Medical Devices for Measuring Respiratory Rate in Children: a Review

Respiratory rate is an important vital sign used for diagnosing illnesses in children as well as prioritising patient care. All children presenting acutely to hospital should have a respiratory rate measured as part of their initial and ongoing assessment. However measuring the respiratory rate remains a subjective assessment and in children can be liable to measurement error especially if the child is uncooperative. Devices to measure respiratory rate exist but many provide only an estimate of respiratory rate due to the associated methodological complexities. Some devices are used within the intensive care, post-operative or more specialised investigatory settings none however have made their way into the everyday clinical setting. A non-contact device may be better tolerated in children and not cause undue stress distorting the measurement. Further validation and adaption to the acute clinical setting is needed before such devices can supersede current methods

Cardiac Arrest Associated with Endotracheal Suctioning Following Surgery for Congenital Heart Disease

(CHD) describes the most common congenital defect and represents a significant health burden worldwide. Yearly, there are more than a million newborns diagnosed with congenital heart disease, many of the defects require surgical correction. The cost of surgical correction can be significant, of the ten congenital defects with the highest hospital cost, six are CHD. Cardiac arrest, like other postoperative complications, can increase the length of intensive care and hospital stay, and is associated with hospital-acquired infections, errors, and poorer long-term outcomes. Several studies included physiological data and hemodynamic monitoring or assigned causation for cardiac arrest to broad categories, such as respiratory, arrhythmia, metabolic or central nervous system, but did not describe specific clinical signs of impending cardiac arrest with the exception of rising serum lactate. The paucity of data in this area demonstrates a gap in the literature on cardiac arrest in children following cardiac surgery. The first manuscript in this dissertation describes the current literature on the effect of endotracheal suctioning in pediatrics, guided by the Neuman Systems model. The second manuscript, using the Knowledge-to-Action theoretical framework, explores available tools for risk adjustment in congenital heart surgery. Lastly, the third manuscript describes the hemodynamic variability preceding cardiac arrest associated with endotracheal suctioning in children following surgery for congenital heart defects compared to others. This dissertation establishes a basis for further research and interventions to avert cardiac arrest in the vulnerable child with congenital heart disease

Non-invasive ventilation during paediatric retrieval: a systematised review

Background: In hospital critical-care and emergency settings, non-Invasive ventilation (NIV) is increasingly used in neonatal and paediatric patients as an alternative to invasive positive pressure ventilation (IPPV). Critically ill children and babies may need transfer to higher levels of care, but the emergency transport setting is lagging behind the hospital sector in terms of availability of NIV. Aim and objectives: The goal of this study was to assess the evidence on the safety and effectiveness of NIV in children during transportation. Safety outcome measures were intubation or escalation of ventilation mode (during and soon after transport) and adverse event (AE) occurrence during transport. Effectiveness outcome measures related to improvement in clinical parameters during transfer. Methods: A systematised review of the literature was conducted, based on searches of MEDLINE via PubMed, EMBASE (via Scopus), Cochrane Central Register of Controlled Trials (CENTRAL), African Index Medicus, Web of Science Citation Index and the World Health Organisation Trials Registry (ICTRP). Two reviewers independently reviewed all identified studies for eligibility, with an initial screening round followed by a full-text review of potentially relevant articles. The quality of studies meeting inclusion criteria was evaluated using an adapted quality assessment tool developed for this study. Results: A total of 1287 records were identified; of these, 12 studies met inclusion criteria. Following quality assessment, eight studies were included and four studies were excluded. There were no randomised controlled trials, quasi-randomised controlled trials or non-randomised studies of intervention, to answer the research question. The included studies were all observational in design: seven studies (n= 708) evaluated in-transport use of continuous positive airway pressure (CPAP) and one study (n=150) reported on use of high-flow nasal cannula (HFNC) in children during transport. During transport on NIV, 3/858 (0.4%) patients required either intubation (1/708; 0.1%; CPAP studies) or escalation of mode of ventilation (2/150; 1%; HFNC study). In the 24 hours following transfer, 63/650 (13%) of children transferred on NIV, were intubated. The odds of intubation within 24 hours were significantly higher for CPAP transfer 60/500 (12%) compared with HFNC 3/150(2%): OR (95% CI) 6.68 (2.40 - 18.63), p=0.00003. Adverse events, where reported, were found to occur in 2-4% of NIV transports, with use of BVM in 8/334 (2%), desaturation episodes in 9/290 (3%), apnoea in 11/290(4%) and administration of CPR in 0/290 (0%) cases being described. There was insufficient reporting of change in vital signs or clinical condition during transport for meaningful analysis. Conclusion: This study is the first systematised review indicating that NIV use in children during transport is likely to be safe. From the low-reliability evidence available, it was calculated that NIV use in children during transport would result in a 0.4% rate of intubation or escalation during transport and an in-transport adverse event rate of 2-4%. There was insufficient evidence to comment on clinical effectiveness of NIV during transfer. Following NIV transfer, 13% of patients were intubated within 24 hours, with significantly higher odds of intubation in children transported on CPAP compared with HFNC. Recommendations: Further research is needed in order to make firm recommendations regarding the safety and effectiveness of NIV during transport of children. A recommended minimum data set, for the standardised reporting of observational studies of paediatric NIV use during transport, is suggested. It is recommended that transport databases and registries are expanded to include NIV details as well as information regarding the presence or absence of pre-specified adverse events during transport

Co-bedding as a Comfort measure For Twins undergoing painful procedures (CComForT Trial)

<p>Abstract</p> <p>Background</p> <p>Co-bedding, a developmental care strategy, is the practice of caring for diaper clad twins in one incubator (versus separating and caring for each infant in separate incubators), thus creating the opportunity for skin-to-skin contact and touch between the twins. In studies of mothers and their infants, maternal skin-to-skin contact has been shown to decrease procedural pain response according to both behavioral and physiological indicators in very preterm neonates. It is uncertain if this comfort is derived solely from maternal presence or from stabilization of regulatory processes from direct skin contact. The intent of this study is to compare the comfort effect of co-bedding (between twin infants who are co-bedding and those who are not) on infant pain response and physiologic stability during a tissue breaking procedure (heelstick).</p> <p>Methods/Design</p> <p>Medically stable preterm twin infants admitted to the Neonatal Intensive Care Unit will be randomly assigned to a co-bedding group or a standard care group. Pain response will be measured by physiological and videotaped facial reaction using the Premature Infant Pain Profile scale (PIPP). Recovery from the tissue breaking procedure will be determined by the length of time for heart rate and oxygen saturation to return to baseline. Sixty four sets of twins (n = 128) will be recruited into the study. Analysis and inference will be based on the intention-to-treat principle.</p> <p>Discussion</p> <p>If twin contact while co-bedding is determined to have a comforting effect for painful procedures, then changes in current neonatal care practices to include co-bedding may be an inexpensive, non invasive method to help maintain physiologic stability and decrease the long term psychological impact of procedural pain in this high risk population. Knowledge obtained from this study will also add to existing theoretical models with respect to the exact mechanism of comfort through touch.</p> <p>Trial registration</p> <p>NCT00917631</p

Neonatal non-contact respiratory monitoring based on real-time infrared thermography

<p>Abstract</p> <p>Background</p> <p>Monitoring of vital parameters is an important topic in neonatal daily care. Progress in computational intelligence and medical sensors has facilitated the development of smart bedside monitors that can integrate multiple parameters into a single monitoring system. This paper describes non-contact monitoring of neonatal vital signals based on infrared thermography as a new biomedical engineering application. One signal of clinical interest is the spontaneous respiration rate of the neonate. It will be shown that the respiration rate of neonates can be monitored based on analysis of the anterior naris (nostrils) temperature profile associated with the inspiration and expiration phases successively.</p> <p>Objective</p> <p>The aim of this study is to develop and investigate a new non-contact respiration monitoring modality for neonatal intensive care unit (NICU) using infrared thermography imaging. This development includes subsequent image processing (region of interest (ROI) detection) and optimization. Moreover, it includes further optimization of this non-contact respiration monitoring to be considered as physiological measurement inside NICU wards.</p> <p>Results</p> <p>Continuous wavelet transformation based on Debauches wavelet function was applied to detect the breathing signal within an image stream. Respiration was successfully monitored based on a 0.3°C to 0.5°C temperature difference between the inspiration and expiration phases.</p> <p>Conclusions</p> <p>Although this method has been applied to adults before, this is the first time it was used in a newborn infant population inside the neonatal intensive care unit (NICU). The promising results suggest to include this technology into advanced NICU monitors.</p

Study design and rationale for a randomized controlled trial to assess effectiveness of stochastic vibrotactile mattress stimulation versus standard non-oscillating crib mattress for treating hospitalized opioid-exposed newborns

The incidence of Neonatal Abstinence Syndrome (NAS) continues to rise and there remains a critical need to develop non-pharmacological interventions for managing opioid withdrawal in newborns. Objective physiologic markers of opioid withdrawal in the newborn remain elusive. Optimal treatment strategies for improving short-term clinical outcomes and promoting healthy neurobehavioral development have yet to be defined. This dual-site randomized controlled trial (NCT02801331) is designed to evaluate the therapeutic efficacy of stochastic vibrotactile stimulation (SVS) for reducing withdrawal symptoms, pharmacological treatment, and length of hospitalization, and for improving developmental outcomes in opioid-exposed neonates. Hospitalized newborns (n = 230) receiving standard clinical care for prenatal opioid exposure will be randomly assigned within 48-hours of birth to a crib with either: 1) Intervention (SVS) mattress: specially-constructed SVS crib mattress that delivers gentle vibrations (30-60 Hz, ~12 mum RMS surface displacement) at 3-hr intervals; or 2) Control mattress (treatment as usual; TAU): non-oscillating hospital-crib mattress. Infants will be studied throughout their hospitalization and post discharge to 14-months of age. The study will compare clinical measures (i.e., withdrawal scores, cumulative dose and duration of medications, velocity of weight gain) and characteristic progression of physiologic activity (i.e., limb movement, cardio-respiratory, temperature, blood-oxygenation) throughout hospitalization between opioid-exposed infants who receive SVS and those who receive TAU. Developmental outcomes (i.e., physical, social, emotional and cognitive) within the first year of life will be evaluated between the two study groups. Findings from this randomized controlled trial will determine whether SVS reduces in-hospital severity of NAS, improves physiologic function, and promotes healthy development

Diagnosis, evaluation, and management of acute kidney injury : a KDIGO summary (part 1)

Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever, international, multidisciplinary, clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. In this review we summarize key aspects of the guideline including definition and staging of AKI, as well as evaluation and nondialytic management. Contrast-induced AKI and management of renal replacement therapy will be addressed in a separate review. Treatment recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided

Early Kangaroo mother care for mild-moderately unstable neonates <2000g in The Gambia

Complications of prematurity are the largest cause of childhood deaths globally, with >1 million deaths and high risk of long-term neurodevelopmental impairment. The first day after birth is the period of greatest risk and greatest potential for improving outcomes, especially with hospital-based small and sick newborn care (SSNC). Kangaroo mother care (KMC) involves continuous skin-to-skin contact and is recommended by WHO for all stable neonates ≤2000g. At PhD onset a priority evidence gap existed for initiation of early KMC before stability, which may contribute towards reducing the Sustainable Development Goal (SDG) for neonatal mortality, especially in low-resource, high-mortality contexts. My PhD aimed to investigate early KMC (< 24h of admission) in unstable neonates <2000g in one Gambian level 2/2+ neonatal unit. There were four objectives: (1) To prepare the research site with mitigation of barriers to trial implementation; (2) To investigate the effect of early KMC on survival and other clinical outcomes and safety (eKMC trial); (3) To explore pathways to preterm mortality and the effect of early KMC on physiological factors; (4) To determine the programmatic/policy and research implications of the PhD findings. The first PhD section provides the rationale for studying this topic and description of the local study site context at PhD onset. Substantial site preparations were required for trial implementation, including establishment of KMC as standard care and development/implementation of SSNC guidelines to minimise bias. Local data informed trial protocol development along with a conceptual framework to guide implementation process data collection. Unavailability of the mother during the first 24h of admission was a key recruitment barrier, mitigated by involving female relatives, and informed by a qualitative study to understand their perceptions towards SSNC and KMC. The second section focuses on the eKMC randomised controlled trial primary and secondary outcome findings. Despite adequate power at trial onset, no evidence of 28-day mortality effect was identified, with possible reasons including (1) Insufficient sample size to detect a between-arm difference due to large reductions in control arm mortality compared to pre-trial mortality (2) Low fidelity of the intervention delivered. However, important insights were gained for secondary outcomes, and feasibility of delivering prolonged KMC contact to unstable neonates, along with safety considerations. The final section presents a conceptual framework to describe pathways to mortality for neonates <2000g and potential amelioration by early KMC. Exploratory analyses of eKMC trial data identified substantial survival gains during the trial period, with 24% relative mortality reduction for all neonates <2000g and 29% relative risk reduction associated with trial participation. Weight <1200g, factors. This PhD provides valuable insights into SSNC in a West African context, underlining the importance of improving quality of SSNC overall as well as the potential for KMC as an entry point for family centred care. Female relatives are key stakeholders for family integrated SSNC and KMC in this socio-cultural context. The eKMC trial findings alone do not support a change to KMC policy, but a recent WHO multi-centre trial is influencing a shift towards immediate KMC. These findings provide rich data and insights into implementation and impact of SSNC, operationalisation of KMC for stable neonates, and novel data regarding the impact, feasibility, and realities of providing early KMC to unstable newborns in a typical African hospital neonatal unit

Stabilization and Resuscitation of Newborns

The majority of newborns do not need medical interventions to manage the neonatal transition after birth. However, every year millions of newborns worldwide require respiratory support immediately after birth, and another considerable number of newborns additionally require extensive resuscitation including chest compressions and drug administration. Despite a significant increase in knowledge and development of enhanced therapy strategies over the past few years, morbidity and mortality caused by failures in neonatal transition remain an important health issue. The purpose of this reprint is to support or introduce novel concepts and add information in the area of the “Stabilization and Resuscitation of Newborns”, aiming to improve neonatal care and, as the major objective, to enhance neuro-developmental outcomes