Colm Patrick Finbarr Odonnell

Objective: To evaluate enteral feeding practices in preterm infants in neonatal intensive care units (NICUs) in high-income countries across three continents, and compare results with a similar survey 13 years earlier. Methods: Web-based survey distributed to neonatologists at 258 NICUs across 15 countries in Europe, Australia, New Zealand and Canada, October 2023 and February 2024. Survey domains focused on availability of human milk, onset of enteral feeding, breast milk fortification (BMF), cytomegalovirus (CMV) screening and enteral supplements including probiotics. Results were compared with a similar survey performed in 2010. Results: Replies were received from 185 (72%) NICUs. Access to donor human milk (DHM) was high (91%). Across all NICUs, feeds were started on day 1 in 64%, 73% and 85% among infants born <25, 25–27 and 28–31 weeks’ gestation, respectively. Bovine milk-based BMF was routinely used in 88% of NICUs, with large variation in when it was commenced and discontinued. Routine use of human milk-based BMF was uncommon (4%). Maternal CMV status was routinely determined in 33% of all NICUs who then pasteurised or froze milk if the mother was CMV-seropositive. Probiotics were provided in 66% of the NICUs, with large variations in products and birth weight/gestational age criteria. Conclusions: Compared with our survey from 2010, more NICUs now start feeding preterm infants on day 1, and DHM availability has increased in some countries. Substantial variation remains in the use of BMF, probiotics and CMV screening. A stronger evidence base is needed to update guidelines, aiming ultimately to improve growth and long-term neurodevelopment.

Introduction Intubation is most often performed electively by anaesthetists in controlled conditions in operating theatres. In neonates, however, it is most often performed by neonatologists or paediatricians in urgent circumstances in the neonatal intensive care unit (NICU) or delivery room (DR). Neonatal intubation is a difficult skill to learn and maintain, and success rates are suboptimal both in the NICU and DR. Video laryngoscopy (VL) has the potential to increase intubation success and safety as it may offer a better view of the airway, which can be shared by the intubator and other clinicians. Objectives To compare the efficacy and safety of using VL to direct laryngoscopy (DL) for intubation of neonates in the NICU and DR. Search methods We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL up to August 2024 without language restrictions. Selection criteria Randomised controlled trials (RCTs), quasi‐RCTs, cluster‐RCTs or cross‐over trials that compared VL to DL for intubation of neonates outside of the neonatal operating theatre. Main results VL improves first attempt intubation success rates, 849 intubations (RR 1.46, 95% CI 1.21 to 1.75), with a number needed to treat (NNT) of 6. Conclusions VL improves intubation success rates without increasing adverse events and should be the standard of care for neonatal intubations in the NICU and DR.

Objective To determine survival and neurodevelopmental outcomes in the Hypotension in Preterm (HIP) trial. Design Prospective follow-up of infants enrolled in randomised controlled trial. Participants 58 infants born before 28 weeks of gestation with low mean arterial blood pressure. Intervention Random allocation to treatment of low blood pressure values with infusion of dopamine or placebo. Primary outcome Survival without neurodevelopmental impairment to 24 months corrected age (CA). Results The HIP trial stopped early due to logistic and recruitment difficulties. Outcomes were determined for 55 infants (27 in the dopamine group and 28 in the placebo group) at 24 months CA. Survival without impairment was present in 13 (48%) infants in the dopamine group and 7 (25%) infants in the placebo group (OR 2.79 (95% CI 0.89, 8.72); p=0.078). The components of the primary outcome were similarly distributed between the two arms. Mean Bayley composite scores and the frequency of somatic impairments did not differ significantly between groups but infants were shorter and lighter at 2 years of age after dopamine administration. Conclusion In this placebo-controlled trial of the treatment of hypotension in extremely preterm infants, dopamine administration did not increase survival without impairment at 2 years CA. However, the study was not sufficiently powered and a clinically important effect cannot be excluded. The role of inotropic medication in facilitating good outcomes requires further study.

Background The Neonatal Resuscitation Program recommends direct laryngoscopy (DL) as the primary method for neonatal intubation. Video laryngoscopy (VL) is suggested as an option, particularly for training novice operators or for intubating infants with difficult airways. The programme outlines specific steps for intubation, including managing the external environment and techniques for visualising key anatomical landmarks. It is unclear whether the DL method can be effectively applied to VL. Objectives To determine the degree of adherence to resuscitation guidelines during intubation using VL, and to examine the relationship between guideline adherence and intubation success. Methods In a cohort of newborn infants who were intubated with VL, we simultaneously recorded the view obtained with the video laryngoscope and an external view of the procedure with a GoPro video camera, and synchronised the recordings for analysis. In each set of recordings, we assessed infant and operator positions, interventions during the procedure, and the anatomical landmarks visualised. Results We assessed 95 intubation attempts in 57 infants (median corrected gestational age: 28 weeks; median weight: 1160 g). Sixty-six of these attempts (69%) were successful. Operators spent more time attempting to insert the endotracheal tube through a visible glottis than locating it. Sixty-six (69%) attempts were performed with an appropriate lift manoeuvre. The vocal cords were visualised in only 58 (61%) attempts, while the glottis was seen in 85 (89%). Conclusions Neonatal intubation using VL differed from the technique recommended in resuscitation guidelines. Revised guidelines considering the use of VL may be warranted.

Gaining and maintaining proficiency at endotracheal intubation is challenging. Recent clinical trials suggest videolaryngoscopy is beneficial for teaching inexperienced clinicians to intubate newborn infants, but may take longer compared to standard laryngoscopy. Preferences for devices among clinicians are unclear. Simulation studies using manikins have shown that use of videolaryngoscopes (VLs) likely improves intubation outcomes, at least in the short term. This study is the first to compare different VLs and SL as they are designed in clinicians with varying levels of experience in term and preterm manikins. This setup more closely mimics real-life clinical practice in comparison to trials exclusively of novices or using VL devices to intubate directly. Our study is relevant to members of the perinatal and neonatal clinical care team and related to using technology to improve neonatal outcomes. It is of particular importance in the current environment of reduced opportunities to learn and maintain neonatal intubation skills due to changes in neonatal practice and clinical care.

Objective Regarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might be improved. Design and intervention International online survey. Results Replies were received from 560 NICUs in 24 countries between January and May 2023. LU uptake varied considerably (20%–98% of NICUs) between countries. In 428 units (76%), LU was used for clinical indications, while 34 units (6%) only used it for research purposes. One-third of units had 5 years of experience. LU was mainly performed by neonatologists. LU was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%). The main pathologies diagnosed by LU were pleural effusion, pneumothorax, transient tachypnoea of the newborn and respiratory distress syndrome. The main barriers for implementation were lack of experience with technical aspects and/or image interpretation. Most units indicated that specific courses and an international guideline on neonatal LU could promote uptake of this technique. Conclusions Although LU has been adopted in neonatal care in most European countries, the uptake is highly variable. The main indications are diagnosis of lung disease, evaluation of acute clinical deterioration and guidance of surfactant. Implementation may be improved by developing courses and publishing an international guideline.

Importance: Preterm newborns at risk of respiratory distress syndrome are supported with continuous positive airway pressure (CPAP). Many newborns worsen despite CPAP and are intubated for surfactant administration, an effective therapy for treatment of respiratory distress syndrome. Endotracheal intubation is associated with adverse effects. Pharyngeal administration of surfactant to preterm animals and humans has been reported as an alternative.Objective: To assess whether giving prophylactic oropharyngeal surfactant to preterm newborns at birth would reduce the rate of intubation for respiratory failure.Design, Setting, and Participants: This unblinded, parallel-group randomized clinical trial (Prophylactic Oropharyngeal Surfactant for Preterm Infants [POPART]) was conducted from December 17, 2017, to September 11, 2020, at 9 tertiary neonatal intensive care units in 6 European countries. Newborns born before 29 weeks of gestation without severe congenital anomalies, for whom intensive care was planned, were eligible for inclusion. The data were analyzed from July 27, 2022, to June 20, 2023.Intervention: Newborns were randomly assigned to receive oropharyngeal surfactant at birth in addition to CPAP or CPAP alone. Randomization was stratified by center and gestational age (GA).Main Outcomes and Measures: The primary outcome was intubation in the delivery room for bradycardia and/or apnea or in the neonatal intensive care unit for prespecified respiratory failure criteria within 120 hours of birth. Caregivers were not masked to group assignment.Results: Among 251 participants (mean [SD] GA, 26 [1.5] weeks) who were well matched at study entry, 126 (69 [54.8%] male) with a mean (SD) birth weight of 858 (261) grams were assigned to the oropharyngeal surfactant group, and 125 (63 [50.4%] male) with a mean (SD) birth weight of 829 (253) grams were assigned to the control group. The proportion of newborns intubated within 120 hours was not different between the groups (80 [63.5%) in the oropharyngeal surfactant group and 81 [64.8%] in the control group; relative risk, 0.98 [95% CI, 0.81-1.18]). More newborns assigned to the oropharyngeal surfactant group were diagnosed with and treated for pneumothorax (21 [16.6%] vs 8 [6.4%]; P = .04).Conclusions and Relevance: This randomized clinical trial found that administration of prophylactic oropharyngeal surfactant to newborns born before 29 weeks’ GA did not reduce the rate of intubation in the first 120 hours of life. These findings suggest that administration of surfactant into the oropharynx immediately after birth in addition to CPAP should not be routinely used.Trial Registration: EudraCT: 2016-004198-41