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Borenstein-Levin L, Avishay N, Soffer O, Arnon S, Riskin A, Dinur G, Lavie-Nevo K, Gover A, Kugelman A, Hochwald O. Transcutaneous CO 2 Monitoring in Extremely Low Birth Weight Premature Infants. J Clin Med 2023; 12:5757. [PMID: 37685823 PMCID: PMC10488371 DOI: 10.3390/jcm12175757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Extremely low birth weight (ELBW) premature infants are particularly susceptible to hypocarbia and hypercarbia, which are associated with brain and lung morbidities. Transcutaneous CO2 (TcCO2) monitoring allows for continuous non-invasive CO2 monitoring during invasive and non-invasive ventilation and is becoming more popular in the NICU. We aimed to evaluate the correlation and agreement between CO2 levels measured by a TcCO2 monitor and blood gas CO2 (bgCO2) among ELBW infants. This was a prospective observational multicenter study. All infants < 1000 g admitted to the participating NICUs during the study period were monitored by a TcCO2 monitor, if available. For each bgCO2 measured, a simultaneous TcCO2 measurement was documented. In total, 1828 pairs of TcCO2-bgCO2 values of 94 infants were collected, with a median (IQR) gestational age of 26.4 (26.0, 28.3) weeks and birth weight of 800 (702, 900) g. A moderate correlation (Pearson: r = 0.64) and good agreement (bias (95% limits of agreement)):(2.9 [-11.8, 17.6] mmHg) were found between the TcCO2 and bgCO2 values in the 25-70 mmHg TcCO2 range. The correlation between the TcCO2 and bgCO2 trends was moderate. CO2 measurements by TcCO2 are in good agreement (bias < 5 mmHg) with bgCO2 among premature infants < 1000 g during the first week of life, regardless of day of life, ventilation mode (invasive/non-invasive), and sampling method (arterial/capillary/venous). However, wide limits of agreement and moderate correlation dictate the use of TcCO2 as a complementary tool to blood gas sampling, to assess CO2 levels and trends in individual patients.
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Affiliation(s)
- Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Noa Avishay
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Orit Soffer
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
| | - Shmuel Arnon
- Department of Neonatology, Meir Medical Center, Kfar-Saba 4428164b, Israel;
- Faculty of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
- Department of Neonatology, Bnai Zion Medical Center, Haifa 32000, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Karen Lavie-Nevo
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
- Department of Neonatology, Carmel Medical Center, Haifa 3436212, Israel
| | - Ayala Gover
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
- Department of Neonatology, Carmel Medical Center, Haifa 3436212, Israel
| | - Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
| | - Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa 3109601, Israel; (O.S.); (G.D.); (A.K.); (O.H.)
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa 3200003, Israel; (N.A.); (A.R.); (K.L.-N.); (A.G.)
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Borenstein-Levin L, Haj A, Riskin A, Dinur G, Littner Y, Hochwald O, Kugelman A. Oxygenation Instability during Bolus versus Continuous Feeding among Very Low Birth Weight Premature Infants, Supported by Noninvasive Ventilation: A Randomized Prospective Study. Am J Perinatol 2023. [PMID: 37494585 DOI: 10.1055/s-0043-1771257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE This study aimed to compare oxygenation instability, as documented by the oxygen saturation (SpO2) histograms, during bolus (over 30 minutes) versus continuous (over 2 hours) feeding among very low birth weight (VLBW) premature infants, supported with noninvasive ventilation (NIV). STUDY DESIGN This was a randomized prospective study. VLBW infants supported with NIV received three consecutive feeds in a random order of bolus-continuous-bolus or continuous-bolus-continuous. During each feed, 30 minutes and 2 hours histograms were documented. RESULTS Twenty-four infants (birth weight [mean ± standard deviation, SD] 820 ± 168 g, gestational age [mean ± SD] 27.0 ± 1.6 weeks) were included in our study (12 infants started with bolus feeding and 12 with continuous feeding) and 72 histograms were obtained (36 during bolus feeding and 36 during continuous feeding). No differences in mean fraction of inspired oxygen (FiO2), and number of apnea events were observed between the two feeding modes. Oxygenation instability as assessed by time spent in different SpO2 ranges and histogram types (stable or unstable) was comparable during bolus and continuous feedings. Changing feeding mode from bolus to continuous or vice versa did not significantly change the oxygenation instability of the group, though individual infants did show a consistence response to feeding length changes. CONCLUSION Among VLBW infants supported with NIV, oxygenation instability, as documented by SpO2 histograms, was comparable between bolus and continuous feedings. Individual infants may benefit from specific feeding length, and this can be easily demonstrated by the SpO2 histograms. KEY POINTS · Feeding length did not affect oxygenation instability of preterm infants on noninvasive respiratory Support.. · Oxygen saturation histograms allow objective quantification of oxygenation instability at the bedside.. · Individual infants benefit from specific feeding length, as demonstrated by SpO2 histograms..
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Affiliation(s)
- Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ahmad Haj
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yoav Littner
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Borenstein-Levin L, Riskin A, Hochwald O, Timstut F, Sendler S, Shoris I, Littner Y, Dinur G, Kugelman A. Continuous versus Bolus Gastric Tube Feeding in Very Low Birth Weight Infants Supported with Noninvasive Respiratory Support: A Randomized, Pilot Study. Am J Perinatol 2022. [PMID: 36096134 DOI: 10.1055/s-0042-1755551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES This study aimed to compare time to full feeding (TFF) between continuous gastric feeding (CGF) and bolus feeding (BF) in very low birth weight (VLBW) infants supported with noninvasive ventilation (NIV) and to evaluate feasibility and identify methodological pitfalls for future large-scale studies. STUDY DESIGN This study is a randomized controlled, prospective, pilot study. VLBW premature infants, supported with NIV, were randomized while still on trophic feeding <20 mL/kg/day to receive feeding over 2 hours of CGF or over 15- to 30-minute BF. The primary outcome was TFF. Analysis was done by intention to treat. RESULTS Overall, 32 infants were included in this analysis, 17 in the CGF group and 15 in the BF group. Infants in the CGF group were significantly younger than the BF group (mean ± standard deviation [SD] gestational age [GA] 26.9 ± 1.2 vs. 28.9 ± 1.5 weeks, respectively). TFF was comparable with median (interquartile range [IQR]) for the two groups, 10.0 (10.0, 19.0) days in the BF group versus 12.0 (9.0, 13.0) days in the CGF group (p = 0.59). Feeding length was not found to significantly affect TFF in multivariate analysis correcting for GA. Groups were comparable in weight gain, gastrointestinal complications, length of NIV, bronchopulmonary dysplasia incidence, and age at discharge. Most infants from both groups (60% of BF and 70% of CGF) required changes in feeding length. CONCLUSION In this pilot study, among VLBW infants supported with NIV, TFF was comparable between the BF and CGF groups. These results should be interpreted with caution due to the small sample size and despite the multivariate analysis correcting for the different GA. Interestingly, most infants required changes in feeding length regardless of their allocation. This feasibility study emphasizes the need for careful attention to randomization and strict feeding protocols including criteria for switching allocation in future large-scale studies aimed at determining the preferred feeding length during NIV in VLBW infants. KEY POINTS · Among infants supported with NIV, length of feeding affects gastric venting.. · BF might increase gastrointestinal reflux, while continuous feeding hinders gastric decompression.. · Among infants supported by NIV, feeding tolerance was comparable between bolus and continuous groups..
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Affiliation(s)
- Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Fanny Timstut
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Sofia Sendler
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Irit Shoris
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel
| | - Yoav Littner
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Borenstein-Levin L, Taha R, Riskin A, Hafner H, Cohen-Vaizer A, Gordin A, Littner Y, Dinur G, Hochwald O, Kugelman A. Effects of neurodevelopmental risk factors on brainstem maturation in premature infants. Pediatr Res 2022; 92:168-173. [PMID: 34789841 DOI: 10.1038/s41390-021-01849-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 10/16/2021] [Accepted: 10/31/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Interpeak latencies (IPL), as measured by the auditory brainstem-evoked responses (ABR) test, represent the conduction time, and therefore the maturation of the brainstem auditory pathway. We aimed to study the effect of various risk factors for the neurodevelopmental delay on the conduction time in the auditory pathway among normal hearing premature infants, at term postmenstrual age (PMA). METHODS Retrospective analysis of 239 premature infants (gestational age 32.5 ± 2.1 weeks, birth weight 1827 ± 483 g). Interpeak latencies, demographic data, and risk factors were recorded. RESULTS Sex, PMA at ABR test, being small for gestational age (SGA), intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), and days of invasive ventilation were found to significantly affect the IPL's in the auditory pathway in a univariate analysis. Multivariable regression analysis revealed that male sex and less advanced PMA at the examination were independent factors associated with prolonged IPL's, while bronchopulmonary dysplasia, IVH or PVL and being SGA shortened the IPL's. Non-invasive mechanical ventilation, did not affect the caudal part of the auditory pathway, despite its high noise level. CONCLUSIONS Among various risk factors for the neurodevelopmental delay, male sex was associated with delayed, while IVH or PVL, BPD and SGA could be associated with accelerated auditory brainstem maturation. IMPACT Auditory brainstem-evoked response (ABR) test, among normal hearing infants, can serve as a clinical tool to assess brainstem auditory maturation. Different neurodevelopmental risk factors could have different effects on the maturity of the auditory pathway. Male sex is significantly associated with prolonged interpeak latencies (IPL) among preterm and term infants, while intraventricular hemorrhage or periventricular leukomalacia, bronchopulmonary dysplasia, and being small for gestation age may be associated with shortened IPL The corrected age at ABR testing is of significance, among preterm and term infants.
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Affiliation(s)
- L Borenstein-Levin
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel. .,Department of Neonatology, Rambam Health Care Campus, Haifa, Israel.
| | - R Taha
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - A Riskin
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Neonatology, Bnai Zion Medical Center, Haifa, Israel
| | - H Hafner
- Laboratory of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | - A Cohen-Vaizer
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of ENT, Rambam Health Care Campus, Haifa, Israel
| | - A Gordin
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of ENT, Rambam Health Care Campus, Haifa, Israel
| | - Y Littner
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - G Dinur
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - O Hochwald
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - A Kugelman
- Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
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Littner Y, Volinsky C, Kuint J, Yekutiel N, Borenstein-Levin L, Dinur G, Hochwald O, Kugelman A. Respiratory morbidity in very low birth weight infants through childhood and adolescence. Pediatr Pulmonol 2021; 56:1609-1616. [PMID: 33657277 DOI: 10.1002/ppul.25329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/09/2021] [Accepted: 02/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To describe the long-term (up to 18 years of age) respiratory outcomes of children and adolescents born at very low birth weight (VLBW; ≤1500 g) in comparison with that of children born >1500 g. METHODS An observational, longitudinal, retrospective study comparing VLBW infants with matched controls, registered at a large health maintenance organization in Israel. Pulmonary outcomes collected anonymously from the electronic medical files included respiratory illness diagnoses, purchased medications for respiratory problems, office visits with either a pediatric pulmonologist or cardiologist and composite respiratory morbidity combining all these parameters. RESULTS Our study included 5793 VLBW infants and 11,590 matched controls born between 1998 and 2012. The majority (99%) of VLBW infants were premature (born < 37 weeks' gestation), while 93% of controls were born at term. The composite respiratory morbidity was significantly higher in VLBW infants compared with controls in all age groups (relative risk [95% confidence interval]: 1 year: 1.22 [1.19-1.26], <2 years: 1.30 [1.27-1.34], 2-6 years: 1.29 [1.27-1.32], 6-12 years: 1.53 [1.47-1.59], 12-18 years: 1.46 [1.35-1.56]; respectively). Both VLBW infants and controls demonstrated a steady decline in the composite respiratory morbidity with aging. In VLBW infants, lower gestational age was associated with higher respiratory morbidity only until 2 years of age and the morbidity declined in each gestational age group until adolescence. CONCLUSION Our study confirmed a strong association between VLBW and pulmonary morbidity. The higher prevalence of respiratory composite morbidity in VLBW infants persists over the years until adolescence. The respiratory morbidity is most evident in the first year of life and declines afterward.
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Affiliation(s)
- Yoav Littner
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Chen Volinsky
- Department of Pediatrics, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jacob Kuint
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,K.S.M Research & Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Naama Yekutiel
- K.S.M Research & Innovation Institute, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Dinur G, Borenstein-Levin L, Vider S, Hochwald O, Jubran H, Littner Y, Fleischer-Sheffer V, Kugelman A. Evaluation of audio-voice guided application for neonatal resuscitation: a prospective, randomized, pilot study. J Perinat Med 2021; 49:520-525. [PMID: 33470963 DOI: 10.1515/jpm-2020-0173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 11/09/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To examine whether audio-voice guidance application improves adherence to resuscitation sequence and recommended time frames during neonatal resuscitation. METHODS A prospective, randomized, pilot study examining the use of an audio-voice application for guiding resuscitation on newborn mannequins, based on the Neonatal Resuscitation Program (NRP) algorithm. Two different scenarios, with and without voice guidance, were presented to 20 medical personnel (2 midwives, 8 nurses, and 10 physicians) in random order, and their performance videotaped. RESULTS Audio-voice guided resuscitation compared with non-guided resuscitation, resulted in significantly better compliance with NRP order sequence (p<0.01), correct use of oxygen supplementation (p<0.01) and performance of MR SOPA (Mask, reposition, suction, open mouth, pressure, airway) (p<0.01), and shortened the time to "positive pressure ventilation" (p<0.01). CONCLUSIONS In this pilot study, audio-voice guidance application for newborn resuscitation simulation on mannequins, based on the NRP algorithm, improved adherence and performance of NRP guidelines.
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Affiliation(s)
- Gil Dinur
- Department of Neonatology, Ruth Rapapport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Technion - Israel Institute of Technology, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Liron Borenstein-Levin
- Department of Neonatology, Ruth Rapapport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Technion - Israel Institute of Technology, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Shachar Vider
- Department of Orthopedic Surgery, Technion - Israel Institute of Technology, Rambam Health Care Campus, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Ori Hochwald
- Department of Neonatology, Ruth Rapapport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Technion - Israel Institute of Technology, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Huda Jubran
- Department of Neonatology, Ruth Rapapport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Technion - Israel Institute of Technology, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Yoav Littner
- Department of Neonatology, Ruth Rapapport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Technion - Israel Institute of Technology, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Vered Fleischer-Sheffer
- Department of Neonatology, Galilee Medical Center, Naharia,Israel.,Bar-Ilan University, Azrieli Faculty of Medicine, Safed, Israel
| | - Amir Kugelman
- Department of Neonatology, Ruth Rapapport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Technion - Israel Institute of Technology, Ruth & Bruce Rappaport Faculty of Medicine, Haifa, Israel
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Hochwald O, Borenstein-Levin L, Dinur G, Kugelman A. Is There a "Direct" Answer: Should We Perform Exchange Transfusion for Neonatal Predominantly Conjugated Hyperbilirubinemia? Clin Pediatr (Phila) 2021; 60:221-225. [PMID: 33853369 DOI: 10.1177/00099228211006686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Gil Dinur
- Rambam Health Care Campus, Haifa, Israel
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Vaisbourd Y, Sharif D, Dinur G, Kugelman A. Ductal steal: does it affect pre-ductal arteries. J Perinatol 2021; 41:4-5. [PMID: 33024257 DOI: 10.1038/s41372-020-00844-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 09/16/2020] [Accepted: 09/24/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Yulia Vaisbourd
- Department of Neonatology, Bnai Zion Medical Center, Rappaport Faculty of Medicine, Haifa, Israel.
| | - Dawod Sharif
- Department of Cardiology, Bnai Zion Medical Center, Rappaport Faculty of Medicine, Haifa, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Medical Center, Rappaport Faculty of Medicine, Haifa, Israel
| | - Amir Kugelman
- Department of Neonatology, Rambam Medical Center, Rappaport Faculty of Medicine, Haifa, Israel
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Miller-Barmak A, Riskin A, Hochwald O, Haddad J, Dinur G, Vortman R, Kugelman A, Borenstein-Levin L. Oxygenation Instability Assessed by Oxygen Saturation Histograms during Supine vs Prone Position in Very Low Birthweight Infants Receiving Noninvasive Respiratory Support. J Pediatr 2020; 226:123-128. [PMID: 32615194 DOI: 10.1016/j.jpeds.2020.06.066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effect of prone vs supine position on the oxygenation instability among very low birth weight (VLBW) infants receiving noninvasive respiratory support, as assessed by the average oxygen saturation (SpO2) histograms. STUDY DESIGN Sixty-nine histograms from 23 VLBW infants were studied prospectively. Each infant was studied during 3 consecutive 3-hour periods of alternating positions; 12 infants started the study while prone and 11 infants started supine, by random order. Histogram classification system was used to quantify oxygenation stability and time spent in different SpO2 ranges. RESULTS The fraction of inspired oxygen values were similar in both positions. Unstable histograms were more common in supine vs prone position (20/34 [59%] vs 10/35 [29%]; P = .02, respectively). Analyzing oxygenation stability as per position change revealed that a change from prone to supine increased oxygenation instability, and supine to prone decreased instability (P = .02). In the supine vs prone position, percent of time spent in SpO2 ≤80% and <90% was higher (5.0 ± 4.2 vs 2.4 ± 3.4 [P < .001] and 24.1 ± 13.7 vs 13.2 ± 10.0 [P < .001], respectively), and percent of time in SpO2 >94% was lower (39.7 ± 26.0 vs 52.4 ± 23.4 [P = .04]). CONCLUSIONS Prone positioning decreased oxygenation instability and resulted in higher oxygenation among VLBW premature infants on noninvasive respiratory support. SpO2 histograms allow easy bedside assessment of oxygenation instability, and quantification of the time spent at different SpO2 ranges.
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Affiliation(s)
- Adi Miller-Barmak
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Arieh Riskin
- Neonatal Intensive Care Unit, Bnai Zion Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Julie Haddad
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Rita Vortman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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10
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Borenstein-Levin L, Kugelman A, Horani A, Sharif Y, Sharif-Rasslan A, Riskin A, Hochwald O, Dinur G, Amshalom A, Bader D, Sharif D. [ALTERATIONS IN SENSITIVE MEASURES OF CARDIAC FUNCTION IN HEALTHY NEONATES DURING PHOTOTHERAPY]. Harefuah 2020; 159:739-744. [PMID: 33103393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Phototherapy has been reported to reduce coronary blood flow in neonates but without affecting gross measures of cardiac function. The aim of our current study was to evaluate earlier, more sensitive changes in cardiac function during phototherapy. METHODS Nineteen neonates with jaundice treated with phototherapy had Doppler echocardiographic evaluation, before, during and after phototherapy and were compared to 25 matched controls. Sensitive measures for cardiac performance in this study included left ventricular dimension, ventricular Doppler parameters and regional function assessment. RESULTS Phototherapy was associated with a significant increase in heart rate. In addition, atrioventricular valve closure to opening interval decreased significantly during phototherapy while ventricular ejection times tended to decrease. However, left and right ventricular filling parameters and outflow velocity parameters, longitudinal tissue-Doppler annular velocities and myocardial performance indices were not affected by phototherapy and were similar to those in controls. Coronary blood velocities and integrals decreased significantly during phototherapy. CONCLUSIONS Our study found no differences in early and sensitive measures of cardiac performance including the diastolic and systolic function, despite modestly lower flow in coronary arteries among healthy neonates during phototherapy.
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Affiliation(s)
- Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Ashraf Horani
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
| | - Yasmin Sharif
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
| | | | - Arieh Riskin
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
- Department of Neonatology, Bnai Zion Medical Center, Haifa, Israel
| | - Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Annat Amshalom
- Department of Neonatology, Bnai Zion Medical Center, Haifa, Israel
| | - David Bader
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
- Department of Neonatology, Bnai Zion Medical Center, Haifa, Israel
| | - Dawod Sharif
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
- Department of Cardiology, Bnai Zion Medical Center, Haifa, Israel
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11
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Lavie-Nevo K, Dinur G, Almagor Y, Barzilay B, Rotschild A, Gover A. [FUNCTIONAL ECHO IN PRETERM INFANTS - PAST, PRESENT AND FUTURE]. Harefuah 2020; 159:759-763. [PMID: 33103397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The use of point of care ultrasound to assess cardiovascular function performed by a neonatologist who is not a cardiologist, is gaining interest in the neonatal intensive care unit (NICU). Clinical signs such as heart rate, blood pressure and capillary refill time provide limited insight into the adequacy of systemic blood flow and organ perfusion. Functional echocardiography (echo) enables real time evaluation of cardiac performance, identifying the nature of cardiovascular compromise, guiding therapeutic decisions and monitoring response to treatment. Application of functional echo in the NICU includes assessment of patent ductus arteriosus (PDA), pulmonary hypertension, shock and placement of umbilical catheters. There is evidence implicating that functional echo alters neonatal treatment and may improve outcome. Functional echo does not aim to replace the detailed structural assessments provided by consultative services of pediatric cardiologists. Close collaboration with pediatric cardiology is essential. In the past two years there is an increasing awareness for using functional echocardiography by neonatologists in Israel. Three conferences and an educational workshop were held in Israel with world renowned lecturers. Protocols defining how the exam should be performed were prepared, and agreement was reached with pediatric cardiologists on how to implement the use of functional echo by neonatologists, with the intention to create a distinct group of neonatologists with knowledge and skills in functional echo and a profound understanding of cardiac and respiratory physiology and hemodynamics.
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Affiliation(s)
- Karen Lavie-Nevo
- Lady Davis Carmel Medical Center
- Rappaport Faculty of Medicine Technion
| | | | | | | | - Avi Rotschild
- Lady Davis Carmel Medical Center
- Rappaport Faculty of Medicine Technion
| | - Ayala Gover
- Lady Davis Carmel Medical Center
- Rappaport Faculty of Medicine Technion
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12
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Hochwald O, Borenstein-Levin L, Dinur G, Jubran H, Ben-David S, Kugelman A. Continuous Noninvasive Carbon Dioxide Monitoring in Neonates: From Theory to Standard of Care. Pediatrics 2019; 144:peds.2018-3640. [PMID: 31248940 DOI: 10.1542/peds.2018-3640] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2019] [Indexed: 11/24/2022] Open
Abstract
Ventilatory support may affect the short- and long-term neurologic and respiratory morbidities of preterm infants. Ongoing monitoring of oxygenation and ventilation and control of adequate levels of oxygen, pressures, and volumes can decrease the incidence of such adverse outcomes. Use of pulse oximetry became a standard of care for titrating oxygen delivery, but continuous noninvasive monitoring of carbon dioxide (CO2) is not routinely used in NICUs. Continuous monitoring of CO2 level may be crucial because hypocarbia and hypercarbia in extremely preterm infants are associated with lung and brain morbidities, specifically bronchopulmonary dysplasia, intraventricular hemorrhage, and cystic periventricular leukomalacia. It is shown that continuous monitoring of CO2 levels helps in maintaining stable CO2 values within an accepted target range. Continuous monitoring of CO2 levels can be used in the delivery room, during transport, and in infants receiving invasive or noninvasive respiratory support in the NICU. It is logical to hypothesize that this will result in better outcome for extremely preterm infants. In this article, we review the different noninvasive CO2 monitoring alternatives and devices, their advantages and disadvantages, and the available clinical data supporting or negating their use as a standard of care in NICUs.
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Affiliation(s)
- Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Huda Jubran
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Shlomit Ben-David
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel; and.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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13
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Hochwald O, Mainzer G, Borenstein-Levin L, Jubran H, Dinur G, Zucker M, Mor M, Khoury A, Kugelman A. Adding Paracetamol to Ibuprofen for the Treatment of Patent Ductus Arteriosus in Preterm Infants: A Double-Blind, Randomized, Placebo-Controlled Pilot Study. Am J Perinatol 2018; 35:1319-1325. [PMID: 29783269 DOI: 10.1055/s-0038-1653946] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE The objective of this study was to compare the closure rate of hemodynamically significant patent ductus arteriosus (hsPDA) of intravenous ibuprofen + paracetamol (acetaminophen) versus ibuprofen + placebo, in preterm infants of 24 to 316/7 weeks postmenstrual age. STUDY DESIGN This is a single-center, double-blind, randomized controlled pilot study. Infants were assigned for treatment with either intravenous ibuprofen + paracetamol (n = 12) or ibuprofen + placebo (n = 12). RESULTS There was no statistical difference in baseline characteristics of the two groups. Echocardiography parameters were comparable before treatment in both groups. There was a trend toward higher hsPDA closure rate in the paracetamol group in comparison to the placebo group (83 vs. 42%, p = 0.08). No adverse effects, clinical or laboratory, were associated with adding paracetamol. CONCLUSION Our pilot study was unable to detect a beneficial effect by adding intravenous paracetamol to ibuprofen for the treatment of hsPDA. Larger prospective studies are needed to explore the positive tendency suggested by our results and to assure safety.
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Affiliation(s)
- Ori Hochwald
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Gur Mainzer
- Department of Pediatric Cardiology and Congenital Heart Disease in Adults, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel.,Department of Pediatric Cardiology, Baruch Padeh Medical Center, Poriya, Israel
| | - Liron Borenstein-Levin
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Huda Jubran
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Gil Dinur
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Meirav Zucker
- Department of Pediatric Cardiology and Congenital Heart Disease in Adults, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Malka Mor
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Asaad Khoury
- Department of Pediatric Cardiology and Congenital Heart Disease in Adults, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
| | - Amir Kugelman
- Neonatal Intensive Care Unit, Ruth Rappaport Children's Hospital, Rambam Health Campus, Rappoart Faculty of Medicine, Technion, Haifa, Israel
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14
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Kugelman A, Borenstein-Levin L, Jubran H, Dinur G, Ben-David S, Segal E, Haddad J, Timstut F, Stein I, Makhoul IR, Hochwald O. Less is More: Modern Neonatology. Rambam Maimonides Med J 2018; 9:RMMJ.10344. [PMID: 30089091 PMCID: PMC6115478 DOI: 10.5041/rmmj.10344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Iatrogenesis is more common in neonatal intensive care units (NICUs) because the infants are vulnerable and exposed to prolonged intensive care. Sixty percent of extremely low-birth-weight infants are exposed to iatrogenesis. The risk factors for iatrogenesis in NICUs include prematurity, mechanical or non-invasive ventilation, central lines, and prolonged length of stay. This led to the notion that "less is more." In the delivery room delayed cord clamping is recommended for term and preterm infants, and suction for the airways in newborns with meconium-stained fluid is not performed anymore. As a symbol for a less aggressive attitude we use the term neonatal stabilization rather than resuscitation. Lower levels of oxygen saturations are accepted as normal during the first 10 minutes of life, and if respiratory assistance is needed, we no longer use 100% oxygen but 0.21-0.3 FiO2, depending on gestational age and the level of oxygen saturation. We try to avoid endotracheal ventilation by using non-invasive respiratory support and administering continuous positive airway pressure early on, starting in the delivery room. If surfactant is needed, non-invasive methods of surfactant administration are utilized. Use of central lines is shortened, and early feeding of human milk is the routine. Permissive hypercapnia is allowed, and continuous non-invasive monitoring not only of the O2 but also of CO2 is warranted. "Kangaroo care" and Newborn Individualized Developmental Care and Assessment Program (NIDCAP) together with a calm atmosphere with parental involvement are encouraged. Whether "less is more," or not enough, is to be seen in future studies.
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Affiliation(s)
- Amir Kugelman
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- To whom correspondence should be addressed. E-mail:
| | - Liron Borenstein-Levin
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Huda Jubran
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Gil Dinur
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Shlomit Ben-David
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Elena Segal
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Julie Haddad
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Fanny Timstut
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - Iris Stein
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
| | - Imad R. Makhoul
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Ori Hochwald
- Department of Neonatology, Rambam Health Care Campus, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
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