 48 h poorly predicted the timing of surgery. PreOp-OI <3 may be a cutoff for optimal timing for surgery in infants for CDH repair., Type of Study: Prognostic Study., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To compare the outcomes of infants with a right (RCDH) versus a left-sided (LCDH) congenital diaphragmatic hernia (CDH) and whether these differed according to whether the infants had undergone fetoscopic tracheal occlusion (FETO)., Methods: Demographics, the type of surgical repair, preoperative and postoperative courses and respiratory, gastrointestinal, surgical and skeletal morbidities at follow-up were compared between infants with a RCDH or LCDH. A sub-analysis was undertaken in those who had undergone FETO., Results: During the study period, there were 167 infants with a LCDH and 24 with a RCDH; 106 underwent FETO (15 RCDH). Overall, the need for inhaled nitric oxide (p = 0.036) was higher in the RCDH group and, at follow-up, infants with RCDH were more likely to have a hernia recurrence (p = 0.043), pectus deformity (p = 0.019), scoliosis (p = 0.029) and suffer chronic respiratory morbidity (p = 0.001). There were, however, no significant differences in short term or long term outcomes (hernia recurrence (p = 0.237), pectus deformity (p = 0.322), scoliosis (p = 0.0174) or chronic respiratory morbidity (p = 0.326)) between infants with a right or left sided CDH who had undergone FETO., Conclusion: Overall, infants with a RCDH compared to those with a LCDH had greater long-term morbidity, but not if they had undergone FETO.

Volutrauma is an important factor in the pathogenesis of bronchopulmonary dysplasia (BPD). Our aims were to identify risk factors in the first 24 h for prolonged ventilator dependence and assess volume delivery and carbon dioxide levels in infants with evolving BPD. A retrospective study was undertaken of 41 infants born at less than 32 weeks of gestational age (GA). A higher tidal volume, minute volume and resistance and a lower GA, birth weight and compliance were associated with a significantly higher risk of ventilator dependence at 28 days. The strongest relationships were with birth weight (area under the receiver operating characteristic curve, AUROC = 0.771) and GA (AUROC = 0.813). Tidal volume remained significantly higher after adjusting for GA in those who remained ventilator dependent at 28 days. The 18 who remained ventilator dependent at 28 days had increased mean carbon dioxide (PCO 2 ) levels with increasing age from a mean of 41 mmHg in the first 24 h to 65 mmHg at 28 days PMA (p < 0.001). The increase in PCO 2 occurred despite increases in peak inflation pressures (p < 0.001), tidal volumes (p = 0.002) and minute volumes (p < 0.001).Conclusion: These results suggest that initial volutrauma may contribute to the development of chronic ventilator dependence. What is Known: • In prematurely born infants, excessive tidal volumes are important in the pathogenesis of bronchopulmonary dysplasia (BPD), but a tidal volume that is too low will increase the risk of atelectasis, work of breathing and energy expenditure. What is New: • A high tidal volume in the first 24 h was associated with an increased risk of ventilator dependence at 28 days, which remained significant after adjusting for gestational age. Carbon dioxide levels significantly increased over the first month despite increased pressures and volumes in those who remained ventilator dependent.

Objectives: To evaluate whether the preoperative chest radiographic thoracic area in newborn infants with congenital diaphragmatic hernia was related to the length of mechanical ventilation and the total length of stay and whether chest radiographic thoracic area predicted survival to discharge from neonatal care., Design: Retrospective observational cohort study., Setting: Tertiary neonatal unit at King's College Hospital National Health Service Foundation Trust, London, United Kingdom., Patients: Newborn infants admitted with congenital diaphragmatic hernia at King's College Hospital in a 10-year period (2007-2017)., Interventions: The chest radiographic thoracic area was assessed by free hand tracing of the perimeter of the thoracic area as outlined by the diaphragm and the rib cage and excluded the mediastinal structures and abdominal contents in the thorax and calculated using the Sectra PACS software (Sectra AB, Linköping, Sweden)., Measurements and Main Results: Eighty-four infants with congenital diaphragmatic hernia (70 left-sided) were included with a median (interquartile range) gestation of 36 weeks (34-39 wk). Fifty-four (64%) survived to discharge from neonatal care. In the infants who survived the chest radiographic thoracic area was not related to the length of mechanical ventilation (r = 0.136; p = 0.328) or the total duration of stay (r = 0.095; p = 0.495). The median (interquartile range) chest radiographic thoracic area was higher in infants who survived (1,780 mm [1,446-2,148 mm]) compared with in the deceased infants (1,000 mm [663-1,449 mm]) after correcting for confounders (adjusted p = 0.01). Using receiver operator characteristics analysis, the chest radiographic thoracic area predicted survival to discharge from neonatal care with an area under the curve of 0.826. A chest radiographic thoracic area higher than 1,299 mm predicted survival to discharge with 85% sensitivity and 73% specificity., Conclusions: The chest radiograph in infants with severe congenital diaphragmatic hernia can predict survival from neonatal care with high sensitivity and moderate specificity.

Objectives: To assess the work of breathing at different levels of volume targeting in prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD)., Design: Randomised crossover study., Setting: Tertiary neonatal intensive care unit., Patients: Eighteen infants born at <32 weeks gestation who remained ventilated at or beyond 1 week after birth, that is, they had evolving or established BPD., Interventions: Infants received ventilation at volume targeting levels of 4, 5, 6 and 7 mL/kg each for 20 minutes, the levels were delivered in random order. Baseline ventilation (without volume targeting) was delivered for 20 minutes between each epoch of volume-targeting., Main Outcome Measures: Pressure-time product of the diaphragm (PTPdi), a measure of the work of breathing, at different levels of volume targeting., Results: The 18 infants had a median gestational age of 26 (range 24-30) weeks and were studied at a median of 18 (range 7-60) days. The mean PTPdi was higher at 4 mL/kg than at baseline, 5 mL/kg, 6 mL/kg and 7 mL/kg (all P≤0.001). The mean PTPdi was higher at 5 mL/kg than at 6 mL/kg (P=0.008) and 7 mL/kg (P<0.001) and higher at 6 mL/kg than 7 mL/kg (P=0.003). Only at 7 mL/kg was the PTPdi significantly lower than at baseline (P=0.001)., Conclusions: Only a tidal volume target of 7 mL/kg reduced the work of breathing below the baseline and may be more appropriate for infants with evolving or established BPD who remained ventilator dependent at or beyond 7 days of age., Competing Interests: Competing interests: AG has held grants from various ventilator manufacturers. AG has received honoraria for giving lectures and advising various ventilator manufacturers. AG is currently receiving a non-conditional educational grant from SLE., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Maternal smoking, substance misuse in pregnancy and prone sleeping increase the risk of sudden infant death syndrome (SIDS). We examined the effect of maternal smoking, substance misuse and sleeping position on the newborn response to hypoxia., Methods: Infants born between 36 and 42 weeks of gestational age underwent respiratory monitoring in the prone and supine sleeping position before and during a hypoxic challenge. Minute ventilation (MV) and end-tidal carbon dioxide (ETCO 2 ) levels were assessed., Results: Sixty-three infants were studied: 22 controls, 23 whose mothers smoked and 18 whose mothers substance-misused and smoked. In the supine position, baseline MV was higher and ETCO 2 levels were lower in infants of substance-misusing mothers compared to controls (p = 0.015, p = 0.017, respectively). Infants of substance-misusing mothers had a lower baseline MV and higher ETCO 2 levels in the prone position (p = 0.005, p = 0.004, respectively). When prone, the rate of decline in minute ventilation in response to hypoxia was greater in infants whose mothers substance-misused and smoked compared to controls (p = 0.002) and infants of smoking mothers (p = 0.016)., Conclusion: The altered response to hypoxia in the prone position of infants whose mothers substance-misused and smoked in pregnancy may explain their increased vulnerability to SIDS.

BackgroundWe tested the hypotheses that caffeine therapy would increase the ventilatory response to hypercarbia in infants above the effect of maturation and those with a weaker ventilatory response to hypercarbia would be more likely to subsequently develop apnea that required treatment.MethodsInfants born at less than 34 weeks of gestation underwent a steady-state hypercarbic challenge using 0, 2, and 4% carbon dioxide soon after birth that was repeated at weekly intervals. The results of the initial study were compared between infants who did or did not subsequently develop apnea requiring treatment with caffeine.ResultsTwenty-six infants born at a median gestation of 32 (range 31-33) weeks were assessed. Caffeine administration was associated with an increase in CO 2 sensitivity, and the mean increase was 15.3 (95% CI: 1-30) ml/kg/min/% CO 2 . Fourteen infants subsequently developed apnea treated with caffeine. After controlling for gestational age and birth weight, they had significantly lower carbon dioxide sensitivity at their initial study compared with those who did not require treatment.ConclusionCaffeine administration was associated with an increase in the ventilatory response to hypercarbia. An initial weaker ventilatory response to hypercarbia was associated with the subsequent development of apnea requiring treatment with caffeine.

Background: Infants with exomphalos major have a high mortality and morbidity. The aims of this study were to identify predictors of survival regardless of the size of the exomphalos, and to analyze morbidity in infants with exomphalos minor., Methods: Patients were classified as having exomphalos major or minor based on whether the liver was in the exomphalos sac, and the size of the abdominal wall defect. The respiratory, gastrointestinal and surgical outcomes of 50 infants with exomphalos (including 27 with exomphalos major) were assessed. Receiver operating characteristic (ROC) curves were constructed to identify factors predictive of survival., Results: No infant with exomphalos minor died; there were seven deaths in the exomphalos major group (P < 0.001). Infants with exomphalos minor who had chromosomal abnormalities (six had a genetic diagnosis of Beckwith-Wiedemann syndrome) developed severe respiratory distress or chronic respiratory morbidity. Nasogastric feeding at discharge was required in 37% of infants with exomphalos major and in 17% with exomphalos minor. Lower gestational age (area under the ROC curve [AUROC], 0.814) and birthweight (AUROC, 0.797), and longer duration of ventilation (AUROC, 0.853) and of supplementary oxygen (AUROC, 0.810) were predictive of mortality., Conclusions: Infants with exomphalos regardless of size can have chronic morbidity. Mortality is commonest in those with exomphalos major born at lower gestational age and birthweight., (© 2018 Japan Pediatric Society.)

Background: Gastro-oesophageal reflux (GOR) and apnoea are common in infants; whether there is a causal relationship is controversial., Objectives: To determine whether there was a temporal relationship between GOR and apnoea, in particular, the frequency of obstructive apnoeas and if the frequency of GOR episodes correlated with apnoea frequency when maturity at testing was taken into account., Methods: Polysomnography and pH/multichannel intraluminal impedance (MII) studies were performed. Apnoeas were classified as central, obstructive, or mixed. MII events were classified as acidic (pH <4) or weakly acidic (4 < pH < 7). Apnoea frequency in the 5-min period after a reflux event was compared to that in the 5-min period preceding the event and that in a 5-min reflux-free period (control period)., Results: Forty infants (median gestational age 29 [range 24-42] weeks) were assessed at a post-conceptional age of 37 (30-54) weeks. Obstructive (n = 580), central (n = 900), and mixed (n = 452) apnoeas were identified; 381 acid reflux events were detected by MII and 153 by the pH probe only. Apnoeas were not more frequent following GOR than during control periods. Both the frequency of apnoeas (p = 0.002) and GOR episodes (p = 0.01) were inversely related to post-conceptional age at testing, but were not significantly correlated with each other when controlled for post-conceptional age., Conclusions: These results suggest that GOR does not cause apnoea., (© 2017 S. Karger AG, Basel.)

Background: Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly with significant mortality., Objectives: The aim of this study was to determine if there were trends in survival over the last decade and to compare patient populations, treatment options, and survival rates between 4 high-volume centres, and hence determine which factors were associated with survival., Methods: In 4 high-volume CDH centres from the CDH EURO Consortium, data from all CDH patients born between 2004 and 2013 were analysed. The predictive value of variables known at birth and the influence of centre-specific treatments (extracorporeal membrane oxygenation, ECMO, and foetoscopic endotracheal occlusion, FETO) on survival were evaluated in multivariable logistic regression analyses., Results: Nine hundred and seventy-five patients were included in the analysis, of whom 274 (28.1%) died. ECMO was performed in 259 patients, of whom 81 (31.3%) died. One hundred and forty-five patients (14.9%) underwent FETO, and from those 76 patients (52.4%) survived. Survival differed significantly between years (p = 0.006) and between the 4 centres (p < 0.001). In the multivariable logistic regression analysis, lung-to-head ratio, gestational age at birth, ECMO, centre of birth, and year of birth were significantly associated with survival, whereas FETO was not., Conclusions: The patient populations were different between centres, which influenced outcomes. There was a significant variability in survival over time and between centres, which should be taken into consideration in the planning of future trials., (© 2017 S. Karger AG, Basel.)

Oxygenation impairment can be assessed non-invasively by determining the degree of right-to-left shunt and ventilation/perfusion (V A /Q) inequality. These indices have been used in sick newborn infants, but normative values have not been reported which are essential to determine the magnitude of the abnormality. We, therefore, aimed to measure the shunt and V A /Q in infants with no history of respiratory conditions and determine if there was any effect of supine or prone position and the reproducibility of the data. Data were analysed from infants who had undergone a hypoxic challenge and in a subset who had been assessed in the supine or prone position. Transcutaneous oxygen saturations (SpO 2 ) were recorded at fractions of inspired oxygen (F I O 2 ) of 0.21 and 0.15. Two independent raters used a computer software algorithm which analysed and fitted paired data for F I O 2 and SpO 2 and derived a curve which represented the best fit for each infant's data and calculated the shunt and V A /Q. The raters ability to interpret the SpO 2 value which corresponded to a given F I O 2 was compared. The downwards displacement of the F I O 2 versus SpO 2 curve was used to estimate the degree of right-to-left shunt and the rightwards shift of the curve was used to calculate the V A /Q ratio. The mean (SD) gestational age of the 145 infants was 39 (1.6) weeks, their birth weight was 2990 (578) gms and median (range) postnatal age at measurement 3 (1-8) days. The mean (SD) V A /Q ratio was 0.95 (0.21). None of the infants had a right-to-left shunt. No significant differences were found in V A /Q in the supine compared to the prone position. The intraclass correlation coefficient of V A /Q between two independent raters was 0.968 (95% CI 0.947-0.980), p < 0.001. Right-to-left shunt and V A /Q ratio in healthy newborn infants were similar in the prone compared to the supine position.

Background: Many infants born at less than 34 weeks of gestational age will require resuscitation in the delivery suite. Yet, different resuscitation techniques are specified in different national guidelines, likely reflecting a limited evidence base. One difference is the length of mechanical inflation initially delivered to infants either via a facemask or endotracheal tube. Some guidelines specify short inflations delivered at rates of 40-60/min, others recommend initial inflations lasting 2-3 s or sustained inflations lasting for ≥ 5 s for initial resuscitation. Research has shown that tidal volumes > 2.2 mL/kg (the anatomical dead space) are seldom generated unless the infant's respiratory effort coincides with an inflation (active inflation). When inflations lasting 1-3 s were used, the time to the first active inflation was inversely proportional to the inflation time. This trial investigates whether a sustained inflation or repeated shorter inflations is more effective in stimulating the first active inflation., Methods: This non-blinded, randomised controlled trial performed at a single tertiary neonatal unit is recruiting 40 infants born at < 34 weeks of gestational age. A 15-s sustained inflation is being compared to five repeated inflations of 2-3 s during the resuscitation at delivery. A respiratory function monitor is used to record airway pressure, flow, expiratory tidal volume and end tidal carbon dioxide (ETCO 2 ) levels. The study is performed as emergency research without prior consent and was approved by the NHS London-Riverside Research Ethics Committee. The primary outcome is the minute volume in the first minute of resuscitation with secondary outcomes of the time to the first active inflation and ETCO 2 level during the first minute of recorded resuscitation., Discussion: This is the first study to compare a sustained inflation to the current UK practice of five initial inflations of 2-3 s., Trial Registration: ClinicalTrials.gov, NCT02967562 . Registered on 15 November 2016.

Objective: To determine whether the respiratory response to resuscitation in infants with congenital diaphragmatic hernia (CDH) as measured by a respiratory function monitor differed between those who did and did not survive., Design: Observational study., Setting: Tertiary perinatal centre., Patients: Thirty-eight infants born at 34 weeks of gestation or greater and diagnosed antenatally with a CDH., Interventions: Expiratory tidal volume (VTe), peak inflation pressure (PIP) and end-tidal carbon dioxide level (ETCO 2 ) were simultaneously recorded during resuscitation using a respiratory function monitor. Oxygen saturation was also monitored., Main Outcome Measures: Mortality related to the median VTe, PIP, compliance (VTe divided by PIP) and ETCO 2 levels in the first and last minute of recorded resuscitation and the maximum oxygen saturation., Results: The median gestational age, birth weight and duration of resuscitation of the 11 infants who died did not differ significantly from those who survived. During the first minute of recorded resuscitation, the VTe (median 1.89 vs 2.68 mL/kg) (p=0.009)), the ETCO 2 (median 11.7 vs 41.7 mm Hg) (p=0.023)) and the compliance (0.06 vs 0.08 mL/cm H 2 O/kg) (p=0.018)) were lower in the non-survivors. In the last minute, the PIP was higher (32.5 vs 30.3 cm H 2 O) (p=0.03)), the VTe (3.22 vs 4.66 mL/kg) (p=0.003)) and compliance (0.10 vs 0.15 mL/cm H 2 O/kg) (p=0.004)) were lower in the non-survivors. The maximum oxygen saturation achieved in the labour suite was lower in the non-survivors (93% vs 100%) (p=0.037)., Conclusions: Infants with CDH who did not survive responded less well even to initial resuscitation., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: To determine at the peak age for sudden infant death syndrome (SIDS) the ventilatory response to hypoxia of infants whose mothers substance misused in pregnancy (SM infants), or smoked during pregnancy (S mothers) and controls whose mothers neither substance misused or smoked. In addition, we compared the ventilatory response to hypoxia during the neonatal period and peak age of SIDS., Working Hypothesis: Infants of S or SM mothers compared to control infants would have a poorer ventilatory response to hypoxia at the peak age of SIDS., Study Design: Prospective, observational study., Patient-Subject Selection: Twelve S; 12 SM and 11 control infants were assessed at 6-12 weeks of age and in the neonatal period., Methodology: Changes in minute volume, oxygen saturation, heart rate, and end tidal carbon dioxide levels on switching from breathing room air to 15% oxygen were assessed. Maternal and infant urine samples were tested for cotinine, cannabinoids, opiates, amphetamines, methadone, cocaine, and benzodiazepines., Results: The S and SM infants had a greater decline in minute volume (P = 0.037, P = 0.016, respectively) and oxygen saturation (P = 0.031) compared to controls. In all groups, the magnitude of decline in minute volume in response to hypoxia was higher in the neonatal period compared to at 6-12 weeks (P < 0.001)., Conclusions: Both maternal substance misuse and smoking were associated with an impaired response to a hypoxic challenge at the peak age for SIDS. The hypoxic ventilatory decline was more marked in the neonatal period compared to the peak age for SIDS indicating a maturational effect. Pediatr Pulmonol. 2017;52:650-655. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Some studies of infants with acute respiratory distress have demonstrated that neurally adjusted ventilator assist (NAVA) had better short-term results compared to non-triggered or other triggered models. We determined if very prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD) had a lower oxygenation index (OI) on NAVA compared to assist control ventilation (ACV). Infants were studied for 1 h each on each mode. At the end of each hour, blood gas analysis was performed and the OI calculated. The inspired oxygen concentration (FiO 2 ), the peak inflation (PIP) and mean airway pressures (MAP) and compliance were averaged from the last 5 min on each mode. Nine infants, median gestational age of 25 (range 22-27) weeks, were studied at a median postnatal age of 20 (range 8-84) days. The mean OI after 1 h on NAVA was 7.9 compared to 11.1 on ACV (p = 0.0007). The FiO 2 (0.36 versus 0.45, p = 0.007), PIP (16.7 versus 20.1 cm H 2 O, p = 0.017) and MAP (9.2 versus 10.5 cm H 2 O, p = 0.004) were lower on NAVA. Compliance was higher on NAVA (0.62 versus 0.50 ml/cmH 2 O/kg, p = 0.005)., Conclusion: NAVA compared to ACV improved oxygenation in prematurely born infants with evolving or established BPD. What is Known: • Neurally assist ventilator adjust (NAVA) uses the electrical activity of the diaphragm to servo control the applied pressure. • In infants with acute RDS, use of NAVA was associated with lower peak inflation pressures and higher tidal volumes. What is New: • This study uniquely reports infants with evolving or established BPD, and their results were compared on 1 h each of NAVA and assist controlled ventilation. • On NAVA, infants had superior (lower) oxygen indices, lower inspired oxygen concentrations and peak and mean airway pressures and higher compliance.