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Abstract Epinephrine is the only recommended vasopressor during neonatal cardiopulmonary resuscitation. However, there are concerns about the potential adverse effects of epinephrine, which might hamper efficacy during cardiopulmonary resuscitation. An alternative might be vasopressin, which has a preferable adverse effect profile, however, its optimal dose and route of administration is unknown. We aimed to compare the pharmacodynamics and pharmacokinetics of various vasopressin doses administered via intravenous (IV), intraosseous (IO), endotracheal (ETT), and intranasal (IN) routes in healthy neonatal piglets. Forty-four post-transitional piglets (1–3 days of age) were anesthetized, intubated via a tracheostomy, and randomized to receive vasopressin via intravenous (control), IO, ETT, or IN route. Heart rate (HR), arterial blood pressure, carotid blood flow, and cardiac function (e.g., stroke volume, ejection fraction) were continuously recorded throughout the experiment. Blood was collected prior to drug administration and throughout the observation period for pharmacodynamics and pharmacokinetic analysis. Significant changes in hemodynamic parameters were observed following IO administration of vasopressin while pharmacokinetic parameters were not different between IV and IO vasopressin. Administration of vasopressin via ETT or IN did not change hemodynamic parameters and had significantly lower maximum plasma concentrations and systemic absorption compared to piglets administered IV vasopressin (p

Background: Recently, the American Heart Association released a statement calling for research examining the appropriate age to transition from the neonatal to pediatric cardiopulmonary resuscitation approach to resuscitation. Aim: To compare neonatal and pediatric resuscitation approach by using either continuous chest compression with asynchronized ventilation (CCaV) or continuous chest compression superimposed with sustained inflation (CC + SI) during infant cardiopulmonary resuscitation. We hypothesized that CC + SI compared to CCaV would reduce time to return of spontaneous circulation (ROSC) in infantile piglets with asphyxia-induced bradycardic cardiac arrest. Methods: Twenty infantile piglets (5–10 days old) were anesthetized and asphyxiated by clamping the endotracheal tube. Piglets were randomized to CC + SI or CCaV for resuscitation (n = 10/group). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, intrathoracic pressure and respiratory parameters were continuously recorded throughout the experiment. Main results: The median (IQR) time to ROSC with CC + SI compared to CCaV was 179 (104–447) vs 660 (189–660), p = 0.05. The number of piglets achieving ROSC with CC + SI and CCaV were 8/10 and 6/10, p = 0.628. Piglets resuscitated with CC + SI required less epinephrine compared to CCaV (p = 0.039). CC + SI increased the intrathoracic pressure throughout resuscitation (p = 0.025) and increased minute ventilation (p

BackgroundNeonatal resuscitation is an important skillset for clinicians attending deliveries. Accredited neonatal resuscitation training is not obligatory in most training centers of standardized medical residency programs before 2022 in China. We investigated the feasibility and effectiveness of neonatal resuscitation simulation training (neo-RST) in residents in Shenzhen, China.MethodsFour two-day neo-RST workshops were conducted in the University of Hong Kong-Shenzhen Hospital and Shenzhen Health Capacity Building and Continuing Education Center in 2020–2021. The workshops had Neonatal Resuscitation Program (NRP)® update, skill stations and simulation practice with debriefing. Each participant had the integrated skill station assessment (ISSA) at the end of workshop. Participants of workshops included residents of different disciplines and health care providers (HCPs) of neonatal and obstetrical departments. We compared demographic characteristics, neonatal resuscitation knowledge before training, ISSA overall and categorical scores on skill sets between residents and HCPs.ResultsIn 2020–2021, 4 neo-RST workshops were conducted with 48 residents and 48 HCPs. The residents group had less working experience, less prior experience in neo-RST and lower neonatal resuscitation knowledge scores than those of HCPs group. After the workshop, residents had higher overall ISSA score than that of HCPs group (90.2 ± 5.9 vs. 86.3 ± 6.6%, P = 0.003, respectively). There was no significant difference in the numbers of participants scored

Background: Epinephrine is currently the only recommended cardio-resuscitative medication for use in neonatal cardiopulmonary resuscitation (CPR), as per the consensus of science and treatment recommendations. An alternative medication, vasopressin, might be beneficial in neonatal CPR due to its combined pulmonary vasodilation and systemic vasoconstriction properties. Aim: We aimed to compare the time to return of spontaneous circulation (ROSC) with administration of vasopressin or epinephrine during CPR of asphyxiated post-transitional piglets. Methods: Newborn piglets (n = 8/group) were anesthetized, tracheotomized and intubated, instrumented, and exposed to 50 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to receive vasopressin (Vaso, 0.4 U/kg) or epinephrine (Epi, 0.02 mg/kg) during CPR. Piglets were resuscitated with chest compressions superimposed with sustained inflations, and were administered either Vaso or Epi intravenously every 3 min until ROSC (max. 3 doses). Hemodynamic and cardiac function parameters were collected. Main Results: The median (IQR) time to ROSC was 106 (93–140) s with Vaso and 128 (100–198) s with Epi (p = 0.28). The number of piglets that achieved ROSC was 8 (100%) with Vaso and 7 (88%) with Epi (p = 1.00). Vaso-treated piglets had a significantly longer post-resuscitation survival time (240 (240–240) min) than Epi-treated piglets (65 (30–240) min, p = 0.02). Vaso-treated piglets had significantly improved carotid blood flow immediately after ROSC (p

BackgroundTo compare chest compression (CC) rates of 60/min with 90/min and their effect on the time to return of spontaneous circulation (ROSC), survival, hemodynamic, and respiratory parameters. We hypothesized that asphyxiated newborn piglets that received CC at 60/min vs. 90/min during cardiopulmonary resuscitation would have a shorter time to ROSC.MethodsNewborn piglets (n = 7/group) were anesthetized, tracheotomized and intubated, instrumented and exposed to 45 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to a CC rate of 60/min or 90/min. CC was performed using an automated CC machine using CC superimposed with sustained inflation. Hemodynamic parameters, respiratory parameters, and applied compression force were continuously measured.ResultsThe mean (IQR) time to ROSC was 97 (65–149) s and 136 (88–395) s for CC rates of 60/min and 90/min, respectively (p = 0.31). The number of piglets that achieved ROSC was 5 (71%) and 5 (71%) with 60/min and 90/min CC rates, respectively (p = 1.00). Hemodynamic parameters (i.e., diastolic and mean blood pressure, carotid blood flow, stroke volume, end-diastolic volume, left ventricular contractile function) and respiratory parameters (i.e., minute ventilation, peak inflation and peak expiration flow) were all similar with a CC rate of 60/min compared to 90/min.ConclusionTime to ROSC, hemodynamic, and respiratory parameters were not significantly different between CC rates of 60/min vs. 90/min. Different CC rates during neonatal resuscitation warrant further investigation.

BackgroundSimulation-based training improves neonatal resuscitation and decreases perinatal mortality in low- and middle-income countries. Interdisciplinary in-situ simulation may promote quality care in neonatal resuscitation. However, there is limited information regarding the effect of multidisciplinary in-situ simulation training (MIST) on neonatal outcomes. We aimed to investigate the impact of MIST on neonatal resuscitation in reducing the incidence of neonatal asphyxia and related morbidities.MethodsWeekly MIST on neonatal resuscitation has been conducted through neonatal and obstetrical collaboration at the University of Hong Kong-Shenzhen Hospital, China, since 2019. Each simulation was facilitated by two instructors and performed by three health care providers from obstetric and neonatal intensive care units, followed by a debriefing of the participants and several designated observers. The incidence of neonatal asphyxia, severe asphyxia, hypoxic-ischemic encephalopathy (HIE), and meconium aspiration syndrome (MAS) before (2017–2018) and after (2019–2020) the commencement of weekly MIST were analyzed.ResultsThere were 81 simulation cases including the resuscitation of preterm neonates of different gestational ages, perinatal distress, meconium-stained amniotic fluid, and congenital heart disease with 1,503 participant counts (225 active participants). The respective incidence of neonatal asphyxia, severe asphyxia, HIE, and MAS decreased significantly after MIST (0.64%, 0.06%, 0.01%, and 0.09% vs. 0.84%, 0.14%, 0.10%, and 0.19%, respectively, all P

Objective: To test the potential utility of applying machine learning methods to regional cerebral (rcSO2) and peripheral oxygen saturation (SpO2) signals to detect brain injury in extremely preterm infants. Study design: A subset of infants enrolled in the Management of Hypotension in Preterm infants (HIP) trial were analysed (n = 46). All eligible infants were 2 measurements performed over the first 72 h and cranial ultrasounds performed during the first week after birth. SpO2 data were available for 32 infants. The rcSO2 and SpO2 signals were preprocessed, and prolonged relative desaturations (PRDs; data-driven desaturation in the 2-to-15-min range) were extracted. Numerous quantitative features were extracted from the biosignals before and after the exclusion of the PRDs within the signals. PRDs were also evaluated as a stand-alone feature. A machine learning model was used to detect brain injury (intraventricular haemorrhage-IVH grade II–IV) using a leave-one-out cross-validation approach. Results: The area under the receiver operating characteristic curve (AUC) for the PRD rcSO2 was 0.846 (95% CI: 0.720–0.948), outperforming the rcSO2 threshold approach (AUC 0.593 95% CI 0.399–0.775). Neither the clinical model nor any of the SpO2 models were significantly associated with brain injury. Conclusion: There was a significant association between the data-driven definition of PRDs in rcSO2 and brain injury. Automated analysis of PRDs of the cerebral NIRS signal in extremely preterm infants may aid in better prediction of IVH compared with a threshold-based approach. Further investigation of the definition of the extracted PRDs and an understanding of the physiology underlying these events are required.

BackgroundComprehensive multidisciplinary assessment of neurodevelopmental outcomes of high-risk neonates may have significant challenges in low- and middle-income countries, in addition to socio-cultural barriers. We aimed to compare the time to diagnosis of neurodevelopmental impairment (NDI) and cerebral palsy (CP) in preterm neonates (

Background: The Neonatal Life Support Consensus on Science With Treatment Recommendations states that chest compressions (CC) be performed preferably with the 2-thumb encircling technique. The aim of this study was to compare the hemodynamic effects of four different finger positions during CC in a piglet model of neonatal asphyxia. Methods: Seven asphyxiated post-transitional piglets were randomized to CC with 2-thumb-, 2-finger-, knocking-fingers-, and over-the-head 2-thumb-techniques for one minute at each technique. CC superimposed with sustained inflations were performed manually. Results: Seven newborn piglets (age 0–4 days, weight 2.0–2.1 kg) were included in the study. The mean (SD) slope rise of carotid blood flow was significantly higher with the 2-thumb-technique and over-the-head 2-thumb-technique (118 (45) mL/min/s and 121 (46) mL/min/s, respectively) compared to the 2-finger-technique and knocking-finger-technique (75 (48) mL/min/s and 71 (67) mL/min/s, respectively) (p < 0.001). The mean (SD) dp/dtmin (as an expression of left ventricular function) was significantly lower with the 2-thumb-technique, with −1052 (369) mmHg/s, compared to −568 (229) mmHg/s and −578(180) mmHg/s (both p = 0.012) with the 2-finger-technique and knocking-finger-technique, respectively. Conclusion: The 2-thumb-technique and the over-the-head 2-thumb-technique resulted in improved slope rises of carotid blood flow and dp/dtmin during chest compression.

Background: To compare chest compression (CC) rates of 90/min with 180/min and their effect on the time to return of spontaneous circulation (ROSC), survival, hemodynamic, and respiratory parameters. We hypothesized that asphyxiated newborn piglets that received CC at 180/min vs. 90/min during cardiopulmonary resuscitation would have a shorter time to ROSC. Methods: Newborn piglets (n = 7/group) were anesthetized, intubated, instrumented and exposed to 45 min normocapnic hypoxia followed by asphyxia and cardiac arrest. Piglets were randomly allocated to a CC rate of 180/min or 90/min. CC was performed using an automated chest compression machine using CC superimposed with sustained inflation. Hemodynamic and respiratory parameters and applied compression force were continuously measured. Results: The mean (SD) time to ROSC was 91 (34) and 256 (97) s for CC rates of 180/min and 90/min, respectively (p = 0.08). The number of piglets that achieved ROSC was 7 (100%) and 5 (71%) with 180/min and 90/min CC rates, respectively (p = 0.46). Hemodynamic parameters (i.e., diastolic and mean blood pressure, carotid blood flow, stroke volume, end-diastolic volume, left ventricular contractile function) and respiratory parameters (i.e., minute ventilation, peak inflation and peak expiration flow) were all improved with a CC rate of 180/min. Conclusion: Time to ROSC and hemodynamic and respiratory parameters were not statistical significant different between CC rates of 90/min and 180/min. Higher CC rates during neonatal resuscitation warrant further investigation.

Background: During pediatric cardiopulmonary resuscitation (CPR), resuscitation guidelines recommend 100% oxygen (O2); however, the most effective O2 concentration for infants unknown. Aim: We aimed to determine if 21% O2 during CPR with either chest compression (CC) during sustained inflation (SI) (CC + SI) or continuous chest compression with asynchronized ventilation (CCaV) will reduce time to return of spontaneous circulation (ROSC) compared to 100% O2 in infant piglets with asphyxia-induced cardiac arrest. Methods: Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure < 25 mmHg with bradycardia. After cardiac arrest, piglets were randomized to CC + SI or CCaV with either 21% or 100% O2 or the sham. Heart rate, arterial blood pressure, carotid blood flow, and respiratory parameters were continuously recorded. Main results: Baseline parameters, duration, and degree of asphyxiation were not different. Median (interquartile range) time to ROSC was 107 (90–440) and 140 (105–200) s with CC + SI 21% and 100% O2, and 600 (50–600) and 600 (95–600) s with CCaV 21% and 100% O2 (p = 0.27). Overall, six (86%) and six (86%) piglets with CC + SI 21% and 100% O2, and three (43%) and three (43%) piglets achieved ROSC with CCaV 21% and 100% O2 (p = 0.13). Conclusions: In infant piglets resuscitated with CC + SI, time to ROSC reduced and survival improved compared to CCaV. The use of 21% O2 had similar time to ROSC, short-term survival, and hemodynamic recovery compared to 100% oxygen. Clinical studies comparing 21% with 100% O2 during infant CPR are warranted.

Background Chest compression (CC) during sustained inflations (CC+SI) compared with CC with asynchronized ventilation (CCaV) during cardiopulmonary resuscitation in asphyxiated pediatric piglets will reduce time to return of spontaneous circulation (ROSC). Methods and Results Piglets (20–23 days of age, weighing 6.2–10.2 kg) were anesthetized, intubated, instrumented, and exposed to asphyxia. Cardiac arrest was defined as mean arterial blood pressure

Abstract Background The need for cardiopulmonary resuscitation (CPR) is often unexpected, and the infrequent use of CPR in the delivery room (DR) limits the opportunity to perform rigorous clinical studies to determine the best method for delivering chest compression (CC) to newborn infants. The current neonatal resuscitation guidelines recommend using a coordinated 3:1 compression-to-ventilation (C:V) ratio (CC at a rate of 90/min and ventilations at a rate of 30/min). In comparison, providing CC during a sustained inflation (SI) (CC + SI) significantly improved hemodynamics, minute ventilation, and time to return of spontaneous circulation (ROSC) compared to 3:1 C:V ratio in asphyxiated piglets. Similarly, a small pilot trial in newborn infants showed similar results. Until now no study has examined different CC techniques during neonatal resuscitation in asphyxiated newborn infants in the DR. To date, no trial has been performed to directly compare CC + SI and 3:1 C:V ratio in the DR during CPR of asphyxiated newborn infants. Methods This is a large, international, multi-center, prospective, unblinded, cluster randomized controlled trial in asphyxiated newborn infants at birth. All term and preterm infants > 28+ 0 by best obstetrical estimate who require CPR at birth due to bradycardia ( 28+ 0 weeks’ gestational age with bradycardia (

In 2020, the global spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection (also known as COVID-19) has led to pandemic health issues with significant changes in individual and community practices. Preterm birth could be one of the risks in pregnant mothers who are infected by the SARS-CoV-2. Preterm births contribute upto 10% of all births and incur significant impact on the child health and cost to the health care system. However, the association of city lockdown during COVID-19 pandemic with the rate of preterm births is unclear. In a cohort study, we examined the association of city lockdown during the COVID-19 pandemic with the births at different gestations in three different cities. Compared with the pre-pandemic epoch, the associative relationships ranged from a decrease in all births, all births across all preterm gestations and to preterm births in moderately and late preterm gestations. We concluded that there were variable associative relationships of city lockdown during COVID-19 pandemic with preterm births. This could be related to the differences in health, societal and cultural factors, which will inspire further studies in this area.

Objective: Pulseless electrical activity (PEA) occurs in asphyxiated newborn piglets and infants. We aimed to examine whether different cardiac rhythms (asystole, bradycardia, PEA) affects the resuscitation outcomes during continuous chest compressions (CC) during sustained inflations (CC+SI).Design: This study is a secondary analysis of four previous randomized controlled animal trials that compared CC+SI with different CC rate (90 or 120/min), SI duration (20 or 60 s), peak inflation pressure (10, 20, or 30 cmH2O), and oxygen concentration (18, 21, or 100%).Setting and Subjects: Sixty-six newborn mixed breed piglets (1–3 days of age, weight 1.7–2.4 kg) were obtained on the day of experimentation from the University Swine Research Technology Center.Interventions: In all four studies, piglets were randomized into intervention or sham. Piglets randomized to “intervention” underwent both hypoxia and asphyxia, whereas, piglets randomized to “sham” received the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia.Measurements: To compare differences in asphyxiation time, time to return of spontaneous circulation (ROSC), hemodynamics, and survival rate in newborn piglets with asystole, bradycardia or PEA.Main Results: Piglets with PEA (n = 29) and asystole (n = 13) had a significantly longer asphyxiation time and time to ROSC vs. bradycardia (n = 24). Survival rates were similar between all groups. Compared to their baseline, mean arterial pressure and carotid blood flow were significantly lower 4 h after resuscitation in all groups, while being significantly higher in the bradycardia group.Conclusion: This study indicates that cardiac rhythm before resuscitation influences the time to ROSC and hemodynamic recovery after ROSC.

Background: Compared with those born at term gestation, infants with complex congenital heart defects (CCHD) who were delivered before 37 weeks gestational age and received neonatal open-heart surgery (OHS) have poorer neurodevelopmental outcomes in early childhood. We aimed to describe the growth, disability, functional, and neurodevelopmental outcomes in early childhood of preterm infants with CCHD after neonatal OHS. Prediction models were evaluated at various timepoints during hospitalization which could be useful in the management of these infants.Study Design: We studied all preterm infants with CCHD who received OHS within 6 weeks of corrected age between 1996 and 2016. The Western Canadian Complex Pediatric Therapies Follow-up Program completed multidisciplinary comprehensive neurodevelopmental assessments at 2-year corrected age at the referral-site follow-up clinics. We collected demographic and acute-care clinical data, standardized age-appropriate outcome measures including physical growth with calculated z-scores; disabilities including cerebral palsy, visual impairment, permanent hearing loss; adaptive function (Adaptive Behavior Assessment System-II); and cognitive, language, and motor skills (Bayley Scales of Infant and Toddler Development-III). Multiple variable logistic or linear regressions determined predictors displayed as Odds Ratio (OR) or Effect Size (ES) with 95% confidence intervals.Results: Of 115 preterm infants (34 ± 2 weeks gestation, 2,339 ± 637 g, 64% males) with CCHD and OHS, there were 11(10%) deaths before first discharge and 21(18%) deaths by 2-years. Seven (6%) neonates had cerebral injuries, 7 had necrotizing enterocolitis; none had retinopathy of prematurity. Among 94 survivors, 9% had cerebral palsy and 6% had permanent hearing loss, with worse outcomes in those with syndromic diagnoses. Significant predictors of mortality included birth weight z-score [OR 0.28(0.11,0.72), P = 0.008], single-ventricle anatomy [OR 5.92(1.31,26.80), P = 0.021], post-operative ventilation days [OR 1.06(1.02,1.09), P = 0.007], and cardiopulmonary resuscitation [OR 11.58 (1.97,68.24), P = 0.007]; for adverse functional outcome in those without syndromic diagnoses, birth weight 2,000–2,499 g [ES −11.60(−18.67, −4.53), P = 0.002], post-conceptual age [ES −0.11(−0.22,0.00), P = 0.044], post-operative lowest pH [ES 6.75(1.25,12.25), P = 0.017], and sepsis [ES −9.70(−17.74, −1.66), P = 0.050].Conclusions: Our findings suggest preterm neonates with CCHD and early OHS had significant mortality and morbidity at 2-years and were at risk for cerebral palsy and adverse neurodevelopment. This information may be important for management, parental counseling and the decision-making process.

Respiratory failure is a common condition faced by critically ill neonates with respiratory distress syndrome (RDS). High frequency oscillatory ventilation (HFOV) is often used for neonates with refractory respiratory failure related to RDS. Volume guarantee (VG) mode has been added to some HFOV ventilators for providing consistent tidal volume. We sought to examine the impact of adding the VG mode during HFOV on systemic and cerebral hemodynamics, which has not been studied to date. A neonatal piglet model of moderate to severe RDS was induced by saline lavage. Piglets (full term, age 1-3 days, weight 1.5-2.4 kg) were randomized to have RDS induced and receive either HFOV or HFOV+VG (n = 8/group) or sham-operation (n = 6) without RDS. Cardiac function measured by a Millar® catheter placed in the left ventricle as well as systemic and carotid hemodynamic and oxygen tissue saturation parameters were collected over 240 min of ventilation. Mean airway pressure, alveolar-arterial oxygen difference and left ventricular cardiac index of piglets on HFOV vs. HFOV+VG were not significantly different during the experimental period. Right common carotid artery flow index by in-situ ultrasonic flow measurement and cerebral tissue oxygen saturation (near-infrared spectroscopy) significantly decreased in HFOV+VG at 240 min compared to HFOV (14 vs. 31 ml/kg/min, and 30% vs. 43%, respectively; p

Background: Male newborns have a greater risk of poor cardiovascular and respiratory outcomes compared to females. The mechanisms associated with the “male disadvantage” remains unclear. We have previously shown no difference between male and female newborn piglets during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery. However, it is unknown if there are differences in resuscitation outcomes between males and females during different cardiopulmonary resuscitation techniques.Intervention and Measurements: Secondary analysis of 184 term newborn mixed breed duroc piglets (1–3 days of age, weighing 2.0 (0.2) kg) from seven different studies, which were exposed to 30–50 min of normocapnic hypoxia followed by asphyxia until asystole. This was followed by cardiopulmonary resuscitation. For the analysis, piglets were divided into male and female groups, as well as resuscitation technique groups (sustained inflation, 3:1 compression-to-ventilation ratio, or asynchronous ventilations during chest compressions). Cardiac function, carotid blood flow, and cerebral oxygenation were continuously recorded throughout the experiment.Main results: Regardless of resuscitation technique, there was no significant difference between males and females in the number achieving return of spontaneous circulation (ROSC) [95/123 (77%) vs. 48/61 (79%)], the time to achieve ROSC [112 (80–185) s vs. 110 (77–186) s], and the 4-h survival rate [81/95 (85%) vs. 40/48 (83%)]. Levels of the injury markers interleukin (IL)−1ß, IL-6, IL-8, and tumor necrosis factor-α in frontoparietal cortex tissue homogenates were similar between males and females.Conclusions: Regardless of resuscitation technique, there was no significant effect of sex on resuscitation outcome, survival, and hemodynamic recovery in asphyxiated newborn piglets.

Objective: To investigate the incidence and risk factors of retinopathy of prematurity (ROP) in very and extremely preterm (28+0-

Adaptations have been proposed for resuscitation of infants born to women with COVID-19, to protect health care providers, maintain infection control, and limit post-natal transmission. Changes especially impact respiratory procedures, personal protective equipment (PPE) use, resuscitation environments, teamwork, and family involvement. Adding viral filters to ventilation devices and modifications to intubation procedures might hinder effective ventilation. PPE could delay resuscitation, hinder task performance, and degrade communication. Changes to resuscitation locations and team composition alter workflow and teamwork. Physical distancing measures and PPE impede family-integrated care. These disruptions need to be considered given the uncertainty of vertical transmission of SARS-CoV-2.

Post-natal maturation of the myocardium starts shortly after birth and could affect how clinicians should provide hemodynamic support during this transition. Our aim was to assess the impact of post-natal maturation on tolerance to tachycardia with altered loading condition in a piglet model.Methods: We report three series of experimentations. Six groups of landrace cross neonatal piglets (NP) (1–3 days) and young piglets (YP) (14–17 days) were assigned to tachycardia (NP, YP), tachycardia and hypervolemia (NPV, YPV) or tachycardia and increased afterload (NPA, YPA) groups (n = 7/group). Under anesthesia, a pressure catheter was placed in the left ventricle and pacing wire in the right atrium. NPV and YPV groups had 60 ml/kg of normal saline infused over 20 min. NPA and YPA had balloon sub-occlusion of the descending aorta. Heart rate was increased by 10 bpm increments to 300 bpm. Left ventricular output was measured by echocardiography.Results: NP maintained left ventricular output throughout the pacing protocol but it decreased in the YP (p < 0.001). With volume loading both NPV and YPV maintained their output with tachycardia. Although increased afterload resulted in reduced output during tachycardia in NPA (p = 0.005), there was no added impact on output in YPA. Interestingly, 4 of 7 NPV had significant desaturation at 300 bpm (baseline 99.7% vs. 300 bpm 87.9%, p = 0.04), associated with a right to left shunt through the patent foramen ovale which resolved immediately on cessation of pacing.Conclusions: Early post-natal maturation is associated with improved myocardial tolerance to increased afterload and poor tolerance of tachycardia, the latter of which may be alleviated by increasing intravascular volume. These data could translate into the development of better strategies to optimize cardiac output at these early development ages.

Objective: To determine the incidence and risk factors associated with neonatal hypoglycemia in the premature population 90%ile for gestational age). Maternal hypertension was systolic blood pressure >140mmHg.Results: 175 infants

BackgroundSustained inflation (SI) during chest compression (CC = CC+SI) has been recently shown as an alternative method during cardiopulmonary resuscitation in neonates. However, the optimal peak inflation pressure (PIP) of SI during CC+SI to improve ROSC and hemodynamic recovery is unknown.ObjectiveTo examine if different PIPs of SI during CC+SI will improve ROSC and hemodynamic recovery in severely asphyxiated piglets.MethodsTwenty-nine newborn piglets (1-3 days old) were anesthetized, intubated, instrumented and exposed to 30-min normocapnic hypoxia followed by asphyxia. Piglets were randomized into four groups: CC+SI with a PIP of 10 cmH2O (CC+SI_PIP_10, n = 8), a PIP of 20 cmH2O (CC+SI_PIP_20, n = 8), a PIP of 30 cmH2O (CC+SI_PIP_30, n = 8), and a sham-operated control group (n = 5). Heart rate, arterial blood pressure, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.ResultsBaseline parameters were similar between all groups. There was no difference in asphyxiation (duration and degree) between intervention groups. PIP correlated positively with tidal volume (VT) and inversely with exhaled CO2 during cardiopulmonary resuscitation. Time to ROSC and rate of ROSC were similar between piglets resuscitated with CC+SI_PIP_10, CC+SI_PIP_20, and CC+SI_PIP_30 cmH2O: median (IQR) 75 (63-193) sec, 94 (78-210) sec, and 85 (70-90) sec; 5/8 (63%), 7/8 (88%), and 3/8 (38%) (p = 0.56 and p = 0.12, respectively). All piglets that achieved ROSC survived to four hours post-resuscitation. Piglets resuscitated with CC+SI_PIP_30 cmH2O exhibited increased concentrations of pro-inflammatory cytokines interleukin-1β and tumour necrosis factor-α in the frontoparietal cerebral cortex (both pConclusionIn asphyxiated term newborn piglets resuscitated by CC+SI, the use of different PIPs resulted in similar time to ROSC, but PIP at 30 cmH2O showed a larger VT delivery, lower exhaled CO2 and increased tissue inflammatory markers in the brain.

Background: Recent neonatal resuscitation guidelines suggest to perform chest compression (CC) at over-the-head (OTH) position instead of lateral position when further interventions including umbilical venous access are needed. Little information is available regarding the quality of cardiopulmonary resuscitation at different positions. Our study compared the quality of CC and ventilation at OTH position vs. lateral position in simulated neonatal resuscitation.Methods: Thirty-nine neonatal practitioners who attended the NRP®-based Provider renewal course workshop participated this study. Laerdal QCPR infant model were used to collect the data (2-miutes continuous recording) on quality of CC and ventilation of all participants at OTH position and lateral position in randomized order, both coordinated with mask ventilation or endotracheal ventilation through a Neopuff© T-piece system. The quality of CC and ventilation were compared. Participants also reported their demographics and opinions in anonymous questionnaires after the session.Results: The quality of CC and ventilation was not different when CPR was performed at OTH position and lateral position, in both mask and endotracheal ventilation. When CPR was performed with endotracheal ventilation, there were small faster frequencies of CC and ventilation at OTH position, compared with those at lateral position (p = 0.004). Most participants (87%) liked the CC performed at OTH position and had no adverse feedback.Conclusions: Performing CC at OTH position was generally well-received in simulated resuscitation; the quality of CC and ventilation at OTH position was not significantly different from that at lateral position, irrespective of mask or endotracheal ventilation.

Objectives: Approximately 10% of newborn infants require resuscitation at birth. Accurate heart rate (HR) assessment guides resuscitation interventions, thereby reducing morbidities and mortality. While existing HR assessment methods have several limitations, the Doppler ultrasound (Doppler-US) might be a promising alternative. We aimed to evaluate accuracy and optimal use of Doppler-US for HR assessments during neonatal asphyxia in a pre-clinical model.Design: HR assessments were performed in 16 term newborn piglets that were anesthetized, intubated, and instrumented. Study I evaluated optimal transducer position, Study II compared aortic (AV) and pulmonary (PV) examination modes, and Study III examined accuracy during asphyxia, for HR assessment.Setting: Experimental setting.Subjects: Asphyxia-induced piglets.Interventions: Study I: Doppler-US (USCOM® 1A) HR was assessed on upper (A), middle (B), and lower (C) third of the sternum; study II: Doppler-US HR was assessed using AV and PV examination modes; study III: HR was assessed during asphyxia. Comparisons were made between Doppler-US and the clinical gold standard for HR assessments, electrocardiography (ECG).Measurements and Main Results: Study I: Mean (SD) Doppler-US HR at position A, B, and C showed no difference when compared to ECG HR. Study II: The mean (SD) Doppler-US HR using AV and PV modes also showed no difference when compared to ECG HR. Study III: Bland-Altman analysis revealed a mean difference (95% limits of agreement) between Doppler-US and ECG HR of 1.5 (−16 to 19) bpm. Additionally, motion artifacts produced false peaks and peak size was seen to decrease as bradycardia progressed.Conclusions: HR assessment using Doppler-US during asphyxia is accurate but has limitations and must be further evaluated prior to clinical use. Doppler-US can be positioned along the sternum and use either AV or PV mode for accurate assessments in a piglet model of neonatal asphyxia.

The objective of this paper was to examine the changes in applied force and rate of chest compression (CC) during 5 min of CC with a target CC rate of 90/min (CC90) or 120/min (CC120) with and without metronome guidance during simulated neonatal cardiopulmonary resuscitation (CPR). We performed a randomized controlled manikin trial. Fourteen neonatal resuscitation program providers performed CC90 and CC120 with or without a metronome in a randomized order. Peak and residual leaning force and CC rate each minute of CPR were analyzed with Friedman's analysis of variance (ANOVA) (within interventions) and two-way repeated measures ANOVA (between interventions). There was a large variability in force application, with no difference between groups. Peak and residual leaning forces in CC90 and CC120 did not change with time with or without a metronome. The CC rate increased with time in all groups except CC90 without a metronome. In conclusion, neither the target CC rate nor using a metronome influenced the peak and residual leaning forces during simulated neonatal CPR.

Objectives: Heart rate (HR) is the most significant parameter to assess a newborn's clinical status at birth. Recently, novel technologies including smartphone applications have been suggested for HR assessment during neonatal resuscitation. The aim of this study was to evaluate the accuracy, speed, and precision of the NeoTapLifeSupport (NeoTapLS) smartphone application using a digital stethoscope (DS) for HR assessment during neonatal resuscitation.Design: Newborn piglets (n = 20, 1–3 days, 1.7–2.4 kg) were anesthetized, intubated, mechanically ventilated, and subjected to 30 min of hypoxia, followed by asphyxia. Asphyxia was induced by clamping the endotracheal tube and disconnecting the ventilator, until asystole was confirmed by zero carotid blood flow (CBF).Setting: Experimental setting.Subjects: Asphyxia-induced newborn piglets.Interventions: During asphyxia, HR assessments were performed with a DS using the NeoTapLS smartphone application, and compared to 6-s method (6 s), and 10-s method (10 s).Measurements and Main Results: Accuracy of obtained HRs was compared to CBF and electrocardiogram and assessment time using NeoTapLS, 6 s, and 10 s were also measured. The mean(SD) HR with the NeoTapLS was 68(26), compared to CBF with 68(27) bpm, 6 s with 68(27), and 10 s with 66(26) bpm during asphyxia. Bland-Altman analysis revealed no difference between HR using the NeoTapLS, 6 s, 10 s, compared to CBF HR, with NeoTapLS showing the smallest difference between 95% limits of agreement. The median (IQR) time required to obtain a HR using the NeoTapLS was 3(2–4) s, compared to 6(6–7), and 10(10–11) s for 6 and 10 s, respectively.Conclusions: Our data suggests that the NeoTapLS is accurate, fast, and precise during neonatal asphyxia to assess heart rate.

Background: Previous studies have investigated hemodynamic recovery using 21% vs. 100% oxygen during cardiopulmonary resuscitation (CPR) with chest compression (CC) in term infants. Animal studies indicate that systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR. One of the main goals of resuscitation is to maintain cerebral oxygen delivery and prevent cerebral hypo- and hyperoxygenation. Oxygen delivery to the brain depends on cerebral hemodynamics, concentration of inhaled oxygen and blood oxygen content. The aim of this paper was to synthesize available research about cerebral oxygen delivery during CPR using different oxygen concentrations. Our research questions included how do different oxygen concentrations during CPR with CC influence cerebral perfusion and oxygen delivery, and how do cerebral hemodynamics during CC influence outcomes.Methods: A search in Medline Ovid using the search terms hypoxia AND oxygen AND cerebrovascular circulation AND infant, newborn. Inclusion criteria included studies of hypoxia and resuscitation of term infants. Studies were excluded if no measures of cerebral blood flow (CBF), oxygenation, or perfusion were reported.Results: The search retrieved 21 papers. None of the studies directly fulfilled our inclusion criteria. The reference lists of some of the retrieved papers provided relevant animal studies with slightly conflicting results regarding blood flow and oxygen delivery to the brain using 21 or 100% oxygen. No study in term infants was identified, but we included one study in preterm infants. Studies in asphyxiated animals indicate that 100% oxygen increases CBF and oxygenation during and after CC with a potential increase in oxidative stress.Conclusion: In asphyxia, cerebral autoregulation may be impaired. Pure oxygen administration during CC may result in cerebral hyperperfusion and increased cerebral oxygen delivery, which may be associated with oxidative stress-related damage to the brain tissue. As systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR, it is important to investigate whether brain damage could be aggravated when 100% oxygen is used.

Background: Male and female newborns have differences in their fetal development, fetal-to-neonatal transition, and postnatal morbidity. However, the cardiovascular fetal-to-neonatal adaption is similar between sexes. No study has examined sex differences in newborns during hypoxia, asphyxia, cardio-pulmonary resuscitation, or post-resuscitation recovery.Methods: Secondary analysis (two previous publications and two studies currently under peer-review) of 110 term newborn mixed breed piglets (1–3 days of age, weighing 2.0 ± 0.2 kg), which were exposed to 30 min normocapnic hypoxia followed by asphyxia until asystole, which was achieved by disconnecting the ventilator and clamping the endotracheal tube. This was followed by cardio-pulmonary resuscitation. For the analysis piglets were divided into female and male groups. Cardiac function, carotid blood flow, and cerebral and renal oxygenation were continuously recorded throughout the experiment.Results: A total of 35/41 (85%) female and 54/69 (78%) male piglets resuscitated achieved ROSC (p = 0.881). The median (IQR) time to achieve return of spontaneous circulation in females and males was 111 (80–228) s and 106 (80–206) s (p = 0.875), respectively. The 4-h survival rate was similar between females and males with 28/35 (80%) and 49/54 (91%) piglets surviving (p = 0.241), respectively.Conclusions: No difference between female and male newborn piglets was observed during hypoxia, asphyxia, resuscitation, and post-resuscitation recovery.

Background: Many asphyxiated neonates have cardiac complications including arrhythmia and contractile dysfunction. Little is known about the relationship between heart rate (HR) and diastolic function in asphyxiated neonates. We aimed to study the relationship between HR and left ventricular (LV) isovolumic relaxation (IVR) in neonates with asphyxia using a swine model.Methods: Term newborn piglets were anesthetized and acutely instrumented with the placement of Millar® catheter in the left ventricle. Hemodynamic parameters including HR, cardiac output, stroke volume, dP/dtmax and dP/dtmin, and IVR time constant (Tau) were continuously measured and recorded. Sixteen piglets were exposed to 50-minute normocapnic hypoxia followed by asphyxia (mean of 3.2 min) by clamping of the endotracheal tube. Sham-operated piglets (n = 11) had no hypoxia nor asphyxia. The relationship between HR and other hemodynamic parameters were analyzed using Pearson Product Moment correlation test.Results: Asphyxiated piglets had cardiogenic shock and metabolic acidosis (vs. sham-operated piglets). There were significant correlations between HR and diastolic function as shown by Tau at baseline (sham-operated: r = -0.68, p = 0.02; asphyxia: r = -0.55, p = 0.03) and during normoxia (53 min) of sham-operated piglets (r = -0.69, p = 0.02). HR and Tau was not correlated during hypoxia-asphyxia (HA) (r = -0.01, p = 0.97). Cardiac output was tightly correlated with stroke volume (p < 0.001) but not HR throughout the experimental period in both groups. There was no significant correlation between HR and other hemodynamic parameters during the experimental period in both groups.Conclusion: We observed an uncoupling between HR and IVR Tau of the neonatal heart during HA, which deserves further studies of the relationship between HR and LV diastolic function.

Background: Asphyxiated neonates often have myocardial dysfunction and renal insufficiency. Previously we demonstrated that doxycycline improved cardio-renal function through matrix metalloproteinase (MMP)-2 inhibition in an acute swine model of neonatal hypoxia-reoxygenation. The prolonged cardio-renal protective effects of doxycycline in neonates still remained unknown. We therefore hypothesized that the protective effects of doxycycline persisted in surviving subjects.Methods: Newborn piglets were instrumented and subjected to 1 h of hypoxia followed by reoxygenation with 21–25% oxygen and observed for 4 days. Intravenous doxycycline (30 mg/kg) or normal saline (1 mL, saline-control group) was given at 5 min of reoxygenation (n = 8/group) in a randomized, blinded fashion. Sham-operated piglets (n = 5) received no hypoxia-reoxygenation. At 96 h after reoxygenation, the left ventricular function was assessed by Millar® catheter. Renal injury was investigated by measuring plasma creatinine, urinary N-acetyl-D-glucosaminidase activity, renal tissue lactate and MMP-2 activity.Results: Both hypoxia-reoxygenation groups had similar hypoxic stress with severe lactate acidosis, and hemodynamic recovery. Doxycycline-treated piglets had higher urine output with lower urine N-acetyl-D-glucosaminidase, plasma creatinine, and renal MMP-2 activity (vs. saline-controls; all p < 0.05). These markers were all negatively correlated with urine output.Conclusions: In newborn piglets surviving hypoxia-reoxygenation, we observed a weak but significant and persistent attenuation of renal injury and improved recovery with the post-resuscitation administration of doxycycline.

AimWe recently demonstrated that asphyxiated piglets commonly had bradycardia displayed on electrocardiography (ECG) while no carotid blood flow (CBF) or audible heart sounds could be detected. Such pulseless electrical activity (PEA) in newborn infants has not previously been thoroughly described. The aim of this study was to further investigate the occurrence of non-perfusing cardiac rhythms in asphyxiated piglets and the potential implications for the success of cardiopulmonary resuscitation (CPR) and short-term survival.MethodsNeonatal piglets (1-4 days, 1.7-2.4kg) had their right common carotid artery exposed and enclosed with a real-time ultrasonic flow probe. Heart rate (HR) was continuously measured and recorded using ECG. This allowed simultaneous monitoring of HR via ECG and CBF. The piglets were asphyxiated until cardiac arrest, defined as no CBF and no audible beat upon precordial auscultation. CPR was performed until return of spontaneous circulation (ROSC, defined as a HR ≥100 bpm). ECG traces were retrospectively assessed.ResultsNine out of 21 piglets (43%) had QRS-complexes on their ECG while no CBF and no audible heart sounds could be detected. Five (56%) of the piglets with PEA and 12/12 (100%) piglets with asystole at cardiac arrest obtained ROSC (p = 0.02). Thirty-three per cent of the piglets with PEA versus 58% with asystole survived to 4 hours post-ROSC (p = 0.39).ConclusionCardiac arrest in the presence of a non-perfusing cardiac rhythm on ECG is common in asphyxiated piglets. Clinical arrest in the presence of a non-perfusing cardiac rhythm on ECG may reduce the success of CPR.

Asphyxiated neonates often have hypotension, shock, and poor tissue perfusion. Various “inotropic” medications are used to provide cardiovascular support to improve the blood pressure and to treat shock. However, there is incomplete literature on the examination of hemodynamic effects of these medications in asphyxiated neonates, especially in the realm of clinical studies (mostly in late preterm or term populations). Although the extrapolation of findings from animal studies and other clinical populations such as children and adults require caution, it seems appropriate that findings from carefully conducted pre-clinical studies are important in answering some of the fundamental knowledge gaps. Based on a literature search, this review discusses the current available information, from both clinical studies and animal models of neonatal asphyxia, on common medications used to provide hemodynamic support including dopamine, dobutamine, epinephrine, milrinone, norepinephrine, vasopressin, levosimendan, and hydrocortisone.

Background: International consensus statements for resuscitation of newborn infants recommend provision of 100% oxygen once chest compressions are required. However, 100% oxygen exacerbates reperfusion injury and reduces cerebral perfusion in newborn babies.Objective: We aimed to establish whether resuscitation with air during chest compression is feasible and safe in newborn infants compared with 100% oxygen.Methods: Systematic search of PubMed, Google Scholar and CINAHL for articles examining variable oxygen concentrations during chest compressions in term newborns.Results: Overall, no human studies but eight animal studies (n = 323 animals) comparing various oxygen concentrations during chest compression were identified. The pooled analysis showed no difference in mortality rates for animals resuscitated with air vs. 100% oxygen (risk ratio 1.04 [0.35, 3.08], I2 = 0%, p = 0.94). ROSC was also similar between groups with a mean difference of −3.8 [−29.7–22] s, I2 = 0%, p = 0.77. No difference in oxygen damage or adverse events were identified between groups.Conclusions: Air had similar time to ROSC and mortality as 100% oxygen during neonatal chest compression. A large randomized controlled clinical trial comparing air vs. 100% oxygen during neonatal chest compression is warranted.

The main aim of this paper was to provide an overview of studies that measured cerebral blood flow (CBF), directly or indirectly, during chest compression (CC) in neonatal animals. Our main research question was: how did different ways of performing CC influence CBF. We also aimed to discuss strengths and limitations of different methods for measuring CBF. Based on a search in Medline Ovid, we identified three studies in piglets that investigated different CC:ventilation (C:V) ratios, as well as three piglet studies investigating continuous CC with asynchronous ventilation. CBF was measured indirectly in all studies by means of carotid artery (CA) flow and regional cerebral oxygenation (rcSO2). The CA provides flow to the brain, but also to extracerebral structures. The relative sizes of the internal and external carotid arteries and their flow distributions are species-dependent. rcSO2 is a non-invasive continuous measure, but does not only reflect CBF, but also cerebral blood volume and the metabolic rate of oxygen in the brain. Continuous CC with asynchronous ventilation at a CC rate of 120/min, and combining CC with a sustained inflation (four studies in piglets and one in lambs) provided a faster CBF recovery compared with the standard 3:1 C:V approach.

Background: In 2015, the neonatal resuscitation guidelines incorporated the use of electrocardiography (ECG) to monitor heart rate of newborns. However, previous studies have indicated that cardiac arrest with pulseless electrical activity rhythm (PEA) may occur in the delivery room, rendering this method problematic.Objective: To evaluate the accuracy of ECG and auscultation to assess heart rate during PEA.Methods: A total of 45 piglets (age 1–3 days, weight 1.7–2.3 kg) were exposed to 30 min normocapnic alveolar hypoxia followed by asphyxia until asystole, achieved by disconnecting the ventilator and clamping the endotracheal tube. During asphyxia, heart rate (HR) was assess using auscultation, ECG, and carotid blood flow (CBF). At the time of asystole (defined as zero CBF) HR auscultated using a neonatal/infant stethoscope was compared to ECG traces.Results: The median (IQR) duration of asphyxia was 325 (200–491) s. In 8 (18%) piglets, CBF, ECG, and auscultation identified asystole. In 22 (49%) piglets no CBF and no audible heart sounds, were observed, while ECG displayed a HR ranging from 17 to 75/min. Fifteen (33%) piglets remained bradycardic (defined as HR of < 100/min) after 10 min of asphyxia, which was identified by CBF, ECG, and auscultation. The overall accuracy of ECG and auscultation in the detection of HR were 51 and 80%, respectively (p = 0.004).Conclusion: In cases with PEA ECG is not superior in correctly identifying HR in newborn piglets.

Sustained inflations and avoidance of endotracheal mechanical ventilation (eMV) are delivery room interventions aimed at preventing bronchopulmonary dysplasia (BPD). Their effectiveness is the subject of the present meta-analysis. The databases MEDLINE, EMBASE and CENTRAL were searched for randomised controlled trials (RCTs) of preterm infants that compared: 1) sustained inflations with intermittent positive-pressure ventilation; and 2) a non-intubated strategy of respiratory support with one that prescribed eMV at an earlier stage. Data extraction and analysis followed the standard methods of the Cochrane Collaboration. The primary outcome was death or BPD, defined as need for oxygen or positive pressure treatment at 36 weeks' postmenstrual age. Avoiding eMV (nine RCTs, 3486 infants) reduced the risk of death or BPD, with a risk ratio of 0.90 (95% CI 0.84–0.97) and a number needed to treat of 35. After sustained inflations (six RCTs, 854 infants), the risk ratio was 0.85 (95% CI 0.65–1.12). A current multicentre RCT of sustained inflations in very preterm infants was halted for increased early mortality in the sustained inflations arm. While strategies aimed at avoiding eMV had a small but significant impact on preventing BPD, sustained inflations had no effect and may even increase mortality in very preterm infants.

Cerebrovascular injury is one of the major detrimental consequences of preterm birth. Recent studies have focused their attention on factors that contribute to the development of brain lesions immediately after birth. Among those factors, hypothermia and lower cerebral oxygen saturation during delivery room resuscitation and high tidal volumes delivered during respiratory support are associated with increased risk of severe neurologic injury. In preterm infants, knowledge about causes and prevention of brain injury must be applied before and at birth. Preventive and therapeutic approaches, including correct timing of cord clamping, monitoring of physiological changes during delivery room resuscitation using pulse oximetry, respiratory function monitoring, near infrared spectroscopy, and alpha EEG, may minimize brain injury, Furthermore, postnatal administration of caffeine or other potential novel treatments (e.g., proangiogenic therapies, antioxidants, hormones, or stem cells) might improve long-term neurodevelopmental outcomes in preterm infants.

Preterm neonates often have hypotension which may be due to various etiologies. While it is controversial to define hypotension in preterm neonates, various vasoactive medications are commonly used to provide the cardiovascular support to improve the blood pressure, cardiac output, or to treat shock. However, the literature on the systemic and regional hemodynamic effects of these antihypotensive medications in neonates is deficient and incomplete, and cautious translation of findings from other clinical populations and animal studies is required. Based on a literature search on published reports, meta-analytic reviews, and selected abstracts, this review discusses the current available information on pharmacologic actions, clinical effects, and side effects of commonly used antihypotensive medications including dopamine, dobutamine, epinephrine, norepinephrine, vasopressin, and milrinone in preterm neonates.

Approximately, 10–20% of newborns require breathing assistance at birth, which remains the cornerstone of neonatal resuscitation. Fortunately, the need for chest compression (CC) or medications in the delivery room (DR) is rare. About 0.1% of term infants and up to 15% of preterm infants receive these interventions, this will result in approximately one million newborn deaths annually worldwide. In addition, CC or medications (epinephrine) are more frequent in the preterm population (~15%) due to birth asphyxia. A recent study reported that only 6 per 10,000 infants received epinephrine in the DR. Further, the study reported that infants receiving epinephrine during resuscitation had a high incidence of mortality (41%) and short-term neurologic morbidity (57% hypoxic-ischemic encephalopathy and seizures). A recent review of newborns who received prolonged CC and epinephrine but had no signs of life at 10 min following birth noted 83% mortality, with 93% of survivors suffering moderate-to-severe disability. The poor prognosis associated with receiving CC alone or with medications in the DR raises questions as to whether improved cardiopulmonary resuscitation methods specifically tailored to the newborn could improve outcomes.

BackgroundDuring antenatal consultation of women hospitalized for preterm labor, information of possible adverse outcomes is provided. This may however create additional maternal stress and raise some ethical concerns.ObjectiveThe aim of the present study was to evaluate the influence of antenatal consultation by a neonatologist on maternal stress after delivery of a preterm infant admitted to NICU.MethodsIn this study, secondary outcome parameters of a prospective two-center pilot observational study were analyzed. Mothers of preterm neonates

The objective of this randomized controlled manikin trial was to examine tidal volume (VT) delivery and ventilation rate during mask positive pressure ventilation (PPV) with five different devices, including a volume-controlled prototype Next StepTM device for neonatal resuscitation. We hypothesized that VT and rate would be closest to target with the Next StepTM. Twenty-five Neonatal Resuscitation Program (NRP) providers provided mask PPV to a newborn manikin (simulated weight 1kg) in a randomized order with: a self-inflating bag (SIB), a disposable T-piece, a non-disposable T-piece, a stand-alone resuscitation system T-piece, and the Next StepTM. All T-pieces used a peak inflation pressure of 20cmH2O and a positive end-expiratory pressure of 5cmH2O. The participants were instructed to deliver a 5mL/kg VT (rate 40-60min-1) for 1min with each device and each of three test lungs with increasing compliance of 0.5, 1.0 and 2.0mL/cmH2O. VT and ventilation rate were compared between devices and compliance levels (linear mixed model). All devices, except the Next StepTM delivered a too high VT, up to six-fold the target at the 2.0mL/cmH2O compliance. The Next StepTM VT was 26% lower than the target in the low compliance. The ventilation rate was within target with the Next StepTM and SIB, and slightly lower with the T-pieces. In conclusion, routinely used newborn resuscitators over delivered VT, whereas the Next StepTM under delivered in the low compliant test lung. The SIB had higher VT and rate than the T-pieces. More research is needed on volume-controlled delivery room ventilation.

In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025.

Abstract Background Infant and neonatal myocardial infarction (MI) has been described in association with congenital heart disease, coronary artery abnormalities, myocarditis, and tumors. MI in the perinatal period in a structurally normal heart and with ventricular arrhythmia as a presenting feature has not been thoroughly described. Published case reports describe treatment methods extrapolated from adult MI. However, due to the rare occurrence, the most appropriate acute treatment for both MI and ventricular arrhythmia in newborn infants remains unknown. Case A male term infant with perinatal asphyxia and need for extensive cardiopulmonary resuscitation at birth had ventricular tachyarrhythmia and ST-elevations on electrocardiogram. Four hours after birth, he died from cardiogenic failure. A thrombus at the right coronary artery was found on autopsy. Conclusion MI in the perinatal period in a structurally normal heart is very rare and mortality is high. Although acute treatments extrapolated from adult MI has been described to result in favorable outcomes in newborn infants, guidelines are lacking on how to manage acute MI and associated ventricular arrhythmia.

BACKGROUND:End-tidal CO2 (ETCO2), partial pressure of exhaled CO2 (PECO2), and volume of expired CO2 (VCO2) can be continuously monitored non-invasively to reflect pulmonary ventilation and perfusion status. Although ETCO2 ≥14 mmHg has been shown to be associated with return of an adequate heart rate in neonatal resuscitation and quantifying the PECO2 has the potential to serve as an indicator of resuscitation quality, there is little information regarding capnometric measurement of PECO2 and ETCO2 in detecting return of spontaneous circulation (ROSC) and survivability in asphyxiated neonates receiving cardiopulmonary resuscitation (CPR). METHODS:Seventeen newborn piglets were anesthetized, intubated, instrumented, and exposed to 45-minute normocapnic hypoxia followed by apnea to induce asphyxia. Protocolized resuscitation was initiated when heart rate decreased to 25% of baseline. Respiratory and hemodynamic parameters including ETCO2, PECO2, VCO2, heart rate, cardiac output, and carotid artery flow were continuously measured and analyzed. RESULTS:There were no differences in respiratory and hemodynamic parameters between surviving and non-surviving piglets prior to CPR. Surviving piglets had significantly higher ETCO2, PECO2, VCO2, cardiac index, and carotid artery flow values during CPR compared to non-surviving piglets. CONCLUSION:Surviving piglets had significantly better respiratory and hemodynamic parameters during resuscitation compared to non-surviving piglets. In addition to optimizing resuscitation efforts, capnometry can assist by predicting outcomes of newborns requiring chest compressions.

OBJECTIVE:Recently, sustained inflations (SI) during chest compression (CC) have been suggested as an alternative to the current approach during neonatal resuscitation. However, the optimal rate of CC during SI has not yet been established. Our aim was to determine whether different CC rates during SI reduce time to return of spontaneous circulation (ROSC) and improve hemodynamic recovery in newborn piglets with asphyxia-induced bradycardia. INTERVENTION AND MEASUREMENTS:Term newborn piglets were anesthetized, intubated, instrumented and exposed to 45-min normocapnic hypoxia followed by asphyxia. Resuscitation was initiated when heart rate decreased to 25% of baseline. Piglets were randomized into three groups: CC superimposed by SI at a rate of 90 CC per minute (SI+CC 90, n = 8), CC superimposed by SI at a rate of 120 CC per minute (SI+CC 120, n = 8), or a sham group (n = 6). Cardiac function, carotid blood flow, cerebral oxygenation and respiratory parameters were continuously recorded throughout the experiment. MAIN RESULTS:Both treatment groups had similar time of ROSC, survival rates, hemodynamic and respiratory parameters during cardiopulmonary resuscitation. The hemodynamic recovery in the subsequent 4h was similar in both groups and was only slightly lower than sham-operated piglets at the end of experiment. CONCLUSION:Newborn piglets resuscitated by SI+CC 120 did not show a significant advantage in ROSC, survival, and hemodynamic recovery as compared to those piglets resuscitated by SI+CC 90.

Danshen, in particular its derivative tanshinone IIA (TS), is a promising compound in the treatment of cardiovascular diseases and has been used for many years in traditional Chinese medicine. Although many actions of TS have been researched, its vasodilator effects in pregnancy remain unknown. There have been a few studies that have shown the ability of TS to reduce blood pressure in women with hypertensive pregnancies; however, there are no studies which have examined the vascular effects of TS in the pregnant state in either normal or complicated pregnancies. Our aim was to determine the vasoactive role of TS in multiple arteries during pregnancy including: rat resistance (mesenteric and uterine) and conduit (carotid) arteries. Further, we aimed to assess the ability of TS to improve uterine blood flow in a rodent model of intrauterine growth restriction. Wire myography was used to assess vascular responses to the water-soluble derivative, sodium tanshinone IIA sulphonate (STS) or to the endothelium-dependent vasodilator, methylcholine. At mid-pregnancy, STS caused direct vasodilation of rat resistance (pEC50 mesenteric: 4.47±0.05 and uterine: 3.65±0.10) but not conduit (carotid) arteries. In late pregnancy, human myometrial arteries responded with a similar sensitivity to STS (pEC50 myometrial: 3.26±0.13). STS treatment for the last third of pregnancy in eNOS-/- mice increased uterine artery responses to methylcholine (Emax eNOS-/-: 55.2±9.2% vs. eNOS-/- treated: 75.7±8.9%, p

If infants fail to initiate spontaneous breathing, resuscitation guidelines recommend respiratory support with positive pressure ventilation (PPV). The purpose of PPV is to establish functional residual capacity and deliver an adequate tidal volume (VT) to achieve gas exchange.The aim of our pilot study was to measure changes in exhaled carbon dioxide (ECO2), VT, and rate of carbon dioxide elimination (VCO2) to assess lung aeration in preterm infants requiring respiratory support immediately after birth.A prospective observational study was performed between March and July 2013. Infants born at

To describe temporal changes in systolic, diastolic, and mean blood pressure (SBP, DBP, and MBP, respectively) in term and preterm infants immediately after birth.Prospective observational two-center study. In term infants SBP, DBP, and MBP were assessed non-invasively every minute for the first 15 minutes, and in preterm infants every minute for the first 15 minutes, as well as at 20, 25, 30, 45, and 60 minutes after birth. Regression analyses were performed by gender and respiratory support in all neonates; and by mode of delivery, cord clamping time, and development of ultrasound-detected brain injury in preterm neonates.Term infants (n = 54) had a mean (SD) birth weight of 3298 (442) g and gestational age of 38 (1) weeks, and preterm infants (n = 94) weighed 1340 (672) g and were 30 (3) weeks gestation. Term infants' SBP, DBP and MBP within the first 15 minutes after birth were independent of gender or respiratory support. Linear mixed regression analysis showed that preterm infants, who were female, born vaginally, had delayed cord clamping and did not require positive pressure ventilation nor develop periventricular injury or ventriculomegaly, had significantly higher SBP, DBP, and MBP at some measurement points within the first hour after birth.We present novel reference ranges of BP immediately after birth in a cohort of term and preterm neonates. They may aid in optimization of cardiovascular support during early transition at all gestations.