Background: The Helping Babies Breathe (HBB) program teaches basic newborn resuscitation techniques to birth attendants in low-resource settings. Previous studies have demonstrated a decrease in mortality following training, mostly in large hospitals. However, low-volume clinics in rural regions with no physician immediately available likely experience a greater relative burden of newborn mortality. This study aimed to determine the impact of HBB trainings provided to rural Ghanaian midwives on their skills retention and on first 24 hour mortality of the newborns they serve. Methods: American Acadamy of Paediatrics (AAP)-trained Master Trainers conducted two 2-day HBB trainings and 2-day refresher courses one year later for 48 midwives from Ghanaian rural health clinics. Trainee skills were evaluated by Objective Structured Clinical Examination (OSCE) at three time points: immediately after training, four months after training, and four months after the refresher. Midwives recorded the single highest level of resuscitation performed on each newborn delivered for one year. Results: 48 midwives attended the two trainings, 32 recorded data from 2,383 deliveries, and 13 completed OSCE simulations at all three time points. The midwives’ OSCE scores decreased from immediately after training (94.9%) to four months later (81.2%, p < 0.00001). However, four months following the refresher course, scores improved to the same high level attained initially (92.7%, p = 0.0013). 5.0% of neonates required bag-mask ventilation and 0.71% did not survive, compared with a nationwide first 24 hour mortality estimate of 1.7%. Conclusions: The midwives’ performance on the simulation exercise indicates that an in-depth refresher course provided one year after the initial training likely slows the decay in skills that occurs after initial training. Our finding that 5.0% of newborns required bag-mask ventilation is consistent with global estimates. Our observed first 24 hour mortality rate of 0.71% is lower than nationwide estimates, indicating the training likely prevented deaths due to birth asphyxia.

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Patient selection for pediatric extracorporeal membrane oxygenation (ECMO) support has broadened over the years to include children with preexisting neurologic morbidities. We aimed to determine the prevalence and nature of pre-ECMO neurologic disorders or disability and investigate the association between pre-ECMO neurologic disorders or disability and mortality and unfavorable neurologic outcome. DESIGN:Multicenter retrospective observational cohort study. SETTING:Eight hospitals reporting to the Pediatric ECMO Outcomes Registry between October 2011 and June 2019. PATIENTS:Children younger than 18 years supported with venoarterial or venovenous ECMO. INTERVENTIONS:The primary exposure was presence of pre-ECMO neurologic disorders or moderate-to-severe disability, defined as Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) 3-5. The primary outcome was unfavorable outcome at hospital discharge, defined as in-hospital mortality or survival with moderate-to-severe disability (discharge PCPC 3-5 with deterioration from baseline). MEASUREMENTS AND MAIN RESULTS:Of 598 children included in the final cohort, 68 of 598 (11%) had a pre-ECMO neurologic disorder, 70 of 595 (12%) had a baseline PCPC 3-5, and 189 of 592 (32%) had a baseline POPC 3-5. The primary outcome of in-hospital mortality (n = 267) or survival with PCPC 3-5 with deterioration from baseline (n = 39) was observed in 306 of 598 (51%). Overall, one or more pre-ECMO neurologic disorders or disability were present in 226 of 598 children (38%) but, after adjustment for age, sex, diagnostic category, pre-ECMO cardiac arrest, and ECMO mode, were not independently associated with increased odds of unfavorable outcome (unadjusted odds ratio [OR], 1.34; 95% CI, 1.07-1.69; multivariable adjusted OR, 1.30; 95% CI, 0.92-1.82). CONCLUSIONS:In this exploratory study using a multicenter pediatric ECMO registry, more than one third of children requiring ECMO support had pre-ECMO neurologic disorders or disability. However, pre-existing morbidities were not independently associated with mortality or unfavorable neurologic outcomes at hospital discharge after adjustment for diagnostic category and other covariates.

Purpose of review The role of extracorporeal membrane oxygenation (ECMO), a method of providing cardiorespiratory support in instances of cardiac or respiratory failure, in neonates and children continues to expand and evolve. This review details the current landscape of ECMO as it applies to neonates and children. Recent findings Specifically, this review provides the most recent evidence for which patients should be considered for the various forms of ECMO including venovenous ECMO, venoarterial-ECMO, and extracorporeal cardiopulmonary resuscitation. Specific topics to be discussed include indications and contraindications for the different types of ECMO in neonates and children, anticoagulation strategies and ways to monitor end-organ function, outcomes specific to the different types and populations with a focus on meaningful survival to discharge and neurologic outcomes, and consideration of special populations such as low birth weight infants, traumatically injured patients, and children who received recent bone marrow transplants. This review also discusses still unanswered questions surrounding the most appropriate use of ECMO as its role and applications continue to evolve. Summary With rapidly increasing utilization of ECMO, neonatologists and pediatricians should be aware of the most recent evidence guiding its indications, applications, and limitations.