Neuromonitoring during newborn transition

Background: Newborn infant neurological function can be measured by monitoring electrical activity (electroencephalography) or cerebral oxygenation via NIRS (near infrared spectroscopy). In practice the clinical applications of electroencephalography (EEG) are limited to monitoring infants following moderate to severe hypoxic ischemic injury (HIE), and for the detection of seizures in at risk infants. NIRS monitoring has been the focus of a number of research trials but has no clinical applications in the immediate newborn period to date, and is not routinely performed in neonatal units. Aim: To assess the feasibility of infant neuromonitoring in the immediate period in two important clinical scenarios. Firstly, to assess the feasibility of monitoring brain activity during the first minutes of life in healthy term infants. Secondly, to assess the feasibility and utility of monitoring newborn preterm infants’ brain activity and cerebral oxygenation in the context of an interventional randomized controlled trial. Methods: 1. Healthy term newborn infants had EEG monitoring performed for the first ten minutes of life. EEG was assessed both qualitatively and quantitatively. All infants had respiratory function monitoring performed simultaneously. 2. Forty-five infants (< 32 weeks gestation) were randomly assigned to different methods of newborn infant cord clamping. All infants had EEG and NIRS monitoring for the first 72 hours of life. Quantitative features of EEG and median NIRS values were compared between groups at 6 and 12 hours of life as a primary outcome measure. Results: 1. Forty-nine infants had EEG recordings. Median (IQR) age at time of initial EEG recording was 3.0 (2·5 to 3·8) minutes. End tidal CO2 and tidal volumes increased over the first 3 minutes of life and then stabilized. Good quality EEG, with continuous mixed frequency activity with a range of 25-50μV, was observed in all infants. The majority of EEG spectral power was within the delta band. 2. There were 45 infants included. One infant died in the delivery room. Median time (IQR) from birth until EEG application was 3.05 (1.85 to 5.38) hrs. For primary outcome measures, data was available for 42/44 (95%) at 6 hrs and 44/44 (100%) at 12 hours. There was no significant difference between groups for measures for EEG values or cerebral NIRS. Conclusion: Infant neuromonitoring in the immediate newborn period is feasible in the first minutes of life in healthy term infants and within the first hours of life in preterm infants. Normative quantitative data for electrical activity in healthy newborn term infants during the first minutes of life is described for the first time. Neuromonitoring during the first day of life as an outcome measure for preterm interventional trials is possible and the outcomes from this research is promising for further trials

Lost in transition: a systematic review of neonatal electroencephalography in the delivery room - Are we forgetting an important biomarker for newborn brain health?

Background: Electroencephalography (EEG) monitoring is routine in neonatal intensive care units (NICUs) for detection of seizures, neurological monitoring of infants following perinatal asphyxia, and increasingly, following preterm delivery. EEG monitoring is not routinely commenced in the delivery room (DR). Objectives: To determine the feasibility of recording neonatal EEG in the DR, and to assess its usefulness as a marker of neurological well-being during immediate newborn transition. Methods: We performed a systematic stepwise search of PubMed using the following terms: infant, newborns, neonate, DR, afterbirth, transition, and EEG. Only human studies describing EEG monitoring in the first 15 min following delivery were included. Infants of all gestational ages were included. Results: Two original studies were identified that described EEG monitoring of newborn infants within the DR. Both prospective observational studies used amplitude-integrated EEG (aEEG) monitoring and found it feasible in infants >34 weeks' gestation; however, technical challenges made it difficult to obtain continuous reliable data. Different EEG patterns were identified in uncompromised newborns and those requiring resuscitation. Conclusion: EEG monitoring is possible in the DR and may provide an objective baseline measure of neurological function. Further feasibility studies are required to overcome technical challenges in the DR, but these challenges are not insurmountable with modern technology

Lost in Transition: A Systematic Review of Neonatal Electroencephalography in the Delivery Room—Are We Forgetting an Important Biomarker for Newborn Brain Health?

BackgroundElectroencephalography (EEG) monitoring is routine in neonatal intensive care units (NICUs) for detection of seizures, neurological monitoring of infants following perinatal asphyxia, and increasingly, following preterm delivery. EEG monitoring is not routinely commenced in the delivery room (DR).ObjectivesTo determine the feasibility of recording neonatal EEG in the DR, and to assess its usefulness as a marker of neurological well-being during immediate newborn transition.MethodsWe performed a systematic stepwise search of PubMed using the following terms: infant, newborns, neonate, DR, afterbirth, transition, and EEG. Only human studies describing EEG monitoring in the first 15 min following delivery were included. Infants of all gestational ages were included.ResultsTwo original studies were identified that described EEG monitoring of newborn infants within the DR. Both prospective observational studies used amplitude-integrated EEG (aEEG) monitoring and found it feasible in infants &gt;34 weeks’ gestation; however, technical challenges made it difficult to obtain continuous reliable data. Different EEG patterns were identified in uncompromised newborns and those requiring resuscitation.ConclusionEEG monitoring is possible in the DR and may provide an objective baseline measure of neurological function. Further feasibility studies are required to overcome technical challenges in the DR, but these challenges are not insurmountable with modern technology

Response: Commentary: Enhanced monitoring of the preterm infant during stabilization in the delivery room

A commentary on: Enhanced Monitoring of the Preterm Infant during Stabilization in the Delivery Room by Hutchon DJ. Front Pediatr (2016) 4:64. doi: 10.3389/fped.2016.0006

Enhanced monitoring of the preterm infant during stabilization in the delivery room

Monitoring of preterm infants in the delivery room (DR) remains limited. Current guidelines suggest that pulse oximetry should be available for all preterm infant deliveries, and that if intubated a colorimetric carbon dioxide detector should provide verification of correct endotracheal tube placement. These two methods of assessment represent the extent of objective monitoring of the newborn commonly performed in the DR. Monitoring non-invasive ventilation effectiveness (either by capnography or respiratory function monitoring) and cerebral oxygenation (near-infrared spectroscopy) is becoming more common within research settings. In this article, we will review the different modalities available for cardiorespiratory and neuromonitoring in the DR and assess the current evidence base on their feasibility, strengths, and limitations during preterm stabilization

All Island Congenital Heart Network brings diagnosis closer to home

Aim: The All-Island congenital heart network appointed paediatricians with expertise in cardiology in regional centres. Prior to these appointments children with suspected congenital heart disease were referred to the national children’s heart centre for investigation. The aim of this study is to quantify paediatric cardiology activity in a regional Irish centre over the first year of service provision. Methods: Data was collected retrospectively on all inpatient neonatal referrals over a 12-month period (January 2019 to January 2020). Results: There were 268 neonatal referrals. Premature infants (< 37 weeks gestation) accounted for 26% (n= 69) of total neonatal referrals. Congenital cardiac disease was identified in 58.5% (n= 113) of referrals. Cardiac intervention in the first year of life was required in 24 infants, 12.2% of referrals (5.6% catheter and 6.6% surgery). Discussion: Our report displays how clinical networks of care can reduce hospital transfers from regional neonatal centres for non-invasive cardiology investigations

A Study of the Impacts of Corporate Culture Initiatives – MVV

The purpose of this report is to study the implementation and impacts of Mission, Vision and Values (MVV) initiatives at a Portland based medium-sized technology Company. In 2009 the Company at the core of this case implemented a refreshed MVV initiative to spur innovation, creativity, productivity and improve employee satisfaction within the Company after the recession and a two year down turn. This paper will begin by outlining the case history and problem statements that lead to the conclusion that the MVV required a re-boot. The study will document the implementation strategy and specific identifiable goals for the MVV. We will analyze results of survey data collected both before and after the roll out of the MVV to qualify the impacts to employee satisfaction. Small improvements were observed for Company vision, creativity and inspiration. The survey also showed a reduction in the key talent retention sentiment in the Company. Additional metrics spanning the MVV initiative period will be examined for the following impacts; innovation, creativity, productivity and turnover. A positive trend in innovation and creativity was observed at multiple locations, a productivity increase was not evident from records provided, human resource management (HRM) statistics showed a temporary drop in voluntary turnover during the period, but turnover increased again in the following years. This study has been conducted through the collection of empirical data from the Company and by conducting with interviews with technical staff and HR professionals at the Company. Based on the outcome of this case study, we will be able to conclude to the impacts of the MVV initiative

Optimal Line and Tube Placement in Very Preterm Neonates: An Audit of Practice

Background: Placement of endotracheal tubes (ETTs) and umbilical catheters (UCs) is essential in very preterm infant care. The aim of this study was to assess the effect of an educational initiative to optimize correct placement of ETTs and UCs in very preterm infants. Methods: A pre–post study design, evaluating optimal radiological position of ETTs and UCs in the first 72 h of life in infants &lt;32 weeks gestational age (GA) was performed. Baseline data was obtained from a preceding 34-month period. The study intervention consisted of information from the pre-intervention audit, surface anatomy images of the newborn for optimal UC positioning, and weight-based calculations to estimate insertion depths for endotracheal intubation. A prospective evaluation of radiological placement of ETTs and UCs was then conducted over a 12-month period. Results: During the study period, 211 infants had at least one of the three procedures performed. One hundred and fifty-seven infants were included in the pre-education group, and 54 in the post-education group. All three procedures were performed in 50.3% (79/157) in the pre-education group, and 55.6% (30/54) in the post-education group. There was no significant difference in accurate placement following the introduction of the educational sessions; depth of ETTs (50% vs. 47%), umbilical arterial catheter (UAC) (40% vs. 43%,), and umbilical venous catheter (UVC)(14% vs. 23%). Conclusion: Despite education of staff on methods for appropriate ETT, UVC and UAC insertion length, the rate of accurate initial insertion depth remained suboptimal. Newer methods of determining optimal position need to be evaluated