Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular hemorrhage in preterm infants

Systematic Review of the Effects of Positioning on Nonautonomic Outcomes in Preterm Infants

OBJECTIVE

To identify and synthesize the available evidence on the effect of different positions (prone, supine, and right and left lateral) on nonautonomic outcomes for preterm infants admitted to the NICU.

DATA SOURCES

We searched the CINAHL, MEDLINE, Scopus, and Cochrane databases for reports of primary research studies using a three-step strategy. We also searched for gray literature and reviewed the reference lists of retrieved articles.

STUDY SELECTION

We included reports of quantitative studies published in English from database inception through February 2022 that focused on positioning and nonautonomic outcomes (pain, comfort, skin integrity, behavioral state, and sleep quality and duration) for preterm infants in the NICU. Two authors independently screened titles and abstracts and assessed articles in full text against the inclusion criteria.

DATA EXTRACTION

Two authors independently extracted the data from the full-text articles using a standardized data extraction tool. We synthesized the data narratively because of the different designs and outcome measures among the included studies.

DATA SYNTHESIS

From a total of 550 records initially screened, we included 17 articles in our review. In the included articles, prone positioning improved sleep quality and duration, whereas supine positioning was associated with increased awakenings and activity. Infants demonstrated fewer self-regulatory behaviors in the prone position compared to supine or side-lying and were less stressed in the prone position. We found minimal evidence on the effect of positioning on skin integrity or pain.

CONCLUSION

There is limited good-quality evidence on the effect of positioning on nonautonomic outcomes in preterm infants. To inform clinical practice, high-quality randomized controlled trials focused on the positioning of premature infants are warranted.

Sensory-based interventions in the NICU: systematic review of effects on preterm brain development

BACKGROUND

Infants born preterm are known to be at risk for abnormal brain development and adverse neurobehavioral outcomes. To improve early neurodevelopment, several non-pharmacological interventions have been developed and implemented in the neonatal intensive care unit (NICU). Sensory-based interventions seem to improve short-term neurodevelopmental outcomes in the inherently stressful NICU environment. However, how this type of intervention affects brain development in the preterm population remains unclear.

METHODS

A systematic review of the literature was conducted for published studies in the past 20 years reporting the effects of early, non-pharmacological, sensory-based interventions on the neonatal brain after preterm birth.

RESULTS

Twelve randomized controlled trials (RCT) reporting short-term effects of auditory, tactile, and multisensory interventions were included after the screening of 1202 articles. Large heterogeneity was identified among studies in relation to both types of intervention and outcomes. Three areas of focus for sensory interventions were identified: auditory-based, tactile-based, and multisensory interventions.

CONCLUSIONS

Diversity in interventions and outcome measures challenges the possibility to perform an integrative synthesis of results and to translate these for evidence-based clinical practice. This review identifies gaps in the literature and methodological challenges for the implementation of RCTs of sensory interventions in the NICU.

IMPACT

This paper represents the first systematic review to investigate the effect of non-pharmacological, sensory-based interventions in the NICU on neonatal brain development. Although reviewed RCTs present evidence on the impact of such interventions on the neonatal brain following preterm birth, it is not yet possible to formulate clear guidelines for clinical practice. This review integrates existing literature on the effect of sensory-based interventions on the brain after preterm birth and identifies methodological challenges for the conduction of high-quality RCTs.

The effect of head positioning on brain tissue oxygenation in preterm infants: a randomized clinical trial study

BACKGROUND

CNS injury in preterm infants is still one of the leading causes of mortality and morbidity. Routine care events might affect the perfusion and cerebral oxygenation of preterm infants. Although positioning the infant's head in a particular condition to improve brain oxygenation is included in many institutions, there is no robust clinical evidence to support this intervention's effectiveness.

OBJECTIVE

The present study aimed to determine the effect of head positioning on brain tissue oxygenation in preterm infants.

METHODS

This study is a randomized clinical trial. In the first 48 h after birth, 39 infants who met the study inclusion criteria underwent head positioning intervention. In this case, the infants were placed in the supine position, and every 2 h, the head position was changed continuously to one of six randomized modes [using random modes generated by SPSS]. During each head positioning, brain tissue oxygenation was recorded by NIRS.

RESULTS

The findings showed a significant difference in brain tissue oxygen saturation among these positions (P < 0.001). Dunn's test showed that the brain tissue oxygen saturation in the third position (head rotates 45-60 degrees from the midline to the right and the head of the bed is zero degrees) was significantly lower than the baseline (P = 0.029; Mean difference = 2.3). Also, in the third position, compared to the first position (P = 0.002; Mean difference = 1.9) and compared to the fourth position (P = 0.003; Mean difference = -2.1), and in the second position compared to the first position (P = 0.046; Mean difference = 1.3), the brain tissue oxygen saturation of the infants was lower.

CONCLUSION

Based on the results of the present study, head positioning was effective on brain tissue oxygenation in preterm infants in the first 48 h after birth; Therefore, it is recommended when possible, not to rotate the infant's head during the first 48 h after birth while the head of the bed is at 0°.

Impact of a “Brain Protection Bundle” in Reducing Severe Intraventricular Hemorrhage in Preterm Infants <30 Weeks GA: A Retrospective Single Centre Study

Background: despite advances in perinatal care, periventricular/intraventricular hemorrhage (IVH) continues to remain high in neonatal intensive care units (NICUs) worldwide. Studies have demonstrated the benefits of implementing interventions during the antenatal period, stabilization after birth (golden hour management) and postnatally in the first 72 h to reduce the incidence of IVH. Objective: to compare the incidence of severe intraventricular hemorrhage (IVH ≥ Grade III) before and after implementation of a “brain protection bundle” in preterm infants <30 weeks GA. Study design: a pre- and post-implementation retrospective cohort study to compare the incidence of severe IVH following execution of a “brain protection bundle for the first 72 h from 2015 to 2018. Demographics, management practices at birth and in the NICU, cranial ultrasound results and short-term morbidities were compared. Results: a total of 189 and 215 infants were included in the pre- and post-implementation phase, respectively. No difference in the incidence of severe IVH (6.9% vs. 9.8%, p = 0.37) was observed on the first cranial scan performed after 72 h of age. Conclusion: the implementation of a “brain protection bundle” was not effective in reducing the incidence of severe IVH within the first 72 h of life in our centre.

Turkish Neonatal Society Guideline on the Diagnosis and Management of Germinal Matrix Hemorrhage-Intraventricular Hemorrhage and Related Complications

Germinal matrix hemorrhage-intraventricular hemorrhage (GMH-IVH) remains an important cause of brain injury in preterm infants, and is associated with high rates of mortality and adverse neurodevelopmental outcomes, despite the recent advances in perinatal care. Close neuroimaging is recommended for both the detection of GMH-IVH and for the follow-up of serious complications, such as post-hemorrhagic ventricular dilatation (PHVD). Although the question when best to treat PHVD remains a matter of debate, recent literature on this topic shows that later timing of interventions predicted higher rates of neurodevelopmental impairment, emphasizing the importance of a well-structured neuroimaging protocol and timely interventions. In this guideline, pathophysiologic mechanisms, preventive measures, and clinical presentations of GMH-IVH and PHVD will be presented, and a neuroimaging protocol as well as an optimal treatment approach will be proposed in light of the recent literature.

Germinal Matrix-Intraventricular Hemorrhage: A Tale of Preterm Infants

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a common intracranial complication in preterm infants, especially those born before 32 weeks of gestation and very-low-birth-weight infants. Hemorrhage originates in the fragile capillary network of the subependymal germinal matrix of the developing brain and may disrupt the ependymal lining and progress into the lateral cerebral ventricle. GM-IVH is associated with increased mortality and abnormal neurodevelopmental outcomes such as posthemorrhagic hydrocephalus, cerebral palsy, epilepsy, severe cognitive impairment, and visual and hearing impairment. Most affected neonates are asymptomatic, and thus, diagnosis is usually made using real-time transfontanellar ultrasound. The present review provides a synopsis of the pathogenesis, grading, incidence, risk factors, and diagnosis of GM-IVH in preterm neonates. We explore brief literature related to outcomes, management interventions, and pharmacological and nonpharmacological prevention strategies for GM-IVH and posthemorrhagic hydrocephalus.

Elevated supine midline head position for prevention of intraventricular hemorrhage in VLBW and ELBW infants: a retrospective multicenter study

OBJECTIVE

To evaluate the impact of elevated supine midline head position on intraventricular hemorrhage (IVH) in very-low-birth-weight (VLBW) infants.

STUDY DESIGN

We reviewed data from four Level III/IV units. Two of these units (mid-line group) cared for infants in midline position and the other two (routine care group) provided routine care. We compared incidence of any and severe IVH in two groups using multivariate logistic regression analyses.

RESULTS

Of 2201 VLBW infants, 1041 were extremely-low-birth-weight (ELBW). Odds of any IVH were not different either for VLBW or ELBW infants. Odds of severe IVH were higher for VLBW infants in mid-line group (OR 1.43, 95% CI 1.007-2.02; p value 0.046) but not for ELBW infants (OR 0.9, 95% CI 0.6-1.4; p value 0.73).

CONCLUSIONS

The incidence of any IVH was similar in the two groups but the incidence of severe IVH was higher in VLBW infants in mid-line group.

The Frequency of Intraventricular Hemorrhage and its Risk Factors in Premature Neonates in a Hospital's NICU

OBJECTIVE

Intra-ventricular hemorrhage (IVH) is the leading cause of mortality and disability in premature neonates. The present study aimed to determine the frequency of IVH and its risk factors in the premature newborns admitted to the Neonatal Intensive Care Unit (NICU)at Fatemieh Hospital in Hamadan, Iran, in 2016.

METHODS & MATERIALS

This retrospective cross-sectional study was conducted on178 neonates with a gestational age of ≤ 32 weeks admitted to Fatemieh Hospital affiliated to the Hamadan University of Medical Sciences, Hamadan, Iran, in 2016. The study population was selected using the census method. The newborns were subjected to cranial ultrasound on the seventh day of life, and they were assigned into two case and control groups (namely neonates with IVH and those without IVH, respectively). Intra- ventricular hemorrhage was classified into four grades regarding Papile classification. The patients' demographic specifications, including 1- and 5-minute Apgar scores, type of delivery, birth weight, use of mechanical ventilation, prenatal corticosteroid, gestational age, and some complications (e.g., Pneumothorax), were collected using a checklist. The data were analyzed using SPSS software version 16.

RESULTS

According to the results, the prevalence of IVH in premature infants admitted to NICU was approximately 20%, and 61.2% of the neonates were male. The participants' mean gestational age was 30.39 weeks. The comparison of delivery type between the case and control groups revealed no significant difference (P=0.197). Furthermore, there was a significant difference between the two groups in terms of their need for mechanical ventilation (P=0.03), Pneumothorax(P=0.001), and 5-minute Apgar scores (P=0.04). Moreover, the incidence of IVH had a significant relationship with the mean gestational age (P=0.001) and birth weight (P=0.04).

CONCLUSION

According to the findings, the premature newborns admitted to the NICU revealed a relatively high prevalence of IVH. The condition is aggravated in preterm neonates by some factors such as low birth weight, 5-minute Apgar score, gestational age, and the need for mechanical ventilation.

Erythropoietin Improves Poor Outcomes in Preterm Infants with Intraventricular Hemorrhage

BACKGROUND

Intraventricular hemorrhage (IVH) is a common complication in preterm infants that has poor outcomes, especially in severe cases, and there are currently no widely accepted effective treatments. Erythropoietin has been shown to be neuroprotective in neonatal brain injury.

OBJECTIVE

The objective of this study was to evaluate the protective effect of repeated low-dose recombinant human erythropoietin (rhEPO) in preterm infants with IVH.

METHODS

This was a single-blinded prospective randomized controlled trial. Preterm infants ≤ 32 weeks gestational age who were diagnosed with IVH within 72 h after birth were randomized to receive rhEPO 500 IU/kg or placebo (equivalent volume of saline) every other day for 2 weeks. The primary outcome was death or neurological disability assessed at 18 months of corrected age.

RESULTS

A total of 316 eligible infants were included in the study, with 157 in the rhEPO group and 159 in the placebo group. Although no significant differences in mortality (p = 0.176) or incidence of neurological disability (p = 0.055) separately at 18 months of corrected age were seen between the rhEPO and placebo groups, significantly fewer infants had poor outcomes (death and neurological disability) in the rhEPO group: 14.9 vs. 26.4%; odds ratio (OR) 0.398; 95% confidence interval (CI) 0.199-0.796; p = 0.009. In addition, the incidence of Mental Development Index scores of < 70 was lower in the rhEPO group than in the placebo group: 7.2 vs. 15.3%; OR 0.326; 95% CI 0.122-0.875; p = 0.026.

CONCLUSIONS

Treatment with repeated low-dose rhEPO improved outcomes in preterm infants with IVH.

TRIAL REGISTRATION

The study was retrospectively registered on ClinicalTrials.gov on 16 April 2019 (NCT03914690).

An EBP to Promote Early Skin-to-Skin Care Intervention and Mother's Own Milk Feedings in the Extremely Low Birth Weight Population

PURPOSE

Describe an evidence-based process (EBP) to promote early skin-to-skin care (SSC) intervention and increase mother's-own-milk (MOM) feedings at discharge among extremely low birth weight (ELBW) infants.

DESIGN

This EBP aimed to address the following clinical question: Among ELBW infants, does early SSC &#ξ2264;16 days of life (DOL), compared to SSC >16 DOL, result in more infants receiving MOM feedings at discharge?

SAMPLE

A retrospective chart review of 199 ELBW infants.

MAIN OUTCOME VARIABLE

Early SSC intervention among ELBW infants and MOM at discharge.

RESULTS

Early SSC intervention increased from 46 to 73 percent among ELBW infants over the EBP period. Frequency of SSC intervention was associated with year of EBP and MOM at discharge (p = <.05). ELBW infants in the early SSC intervention group received more MOM at discharge.

Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: a multicentre cohort study

OBJECTIVE

To investigate the effect of a nursing intervention bundle, applied during the first 72 hours of life, on the incidence of germinal matrix-intraventricular haemorrhage (GMH-IVH) in very preterm infants.

DESIGN

Multicentre cohort study.

SETTING

Two Dutch tertiary neonatal intensive care units.

PATIENTS

The intervention group consisted of 281 neonates, whereas 280 infants served as historical controls (gestational age for both groups <30 weeks).

INTERVENTIONS

After a training period, the nursing intervention bundle was implemented and applied during the first 72 hours after birth. The bundle consisted of maintaining the head in the midline, tilting the head of the incubator and avoidance of flushing/rapid withdrawal of blood and sudden elevation of the legs.

MAIN OUTCOME MEASURES

The incidence of GMH-IVH occurring and/or increasing after the first ultrasound (but within 72 hours), cystic periventricular leukomalacia and/or in-hospital death was the primary composite outcome measure. Logistic regression analysis was used to explore differences between groups.

RESULTS

The nursing intervention bundle was associated with a lower risk of developing a GMH-IVH (any degree), cystic periventricular leukomalacia and/or mortality (adjusted OR 0.42, 95% CI 0.27 to 0.65). In the group receiving the bundle, also severe GMH-IVH, cystic periventricular leukomalacia and/or death were less often observed (adjusted OR 0.54, 95% CI 0.33 to 0.91).

CONCLUSIONS

The application of a bundle of nursing interventions is associated with reduced risk of developing a new/progressive (severe) GMH-IVH, cystic periventricular leukomalacia and/or mortality in very preterm infants when applied during the first 72 hours postnatally.

Beyond Anesthesia Toxicity: Anesthetic Considerations to Lessen the Risk of Neonatal Neurological Injury

Infants who undergo surgical procedures in the first few months of life are at a higher risk of death or subsequent neurodevelopmental abnormalities. Although the pathogenesis of these outcomes is multifactorial, an understanding of the nature and pathogenesis of brain injury in these infants may assist the anesthesiologist in consideration of their day-to-day practice to minimize such risks. This review will summarize the main types of brain injury in preterm and term infants and their key pathways. In addition, the review will address key potential pathogenic pathways that may be modifiable including intraoperative hypotension, hypocapnia, hyperoxia or hypoxia, hypoglycemia, and hyperthermia. Each of these conditions may increase the risk of perioperative neurological injury, but their long-term ramifications are unclear.

Neuroprotection from acute brain injury in preterm infants

Infants born at ≤32⁺⁶ weeks gestation are at higher risk for intracranial ischemic and hemorrhagic injuries, which often occur in the first 72 hours postbirth. Antenatal strategies to reduce the incidence of acute brain injuries include administering maternal corticosteroids and prompt antibiotic treatment for chorioamnionitis. Perinatal strategies include delivery within a tertiary centre, delayed cord clamping, and preventing hypothermia. Postnatal strategies include empiric treatment with antibiotics when chorioamnionitis is suspected, the cautious use of inotropes, the avoidance of blood PCO2 fluctuation, and neutral head positioning. Clinicians should be aware of the policies and procedures that, especially when combined, can provide neuroprotection for preterm infants.

Survey of preterm neuro-centric care practices in California neonatal intensive care units

OBJECTIVE

Examine the adoption and presence of preterm, neuro-centric care practices across neonatal intensive care units (NICUs).

STUDY DESIGN

Statewide, cross-sectional survey of California NICUs. Data were collected surrounding the timing of adoption and presence of delivery room practices, nursing protocols, provider management practices and quality improvement initiatives.

RESULT

Among the 95 NICUs completing the survey (65%), adoption of all surveyed practices increased between 2005 and 2016, though rates of uptake changed over time and varied by practice. Adoption of indomethacin prophylaxis increased 1.8-fold, whereas delayed cord clamping increased 78-fold. Adoption of premedication for intubation and a patent ductus arteriosus management algorithm differed by unit level. Additionally, two underlying practice domains were identified; adoption of delivery room practices and adoption of any preterm practice.

CONCLUSION

Adoption of preterm, neuro-centric care practices across California NICUs has increased, though uptake patterns vary by practice and level.

Supine vs. Prone Position With Turn of the Head Does Not Affect Cerebral Perfusion and Oxygenation in Stable Preterm Infants ≤32 Weeks Gestational Age

Intraventricular hemorrhage (IVH) is a frequent major damage to the brain of premature babies ≤32 weeks gestational age, and its incidence (20–25%) has not significantly changed lately. Because of the intrinsic fragility of germinal matrix blood vessels, IVH occurs following disruption of subependymal mono-layer arteries and is generally attributed to ischemia-reperfusion alterations or venous congestion, which may be caused by turn of the head. Therefore, supine position with the head in a midline position is considered a standard position for preterm infants during their first days of life. We asked whether a change in body position (supine vs. prone) linked with a turn of the head by 90° in the prone position would change blood flow velocities and resistance indices in major cerebral arteries and veins of stable premature babies at two different time points (t0, day of life 2, vs. t1, day 9). Moreover, we assessed cerebral tissue oxygenation (cStO2) by near-infrared spectroscopy and determined correlations for changes in velocities and oxygenation. Twenty one premature infants [gestational age 30 (26–32) weeks] with sufficiently stable gas exchange and circulation were screened by ultrasonography and near-infrared spectroscopy. Peak systolic and end-diastolic blood flow velocities in the anterior cerebral arteries (29 ± 6 m/s vs. 28 ± 7 peak flow at t0, 36 ± 8 vs. 35 ± 7 at t1), the basilar artery, the right and the left internal carotid artery, and the great cerebral vein Galen (4.0 ± 0.8 m/s vs. 4.1 ± 1.0 maximum flow at t0, 4.4 ± 0.8 vs. 4.4 ± 1.0 at t1) did not show significant differences following change of body and head position. Also, there were no differences in cStO₂ (83 ± 7% vs. 84 ± 7 at t0, 76 ± 10 vs. 77 ± 11 at t1) and in vital signs such as heart rate and blood pressure. We conclude that change in body position with turn of the head in the prone position does not elicit significant alterations in cerebral blood flow velocities or in oxygenation of cerebral tissues. Maturational changes in arterial flow velocities and cStO₂ are not correlated. For this subgroup of premature infants at low risk of IVH our data do not support the concept of exclusive preterm infant care in supine position.

Respiratory Care for the Ventilated Neonate

Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.