Damnedifyoudon’t-improvingoutcomeintheveryprematureinfant

JessievanDykDivisionHead,NeonatologyStJoseph’sHealthCentre

UniversityofToronto

Conflictofinterest

Nothingtodeclare…

Outline

•  Theimportanceofhavingaplan•  Thegoldenhour•  Smallbabyprotocol•  Preventingmorbidity•  Family-integratedcare

PrematureBirth•  ‘Burdenofprematurity’•  Majorityofpretermsfreeofmajormorbidity

•  Majormorbidityaccountsfor6-25%–  Cerebralpalsy–  Visionimpairment–  Hearingimpairment–  Cognitiveimpairment

•  50-70%mayhaveminormorbidities

Starthere…

Haveaplan…

•  Borrowcarefully•  Takeintoaccountlocalresources&expertise

•  Ensurepre-implementationtraining&audits

•  Guidelinesensureeveryonereceivesatleastminimumbeststandardofcare…butleaveroomforpatientvariation

•  Canidentifysystemerrorsordeficiencies,especiallywhenbuiltintoEMR’s

Antenatalcounseling

•  RevisedCanadianPaediatricSocietystatementadvisesprognosis-basedapproachthattakesintoaccount

ü BestestimateofGAü Estimatedfetalweightü Receiptofantenatalsteroidsü Singletonversusmultiplepregnancyü FetalstatusandpresenceofanomaliesonUSü Placeofbirth

Justtokeepthingsinteresting…

23wksGAn(%)

24wksGAn(%)

25wksGAn(%)

26wksGAn(%)

Fullweek 92(94.8) 272(80.5) 277(64.1) 222(48.8)

0-3 40(95.2) 172(85.6) 174(69.6) 157(55.9)

4-6 52(94.5) 100(73) 103(56.6) 65(37.4)

95%CI (-8.8,10.2) (3.1,22.1) (3.3,22.7) (8.8,28.2)

p-value 1 0.0064 0.0073 0.004

Whataboutatthewatershedweeks?234-6vs.240-3weeks(p-value=0.14)244-6vs.250-3weeksGA(p-value=0.6)Thusnodifferenceincompositeoutcome(neonatalmorbidityandmortality)

Thegoldenhour

Successfulstabilisationbeginswithobstetricalmanagement

•  Deliverinahigh-riskperinatalcentre•  Antenatalsteroids•  AntenatalMgSo4•  Preventchorioamnionitis•  Timely,gentle,atraumaticdelivery-AssessmentandmanagementbyexperiencedMFMspecialist-Considerdeliveringencaul-Caesariansection(classical)ifmalpositioning/fetaldistress•  Delayedumbilicalcordclampingifpossible

Careofmotheratriskforextremelypretermdelivery

AssessingGA•  USmostaccurate(afterIVF)•  1sttrimestercrown-rumplength

accuratewithin3-8days•  Degreeofimprecisionincreases

withGA(±10daysat16-22wks,±14daysat24wks)

Modeofdelivery•  Notenoughevidencetosupport

routineC-section(potentialharmtomothervsbenefitforinfant,weighharmsvsbenefitforeachcase)

Antenatalsteroids•  Debates:infants<24wksGAnot

initiallyincludedinNIHconsensusstatement,fearsofharmafter>1course(maxefficacywithin7days)

•  Latestguideline:givetoallmothersinTPTLat≥22wksGAwhereearlyintensivecareisanticipated,probablynoharminrepeatedcourses(reducedRDSandothermorbidities,noevidenceofharminlaterchildhood)

Placeofcare•  Improvedmortalityandmorbidity

withdeliveryattertiarycentresàtransferin-uterowheneverpossible

•  194interventioncasesvs194retrospectivelymatchedcontrols

•  Comprehensiveprotocolchange-dedicateddeliveryarea,improvedplanningandcommunicationaswellaschangesinpractice–cordbloodsampling,temperaturecontroletc

•  Improvedadmissiontemperature(p<0.001),BPD(p=0.028)andlate-onsetsepsis(p=0.035)

•  Trendtowardslowerratesofearlybloodtransfusionandventilationduration

‘Gentleresuscitation’…

•  ‘Mybiasisthatthedeliveryroombeepershouldinitiateafocusontransition-adaptationand,withpatienceandafterabitoftime,resuscitationifnecessary.’

•  ‘Thereisperhapsnothingmoredangerousforthepretermlung

thanananxiousphysicianwithanendotrachealtubeandabag.’

AlanJobe,JournalofPediatrics,2005

•  Idealstartingoxygenlevelforpreterminfantsremainsunknown

•  Mostinfants<32weekswillrequireatleastsomeoxygen

Pediatrics,2019

EuropeanConsensusGuidelinesontheManagementofRespiratoryDistressSyndrome–2016update

•  ControlO2forresuscitationwithblender

•  Initialconcentrationof30%appropriateforinfants<28weeksGA,and21-30%forinfants28-31weeksGA

•  Titrationupordowndonebysaturationmonitoringfrombirth

2015ILCORguidelines:delayedcordclamping

•  Outcomes:mortality,severeIVH,anyIVH,haemodynamicstability,hyperbilirubinemia,neurodevelopment

•  Sixteenarticlesincluded-12RCTs(691cases)+4non-RCTs(811cases)•  NodifferenceinmortalityorsevereIVH•  Dataawaitedforneurodevelopment•  ReducedanyIVHandimprovedhaemodynamicstabilityILCORrecommendation:suggestDCCfor30secforpreterminfantsnotrequiringimmediateresuscitationafterbirth

‘Smallbabyprotocol’

•  Pediatrics,2015•  2yearsafterimplementingspecifictreatmentprotocols•  Reducedchroniclungdisease(47.5%to34.5%,p=0.097),

hospital-acquiredinfection(39.3%to19.4%,p<0.001)•  Lessinfantsdischargedwithgrowthrestriction(62.3%to

37.3%,p=0.001)•  Lowerresourceutilisation(decreasedlabtestsand

radiographs)

CorePBPs(‘ProbablyBestPractices’)

PotentiallyBetterPractice1PBP1:Ensurethattheinfantisdeliveredinoptimalconditionandthefamilyiswellsupportedthroughoutthedeliveryprocess

SupportingPBPs:1.  Administerafullcourseofantenatalcorticosteroidsto

mother2.  Conductapre-deliverybriefingthatincludesObstetrics,

NICUteamandthefamily3. Minimizebirthtrauma4.  Practicedelayedcordclamping

PotentiallyBetterPractice2PBP2:Providegentle,effectiveGoldenHourmanagementSupportingPBPs:1.  Preventheatlossandsupportnormothermia2.  Ensurethatprimaryairwaymanagementisprovidedbyteammember

withextensiveexperienceandhighlevelofskill3.  Uselungprotectivestrategiesduringtransitionandforinitial

respiratorysupport4.  ProvidesurfactanttoinfantsrequiringintubationorifFiO2exceeds

0.30onnCPAP5.  Insertumbilicalarterialandvenouscathetersandbegininfusionof

fluids6.  Engageparentsbyinvitingongoingpresenceandphysicalcontact

PotentiallyBetterPractice3PBP3:Usemother’sownmilk(MOM)ordonorhumanmilk(DHM)forenteralfeeding

SupportingPBPs:1.  Initiatelactationintheimmediatepost-birthperiodviahandexpressionof

colostrum2.  Provideeducationandsupportivelactationcareforwomentoenhance

successinprovidingMOM3.  ProvideOralImmuneTherapyascolostrumswabs/dropsstartingonDay

1andenteralfeedingswithcolostrumasap4.  UtilizeDHMasabridgeifsupplyofMOMisinsufficientorasan

alternativeiffeedingwithMOMiscontraindicated5.  Utilizeassessmenttools(i.e.pumpinglog)tomonitorMOMvolumesand

intervenewithadditionalsupport/re-educationifsupplyisinadequateordiminishing

PotentiallyBetterPractice4PBP4:Developandutilizeevidence-basedstrategiestopreventhospital-acquiredinfections

SupportingPBPs:

1. Minimizedurationofantibiotictreatmentforinfantswithnegativebloodcultures

2. Usecentrallinebundlewithinsertionchecklist3. Usestandardizedapproachtomaintenanceofcentrallines4.  Removecentrallineswhenenteralfeedsvolumeof120ml/

kg/dhasbeenreached5.  Ensurecompliancewithhandhygieneforstaffandfamilies

PotentiallyBetterPractice5PBP5:Ensuremaximalcompliancewithevidence-basedoxygensaturationtargets

SupportingPBPs:

1.  Determineanddisseminateguidelinesforsaturationtargets,alarmlimitsandrequiredresponses

2.  Educatefamiliesaboutoxygentherapy,monitorsandalarms.Engagetheminfacilitatingappropriateresponsestoalarms

3.  Ensurethatallmonitorshavealarmsettingsincompliancewithguidelines4.  Developgoalsforthepercentageoftimeindividualpatientsareachieving

O2saturationtargets.Regularlyassesscompliancewhileprovidingfeedbacktostaffusingmethodssuchasreviewofmonitor-generatedhistogramsanddiscussstrategiestoimprovepracticeandoutcomes

PotentiallyBetterPractice6PBP6:Utilizelung-protectivestrategieswhenprovidingrespiratorysupport

SupportingPBPs:

1.  InitiaterespiratorysupportwithnCPAPinDRwheneverpossible2.  Allowmodestpermissivehypercapniaduringnon-invasiveor

invasivesupport3.  UseHFOVorvolume-targetedmethodsifinvasiveventilationis

required4.  Avoidatelectraumabyutilizinganopenlungapproach5.  Treatwithcaffeinesoonafterbirth6.  Extubateassoonaspossible

PotentiallyBetterPractice7PBP7:Promoteandreinforceencounterswiththeinfantthataredevelopmentallysupportiveandpositive

SupportivePBPs:

1.  Reducepainfultissue-damagingprocedurestoaminimumforsafecare2.  Minimizestressfulprocedures(definedasanyhandlingthatisnotforthe

purposeofnurturing)3.  Whenpainfulorstressfulproceduresarenecessary,utilizestrategiesthat

supporttheinfantincludingcontainment,two-personhandlingandpositiveinputs

4.  Makeskin-to-skinwiththeparentthepreferredlocusofcarefortheinfant

5.  Educateparentsindevelopmentallysupportivemethods

PotentiallyBetterPractice8PBP8:Ensurefamilyintegrationincaretoimproveoutcome,buildconfidenceandpromoteattachment

SupportingPBPs:1.  WELCOME:Ensureeveryfamilyreceivestimelyandcompleteorientationtothe

unitandhospital2.  LEARN:Ensurethateachfamilyhasbeeninterviewedwithintakequestionnaire3.  TEACH:Createeducationalandsupportiveprogrammingforfamilies4.  ENGAGE:Includefamilyonroundsasactiveparticipantsandenableaccesstothe

medicalteam,particularlybeforekeytransitionalmomentsforthebabyand/orfamily.Whenfamiliesarepresent,ensuretheyaresupportedandencouragedtoprovidecareandarethesecondsetofhandssupportingthebabyduringprocedures

5.  PREPARE:Provideon-goingindividualizedcommunicationabouttheinfant’sNICUstayandplanofcareemphasizingconsistencyofinformation(independentofdeliverymechanism)andincludinganticipatoryguidance

0 1 2AntenatalSteroids None Partial CompleteDCC/Milking None Partial CompleteSkinIntegrity(Bruising/Damage) Severe Mild NoneApgar1Min <3 3to5 >6Pre-deliveryBriefing None Cursory Complete

Fi02 at1hr >.30 0.22-.30 0.21pC02 from1stbloodgas <35or>55 35-39or51-55 40-50Temp(closestto1hr) <35°C/>38°C 35-36.4,37.6-38 36.5-37.5°CVascularAccess None Venousaccess CVL/AVLinfusing

FamilyContact None Updatedonstatus

Metteam/Touchedbaby

LactationSupport >24hrs <24hrsafterdel AntenatalHandExpression/1stPump >12hrs 6-12hrsafterdel <6hrsafterdelOralColostrum >12hrs 6-12hrafterdel <6hrsafterdelInitiateHMFeeds >48hrs 24-48hrafterdel <24hrsafterdelHumanMilk None MOM/DHM MOM

Antibx1st2weeks >96hrs 48-96hrs <48hrsCLInsertChecklist Notused 80%itemscheck Allitemschecked

CLCarebyguideline <50%ornotassessed 50-90%correct 90-100%correct

CLRemoval >120ml/kgw/nodoc.

>120ml/kgw/docofneed <120ml/kg

HandHygieneCompliance <80%/notassessed 80-90% >90%

Monitor/Alarmsetcorrectly <80% 80-99% 100%FamilyEducation Notdone General SpecificHistogram/Satsreveiwed–rounds Never Daily EachShiftO2 Sat>95% >30% 15-30% <15%O2 Sat<80% >10% 5-10% <5%

CPAPinDeliveryRoom None InitialthenETT Sustained1stCaffeine >3days/Never <3days>24hr <24hrs

ExtubationReadiness Nodiscussionor<once/day Once/day >Twice/day

pCO2 <40Wk1;<50Wk2 >20% 1-20% 0%Maxdaily02>30% 10-14days 3-9days <3days

Stressfuls1st5days >20/day 12-20/day <12/day2personpain/stresshandling <25% 25-50% >50%FamilyEdondevelopmetallysupportivecare

None written writtenw/discussion

SkintoSkin(Week2) 3-6hr/week 7-12hr/week >12hr/weekAvgDailyPainfulprocedures >10/day 6-10/day <6/day

NICUOrientation None/>7days By3-7days Within2daysFamilyIntakeTool None Day6-14 By5daysParentsonRounds1st2weeks <twice 3-7times >7timesParents-2ndHands Never Daily >Twice/dayCollaborativeCarePlan None/Informal 8-14days 1st7days

TOTALSCORE

DEV

SUPPORT

IVECA

REFA

MILY

Integration

LUNGPRO

TECTION

INFECPR

EVEN

TION

O2SA

TURA

TION

SCORE

SubTotal

BIRT

HCONDITION

GOLDEN

HOUR

HUMAN

MILK

MicropremiePBPAuditTool

Preventingmorbidity

ImpactofBronchopulmonaryDysplasia,BrainInjury,andSevereRetinopathyontheOutcomeof

ExtremelyLow-Birth-WeightInfantsat18MonthsResultsfromtheTrialofIndomethacinProphylaxisinPretermsSchmidtetal,JAMA2003•  910infants,birthweight500-999g•  32NICU’sUS,Canada,Australia,NewZealandandHongKong•  Survivedto36weeksPMA

•  ROP,BPDandbraininjuryeachsimilarly&independentlycorrelatedtopoor18mooutcome

•  NoROP,BPDorbraininjury–rateofpoorlongtermoutcome18%

•  With1,2or3ofmorbidities–correspondingrates42%,62%and88%

•  Additionalroleofinfectionornecrotizingenterocolitis,butsmalleroddsratiothanBPD,ROPorbraininjury

Neuroprotectionbundle

•  Handhuggingbyfamilyand/orstaffasearlyaspossibleafterbirth

•  Kangaroocareonlyafter72hrs•  Midlineheadpositioningandheadelevation15-30

degreesfor72hrs•  Handlingandpositioningby2peoplewhenever

possible(familyand/orstaff)•  Minimizehandlingtoq6horaccordingtocues

Neutral/midlineheadpositioning

20.4%20.9%

14.0%

6.5%

13.6%

10.7%

0%

5%

10%

15%

20%

25%

AllMicroprems InbornMicroprems

SevereIVHRate

SevereIVHRateinMicropremature Infants

BeforeBrainCareLaunch

AfterLaunch:First10months

Afterlaunch:40months

Includingfamiliesinpatientcare

EffectivenessofFamilyIntegratedCareinneonatalintensivecareunitsoninfantandparentoutcomes:amulticentre,multinational,cluster-randomisedcontrolledtrialKarelO'Brien,KateRobson,MarianneBracht,MelindaCruz,KeiLui,RubenAlvaro,OrlandodaSilva,LuisMonterrosa,MichaelNarvey,EugeneNg,AmuchouSoraisham,XiangYYe,LuciaMirea,WilliamTarnow-Mordi,ShooKLeeTheLancetchild&adolescenthealth2018,2(4):245-254

•  26tertiaryNICUsfromCanada,Australia,andNewZealand•  FICareorstandardNICUcare•  Eligibleinfantswerebornat33weeks'gestationorearlier,and

hadnoorlow-levelrespiratorysupport•  ParentsintheFICaregrouphadtocommittobepresentforat

least6haday,attendeducationalsessions,andactivelycarefortheirinfant

•  Theprimaryoutcome:infantweightgainatday21afterenrolment

•  Secondaryoutcomes:weightgainvelocity,highfrequencybreastfeeding(≥6timesaday)athospitaldischarge,parentalstressandanxietyatenrolmentandday21,NICUmortalityandmajorneonatalmorbidities,safety,andresourceuse(includingdurationofoxygentherapyandhospitalstay)

Findings•  RandomlyassignedtoprovideFICare(n=14)orstandardcare

(n=12)•  895infantseligibleinFICaregroupvs891instandardcaregroup•  Day21weightgaingreaterinFICaregroupthaninthestandard

caregroup(meanchangeinZscores-0·071[SD0·42]vs-0·155[0·42];p<0·0002)

•  AveragedailyweightgainsignificantlyhigherininfantsreceivingFICare(meandailyweightgain26·7g[SD9·4]vs24·8g[9·5];p<0·0001)

•  Thehigh-frequencyexclusivebreastmilkfeedingrateatdischargewashigherforinfantsintheFICaregroup(279[70%]of396vs394[63%]of624;p=0·016)

•  ParentsintheFICaregrouphadlowermeanstressscores(2·3[SD0·8]vs2·5[0·8];p<0·00043),andlowermeananxietyscores(70·8[20·1]vs74·2[19·9];p=0·0045)

•  Nosignificantdifferencesbetweengroupsinratesofthesecondaryoutcomesofmortality,majormorbidity,durationofoxygentherapy,anddurationofhospitalstay

‘SSCisaneffectiveandevidence-basedcarestrategythatreducestheinfant’straumaticNICUexperiencesbyimprovingparentalproximity,

attachment,andlactation;decreasingstressandpain;improvingphysiologicstability;supportingsleep;andenhancingneurologicoutcomes.’

Includefamiliesindevelopmentalcare

LessonsfromNIDCAPNIDCAPapproachbasedon3assumptions:•  Detailedobservationofbehaviorprovidesbasisforrecommendationsinhowtominimizestressandoptimizedevelopment

•  Caregiversbenefitfromsupportiveeducation,aswellasguidanceandmodelinginimplementingrecommendations

•  Resultantchangesleadtoimprovedmedicalandneurobehavioralfunctioning

AlsH.NewbornIndividualizedDevelopmentandAssessmentProgram(NIDCAP):Newfrontierforneonatalandperinatalmedicine.JNeoPerinatalMed2009;2:135-149.

Whataboutfeeding?

Whydofeedingproblemsoccur?

•  Earlysensoryinformationmayhaveaneffectonthearchitectureofthebrain(Sweeney,2010,Shaker,2013)–  Structurally(braininjury,reducedcorticalandcerebellarvolumes)–  Functionally-“wiring”

•  Combinationofphysiologicinstabilitycoupledwith(toxic)stress,imposedonasensorysystemthatisundergoingrapiddevelopment:–  Maycausealteredsensorymotorpathwaysinthebrain–  Maybeariskfactorforneurobehavioralanddevelopmentaldysfunctionlater

inlife–  MayaffecttheabilityanddesiretoeatbothintheNICUandafterdischarge

(Ross,2009)

Evenafterdischarge

Whatisnext?

Nextstep…?

Resources•  Tysonneonatalmortality/

morbiditycalculator(infants<26weeks)https://www1.nichd.nih.gov/epbo-calculator/Pages/epbo_case.aspx

•  VermontOxfordNetworkwebpagehttps://public.vtoxford.org/

•  Cochranelibraryhttps://www.cochranelibrary.com/