Elsevier

Resuscitation

Volume 85, Issue 8, August 2014, Pages 1072-1076
Resuscitation

Clinical Paper
Changes over time in delivery room management of extremely low birth weight infants in Italy

https://doi.org/10.1016/j.resuscitation.2014.04.024Get rights and content

Abstract

Aim

To identify changes in practice between two historical periods (2002 vs. 2011) in early delivery room (DR) management of ELBWI in Italian tertiary centres.

Methods

A questionnaire was sent to the directors of all Italian level III centres between April and August 2012. The same questionnaire was used in a national survey conducted in 2002. Among the participating centres, those that filled the questionnaire in both study periods were selected for inclusion in this study.

Results

There was an 88% (n = 76/86) and 92% (n = 98/107) response rate in the 2 surveys, respectively. The two groups overlapped for 64 centres. During the study period, the use of polyethylene bags/wraps increased from 4.7% to 59.4% of the centres. The units using 100% oxygen concentrations to initiate resuscitation of ELBWI decreased from 56.2% to 6.2%. The approach to respiratory management was changed for the majority of the examined issues: positive pressure ventilation (PPV) administered through a T-piece resuscitator (from 14.0% to 85.9%); use of PEEP during PPV (from 35.9% to 95.3%); use of CPAP (from 43.1% to 86.2%). From 2002 to 2011, the percentages of ELBWI intubated in DR decreased in favor of those managed with N-CPAP; ELBWI receiving chest compressions and medications at birth were clinically comparable.

Conclusions

During the two study periods, the approach to the ELBWI at birth significantly changed. More attention was devoted to temperature control, use of oxygen, and less-invasive respiratory support. Nevertheless, some relevant interventions were not uniformly followed by the surveyed centres.

Introduction

Approximately 5–10% of newborns require some assistance to begin breathing at birth; about 3% are managed with positive pressure ventilation (PPV) and less than 1% requires extensive resuscitative measures; these percentages noticeably rise when referred to preterm infants.1, 2, 3

Some interventions, such as the use of polyethylene/polyurethane wrapping,4, 5 titrating inspiratory fraction of oxygen,6 and the use of non-invasive ventilation have been recently evaluated in prospective randomized clinical trials.7 An increasing body of evidence suggests that these interventions in the delivery room (DR) management of extremely low birth weight infants (ELBWI) may have a direct influence on the immediate survival and also on long-term morbidity.3, 8, 9 Therefore, the general outcome might be improved throughout a structured and well coded approach starting from the first minutes of life.

International clinical guidance describes a standardized approach to newborn resuscitation in the DR and national clinical algorithms are guided by these consensus statements.1, 10, 11 However, a few large studies have examined the consistency of practice and the adherence to the International Guidelines in early DR management.11, 12, 13, 14, 15

In 2002, we conducted a survey on the approach to neonatal resuscitation of ELBWI at the Italian level III centres.15 The data showed that the DR management of these infants was very different across the Italian tertiary centres, reflecting a paucity of evidence and consequent uncertainty among clinicians.

Since then, two iterations of the International Liaison Committee on Resuscitation (ILCOR) guidelines for neonatal resuscitation have been released, the most recent of which in 2010.1, 16 In these versions, the body of recommendations devoted to neonatal resuscitation of ELBWI has been progressively increasing.

In 2012, we conducted a second national survey in order to verify the compliance of level III centres with the new guidelines.

To obtain a reliable comparison in overall attitude over time, we focused on those centres that participated in both surveys. Our aim was to identify changes in early DR management of ELBWI in Italy over a period of approximately ten years (2002–2011).

Section snippets

Participants and evaluation instrument

A structured 73 item questionnaire in Italian and an accompanying introductory letter were sent by email to the directors of the 107 Italian level III centres provided with on site delivery (Italian Society of Neonatology database). A reminder was sent to non responders every 2 weeks for a maximum of three times. At that point, if we had not received an answer yet, the participant was contacted by phone by an investigator (IS) and a new email was sent.

Participation was entirely voluntary. The

Results

A total response rate of 87% (n = 76/86) and 92% (n = 98/107) was obtained for the first (2002) and second (2011) historical period, respectively.

Discussion

This study explores the changes in ELBWI management at birth in Italian tertiary centres during a period of ten years.

Our data show that many of the new recommendations from the International Guidelines for Neonatal Resuscitation, especially those regarding respiratory management and monitoring, have been implemented by a large number of units during the two study periods.

This improvement could be explained by some factors: (a) DR care for preterm infants has received little attention in

Conclusions

In conclusion, our study is the first to assess the consistency of practice and the adherence to the International Guidelines in early DR management of ELBWI over time. During the two study periods, the approach to the ELBWI at birth significantly changed suggesting a good compliance with the International Guidelines for Neonatal Resuscitation. More attention was devoted to temperature control, use of oxygen, and less-invasive respiratory support. The availability of new evidence based

Contributors

DT conceived and designed the study. He drafted the initial manuscript, revised it for important intellectual content, and approved the final manuscript as submitted. IS and ND prepared the questionnaire and sent it to the Centres, contributed to interpretation of data, revised the manuscript and approved the final manuscript as submitted. GC, FC carried out the analyses, contributed to interpretation of data, revised the manuscript and approved the final manuscript as submitted. CG, CM, FC,

Conflict of interest statement

None.

Funding

The project was done with no specific support.

Acknowledgements

We acknowledge Dr Matteo Parotto for revising the manuscript, and the heads of the participating centres for their assistance with this survey.

References (23)

  • D. Trevisanuto et al.

    Oxygen administration for the resuscitation of term and preterm infants

    J Matern Fetal Neonatal Med

    (2012)
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