While it is now recognized that umbilical cord clamping (UCC) at birth is not necessarily an innocuous act, there is still much confusion concerning the potential benefits and harms of this common procedure. It is most commonly assumed that delaying UCC will automatically result in a time-dependent net placental-to-infant blood transfusion, irrespective of the infant’s physiological state. Whether or not this occurs, will likely depend on the infant’s physiological state and not on the amount of time that has elapsed between birth and umbilical cord clamping (UCC). However, we believe that this is an overly simplistic view of what can occur during delayed UCC and ignores the benefits associated with maintaining the infant’s venous return and cardiac output during transition. Recent experimental evidence and observations in humans have provided compelling evidence to demonstrate that time is not a major factor influencing placental-to-infant blood transfusion after birth. Indeed, there are many factors that influence blood flow in the umbilical vessels after birth, which depending on the dominating factors could potentially result in infant-to-placental blood transfusion. The most dominant factors that influence umbilical artery and venous blood flows after birth are lung aeration, spontaneous inspirations, crying and uterine contractions. It is still not entirely clear whether gravity differentially alters umbilical artery and venous flows, although the available data suggests that its influence, if present, is minimal. While there is much support for delaying UCC at birth, much of the debate has focused on a time-based approach, which we believe is misguided. While a time-based approach is much easier and convenient for the caregiver, ignoring the infant’s physiology during delayed UCC can potentially be counter-productive for the infant.

Aim: To determine whether the use of a respiratory function monitor (RFM) during PPV of extremely preterm infants at birth, compared with no RFM, leads to an increase in percentage of inflations with an expiratory tidal volume (Vte) within a predefined target range. Methods: Unmasked, randomised clinical trial conducted October 2013 -May 2019 in 7 neonatal intensive care units in 6 countries. Very preterm infants (24-27 weeks of gestation) receiving PPV at birth were randomised to have a RFM screen visible or not. The primary outcome was the median proportion of inflations during manual PPV (face mask or intubated) within the target range (Vte 4-8 mL/kg). There were 42 other prespecified monitor measurements and clinical outcomes. Results: Among 288 infants randomised (median (IQR) gestational age 26 +2 (25 +3 -27 +1 ) weeks), a total number of 51,352 inflations were analysed. The median (IQR) percentage of inflations within the target range in the RFM visible group was 30.0 (18.0-42.2)% vs 30.2 (14.8-43.1)% in the RFM non-visible group (p = 0.721). There were no dierences in other respiratory function measurements, oxygen saturation, heart rate or FiO 2 . There were no dierences in clinical outcomes, except for the incidence of intraventricular haemorrhage (all grades) and/or cystic periventricular leukomalacia (visible RFM: 26.7% vs non-visible RFM: 39.0%; RR 0.71 (0.68-0.97); p = 0.028). Conclusion:In very preterm infants receiving PPV at birth, the use of a RFM, compared to no RFM as guidance for tidal volume delivery, did not increase the percentage of inflations in a predefined target range. Trial registration: Dutch Trial Register NTR4104, clinicaltrials.gov NCT03256578.

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Several studies demonstrated an increase in time spent within target range when automated oxygen control (AOC) is used. However the effect on clinical outcome remains unclear. We compared clinical outcomes of preterm infants born before and after implementation of AOC as standard of care. In a retrospective pre-post implementation cohort study of outcomes for infants of 24–29 weeks gestational age receiving respiratory support before (2012–2015) and after (2015–2018) implementation of AOC as standard of care were compared. Outcomes of interest were mortality and complications of prematurity, number of ventilation days, and length of stay in the Neonatal Intensive Care Unit (NICU). A total of 588 infants were included (293 pre- vs 295 in the post-implementation cohort), with similar gestational age (27.8 weeks pre- vs 27.6 weeks post-implementation), birth weight (1033 grams vs 1035 grams) and other baseline characteristics. Mortality and rate of prematurity complications were not different between the groups. Length of stay in NICU was not different, but duration of invasive ventilation was shorter in infants who received AOC (6.4 ± 10.1 vs 4.7 ± 8.3, p = 0.029).Conclusion: In this pre-post comparison, the implementation of AOC did not lead to a change in mortality or morbidity during admission. What is Known:• Prolonged and intermittent oxygen saturation deviations are associated with mortality and prematurity-related morbidities.• Automated oxygen controllers can increase the time spent within oxygen saturation target range.What is New:• Implementation of automated oxygen control as standard of care did not lead to a change in mortality or morbidity during admission.• In the period after implementation of automated oxygen control, there was a shift toward more non-invasive ventilation.

While Vte during breathing on CPAP was lower compared with PPV coinciding with breathing, breathing on CPAP was most effective in gas exchange and plethysmography amplitude gain compared with PPV and PPV coinciding with breathing.

Objective: Continuous positive airway pressures (CPAP) used to assist preterm infants at birth are limited to 4–8 cmH2O due to concerns that high-CPAP may cause pulmonary overexpansion and adversely affect the cardiovascular system. We investigated the effects of high-CPAP on pulmonary (PBF) and cerebral (CBF) blood flows and jugular vein pressure (JVP) after birth in preterm lambs.Methods: Preterm lambs instrumented with flow probes and catheters were delivered at 133/146 days gestation. Lambs received low-CPAP (LCPAP: 5 cmH2O), high-CPAP (HCPAP: 15 cmH2O) or dynamic HCPAP (15 decreasing to 8 cmH2O at ~2 cmH2O/min) for up to 30 min after birth.Results: Mean PBF was lower in the LCPAP [median (Q1–Q3); 202 (48–277) mL/min, p = 0.002] compared to HCPAP [315 (221–365) mL/min] and dynamic HCPAP [327 (269–376) mL/min] lambs. CBF was similar in LCPAP [65 (37–78) mL/min], HCPAP [73 (41–106) mL/min], and dynamic HCPAP [66 (52–81) mL/min, p = 0.174] lambs. JVP was similar at CPAPs of 5 [8.0 (5.1–12.4) mmHg], 8 [9.4 (5.3–13.4) mmHg], and 15 cmH2O [8.6 (6.9–10.5) mmHg, p = 0.909]. Heart rate was lower in the LCPAP [134 (101–174) bpm; p = 0.028] compared to the HCPAP [173 (139–205)] and dynamic HCPAP [188 (161–207) bpm] groups. Ventilation or additional caffeine was required in 5/6 LCPAP, 1/6 HCPAP, and 5/7 dynamic HCPAP lambs (p = 0.082), whereas 3/6 LCPAP, but no HCPAP lambs required intubation (p = 0.041), and 1/6 LCPAP, but no HCPAP lambs developed a pneumothorax (p = 0.632).Conclusion: High-CPAP did not impede the increase in PBF at birth and supported preterm lambs without affecting CBF and JVP.

have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device. AbstractMajor changes in cardiovascular and respiratory physiology underpin the successful transition from fetal to neonatal life, and it is now apparent that lung aeration and the onset of pulmonary ventilation trigger such changes. Because preterm infants commonly have difficulty in making the transition to neonatal life, it is important to understand the mechanisms of lung aeration and how this action can be facilitated to improve the transition in these very immature infants. Recent imaging studies have demonstrated that after birth, airway liquid clearance and lung aeration are intrinsically linked and regulated primarily by transpulmonary pressures generated during inspiration. This indicates that airway liquid clearance is not solely dependent on sodium reabsorption and that a variety of mechanisms that may act before, during, and after birth are involved. The level of contribution of each mechanism likely depends on the timing and mode of delivery. Based on the knowledge that transpulmonary pressures primarily regulate airway liquid clearance after birth, it is possible to devise ventilation strategies that facilitate this process in very preterm infants. In particular, such strategies should initially focus on moving liquid rather than air through the airways because liquid has a much higher resistance and should assist in establishing and maintaining functional residual capacity. Two potential strategies are an initial sustained inflation and ventilation with a positive end-expiratory pressure.Objectives After completing this article, readers should be able to:1. Review all mechanisms that may contribute to airway liquid clearance before, during, and after birth. 2. Discuss the mechanisms that facilitate the development and maintenance of a functional residual capacity after birth. 3. Delineate ventilatory strategies that facilitate airway liquid clearance and lung aeration at the onset of pulmonary ventilation after birth. 4. List factors that may adversely affect lung aeration at birth.

Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.