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Extubation failure in premature infants is common. A spontaneous breathing trial (SBT) was prospectively evaluated to determine timing of extubation. Compared with historical controls, infants were extubated at significantly higher ventilator rates and airway pressures using the SBT. No differences in rates of bronchopulmonary dysplasia or duration of ventilation were seen. [ABSTRACT FROM AUTHOR]

Aim: Prevention of hypothermia after birth is a global problem in late preterm and term neonates. The aim of this systematic review and meta-analysis was to evaluate delivery room strategies to maintain normothermia and improve survival in late preterm and term neonates (≥34 weeks' gestation)., Methods: Medline, Embase, CINAHL, CENTRAL and international clinical trial registries were searched. Randomized controlled trials (RCTs), quasi-RCTs and observational studies were eligible for inclusion. Risk of bias for each study and GRADE certainty of evidence for each outcome were assessed., Results: 25 RCTs and 10 non-RCTs were included. Room temperature of 23 °C compared to 20 °C improved normothermia [Risk Ratio (RR), 95% Confidence Interval (CI): 1.26, 1.11-1.42)] and body temperature [Mean Difference (MD), 95% CI: 0.30 °C, 0.23-0.37 °C), and decreased moderate hypothermia (RR, 95% CI: 0.26, 0.16-0.42). Skin to skin care (SSC) compared to no SSC increased body temperature (MD, 95% CI: 0.32, 0.10-0.52), reduced hypoglycemia (RR, 95% CI: 0.16, 0.05-0.53) and hospital admission (RR, 95% CI: 0.34, 0.14-0.83). Though plastic bag or wrap (PBW) alone or when combined with SSC compared to SSC alone improved temperatures, the risk-benefit balance is uncertain. Clinical benefit or harm could not be excluded for the primary outcome of survival for any of the interventions. Certainty of evidence was low to very low for all outcomes., Conclusions: Room temperature of 23 °C and SSC soon after birth may prevent hypothermia in late preterm and term neonates. Though PBW may be an effective adjunct intervention, the risk-benefit balance needs further investigation., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: Neonatal endotracheal intubation is an essential but potentially destabilising procedure. With an increased focus on avoiding mechanical ventilation, particularly in preterm infants, there are fewer opportunities for clinicians to gain proficiency in this important emergency skill. Rates of successful intubation at the first attempt are relatively low, and adverse event rates are high, when compared with intubations in paediatric and adult populations. Interventions to improve operator success and patient stability during neonatal endotracheal intubations are needed. Using nasal high flow therapy extends the safe apnoea time of adults undergoing upper airway surgery and during endotracheal intubation. This technique is untested in neonates., Methods and Analysis: The S tabilisation with nasal H igh flow during I ntubation of NE onates (SHINE) trial is a multicentre, randomised controlled trial comparing the use of nasal high flow during neonatal intubation with standard care (no nasal high flow). Intubations are randomised individually, and stratified by site, use of premedications, and postmenstrual age (<28 weeks' gestation; ≥28 weeks' gestation). The primary outcome is the incidence of successful intubation on the first attempt without physiological instability of the infant. Physiological instability is defined as an absolute decrease in peripheral oxygen saturation >20% from preintubation baseline and/or bradycardia (<100 beats per minute)., Ethics and Dissemination: The SHINE trial received ethical approval from the Human Research Ethics Committees of The Royal Women's Hospital, Melbourne, Australia and Monash Health, Melbourne, Australia. The trial is currently recruiting in these two sites. The findings of this study will be disseminated via peer-reviewed journals and presented at national and international conferences., Trial Registration Number: ACTRN12618001498280., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To reduce the risks of hypoxia and hyperoxia in preterm infants in the delivery room; national and international guidelines recommend titrating supplemental oxygen delivery to achieve specific oxygen saturation (SpO 2 ) targets. Our aim was to measure the proportion of time infants <32 weeks' gestation spent within and outside prescribed SpO 2 targets during the first 10 min after birth., Method: Prospective observational study using data from a preductal SpO 2 sensor and oxygen analyser measuring fraction of inspired oxygen (FiO 2 ) in the inspiratory limb of the respiratory circuit. Measurements of SpO 2 , heart rate and FiO 2 were recorded every 2 s. We assessed compliance with the upper SpO 2 limit only when infants were receiving supplemental oxygen. SpO 2 measurements were recorded as being below, within or above the target at each time point. We measured the number of times infants were continuously below or above the target range for more than 30 s., Results: Twenty-seven infants; mean (SD) 28 (3.4) weeks and 962 (370) g were studied. Infants were below, within and above the prescribed targets for 28%, 35% and 37% of the first 10 min after birth, respectively., Conclusions: Preterm infants spent almost two-thirds of the first 10 min after birth with oxygen saturations outside prescribed target ranges. New titration strategies are required to reduce the risks of hypoxia and hyperoxia., 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/.)

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.)

Objective: Leak around the face mask is a common problem during neonatal resuscitation. A newly designed face mask using a suction system to enhance contact between the mask and the infant's face might reduce leak and improve neonatal resuscitation. The aim of the study is to determine whether leak is reduced using the suction mask (Resusi-sure mask) compared with a conventional mask (Laerdal Silicone mask) in a manikin model., Methods: Sixty participants from different professional categories (neonatal consultants, fellows, registrars, nurses, midwives and students) used each face mask in a random order to deliver 2 min of positive pressure ventilation to a manikin. Delivered airway pressures were measured using a pressure line. Inspiratory and expiratory flows were measured using a flow sensor, and expiratory tidal volumes and mask leaks were derived from these values., Results: A median (IQR) leak of 12.1 (0.6-39.0)% was found with the conventional mask compared with 0.7 (0.2-4.6)% using the suction mask (p=0.002). 50% of the participants preferred to use the suction mask and 38% preferred to use the conventional mask. There was no correlation between leak and operator experience., Conclusions: A new neonatal face mask based on the suction system reduced leak in a manikin model. Clinical studies to test the safety and effectiveness of this mask are needed., (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/)

Background: Basic life support guidelines recommend placing spontaneously breathing children and adults on their side. Though the majority of preterm newborns breathe spontaneously, they are routinely placed on their back after birth. We hypothesised that they would breathe more effectively when placed on their side., Objective: To determine whether preterm newborns placed on their left side at birth, compared with those placed on their back, have higher preductal oxygen saturation (SpO2) at 5 min of life., Design/methods: We randomised infants <32 weeks to be placed on their back or on their left side immediately after birth. Respiratory support was given with a T-piece and face mask with initial fraction of inspired oxygen (FiO2) of 0.3. The FiO2 was increased if SpO2 was <70% at 5 min., Results: We enrolled 87 infants, 41 randomised to back and 46 to left side. The groups were well matched for demographic variables. Fourteen (6 back and 8 left side) infants did not receive respiratory support in the first 5 min. The mean (SD) SpO2 was not different between the groups (back 72 (23) % versus left side 71 (24) %, p=0.956). We observed no adverse effects of placing infants on their side and found no differences in secondary outcomes between the groups., Conclusions: Preterm infants on their left side did not have higher SpO2 at 5 min of life. Placing preterm infants on their side at birth is feasible and appears to be a reasonable alternative to placing them on their back., Trial Registration Number: ISRCTN74486341., (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/)

Background and Objectives: Data from clinical trials support the use of continuous positive airway pressure (CPAP) for initial respiratory management in preterm infants, but there is concern regarding the potential failure of CPAP support. We aimed to examine the incidence and explore the outcomes of CPAP failure in Australian and New Zealand Neonatal Network data from 2007 to 2013., Methods: Data from inborn preterm infants managed on CPAP from the outset were analyzed in 2 gestational age ranges (25-28 and 29-32 completed weeks). Outcomes after CPAP failure (need for intubation <72 hours) were compared with those succeeding on CPAP using adjusted odds ratios (AORs)., Results: Within the cohort of 19 103 infants, 11 684 were initially managed on CPAP. Failure of CPAP occurred in 863 (43%) of 1989 infants commencing on CPAP at 25-28 weeks' gestation and 2061 (21%) of 9695 at 29-32 weeks. CPAP failure was associated with a substantially higher rate of pneumothorax, and a heightened risk of death, bronchopulmonary dysplasia (BPD) and other morbidities compared with those managed successfully on CPAP. The incidence of death or BPD was also increased: (25-28 weeks: 39% vs 20%, AOR 2.30, 99% confidence interval 1.71-3.10; 29-32 weeks: 12% vs 3.1%, AOR 3.62 [2.76-4.74]). The CPAP failure group had longer durations of respiratory support and hospitalization., Conclusions: CPAP failure in preterm infants is associated with increased risk of mortality and major morbidities, including BPD. Strategies to promote successful CPAP application should be pursued vigorously., (Copyright © 2016 by the American Academy of Pediatrics.)

Background: The rate of caesarean sections around the world is rising each year, reaching epidemic proportions. Although many caesarean sections are performed for concerns about fetal welfare on the basis of abnormal cardiotocography, the majority of babies are shown to be well at birth, meaning that the operation, with its inherent short and long term risks, could have been avoided without compromising the baby's health. Previously, fetal scalp blood sampling for pH estimation was performed in the context of an abnormal cardiotocograph, to improve the identification of babies in need of expedited delivery. This test has largely been replaced by lactate measurement, although its validity is yet to be established through a randomised controlled trial. This study aims to test the hypothesis that the performance of fetal scalp blood lactate measurement for women in labour with an abnormal cardiotocograph will reduce the rate of birth by caesarean section from 38 % to 25 % (a 35 % relative reduction)., Methods/design: Prospective unblinded randomised controlled trial conducted at a single tertiary perinatal centre. Women labouring with a singleton fetus in cephalic presentation at 37 or more weeks' gestation with ruptured membranes and with an abnormal cardiotocograph will be eligible. Participants will be randomised to one of two groups: fetal monitoring by cardiotocography alone, or cardiotocography augmented by fetal scalp blood lactate analysis. Decisions regarding the timing and mode of delivery will be made by the treating team, in accordance with hospital protocols. The primary study endpoint is caesarean section with secondary outcomes collected from maternal, fetal and neonatal clinical course and morbidities. A cost effectiveness analysis will also be performed. A sample size of 600 will provide 90 % power to detect the hypothesised difference in the proportion of women who give birth by caesarean section., Discussion: This world-first trial is adequately powered to determine the impact of fetal scalp blood lactate measurement on rates of caesarean section. Preventing unnecessary caesarean sections will reduce the health and financial burdens associated with this operation, both in the index and any future pregnancies., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12611000172909.

Background: Neonatal endotracheal intubation is a necessary skill. However, success rates among junior doctors have fallen to <50%, largely owing to declining opportunities to intubate. Videolaryngoscopy allows instructor and trainee to share the view of the pharynx. We compared intubations guided by an instructor watching a videolaryngoscope screen with the traditional method where the instructor does not have this view., Methods: A randomized, controlled trial at a tertiary neonatal center recruited newborns from February 2013 to May 2014. Eligible intubations were performed orally on infants without facial or airway anomalies, in the delivery room or neonatal intensive care, by doctors with <6 months' tertiary neonatal experience. Intubations were randomized to having the videolaryngoscope screen visible to the instructor or covered (control). The primary outcome was first-attempt intubation success rate confirmed by colorimetric detection of expired carbon dioxide., Results: Two hundred six first-attempt intubations were analyzed. Median (interquartile range) infant gestation was 29 (27 to 32) weeks, and weight was 1142 (816 to 1750) g. The success rate when the instructor was able to view the videolaryngoscope screen was 66% (69/104) compared with 41% (42/102) when the screen was covered (P < .001, OR 2.81, 95% CI 1.54 to 5.17). When premedication was used, the success rate in the intervention group was 72% (56/78) compared with 44% (35/79) in the control group (P < .001, OR 3.2, 95% CI 1.6 to 6.6)., Conclusions: Intubation success rates of inexperienced neonatal trainees significantly improved when the instructor was able to share their view on a videolaryngoscope screen., (Copyright © 2015 by the American Academy of Pediatrics.)

Objective: To compare the nasal tube with face mask as interfaces for stabilization of very preterm infants at birth by using physiological measurements of leak, obstruction, and expired tidal volumes during positive pressure ventilation (PPV)., Study Design: In the delivery room, 43 infants <30 weeks gestation were allocated to receive respiratory support by nasal tube or face mask. Respiratory function, heart rate, and oxygen saturation were measured. Occurrence of obstruction, amount of leak, and tidal volumes were compared using a Mann-Whitney U test or a Fisher exact test., Results: The first 5 minutes after initiation of PPV were analyzed (1566 inflations in the nasal tube group and 1896 inflations in the face mask group). Spontaneous breathing coincided with PPV in 32% of nasal tube and 34% of face mask inflations. During inflations, higher leak was observed using nasal tube compared with face mask (98% [33%-100%] vs 14 [0%-39%]; P < .0001). Obstruction occurred more often (8.2% vs 1.1%; P < .0001). Expired tidal volumes were significantly lower during inflations when using nasal tube compared with face mask (0.0 [0.0-3.1] vs 9.9 [5.5-12.8] mL/kg; P < .0001) and when spontaneous breathing coincided with PPV (4.4 [2.1-8.4] vs 9.6 [5.4-15.2] mL/kg; P < .0001) but were similar during breathing on continuous positive airway pressure (4.7 [2.8-6.9] vs 4.8 [2.7-7.9] mL/kg; P > 0.05). Heart rate was not significantly different between groups, but oxygen saturation was significantly lower in the nasal tube group the first 2 minutes after start of respiratory support., Conclusions: The use of a nasal tube led to large leak, more obstruction, and inadequate tidal volumes compared with face mask., Trial Registration: Trial registration Registered with the Dutch Trial Registry (NTR 2061) and the Australia and New Zealand Clinical Trials Register (ACTRN 12610000230055)., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To measure exhaled carbon dioxide (ECO2) in term infants immediately after birth., Study Design: Infants >37 weeks gestation born at The Royal Women's Hospital, Melbourne, Australia were eligible. A combined flow sensor and mainstream carbon dioxide (CO2) analyzer was placed in series proximal to a facemask to measure ECO2 and tidal volumes in the first 120 seconds after birth., Results: Term infants (n = 20) with a mean (SD) birth weight of 2976 (697) g and gestational age of 38 (2) weeks were included. Infants took a median (range) 3 (1-8) breaths before ECO2 was detected. The median (range) of maximum ECO2 was 51 (40-73) mm Hg at 70 (21-106) seconds after birth. Within the first 10 breaths, CO2 increased from 0-27 (22-34) mm Hg. The median (IQR) tidal volume during the breaths without CO2 was 1.2 (0.8-3.1) mL/kg compared with 7.3 (3.2-10.9) mL/kg during the first 10 breaths where CO2 was exhaled., Conclusions: The first breaths for an infant after birth did not contain ECO2. With aeration of the distal gas exchange regions, tidal volume and ECO2 significantly increased. ECO2 can be used to monitor lung aeration immediately after birth., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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., (©2014 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Aims: To describe the rate of early- and late-onset sepsis in neonates admitted to the neonatal intensive care unit at the Royal Women's Hospital and to compare the rate of late-onset sepsis (LOS) with a published (2008) cohort from the same unit. The secondary aim was to examine clinicians' compliance with antibiotic guidelines., Methods: Infants born <32 weeks' gestation or <1500 g admitted between 1 July 2011 and 31 December 2011 were included. Strict definitions of sepsis and compliance with antibiotic guidelines were applied., Results: One hundred and seventy-two infants met the inclusion criteria, with 152 having blood culture evaluations for early-onset sepsis (EOS) and 58 having 109 evaluations for LOS. Definite EOS occurred in 1.3% with Escherichia coli isolated. The rate of definite LOS in 2011 of 22% was not significantly different than the 27% in 2008, with coagulase-negative staphylococcus the main isolate. Antibiotic continuation beyond 72 h in infants with negative blood cultures was the main reason for non-compliance with antibiotic guidelines., Conclusions: The rate of EOS is comparable with published reports and the rate of LOS has remained stable over a 3-year period. Discontinuation of antibiotics with negative septic markers and blood cultures at 48-72 h is encouraged., (© 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Background: It is now recognized that preterm infants ≤28 weeks gestation can be effectively supported from the outset with nasal continuous positive airway pressure. However, this form of respiratory therapy may fail to adequately support those infants with significant surfactant deficiency, with the result that intubation and delayed surfactant therapy are then required. Infants following this path are known to have a higher risk of adverse outcomes, including death, bronchopulmonary dysplasia and other morbidities. In an effort to circumvent this problem, techniques of minimally-invasive surfactant therapy have been developed, in which exogenous surfactant is administered to a spontaneously breathing infant who can then remain on continuous positive airway pressure. A method of surfactant delivery using a semi-rigid surfactant instillation catheter briefly passed into the trachea (the "Hobart method") has been shown to be feasible and potentially effective, and now requires evaluation in a randomised controlled trial., Methods/design: This is a multicentre, randomised, masked, controlled trial in preterm infants 25-28 weeks gestation. Infants are eligible if managed on continuous positive airway pressure without prior intubation, and requiring FiO2 ≥ 0.30 at an age ≤6 hours. Randomisation will be to receive exogenous surfactant (200 mg/kg poractant alfa) via the Hobart method, or sham treatment. Infants in both groups will thereafter remain on continuous positive airway pressure unless intubation criteria are reached (FiO2 ≥ 0.45, unremitting apnoea or persistent acidosis). Primary outcome is the composite of death or physiological bronchopulmonary dysplasia, with secondary outcomes including incidence of death; major neonatal morbidities; durations of all modes of respiratory support and hospitalisation; safety of the Hobart method; and outcome at 2 years. A total of 606 infants will be enrolled. The trial will be conducted in >30 centres worldwide, and is expected to be completed by end-2017., Discussion: Minimally-invasive surfactant therapy has the potential to ease the burden of respiratory morbidity in preterm infants. The trial will provide definitive evidence on the effectiveness of this approach in the care of preterm infants born at 25-28 weeks gestation., Trial Registration: Australia and New Zealand Clinical Trial Registry: ACTRN12611000916943; ClinicalTrials.gov: NCT02140580.

Aim: Neonatal abstinence syndrome (NAS) is an increasingly common disorder diagnosed in infants exposed to various drugs, causing immense financial and social burden. Recommendations from various bodies are for babies to be monitored for 4 to 7 days following birth so that prompt treatment can commence should symptoms develop. We aimed to determine the best post-natal observation period in babies at risk of NAS., Methods: A retrospective review was undertaken of infants ≥35 weeks' gestation who received treatment for NAS in the period 2001-2010. During this time, the standard post-natal observation period was a minimum of 7 days. Data including drug exposure, day of admission and day of treatment were collected., Results: Two hundred and ten babies were included. Drug exposure was predominantly to opiates (99%); however, most infants (58%) were exposed to additional substances (benzodiazepines, cannabis or amphetamines). Ninety-five per cent of infants were admitted by day 5 of life. Of the babies treated by day 7, 98.5% had been admitted to the nursery by day 5. Infants with polydrug exposure were admitted significantly earlier; however, time to treatment was not significantly different to those exposed to opiate replacement therapy alone., Conclusions: In our hospital, babies treated for NAS often required admission before day 5. This has implications for hospital resource allocation, suggesting that routine post-natal observation for NAS could be shortened to 5 days. Further research is needed to help identify neonates who require more careful post-natal observation., (© 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Aim: To identify factors that distinguish duct-dependent congenital heart disease (DDCHD) from non-DDCHD in newborn infants., Method: A retrospective, cohort study. The Newborn Emergency Transport Service, Victoria (NETS) is a retrieval service for all inter-hospital neonatal transfers, and the Royal Children's Hospital, Melbourne (RCH) is a paediatric cardiac referral centre for the state of Victoria, Australia. All infants ≤10 days and ≥34 weeks gestation with suspected CHD and/or persistent pulmonary hypertension of the newborn (PPHN), transferred by NETS from non-tertiary neonatal units to RCH, over a 4-year period., Results: Of 142 eligible infants, 81 had DDCHD and 61 had non-DDCHD, of whom 51 had PPHN. Diagnostic accuracy of DDCHD by the NETS team was 77%. Presence of a heart murmur, abnormal pulses, upper and lower limb blood pressure (BP) difference >10 mmHg, cardiomegaly, initial SpO2 of <92%, PaO2 <50 mmHg, and pre-post ductal SpO2 difference >10% were significantly associated with DDHCD on univariate analysis. No single clinical finding was significantly associated with DDCHD on multivariate analysis. Labile SpO2 , abnormal lung parenchyma, mean BP <40 mmHg, pH <7.25, lactate >5 and FiO2 >0.5 were significantly associated with non-DDCHD, but at multivariate analysis only labile SpO2 and mean BP <40 mmHg were associated with non-DDCHD., Conclusions: Clinical diagnosis of DDCHD outside of a cardiac centre is challenging. No single factor predicts DDCHD. Combined interpretation of clinical, physiological and x-ray findings may assist., (© 2013 The Authors. Journal of Paediatrics and Child Health © 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Objective: To determine the proportion of infants who had the tasks recommended in the neonatal resuscitation guidelines performed within 30 and 60 seconds of birth, and the time taken to perform each task., Study Design: From video recordings in delivery rooms, we determined the time from birth and arrival on a resuscitation table to warm, assess heart rate (HR), attach an oximeter, and provide respiratory support for each infant. We determined the proportion of infants who had these tasks completed by 30 and 60 seconds, and the median time taken to perform each task., Results: We reviewed and analyzed data from 189 infants (median gestational age, 29 weeks [IQR, 27-34 weeks]; median birth weight, 1220 g [IQR, 930-2197 g]). Twelve infants (6%) were not on the resuscitation table within 30 seconds of birth. Less than 10% of infants were placed in polyethylene bags or had their HR determined by 30 seconds. By 60 seconds, 48% were in polyethylene bags, 33% had their HR determined, 38% received respiratory support, and 60% had an oximeter attached. The median time taken to perform all tasks was greater than that recommended in the guidelines., Conclusion: Most newborns were not managed within the time frame recommended in resuscitation guidelines. The recommended 30- and 60-second intervals may be too short., (Copyright © 2013 Mosby, Inc. All rights reserved.)

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 (SpO2 ) 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, SpO2 measurements and signal quality were extracted. Bland-Altman analysis was used to determine agreement between HR from the ECG and each oximeter, and between SpO2 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 SpO2. The mean difference (±2SD) between HRECG and HRN ellcor was -0.8 (±11) beats per minute (bpm); between HRECG and HRM asimo was 0.2 (±9) bpm. The mean (±2SD) difference between SpO2Masimo and SpO2Nellcor was -3 (±15)%. The Nellcor PO measured 20% higher than the Masimo PO at SpO2 <70%., Conclusion: Both oximeters accurately measure HR. There was good agreement between SpO2 measurements when SpO2 ≥70%. At lower SpO2 , agreement was poorer., (©2013 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objective: To measure tidal volumes (VT) and describe the interactions between spontaneous breaths and positive pressure ventilation (PPV) inflations during stabilisation of preterm infants in the delivery room (DR). We used a respiratory function monitor (RFM) to evaluate the first 5 min of mask respiratory support provided to preterm infants., Study Design: An observational study of infants <32 weeks gestation, born in a single tertiary perinatal centre receiving mask PPV in the DR. PPV was delivered with a round silicone facemask connected to a T-piece device and RFM. The RFM display was not visible to the resuscitator. Respiratory function parameters in the first 5 min after birth were analysed by breath-type (inflations, assisted inflations, spontaneous breaths between PPV, and breaths during continuous positive airway pressure (CPAP)). Parameters measured included VT, peak inspiratory pressure, peak end expiratory pressure and mask leak., Results: A total of 2605 inflations and breaths from 29 subjects were analysed. Substantial leak was observed during all four breath types with median leaks ranging from 24% to 59%. Median tidal volumes were greater during inflations (8.3 ml/kg) and assisted inflations (9.3 ml/kg) than spontaneous breaths between PPV (3.2 ml/kg) and breaths during CPAP (3.3 ml/kg)., Conclusions: Facemask leak is large during resuscitation of preterm infants using round silicone masks. Tidal volumes delivered during PPV inflations are much higher than those generated during spontaneous breathing by an infant on CPAP.

Objective: Positive-pressure ventilation (PPV) using a manual ventilation device and a face mask is recommended for compromised newborn infants in the delivery room (DR). Mask ventilation is associated with airway obstruction and leak. A nasal tube is an alternative interface, but its safety and efficacy have not been tested in extremely preterm infants., Methods: An unblinded randomized controlled trial was conducted in Australia, and the Netherlands. Infants were stratified by gestational age (24-25/26-29 weeks) and center. Immediately before birth infants were randomly assigned to receive PPV and/or continuous positive airway pressure with either a nasal tube or a size 00 soft, round silicone mask. Resuscitation protocols were standardized; respiratory support was provided using a T-piece device commencing in room air. Criteria for intubation included need for cardiac compressions, apnea, continuous positive airway pressure >7 cm H2O, and fraction of inspired oxygen >0.4. Primary outcome was endotracheal intubation in the first 24 hours from birth., Results: Three hundred sixty-three infants were randomly assigned; the study terminated early on the grounds of futility. Baseline variables were similar between groups. Intubation rates in the first 24 hours were 54% and 55% in the nasal tube and face mask groups, respectively (odds ratio: 0.97; 95% confidence interval: 0.63-1.50). There were no important differences in any of the secondary outcomes within the whole cohort or between the 2 gestational age subgroups., Conclusions: In infants at <30 weeks' gestation receiving PPV in the DR, there were no differences in short-term outcomes using the nasal tube compared with the face mask.

Introduction: Various supraglottic airway devices are routinely used to maintain airway patency in children and adults. However, oropharyngeal airways or laryngeal masks (LM) are not routinely used during neonatal resuscitation., Methods: The aim of this article was to review the available literature about the use of supraglottic airway devices during neonatal resuscitation. We reviewed books, resuscitation manuals and articles from 1830 to the present using the search terms "Infant", "Newborn", "Delivery Room", "Resuscitation", "Airway management", "Positive Pressure Respiration", "Oropharyngeal Airway" and "Laryngeal Mask"., Results: No study was identified using oropharyngeal airways during neonatal resuscitation. Four trials including 509 infants compared positive pressure ventilation with a LM, bag and mask or an endotracheal tube. Infants in the LM group were intubated less frequently compared to infants in the bag and mask ventilation group 4/275 vs. 28/234 (OR 0.13, 95% CI 0.05-0.34). Infants resuscitated with the LM had significantly less unsuccessful resuscitations 4/275 vs. 31/234 (OR 0.10, 95% CI 0.03-0.28). Two trials including 34 preterm infants compared surfactant administration via LM vs. endotracheal tube. LM surfactant administration was safe and no adverse events were reported., Conclusion: The efficacy and safety of oropharyngeal airways during neonatal resuscitation remain unclear and randomized trials are required. The current evidence suggests that resuscitation with a LM is a feasible and safe alternative to mask ventilation in infants >34 weeks gestation and birth weight >2000 g. However, further randomized control trials are needed to evaluate short- and long-term outcomes following use of laryngeal masks. In addition, surfactant administration via LM should be used only within clinical trials., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate the applicability and potential effectiveness of a technique of minimally-invasive surfactant therapy (MIST) in preterm infants on continuous positive airway pressure (CPAP)., Methods: An open feasibility study of MIST was conducted at two sites. Infants were eligible for MIST if needing CPAP pressure ≥7 cm H(2)O and FiO(2) ≥0.3 (25-28 weeks gestation, n=38) or ≥0.35 (29-32 weeks, n=23). Without premedication, a narrow-bore catheter was inserted through the vocal cords under direct vision. Surfactant (100 or 200 mg/kg Curosurf) was then instilled, followed by reinstitution of CPAP. Outcomes were compared between surfactant-treated infants and historical controls achieving the same CPAP and FiO(2) thresholds., Results: Surfactant was successfully administered via MIST in all cases, with a rapid and sustained reduction in FiO(2) thereafter. For infants at 25-28 weeks gestation, need for intubation <72 h was diminished after MIST compared with controls (32% vs 68%; OR 0.21, 95% CI 0.083 to 0.55), with a similar trend at 29-32 weeks (22% vs 45%; OR 0.34, 95% CI 0.11 to 1.1). Duration of ventilation and incidence of bronchopulmonary dysplasia were similar, but infants receiving MIST had a shorter duration of oxygen therapy., Conclusion: Surfactant delivery via a narrow-bore tracheal catheter is feasible and potentially effective, and deserves further investigation in clinical trials.

Aim: Viral bronchiolitis is the most common lower respiratory tract infection in children less than 12 months of age. Prematurity is an independent risk factor for disease severity. Many infected infants require hospitalisation and those living in regional centres frequently require transfer to metropolitan hospitals capable of providing assisted ventilation., Method: We reviewed infants with bronchiolitis transported by the Victorian Newborn Emergency Transport Service between January 2003 and June 2007. We compared the clinical presentation and treatment required by infants born preterm with those of their term counterparts., Results: Of the 192 infants transported, 92 were born preterm. Preterm infants were younger at time of transport (mean post-menstrual age 41 weeks vs. 45 weeks) and were more likely to require invasive ventilation (60% vs. 32%, P < 0.001) and to receive a fluid bolus (47% vs. 34%, P = 0.04) when compared with infants who had been born at term. Apnoea, either as a presenting symptom or in combination with respiratory distress, was more common in the preterm group (70% vs. 36%, P < 0.001)., Conclusion: Higher illness severity should be anticipated in ex-preterm infants who present with bronchiolitis. Preterm infants with bronchiolitis are more likely to require invasive ventilation and fluid resuscitation than term infants, suggesting the need for a lower threshold for referral and medical retrieval., (© 2012 The Authors. Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Background: A spontaneous breathing trial (SBT) has been used to guide suitability of extubation in VLBW infants. Respiratory variability (RV) has been used to assess extubation readiness in adults but was never investigated in preterms. The combination of a SBT and RV may further improve prediction of successful extubation., Study Design: Using data previously collected during the SBT, the following respiratory variables were analysed: inspiratory time (T(I)), expiratory time (T(E)), T(I)/total breath time, tidal volume (V(T)) and mean inspiratory flow (V(T)/T(I)). RV was quantified using time-domain analysis for each respiratory variable and expressed as a variability index (VI). The sensitivity, specificity, positive and negative predictive values (PPV and NPV) of the SBT, each VI and combined SBT+VI were calculated. Extubation failure was defined as need of re-intubation within 72 h., Results: A total of 44 infants were included. Successfully (n=36) and unsuccessfully (n=8) extubated infants had similar baseline characteristics and number of breaths analysed. VI for V(T)/T(I)was significantly decreased in the failure group. The combination of the SBT and VI of either T(I)or V(T)were the most accurate predictors of successful extubation with a sensitivity of 100% and specificity of 75% and a PPV and NPV for extubation success of 95% and 100%, respectively., Conclusions: A significant decrease in V(T)/T(I)variability occurred in infants requiring re-intubation. The combination of a SBT failure and decreased variability in T(I)or V(T)was highly predictive of failure. This combination is promising but requires prospective evaluation in a larger population.

Background: Preterm infants ≤32 weeks' gestation are increasingly being managed on continuous positive airway pressure (CPAP), without prior intubation and surfactant therapy. Some infants treated in this way ultimately fail on CPAP and require intubation and ventilation., Objectives: To define the incidence, predictors and consequences of CPAP failure in preterm infants managed with CPAP from the outset., Methods: Preterm infants 25-32 weeks' gestation were included in the study if inborn and managed with CPAP as the initial respiratory support, with division into two gestation ranges and grouping according to whether they were successfully managed on CPAP (CPAP-S) or failed on CPAP and required intubation <72 h (CPAP-F). Predictors of CPAP failure were sought, and outcomes compared between the groups., Results: 297 infants received CPAP, of which 65 (22%) failed, with CPAP failure being more likely at lower gestational age. Most infants failing CPAP had moderate or severe respiratory distress syndrome radiologically. In multivariate analysis, CPAP failure was found to be predicted by the highest FiO₂ in the first hours of life. CPAP-F infants had a prolonged need for respiratory support and oxygen therapy, and a higher risk of death or bronchopulmonary dysplasia at 25-28 weeks' gestation (CPAP-F 53% vs. CPAP-S 14%, relative risk 3.8, 95% CI 1.6, 9.3) and a substantially higher risk of pneumothorax at 29-32 weeks., Conclusion: CPAP failure in preterm infants usually occurs because of unremitting respiratory distress syndrome, is predicted by an FiO₂ ≥0.3 in the first hours of life, and is associated with adverse outcomes., (Copyright © 2013 S. Karger AG, Basel.)

Objective: Endotracheal intubation of newborn infants is a common and potentially lifesaving procedure but a skill that trainees find difficult. Despite widespread use, no data are available on whether the use of a stylet (introducer) improves success rates. We aimed to determine whether pediatric trainees were more successful at neonatal orotracheal intubation when a stylet was used., Methods: An unblinded randomized controlled trial conducted between July 2006 and January 2009 at a tertiary perinatal center, the Royal Women's Hospital, Melbourne, Australia. Eligible participants were newborn infants in the delivery room or NICU requiring endotracheal intubation for respiratory support. Infants were intubated by pediatric residents or fellows. Infants were randomized to have the procedure performed by using either an endotracheal tube alone or with a stylet. Successful intubation at the first attempt assessed by colorimetric detection of expired carbon dioxide was the primary outcome., Results: Three hundred two intubations were performed in 232 infants (residents performed 75%, fellows 25%). Intubation was successful in 57% of the stylet group and 53% of the no stylet group (P = .47); odds ratio 1.18 (95% confidence interval 0.75-1.86). There were no differences in the duration of attempts or in the rate of upper airway trauma between the 2 groups. These results were consistent across subgroups of infants based on birth weight, gestational age, and site of intubation (delivery room or NICU)., Conclusions: Using an endotracheal stylet did not significantly improve the success rate of pediatric trainees at neonatal orotracheal intubation.

Aim: Infants with viral bronchiolitis are often hospitalised with a proportion requiring respiratory support. The aim of this review was to examine the use of nasal prong continuous positive airway pressure (CPAP) as a management strategy for infants with a diagnosis of bronchiolitis, who required stabilisation and transport to a tertiary centre., Method: A retrospective audit of infants with bronchiolitis requiring CPAP during transport between January 2003 and June 2007., Results: Nasal CPAP was initiated in 54 infants with 51 of these (34 ex-preterm, 17 term) subsequently continuing on CPAP during retrieval. Mean CPAP pressure was 7 cmH(2)O. Oxygenation improved between stabilisation and the end of retrieval (P < 0.01). During retrieval, there was no significant increase in transcutaneous CO(2), no infant required endotracheal ventilation and no adverse events were noted. Five infants were intubated within the first 24 h of admission at the receiving hospital., Conclusion: This review demonstrated that use of nasal prong CPAP to transport infants with bronchiolitis was a safe management strategy in those with moderate to severe disease severity., (© 2012 The Authors. Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

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 (HR(PO) = HR(ECG) ± 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., (© 2011 The Author(s)/Acta Paediatrica © 2011 Foundation Acta Paediatrica.)

Objective: To investigate whether using a respiratory function monitor (RFM) during mask resuscitation of preterm infants reduces face mask leak and improves tidal volume (V(T))., Study Design: Infants receiving mask resuscitation were randomized to have the display of an RFM (airway pressure, flow, and V(T) waves) either visible or masked., Result: Twenty-six infants had the RFM visible, and 23 had the RFM masked. The median mask leak was 37% (IQR, 21%-54%) in the visible RFM group and 54% (IQR, 37%-82%) in the masked RFM group (P = .01). Mask repositioning was done in 19 infants (73%) of the visible group and in 6 infants (26%) of the masked group (P = .001). The median expired V(T) was similar in the 2 groups. Oxygen was provided to 61% of the visible RFM group and 87% of the RFM masked group (P = .044). Continuous positive airway pressure use was greater in the visible RFM group (73% vs 43%; P = .035). Intubation in the delivery room was done in 21% of the visible group and in 57% of the masked group (P = .035)., Conclusion: Using an RFM was associated with significantly less mask leak, more mask adjustments, and a lower rate of excessive V(T)., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Purpose: Reduced mortality for infants born at less than 30 weeks’ gestation after prophylactic surfactant administration has led many to advocate routine intubation and administration of surfactant in all infants at risk of respiratory distress syndrome. However, surfactant administration is associated with adverse events including bradycardia, changes in cerebral blood flow and endotracheal tube obstruction. The aim of this study was to analyse respiratory function immediately before and after surfactant administration in the delivery room., Methods: We reviewed video recordings of the initial resuscitation in the delivery room of infants born at less than 32 weeks’ gestation between February 2007 and March 2010. Positive pressure ventilation was delivered with either a Neopuff T-piece or self-inflating bag. Respiratory parameters were recorded with a respiratory function monitor (RFM). Each RFM recording was analysed for 30 s before and 2 min after surfactant administration., Results: Of 230 infants recorded during the study period 16 infants received surfactant in the delivery room. Their mean (standard deviation, SD) gestation and birth weight were 25 (1) weeks and 757 (249) g, respectively. Complete airway obstruction was seen in 4/16 (25%) infants. The median (interquartile range, IQR) duration of this obstruction was 16 (8–27) s. The median (IQR) expired tidal volume before surfactant delivery was 8.0 (5.2–11.2) mL/kg compared to 4.6 (4.1–7.3) mL/kg (p = 0.03) after surfactant administration., Conclusion: Substantial tidal volume changes occur before, during and after surfactant administration in the delivery room. Complete airway obstruction is common. Monitoring respiratory function during this procedure may help to assess the delivered tidal volume and airway pressures after surfactant treatment.

Aim: The study aims to compare three commonly used neonatal resuscitation devices, the Laerdal self-inflating bag with a positive end expiratory pressure (PEEP) valve, a T-piece resuscitator (T-piece) and a flow-inflating bag to provide peak inflation pressure (PIP) and PEEP., Methods: Participants were asked to use each device to give positive pressure ventilation to a modified neonatal mannequin via a face mask to achieve 40-60 inflations per minute, aiming for a PIP/PEEP of 30/5 cm H₂O. A manometer was visible to participants with each device. PIP, PEEP, percentage leak at the face mask and expired tidal volume were measured using a hot-wire anemometer. We analysed 20 inflations from each participant for each device., Results: Fifty participants provided PIP and PEEP with each device. The T-piece was the most accurate and consistent. The flow-inflating bag had the most variation. The leak was lowest with the self-inflating bag and PEEP and highest with the flow-inflating bag, but all had wide variation., Conclusion: Each device was able to provide PIP and PEEP when used appropriately. When compared with other resuscitation devices, the T-piece provided the most accurate and consistent PIP and PEEP., (© 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Introduction: Preterm infants with inadequate breathing receive positive pressure ventilation (PPV) by mask with variable success. The authors examined recordings of PPV given to preterm infants in the delivery room for prevalence of mask leak and airway obstruction., Methods and Patients: The authors reviewed recordings of infants at <32 weeks' gestation born between February 2006 and March 2009. PPV was delivered with a T-piece or self-inflating bag and a round silicone face mask. Airway pressures and gas flow were recorded with a respiratory function monitor (RFM). Videos recorded from a web camera were used to review the resuscitation. The first 2 min of PPV were analysed for each infant. Obstruction was arbitrarily defined as a 75% reduction in delivered expired tidal volume (V(Te)) and significant face-mask leak as >75%., Results: The authors analysed recordings of 56 preterm infants. Obstruction occurred in 14 (26%) recordings and leaks in 27 (51%). Both obstruction and mask leaks were seen in eight (14%) recordings, and neither was seen in 15 (27%). Obstruction occurred at a median (IQR) of 48 (24-60) s after the start of PPV. A median (range) of 22 (3-83) consecutive obstructed inflations were delivered. Face-mask leaks occurred from the first inflation in 19/27 (70%) and in the remaining eight at a median (IQR) of 30 (24-46) s after the start of PPV. A median (range) of 10 (3-117) consecutive inflations with a leak >75% were delivered., Conclusion: Airway obstruction and face-mask leak are common during the first 2 min of PPV. An RFM enables detection of important airway obstruction and mask leak.

Objective: To investigate whether infants < 29 weeks gestation who receive positive pressure ventilation (PPV) immediately after birth with a T-piece have higher oxygen saturation (SpO₂) measurements at 5 minutes than infants ventilated with a self inflating bag (SIB)., Study Design: Randomized, controlled trial of T-piece or SIB ventilation in which SpO₂ was recorded immediately after birth from the right hand/wrist with a Masimo Radical pulse oximeter, set at 2-second averaging and maximum sensitivity. All resuscitations started with air., Results: Forty-one infants received PPV with a T-piece and 39 infants received PPV with a SIB. At 5 minutes after birth, there was no significant difference between the median (interquartile range) SpO₂ in the T-piece and SIB groups (61% [13% to 72%] versus 55% [42% to 67%]; P = .27). More infants in the T-piece group received oxygen during delivery room resuscitation (41 [100%] versus 35 [90%], P = .04). There was no difference in the groups in the use of continuous positive airway pressure, endotracheal intubation, or administration of surfactant in the delivery room., Conclusion: There was no significant difference in SpO₂ at 5 minutes after birth in infants < 29 weeks gestation given PPV with a T-piece or a SIB as used in this study., (Crown Copyright © 2011. Published by Mosby, Inc. All rights reserved.)

Background: Some national resuscitation guidelines advocate using sustained initial inflations (2-3 s) for babies requiring resuscitation. Inflation times ≥10 s have been used for preterm infants., Objectives: This study examines the ability of operators of varying experience to provide a sustained inflation using three different manual ventilation devices., Methods: We compared a self-inflating bag, a flow-inflating bag and a pressure-limited T-piece device. Fifty clinical staff members from five professional groups gave a sustained inflation with a target peak pressure of 30 cm H2O and target duration of 10 s to an internal leak-free manikin. We measured peak inflating pressure (PIP) and mean inflating pressure (MIP) during the sustained inflation, and the duration of inflating pressure (IP) >20 and 25 cm H2O., Results: Median (IQR) duration of IP >25 cm H2O was: self-inflating bag 2.5 s (0.8-5.7), flow-inflating bag 10.6 s (8.4-12.9) and the T-piece 10.7 s (8.9-11.9). There was a weak correlation between experience using a self-inflating bag and longer inflation times (R = 0.290, p = 0.041). When compared with the T-piece, the flow-inflating bag had lower mean MIP (27.0 ± 1.8 vs. 28.8 ± 2.0 cm H2O) and higher mean PIP (32.3 ± 3.7 vs. 29.8 ± 1.8 cm H2O). There were no differences in performance between operator groups., Conclusion: The T-piece provided consistent PIP during a single 10 s sustained inflation with less variation in pressure compared with the flow-inflating bag. Sustained inflations >3 s were difficult to achieve with a self-inflating bag., (Copyright © 2011 S. Karger AG, Basel.)

Objective: The goal was to define reference ranges for pulse oxygen saturation (Spo(2)) values in the first 10 minutes after birth for infants who received no medical intervention in the delivery room., Methods: Infants were eligible if a member of the research team was available to record Spo(2) immediately after birth. Infants were excluded if they received supplemental oxygen or any type of assisted ventilation. Spo(2) was measured with a sensor applied to the right hand or wrist as soon as possible after birth; data were collected every 2 seconds., Results: We studied 468 infants and recorded 61650 Spo(2) data points. The infants had a mean + or - SD gestational age of 38 + or - 4 weeks and birth weight of 2970 + or - 918 g. For all 468 infants, the 3rd, 10th, 50th, 90th, and 97th percentile values at 1 minute were 29%, 39%, 66%, 87%, and 92%, respectively, those at 2 minutes were 34%, 46%, 73%, 91%, and 95%, and those at 5 minutes were 59%, 73%, 89%, 97%, and 98%. It took a median of 7.9 minutes (interquartile range: 5.0-10 minutes) to reach a Spo(2) value of >90%. Spo(2) values for preterm infants increased more slowly than those for term infants. We present percentile charts for all infants, term infants of > or = 37 weeks, preterm infants of 32 to 36 weeks, and extremely preterm infants of <32 weeks., Conclusion: These data represent reference ranges for Spo(2) in the first 10 minutes after birth for preterm and term infants.

We reviewed videos of 61 extremely preterm infants taken immediately after birth. The majority cried (69%) and breathed (80%) without intervention. Most preterm infants are not apneic at birth.

The normal range of heart rate (HR) in the first minutes after birth has not been defined. Objective To describe the HR changes of healthy newborn infants in the delivery room (DR) detected by pulse oximetry. Study Design All inborn infants were eligible and included if a member of the research team attended the birth. Infants were excluded if they received any form of medical intervention in the DR including supplemental oxygen, or respiratory support. HR was measured using a pulse oximeter (PO) with the sensor applied to the right hand or wrist immediately after birth. PO data (oxygen saturation, HR and signal quality) were downloaded every 2 sec and analysed only when the signal had no alarm messages (low IQ signal, low perfusion, sensor off, ambient light). Results Data from 468 infants with 61 650 data points were included. Infants had a mean (range) gestational age of 38 (25-42) weeks and birth weight 2970 (625-5135) g. At 1 min the median (IQR) HR was 96 (65-127) beats per min (bpm) rising at 2 min and 5 min to 139 (110-166) bpm and 163 (146-175) bpm respectively. In preterm infants, the HR rose more slowly than term infants. Conclusions The median HR was <100 bpm at 1 min after birth. After 2 min it was uncommon to have a HR <100 bpm. In preterm infants and those born by caesarean section the HR rose more slowly than term vaginal births.

Background: Some neonatologists state that at the delivery of extremely premature infants they rely on "how the baby looks" when deciding whether to initiate resuscitation. Previous studies have reported poor correlation between early clinical signs and prognosis., Objective: To determine if neonatologists can accurately predict survival to discharge of extremely premature infants on the basis of observations in the first minutes after birth., Methods: We showed videos of the resuscitation of 10 extremely premature infants (<26 weeks' gestation) to attending neonatologists and fellows from the 3 major perinatal centers in Melbourne, Australia. Antenatal information was available to the observers. A monitor visible in each video displayed the heart rate and oxygen saturation of the infant. Observers were asked to estimate the likelihood of survival to discharge for each infant at 3 time points: 20 seconds, 2 minutes, and 5 minutes after birth. The predictive ability of observers was expressed as the area (95% confidence interval [CI]) under the receiver-operating-characteristic curve., Results: Seventeen attending neonatologists and 17 neonatal fellows completed the study. Receiver-operating-characteristic curves were generated for the combined and individual groups. Observers' ability to predict survival was poor (combined results): 0.61 (95% CI: 0.54-0.67) at 20 seconds, 0.59 (95% CI: 0.52-0.64) at 2 minutes, and 0.61 (95% CI: 0.55-0.67) at 5 minutes. Level of experience did not affect the observers' accuracy of predicting survival., Conclusion: Neonatologists' reliance on initial appearance and early response to resuscitation in predicting survival for extremely premature infants is misplaced.

Non-invasive respiratory support is increasingly popular but is associated with complications including nasal trauma. The present report describes a novel method of oral continuous positive airway pressure (CPAP) delivery in an extremely premature infant with severe nasal septum erosion. The distal end of a cut down endotracheal tube was passed through a small hole made in the teat of a dummy (infant pacifier) and sutured in place. The dummy was secured in the infant's mouth and CPAP was delivered to the pharynx. The device was well tolerated and the infant was successfully managed using this technique for 48 days, avoiding endotracheal intubation and ventilation.

Objective: To measure changes in ventilator parameters in preterm infants receiving surfactant during assist control volume guarantee (AC/VG) ventilation., Methods: 22 preterm infants (up to 32 weeks' gestation) receiving surfactant for respiratory distress syndrome were enrolled in a prospective study of ventilator parameters during AC/VG ventilation at a tertiary neonatal intensive care unit. Ventilator pressures, flow and tidal volume waveforms were recorded from the Dräger Babylog 8000 plus in real time, and compared to pre-surfactant measurements., Results: Following surfactant administration, 21 of 22 babies experienced completely obstructed endotracheal gas flow. Peak inflation pressure (PIP) increased by a median (IQR) of 8 (4-10) cm H2O, and took 30-60 min to return to baseline. Inspired oxygen concentration was reduced from a median (IQR) of 39% (26%-44%) to 26% (21%-30%) in the first 5 min. The set maximum PIP (Pmax) limited the delivered PIP such that most babies received tidal volumes less than the target value (V(Ttarget)) immediately following surfactant delivery. Four infants, in a subgroup of 11 infants where Pmax was set to less than 10 cm H2O above baseline PIP, were still receiving <90% of V(Ttarget) 20 min post surfactant., Conclusions: When giving surfactant during AC/VG ventilation, complete obstruction is common. PIPs increased and remain elevated for 30-60 min. The Pmax setting may restrict tidal volume delivery.

Background: Because of concerns about harmful effects of 100% oxygen on newborn infants, air has started to be used for resuscitation in the delivery room., Objective: To describe changes in preductal oxygen saturation (Spo(2)) and heart rate (HR) in the first 10 min after birth in very preterm infants initially resuscitated with 100% oxygen (OX(100)) or air (OX(21))., Patients and Methods: In July 2006, policy changed from using 100% oxygen to air. Observations of Spo(2) and HR before and after the change were recorded whenever a member of the research team was available to attend the birth., Results: There were 20 infants in the OX(100) group and 106 in the OX(21) group. In the OX(100) group, Spo(2) had risen to a median of 84% after 2 min and 94% by 5 min. In the OX(21) group, median Spo(2) was 31% at 2 min and 54% at 5 min. In the OX(21) group, 92% received supplemental oxygen at a median of 5 min; the Spo(2) rose to a median of 81% by 6 min. In the first 10 min after birth, 80% and 55% of infants in the OX(100) and OX(21) groups, respectively, had an Spo(2) > or =95%. Increases in HR over the first 10 min were very similar in the two groups., Conclusions: Most very preterm infants received supplemental oxygen if air was used for the initial resuscitation. In these infants, the use of backup 100% oxygen and titration against Spo(2) resulted in a similar course to "normal" term and preterm infants. Of the infants resuscitated with 100% oxygen, 80% had Spo(2) > or =95% during the first 10 min. The HR changes in the two groups were very similar.

Background: Two unexpected observations were made during ventilation with the Dräger Babylog 8000+ in volume-guarantee mode: (a) during complete obstruction to gas flow down the endotracheal tube (ETT), positive inspiratory pressure (PIP) was reduced to half way between the maximum inflating pressure and the positive end expiratory pressure (PEEP) even though the set expired tidal volume had not been achieved; (b) an external Dräger waveform monitor may stop displaying real-time waveforms when a tube-obstructed alarm is activated., Objective: To investigate these phenomena using a test lung., Method: A 50 ml Dräger test lung was attached to the ventilation circuit of a Dräger Babylog 8000+. Partial obstruction to ETT flow was induced by compressing the tubing leading to the test lung, and complete obstruction was achieved by clamping. Recordings were made from the digital output of the ventilator at 125 Hz., Results: When the ETT flow was completely obstructed during VG ventilation, a constant PIP was set midway between the set maximum and PEEP. This did not happen during partial obstruction. The external waveform monitor display froze when ETT flow was completely obstructed., Conclusions: During complete ETT obstruction, the PIP is set to a pressure midway between maximum PIP and PEEP even if this is less than the PIP used before the obstruction. Further research is needed to evaluate whether this reduction in PIP is associated with prolongation of precipitating events.