Conventional MRI at term age has been reported to be superior to cranial ultrasound (cUS) in detecting white matter (WM) abnormalities and predicting outcome in preterm infants. However, in a previous study cUS was performed during the first 6 weeks only and not in parallel to MRI at term age. Therefore, the aim of the present work was to study brain injuries in preterm infants performing concomitant cUS and MRI at full-term age.

In a population-based cohort of 72 extremely low gestational age infants paired cUS and conventional MRI were performed at term age. Abnormalities on MRI were graded according to a previously published scoring system. On cUS images the lateral ventricles, the corpus callosum, the interhemispheric fissure and the subarachnoidal spaces were measured and the presence of cysts, grey matter abnormalities and gyral folding were scored.

Moderate or severe WM abnormalities were detected on MRI in 17% of infants and abnormalities of the grey matter in 11% of infants. Among infants with normal ultrasound (n=28, 39%) none had moderate or severe WM abnormalities or abnormal grey matter on MRI. All infants with severe abnormalities (n=3, 4%) were identified as severe on MRI and cUS.

All severe WM abnormalities identified on MRI at term age were also detected by cUS at term, providing the examinations were performed on the same day. Infants with normal cUS at term age were found to have a normal MRI or only mild WM abnormalities on MRI at term age.

Guidelines recommend avoidance of excessive oxygen administration during neonatal resuscitation. Blenders are used in some but not all hospitals. It has been suggested that self-inflating bags without a reservoir deliver around 40% oxygen and could be used to provide an inexpensive and effective technique of avoiding oxygen toxicity.

To explore how much oxygen is delivered when using two different brands of neonatal self-inflating resuscitation bags without a reservoir.

In a benchtop setting, the smallest non-disposable self-inflating bags from the Laerdal and Ambu ranges were tested. Oxygen concentration delivered by these devices under a variety of conditions was measured. 108 combinations of oxygen flow rates (10; 5 to 1 litre/min), ventilation rates (30, 60, 100 inflations/min) and peak inspiratory pressure ranges (20 to 25 cm H₂O, 35 to 40 cm H₂O or pop-off valve range, 55 to 60 cm H₂O) were tested.

Delivered oxygen concentration varied depending on three parameters: gas flow rate, ventilatory rate and pressure. At a pressure of 20 to 25 cm H₂O, mean oxygen concentration delivered by both bags exceeded 70% at any gas flow rate except for 1 litre/min (where delivered oxygen concentration was 60% to 70%). When the pop-off valve was opened at 35 to 40 cm H₂0, oxygen concentrations fell to 30% to 45% at gas flow rates ≤2 litres/min. The Ambu bag delivered a lower oxygen concentration than the Laerdal bag but this difference was not clinically important.

When using the Laerdal and Ambu infant resuscitation self-inflating bags without a reservoir, delivered oxygen concentration is >70% for currently recommended flow and pressure settings.

To compare healthcare use from neonatal discharge to 18 months corrected age (CA) of two groups of extremely preterm neonates (23–25 vs 26–28 weeks).

Cohort study.

Infants born at ≤28 weeks and admitted in three hospital centres in Quebec, Canada (n=254).

Neurodevelopmental outcomes and healthcare use from neonatal discharge to 18 months CA.

Re-hospitalisation rates occurred in 57% of children born at 23–25 weeks and in 49% of those born at 26–28 weeks. In these two age groups, by 18 months, 61% vs 59% were followed in physical or occupational therapy, 29% vs 17% were enrolled in a long-term rehabilitation program, 38% vs 28% used prescribed medication, and 59% vs 33% required medical assistive devices, respectively. Risk of re-hospitalisation was related to bronchopulmonary dysplasia (BPD), severe brain injury, use of home oxygen or an apnoea monitor and older age at neonatal discharge. Multiple births, BPD, severe brain injury, older age at neonatal discharge and single parenthood were associated with risk of using out-patient health services above average (>2 services).

Extremely preterm children are frequently re-hospitalised during infancy and use a substantial amount of healthcare resources. These results highlight the importance of resource allocation to preterm infants for medical and rehabilitation services after discharge from the neonatal intensive care unit.

To compare the need for positive pressure ventilation (PPV) by bag and mask and by bag and endotracheal tube in newly born term infants with vertex presentation delivered by non-urgent caesarean section under regional anaesthesia or non-instrumental vaginal delivery.

Cross-sectional study.

35 public hospitals in 20 Brazilian state capitals.

6929 inborn infants without congenital anomalies, with gestational ages from 37^0/7 to 41^6/7 weeks with vertex presentation, born between 1 and 30 September 2003.

Non-urgent caesarean versus non-instrumental vaginal delivery. Non-urgent caesarean was defined as delivery occurring in the absence of prolapsed cord, third trimester haemorrhage, failure of labour induction, fetal distress or non-clear amniotic fluid.

PPV with bag and mask and with bag and endotracheal tube. Both outcomes were adjusted for potential confounding variables by logistic regression analysis.

2087 infants were born by non-urgent caesarean and 4842 by non-instrumental vaginal delivery. Non-urgent caesarean delivery under regional anaesthesia compared to vaginal delivery under local or no anaesthesia increased the risk of bag and mask ventilation (OR 1.42, 95% CI 1.07 to 1.89) adjusted for number of gestations, maternal hypertension and birth weight. Ventilation with bag and endotracheal tube was associated only with low birth weight, adjusted for delivery mode and twin gestation.

Term neonates with vertex presentation and clear amniotic fluid born by non-urgent caesarean section under regional anaesthesia need to be assisted at birth by health professionals skilled in PPV.

During proportional assist ventilation (PAV) the timing and frequency of inflations are controlled by the patient and the patient's work of breathing may be relieved by elastic and/or resistive unloading. It is important and the authors' objective to determine whether ventilators delivering PAV function well in situations mimicking neonatal respiratory conditions.

In vitro laboratory study.

Tertiary neonatal ICU.

Dynamic lung models were developed which mimicked respiratory distress syndrome, bronchopulmonary dysplasia and meconium aspiration syndrome to assess the performance of the Stephanie® neonatal ventilator.

The effects of elastic and resistive unloading on inflation pressures and airway pressure wave forms and whether increasing unloading was matched by an ‘inspiratory’ load reduction.

During unloading, delivered pressures were between 1 and 4 cm H₂O above those expected. Oscillations appeared in the airway pressure wave form when the elastic unloading was greater than 0.5 cm H₂O/ml with a low resistance model and 1.5 cm H₂O/ml with a high resistance model and when the resistive unloading was greater than 100 cm H₂O/l/s. There was a time lag in the delivery of airway pressure of at least 60 ms, but increasing unloading was matched by an inspiratory load reduction.

During PAV, unloading does reduce inspiratory load, but there are wave form abnormalities and a time lag in delivery of the inflation pressure. The impact of these problems needs careful evaluation in the clinical setting.

There has been no study assessing cranial ultrasound (cUS) scans in newborn infants born in equatorial Africa.

To assess the cUS scans of apparently well newborn term Ugandan infants and to correlate the findings with perinatal data.

An observational study of apparently healthy postnatal ward term Ugandan infants at Mulago Hospital, Makerere University Hospital, Kampala, Uganda.

Data from 112 infants scanned at a median age of 1.4 postnatal days were analysed. Only 57 (51%) infants had scans considered normal, including 30 infants with isolated focal peritrigonal white matter (WM) echogenicity that was very common, occurring in 60 (53%) of infants. More extensive WM echogencities were seen in nine (7.5%) and focal unilateral central grey matter echogenicity in eight (6.5%) infants. Haemorrhage was not common. Subependymal pseudocysts (SEP) and choroid plexus cysts (CPC) occurred in 19.6% of infants each. Four infants only had lenticulostriate vasculopathy. No correlation was found between mode of delivery, birth weight, head circumference or gestational age, maternal HIV status and any cUS abnormality.

Apparently well term-born Ugandan infants frequently have abnormalities on cUS. These are mainly increased WM echogenicity, SEP and CPC. These may relate to the reported high incidence of congenital infections in this population but this remains to be confirmed. The observations provide baseline data for comparison with scans from sick infants from similar communities and are also important for studies in which cUS will be used to assess progress.

Surfactant replacement therapy (SRT) reduces respiratory morbidity and mortality in premature infants. The goal of this study was to characterise the effects of delivery room SRT on the ductus arteriosus and early neonatal haemodynamics.

A prospective observational study was conducted in preterm infants of less than 32 weeks' gestation who received SRT within 30 min of birth. Serial echocardiography was performed before and after SRT. Characteristics of the ductus arteriosus, myocardial performance, right ventricular output (RVO) and left ventricular output (LVO) and the ratio of RVO:LVO were measured.

Sixteen babies, born at 28.3±1.3 weeks' gestation and weighing 1289±224 g, were studied. SRT was associated with an improvement in the arterial oxygen tension:fractional inspired oxygen ratio (p<0.001), increased systolic and decreased diastolic arterial pressure (p<0.05). The ductus arteriosus was patent in all and transductal flow was unrestrictive and exclusively left-to-right after SRT. An increase in transductal diameter (p<0.001), left atrium:aortic ratio (p=0.006) but a decrease in left ventricular end-diastolic dimension (p=0.02) was identified.

SRT administration was followed by increased RVO but decreased LVO, resulting in an increased RVO:LVO ratio and an increase in ductal size. Delivery room administration of SRT is associated with major haemodynamic changes. The impact of these changes needs prospective evaluation.

Preterm infants often need red blood cell (RBC) transfusions. The aim of this study was to determine whether haemoglobin levels before transfusion were associated with regional cerebral tissue oxygen saturation (r_cSO₂) and fractional tissue oxygen extraction (FTOE) and whether RBC transfusions were associated with r_cSO₂ and FTOE during the 24-h period thereafter.

Prospective observational cohort study.

Third level neonatal intensive care unit.

Thirty-three preterm infants (gestational age 25–34 weeks, birth weight 605–2080 g) were included.

None.

R_cSO₂ was measured during a 1-h period, before, 1 h after and 24 h after a 15 ml/kg RBC transfusion in 3 h. Using r_cSO₂ and transcutaneous arterial oxygen saturation (tcSaO₂) values, FTOE was calculated: FTOE=(tcSaO₂–r_cSO₂)/tcSaO₂.

Forty-seven RBC transfusions were given. R_cSO₂ and FTOE correlated strongly with haemoglobin before transfusion (r=0.414 and r=–0.462, respectively, p<0.005). TcSaO₂ did not correlate with haemoglobin before transfusion. 24 h after transfusion, r_cSO₂ increased from a weighted mean of 61% to 72% and FTOE decreased from a weighted mean of 0.34 to 0.23. The decrease in FTOE was strongest in the group with haemoglobin below 6.0 mmol/l (97 g/l). The decrease in FTOE was already present 1 h after transfusion and remained unchanged at 24 h after transfusion.

Following RBC transfusion, cerebral tissue oxygen saturation increases and FTOE decreases. The data suggest that cerebral oxygenation in preterm infants may be at risk when haemoglobin decreases under 6 mmol/l (97 g/l).

Nasal intermittent positive pressure ventilation (NIPPV) is a mode of non-invasive respiratory support. Its mechanisms of action and optimal delivery techniques are unknown.

This observational study aimed to investigate and quantify delivered peak pressures during non-synchronised ventilator-generated NIPPV.

Infants born below 30 weeks gestation receiving ventilator-generated NIPPV delivered via Hudson prongs were recruited. Intraprong pressure, change in tidal volume, respiratory rate, oxygen saturations, inspired oxygen and video images were recorded.

Eleven infants (four infants were female) of median (interquartile range; IQR) gestational age 25^±3 (25^±2 26^+/-0) weeks and birth weight 732 (699–895) g, were studied at 24 (19–41) days of age. Six infants, with set peak pressure (peak inflation pressure; PIP) of 20 cm H²O, received a median pressure of 15.9 (IQR 13.6–17.9) cm H²O. 37% of inflations were delivered at least 5 cm H²O below set PIP. 12.7% of inflations were delivered above set PIP. Five infants with set PIP of 25 cm H²O received a median PIP of 17.2 (IQR 15.0–18.3) cm H²O. 83% of inflations were delivered at least 5 cm H²O below set PIP, with 6.1% delivered higher than set PIP. The difference in delivered PIP between the groups was 1.3 cm H²O. PIP was highest and most variable when the infant was moving. Delivered PIP did not vary whether it coincided with spontaneous inspiration or expiration.

During ventilator-generated non-synchronised NIPPV delivered PIP was variable and frequently lower than set PIP. Delivered PIP was occasionally greater than set PIP.

To assess how UK neonatal units address parent communication, support and information needs during neonatal care and the early months after discharge.

All units were invited to participate in a survey of practice and policy relating to the needs of parents with babies admitted for neonatal care.

Neonatal care, UK.

Proportions of units by unit level providing specific facilities, information, policies and support mechanisms.

Facilities, information and support for parents vary and can be quite limited: units may have as many as 10 babies receiving intensive or high dependency care in one room; 24% have no rooms in which to accommodate one or two babies only; 96% have at least one room for parents to stay overnight, 27% of rooms have ensuite amenities; 72% have written information about the equipment used, 64 % on ventilation and 91% on breastfeeding; parents have free access to notes in 20% of units and in 14% parents are excluded from ward rounds; 27% have a policy on keeping in contact with parents, 47% did not have the services of a social worker, psychologist, counsellor or psychiatrist and only 15% have a unit-based family care nurse.

Elements of unit policy and practice that support family-centred care are variably in place currently and units need to address the gaps.

Central blood flow measurements can provide detailed information on the hemodynamic condition of the preterm infant. However, reference values for right and left ventricular output (RVO and LVO) and superior vena cava flow (SVC flow) are only available for infants in the transitional period. The aim of this study was to determine RVO, LVO and SVC after the transitional period in stable preterm infants.

RVO, LVO and SVC flow were measured with functional echocardiography on days 7 and 14 of life in stable preterm infants less than 32 weeks gestation, with minimal respiratory support and no cardiovascular support. Infants with a clinical suspicion of an infection within 48 h after data collection or a ductal diameter >1.4 mm were excluded from analysis.

We performed 111 measurements in 62 preterm infants with a median (range) gestational age of 28 (25–31) weeks and birth weight of 1105 (650–2370) g. 57 measurements were analysed on day 7 and 47 on day 14. The mean (SD) RVO, LVO and SVC flow were 429 (116), 296 (74) and 89 (33) ml/kg/min on day 7 and 433 (81), 300 (79) and 86 (26) ml/kg/min on day 14. There were no significant differences in flows between days 7 and 14 in the paired measurements.

This study provides central blood flow values in stable preterm infants after the transitional period. The flow variables were shown to remain stable between days 7 and 14.

The precision of temperature control achieved in clinical practice during therapeutic hypothermia in neonates has not been described.

The hourly rectal temperature recordings from 17 infants treated with servo controlled and an equal number treated with manually adjusted cooling equipment were examined. The target rectal temperature for all infants is 33.5°C for 72 h.

During 6 to 72 h after start of cooling, the mean (95% CI, variance) of the averaged rectal temperatures was 33.6°C (95% CI 33.4°C to 33.8°C, 0.1°C) in the manually adjusted group and 33.4°C (95% CI 33.3°C to 33.5°C, 0.04°C) in the servo controlled group (means, p=0.08; equality of variance, p=0.03). The variance was also significantly different between infant groups during 1 to 5 h after start of cooling, p=0.01, but not during rewarming.

The rectal temperature can be maintained close to the target temperature with either manually adjusted or servo controlled equipment, but there is less temperature variability with the servo controlled system in use in the UK.