Suctioning of clear amniotic fluid at birth: A systematic review

Context Upper airway suctioning at birth was considered standard procedure and is still commonly practiced. Negative effects could exceed benefits of suction. Question In infants born through clear amniotic fluid (P) does suctioning of the mouth and nose (I) vs no suctioning (C) improve outcomes (O). Data sources Information specialist conducted literature search (12th September 2021, re-run 17th June 2022) using Medline, Embase, Cochrane Databases, Database of Abstracts of Reviews of Effects, and CINAHL. RCTs, non-RCTs and observational studies with a defined selection strategy were included. Unpublished studies, reviews, editorials, animal and manikin studies were excluded. Data extraction Two authors independently extracted data, risk of bias was assessed using the Cochrane ROB2 and ROBINS-I tools. Certainty of evidence was assed using the GRADE framework. Review Manager was used to analyse data and GRADEPro to develop summary of evidence tables. Meta-analyses were performed if ≥2 RCTs were available. Outcomes Primary: assisted ventilation. Secondary: advanced resuscitation, oxygen supplementation, adverse effects of suctioning, unanticipated NICU admission. Results Nine RCTs (n = 1096) and 2 observational studies (n = 418) were identified. Two RCTs (n = 280) with data concerns were excluded post-hoc. Meta-analysis of 3 RCTs, (n = 702) showed no difference in primary outcome. Two RCTs (n = 200) and 2 prospective observational studies (n = 418) found lower oxygen saturations in first 10 minutes of life with suctioning. Two RCTs (n = 200) showed suctioned newborns took longer to achieve target saturations. Limitations Certainty of evidence was low or very low for all outcomes. Most studies selected healthy newborns limiting generalisability and insufficient data was available for planned subgroup analyses. Conclusions Despite low certainty evidence, this review suggests no clinical benefit from suctioning clear amniotic fluid from infants following birth, with some evidence suggesting a resulting desaturation. These finding support current guideline recommendations that this practice is not used as a routine step in birth.publishedVersio

Randomised trial of cord clamping and initial stabilisation at very preterm birth

Objectives: For very preterm births, to compare alternatives policies for umbilical cord clamping and immediate neonatal care. Design: Parallel group randomised (1:1) trial, using sealed opaque numbered envelopes. Setting: Eight UK tertiary maternity units. Participants: 261 women expected to have a livebirth before 32 weeks, and their 276 babies. Interventions: Cord clamping after at least two minutes and immediate neonatal care with cord intact, or clamping within 20 seconds and immediate neonatal care after clamping. Main outcome measures: Intraventricular haemorrhage (IVH), death before discharge. Results: 132 women (137 babies) were allocated clamping ≥2 minutes and neonatal care cord intact, and 129 (139) clamping ≤20 and neonatal care after clamping; 6 mother infant dyads were excluded (2, 4) as birth was after 35+6 weeks, 1 withdrew (death data only available) (0, 1). Median gestation was 28.9 weeks for those allocated clamping ≥2 minutes, and 29.2 for those allocated clamping ≤20 seconds. Median time to clamping was 120 and 11 seconds respectively. 7 of 135 infants (5.2%) allocated clamping ≥2 minutes died and 15 of 135 (11.1%) allocated clamping ≤20 seconds; risk difference (RD) -5.9% (95% confidence interval -12.4% to 0.6%). Of livebirths, 43 of 134 (32%) had IVH versus 47 of 132 (36%) respectively; RD -3.5% (-14.9% to 7.8%). There were no clear differences in other outcomes for infants or mothers. Conclusions: This is promising evidence that clamping after at least 2 minutes and immediate neonatal care with cord intact at very preterm birth may improve outcome; a large trial is urgently needed

Optimising frontline learning and engagement between consultant-led neonatal teams in the West Midlands: a survey on the utility of an augmented simulation training technique

© The Authors. Published by BMC (Springer). This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: https://doi.org/10.1186/s41077-021-00181-1Background: In England neonatal care is delivered in operational delivery networks, comprising a combination of Neonatal Intensive Care(NICU), Local-Neonatal(LNU) or Special-Care Units (SCU), based on their ability to care for babies with different degrees of illness or prematurity. With the development of network care-pathways, the most premature and sickest are mostly triaged for delivery in services linked to NICU. This has created anxiety for teams in LNU and SCU. Less exposure to sicker babies has resulted in limited opportunities to maintain expertise for when these babies unexpectedly deliver at their centre and thereafter require transfer for care, to NICU. Simultaneously, LNU and SCU teams develop skills in care of the less ill and premature baby which would also be of benefit to NICU teams. A need for mutual learning through inter-unit multidirectional collaborative learning and engagement (hereafter also called neonatal networking) between teams of different designations emerged. Here neonatal networking is defined as collaboration, shared clinical learning and developing an understanding of local systems strengths and challenges between units of different and similar designations. We describe the responses to the development of a clinical and systems focused platform for this engagement between different teams within our neonatal ODN. Method: An interactive one-day programme was developed in the West Midlands, focusing on a non-hierarchical, equal partnership between neonatal teams from different unit designations. It utilised simulation around clinical scenarios, with a slant towards consultant engagement. Four groups rotating through four clinical simulation scenarios were developed. Each group participated in a clinical simulation scenario, led by a consultant and supported by nurses and doctors in training together with facilitators, with a further ~two consultants, as observers within the group. All were considered learners. Consultant candidates took turns to be participants and observers in the simulation scenarios so that at the end of the day all had led a scenario. Each simulation-clinical debrief session was lengthened by a further ~ 20 minutes, during which free style discussion with all learners occurred. This was to promote further bonding, through multidirectional sharing, and with a systems focus around understanding strengths and challenges of practices in different units. A consultant-focus was adopted to promote long-term engagement between units around shared care. There were four time points for this neonatal networking during the course of the day. Qualitative assessment and a Likert scale were used to assess this initiative over 4 years. Results: 155 individuals involved in frontline neonatal care participated. 77 were consultants, supported by neonatal trainees, staff grade doctors, clinical fellows, advanced neonatal nurse practitioners and nurses in training. All were invited to participate in the survey. The survey response rate was 80.6%. 79% felt that this learning strategy was highly relevant; 96% agreed that for consultants this was appropriate adult learning. 98% agreed that consultant training encompassed more than bedside clinical management, including forging communication links between teams. Thematic responses suggested that this was a highly useful method for multi-directional learning around shared care between neonatal unit. Conclusion: Simulation, enhanced with systems focused debrief, appeared to be an acceptable method of promoting multidirectional learning within neonatal teams of differing designations within the WMNODN

Combined point of care nucleic acid and antibody testing for SARS-CoV-2 following emergence of D614G Spike Variant

Rapid COVID-19 diagnosis in hospital is essential, though complicated by 30-50% of nose/throat swabs being negative by SARS-CoV-2 nucleic acid amplification testing (NAAT). Furthermore, the D614G spike mutant now dominates the pandemic and it is unclear how serological tests designed to detect anti-Spike antibodies perform against this variant. We assess the diagnostic accuracy of combined rapid antibody point of care (POC) and nucleic acid assays for suspected COVID-19 disease due to either wild type or the D614G spike mutant SARS-CoV-2. The overall detection rate for COVID-19 is 79.2% (95CI 57.8-92.9%) by rapid NAAT alone. Combined point of care antibody test and rapid NAAT is not impacted by D614G and results in very high sensitivity for COVID-19 diagnosis with very high specificity

SARS-CoV-2 B.1.617.2 Delta variant replication and immune evasion

Abstract: The B.1.617.2 (Delta) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first identified in the state of Maharashtra in late 2020 and spread throughout India, outcompeting pre-existing lineages including B.1.617.1 (Kappa) and B.1.1.7 (Alpha)1. In vitro, B.1.617.2 is sixfold less sensitive to serum neutralizing antibodies from recovered individuals, and eightfold less sensitive to vaccine-elicited antibodies, compared with wild-type Wuhan-1 bearing D614G. Serum neutralizing titres against B.1.617.2 were lower in ChAdOx1 vaccinees than in BNT162b2 vaccinees. B.1.617.2 spike pseudotyped viruses exhibited compromised sensitivity to monoclonal antibodies to the receptor-binding domain and the amino-terminal domain. B.1.617.2 demonstrated higher replication efficiency than B.1.1.7 in both airway organoid and human airway epithelial systems, associated with B.1.617.2 spike being in a predominantly cleaved state compared with B.1.1.7 spike. The B.1.617.2 spike protein was able to mediate highly efficient syncytium formation that was less sensitive to inhibition by neutralizing antibody, compared with that of wild-type spike. We also observed that B.1.617.2 had higher replication and spike-mediated entry than B.1.617.1, potentially explaining the B.1.617.2 dominance. In an analysis of more than 130 SARS-CoV-2-infected health care workers across three centres in India during a period of mixed lineage circulation, we observed reduced ChAdOx1 vaccine effectiveness against B.1.617.2 relative to non-B.1.617.2, with the caveat of possible residual confounding. Compromised vaccine efficacy against the highly fit and immune-evasive B.1.617.2 Delta variant warrants continued infection control measures in the post-vaccination era

Age-related immune response heterogeneity to SARS-CoV-2 vaccine BNT162b2

Abstract: Although two-dose mRNA vaccination provides excellent protection against SARS-CoV-2, there is little information about vaccine efficacy against variants of concern (VOC) in individuals above eighty years of age1. Here we analysed immune responses following vaccination with the BNT162b2 mRNA vaccine2 in elderly participants and younger healthcare workers. Serum neutralization and levels of binding IgG or IgA after the first vaccine dose were lower in older individuals, with a marked drop in participants over eighty years old. Sera from participants above eighty showed lower neutralization potency against the B.1.1.7 (Alpha), B.1.351 (Beta) and P.1. (Gamma) VOC than against the wild-type virus and were more likely to lack any neutralization against VOC following the first dose. However, following the second dose, neutralization against VOC was detectable regardless of age. The frequency of SARS-CoV-2 spike-specific memory B cells was higher in elderly responders (whose serum showed neutralization activity) than in non-responders after the first dose. Elderly participants showed a clear reduction in somatic hypermutation of class-switched cells. The production of interferon-γ and interleukin-2 by SARS-CoV-2 spike-specific T cells was lower in older participants, and both cytokines were secreted primarily by CD4 T cells. We conclude that the elderly are a high-risk population and that specific measures to boost vaccine responses in this population are warranted, particularly where variants of concern are circulating

Complement lectin pathway activation is associated with COVID-19 disease severity, independent of MBL2 genotype subgroups

IntroductionWhile complement is a contributor to disease severity in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, all three complement pathways might be activated by the virus. Lectin pathway activation occurs through different pattern recognition molecules, including mannan binding lectin (MBL), a protein shown to interact with SARS-CoV-2 proteins. However, the exact role of lectin pathway activation and its key pattern recognition molecule MBL in COVID-19 is still not fully understood.MethodsWe therefore investigated activation of the lectin pathway in two independent cohorts of SARS-CoV-2 infected patients, while also analysing MBL protein levels and potential effects of the six major single nucleotide polymorphisms (SNPs) found in the MBL2 gene on COVID-19 severity and outcome.ResultsWe show that the lectin pathway is activated in acute COVID-19, indicated by the correlation between complement activation product levels of the MASP-1/C1-INH complex (p=0.0011) and C4d (p<0.0001) and COVID-19 severity. Despite this, genetic variations in MBL2 are not associated with susceptibility to SARS-CoV-2 infection or disease outcomes such as mortality and the development of Long COVID.ConclusionIn conclusion, activation of the MBL-LP only plays a minor role in COVID-19 pathogenesis, since no clinically meaningful, consistent associations with disease outcomes were noted

Cognitive and educational outcomes at 11 years following extremely preterm birth

Aims: To assess cognitive ability, academic attainment and special educational needs (SEN) in extremely preterm children at 11 years

Neurodevelopmental disability through 11 years of age in children born before 26 weeks of gestation

Background: To assess functional disability in children born before 26 weeks of gestation at 11 years of age and the stability of findings in individuals between 6 and 11 years of age. Methods: Of 307 surviving children born in 1995, 219 (71%) were assessed at 11 years of age alongside 153 classmates. Children were evaluated by using standardized tests of cognitive ability and clinical condition at both ages. Results: Using classmate data to determine reference ranges, serious cognitive impairment (score of less than -2 SD) was present in 40% of extremely preterm children and 1.3% of classmates (odds ratio [OR]: 50 [95% confidence interval (CI): 12-206]) at 11 years of age. Overall, 38 (17%) extremely preterm children had cerebral palsy; moderate or severe impairment of neuromotor function, vision, and hearing was present in 10%, 9%, and 2% of these children, respectively. Combining impairment across domains, 98 (45%) extremely preterm children had serious functional disability compared with 1% of the classmates (OR: 61 [95% CI: 15-253]); this was more common in boys than girls (OR: 1.8 [95% CI: 1.0-3.1]) and in those born at 23 or 24 weeks' gestation compared with those born at 25 weeks' gestation (OR: 1.8 [95% CI: 1.0-3.1]). The prevalence of serious functional disability was 46% at 6 years of age and 45% at 11 years of age. Using multiple imputation to correct for selective dropout, it is estimated that 50% (95% CI: 44%-57%) of extremely preterm children are free of serious disability at 11 years of age. Conclusions: Extremely preterm children remain at high risk for neurodevelopmental disability at 11 years of age compared with term peers. The prevalence of disability remained stable between 6 and 11 years of age, and large individual shifts in classification of disability were unusual. Pediatrics 2009; 124: e249-e25