Sustained Inflation vs Standard Resuscitation for Preterm Infants

Abstract

IMPORTANCEMost preterm infants require respiratory support to establish lung aeration after birth. Intermittent positive pressure ventilation and continuous positive airway pressure are standard therapies. An initial sustained inflation (inflation time >5 seconds) is a widely practiced alternative strategy.OBJECTIVE To conduct a systematic review and meta-analysis of sustained inflation vs intermittent positive pressure ventilation and continuous positive airway pressure for the prevention of hospital mortality and morbidity for preterm infants.DATA SOURCES MEDLINE (through PubMed), Embase, the Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials were searched through June 24, 2019.STUDY SELECTION Randomized clinical trials of preterm infants born at less than 37 weeks' gestation that compared sustained inflation (inflation time >5 seconds) vs standard resuscitation with either intermittent positive pressure ventilation or continuous positive airway pressure were included. Studies including other cointerventions were excluded.DATA EXTRACTION AND SYNTHESIS Two reviewers assessed the risk of bias of included studies. Meta-analysis of pooled outcome data used a fixed-effects model specific to rarer events. Subgroups were based on gestational age and study design (rescue vs prophylactic sustained inflation). MAIN OUTCOMES AND MEASURES Death before hospital discharge.RESULTS Nine studies recruiting 1406 infants met inclusion criteria. Death before hospital discharge occurred in 85 of 736 infants (11.5%) treated with sustained inflation and 62 of 670 infants (9.3%) who received standard therapy for a risk difference of 3.6% (95% CI, −0.7% to 7.9%). Although analysis of the primary outcome identified important heterogeneity based on gestational age subgroups, the 95% CI for the risk difference included 0 for each individual gestational age subgroup. There was no difference in the primary outcome between subgroups based on study design. Sustained inflation was associated with increased risk of death in the first 2 days after birth (risk difference, 3.1%; 95% CI, 0.9%-5.3%). No differences in the risk of other secondary outcomes were identified. The quality-of-evidence assessment was low owing to risk of bias and imprecision. CONCLUSIONS AND RELEVANCEThere was no difference in the risk of the primary outcome of death before hospital discharge, and there was no evidence of efficacy for sustained inflation to prevent secondary outcomes. These findings do not support the routine use of sustained inflation for preterm infants after birth.

Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

“…27 There is no evidence of maternal harm from delayed cord clamping compared with early cord clamping. [10][11][12][28][29][30][31][32][33][34] Cord milking is being studied as an alternative to delayed cord clamping but should be avoided in babies less than 28 weeks' gestational age, because it is associated with brain injury. 23…”

“…8 Ten RCTs found no difference in postpartum hemorrhage rates with delayed cord clamping versus early cord clamping. [10][11][12][28][29][30][31][32][33][34] 2. Compared with term infants receiving early cord clamping, term infants receiving delayed cord clamping had increased hemoglobin concentration within the first 24 hours and increased ferritin concentration in the first 3 to 6 months in meta-analyses of 12 and 6 RCTs, 9-21 respectively.…”

“…Compared with term and late preterm infants receiving early cord clamping, those receiving delayed cord clamping showed no significant difference in mortality, admission to the neonatal intensive care unit, or hyperbilirubinemia leading to phototherapy in metaanalyses of 4, 10,13,29,35 10, 10,12,17,19,21,28,31,34,36,37 and 15 RCTs, respectively. 9,12,14,[18][19][20][21][28][29][30][32][33][34]38,39 Compared with term infants receiving early cord clamping, those receiving delayed cord clamping had increased polycythemia in metaanalyses of 13 10,11,13,14,17,18,21,29,30,33,[39][40][41] and 8 RCTs, 9,10,13,19,20,28,30,34 respectively.…”

Changes in respiratory mechanics at birth in preterm infants: A pilot study

“…Recent randomized controlled preclinical 5 and clinical studies 19,20 have failed to prove better outcomes when SI is applied.…”

Patients With COVID‐19 Undergoing Cesarean Deliveries: Adapting the OR Suite and Perioperative Care to Prevent Transmission

“…Appropriately sized intubation equipment and bag-valvemasks, epinephrine, and oxygen also were available in the event that emergency resuscitation of the newborn was necessary. 15 The attending obstetrician or obstetric resident physician clamped and cut the umbilical cord as soon as possible to remove the newborn from the mother. We immediately separated the newborn from the mother to prevent transmission of COVID-19 from the mother to the newborn.…”