Kill them with kindness

Kill them with kindness

These were the words spoken to me when I was a medical student doing an elective rotation in maternal fetal medicine at Mt. Sinai hospital in Toronto in 1997.  Setting aside your surprise that I once wanted to be an Obstetrician (yes it’s true), I should put in context the situation that I heard this career changing advice.  The service I was on was intense.  Intense in the sense that some of the attendings were quite demanding and in their endless pursuit of excellence in care demanded a great deal from the medical students, residents and fellows around them.  While I don’t remember the name of the fellow I was working with any longer, I do recall the verbal abuse she took on a daily basis likely from some misguided notion that since the attending had to endure such humiliation during training others should have to experience such joy themselves.  After one such encounter, I had the opportunity to go for a coffee with my fellow and I took the opportunity to learn her coping mechanisms.

“Kill Them With Kindness”

You see this was no ordinary fellow.  No matter how much verbal abuse was hurled her way she smiled at the attending and asked what she could do to resolve whatever shortcoming was pointed out to her.  She never seemed upset (although on the inside I can’t imagine how she couldn’t) but kept her composure.  When I asked her how she endured the daily grind all she said were those four words.  I was very curious about this strategy.  It seemed to me that she was enabling such behaviour and quite honestly in this era of medicine I have my doubts that the attending could get away with it.  Having said that while it might not be so dramatic these days, it does happen but to a lesser degree.  She explained to me that she believed that when you are consistently nice to someone even in the face of aggression they have no choice but to settle down.  As she put it, staying angry in the face of someone who is smiling and thanking you sincerely for your input is difficult even for the most aggressive types.  I suppose it is similar to a someone who is teasing you, stopping when they see they can’t get a rise out of you.  I really took what she said to heart and built my career around this principle.

The Power of the Word Please

A funny thing happened today which really is what triggered this memory for me.  One of our nurses chose to write a verbal order for me.  She started the verbal order off with “please”.  When I saw the start of the order I laughed and said that is the way I would have written it and she told me she knew as that is how I usually start my orders!  It is sincere and not meant to be a trick but I think I owe it in part to that fellow from many years ago who taught me to “kill them with kindness”.  My use of the word please which I realize now I use more often than not might seem odd but I think it sends a message of respect.  An order should be followed but perhaps the word please is a way of saying “I realize you are busy but if you could do this I would appreciate it!”  In the end we are a team and putting a little niceness into our daily routine can go a long way.

No Place For Rudeness

In a RCT designed to measure the impact of rudeness, medical teams were given a case to manage in a simulation exercise.  The case was of a preterm infant now 23 days old with symptoms of NEC.  Half the group met with a visitor who claimed to have observed such teams in their country before and in the rude environment made a disparaging comment about the past performance of the other teams. In the other group he simply mentioned he had observed other teams without commenting about their lack of skill.  Simply planting the seed that previous performance of a similar team had been poor had damaging effects on team performance as shown below.  Each  item was rated from 1 = fail to 5 = excellent.

rudeness

As you can see on many domains, team performance was impacted and in a significant way.  Imagine how powerful more overt rudeness can be and damaging to the confidence and performance of the trainees and teams around you!

Let’s Get It Right

It’s July and that means there is a new crop of residents and fellows starting their journey towards becoming independent practitioners.  This isn’t simulation anymore, this is the big leagues and they are working on real patients at risk of real adverse outcomes.  Imagine if you will if the performance in the simulation above translated into poor performance in the hospital!  We do our best to teach these “green” trainees the right way to do things but no amount of information will do them any good if we kill their confidence.  Life as a new trainee is stressful enough.  Can’t we all do a little to make things just a bit easier?

Yes it can be frustrating when they miss something important and yes that can have a consequence to patient care but if we want to minimize the greater risk to the patient population couldn’t we all do a little more to “Kill them with kindness” and say “please” from time to time?

 

No more intubating for meconium? Not quite.

No more intubating for meconium? Not quite.

After the recent CPS meeting I had a chance to meet with an Obstetrical colleague and old friend in Nova Scotia.  It is easy to get lost in the beauty of the surroundings which we did. Hard to think about Neonatology when visits to places like Peggy’s Cove are possible. IMG_0416Given out mutual interest though in newborns our our conversation eventually meandered along the subject of the new NRP.  What impact would the new recommendations with respect to meconium have on the requirements for providers at a delivery.  This question gave me reason to pause as I work in a level III centre and with that lens tend to have a very different perspective than those who work in level I and II centres (I know we don’t label them as such anymore but for many of you that has some meaning).  Every delivery that is deemed high risk in our tertiary centre has ready access to those who can intubate so the changes in recommendations don’t really affect our staffing to any great degree.  What if you are in a centre where the Pediatrician needs to be called in from home?  Do you still have to call in people to prepare for a pending delivery of a baby through meconium stained fluid?

What does the new recommendation actually say?NRP Logo_full.jpeg

These recommendations are from the American Heart Association and are being adopted by the NRP committees in the US and Canada.  The roll-out for this change is coming this fall with all courses required to teach the new requirements as of September 2017.

“However, if the infant born through meconium-stained amniotic fluid presents with poor muscle tone and inadequate breathing efforts, the initial steps of resuscitation should be completed under the radiant warmer. PPV should be initiated if the infant is not breathing or the heart rate is less than 100/min after the initial steps are completed. Routine intubation for tracheal suction in this setting is not suggested, because there is insufficient evidence to continue recommending this practice. (Class IIb, LOE C-LD)

The rationale for the change is that is that there is a lack of evidence to demonstrate that routine suctioning will reduce the incidence of meconium aspiration syndrome and its consequences.  Rather priority is placed on the establishment of adequate FRC and ventilation thereby placing a priority on teaching of proper bag-valve mask or t-piece resuscitator.  Better to establish ventilation than delay while atempting to intubate and run the risk of further hypoxia and hypercarbia causing pulmonary hypertension.

Does this mean you don’t need to have a person skilled in intubation at such deliveries?

This question is the real reason for the post.  At least from my standpoint the answer is that you do in fact still require such people.  This may seem to be in conflict with the new position but if you move past that recommendation above you will see there is another line that follows afterwards that is the basis for my argument.

“Appropriate intervention to support ventilation and oxygenation should be initiated as indicated for each individual infant. This may include intubation and suction if the airway is obstructed.”

While we should not routinely perform such intubations there may be a time and a place.  If one has intiated PPV with a mask and is not obtaining a rising heart rate, MRSOPA should be followed and attempts made to optimize ventilation.  What if that is unsuccessful though and heart rate continues to be poor.  You could have a plug of meconium distal to the vocal cords and this is the reason that intubation should be considered.  In order to remove such a plug one would need to have an intubator present.

Where do we go from here?

As much as I would like to tell my colleague that he doesn’t need to have this skill set at a delivery for meconium I am afraid the skill still needs to be present.  It will be interesting to see how instructors roll this out and answer such questions.  It is a little concerning to me that in our world of wanting the “skinny” or “Coles’ Notes” version of things, the possibility of still needing the intubator on short notice may be lost.  Having someone on call who is only “5 minutes away” may seem to be alright but at 3 AM I assure you the 5 minutes will become 15 as the person is woken, dresses, gets to the car and parks.  Whether it is 5 or 15 minutes each centre needs to ask themselves if the baby is in need of urgent intubation are you willing to wait that amount of time for that to happen?

I hope not.

A little cream may go a long way in reducing BPD

A little cream may go a long way in reducing BPD

 

Breast milk has many benefits and seems to be in the health care news feeds almost daily.  As the evidence mounts for long term effects of the infant microbiome, more and more centres are insisting on providing human milk to their smallest infants.  Such provision significantly reduces the incidence of NEC, mortality and length of stay.  There is a trade-off though in that donor milk after processing loses some of it’s benefits in terms of nutritional density.  One such study demonstrated nutritional insufficiencies with 79% having a fat content < 4 g/dL, 56% having protein content< 1.5 g/dL, and 67% having an energy density < 67 kcal/dL (< 20 Kcal/oz).  It is for this reason that at least in our unit many infants on donor milk ultimately receive a combination of high fluid volumes, added beneprotein or cow’s milk powders to achieve adequate caloric intake.  Without such additions, growth failure ensues.  Such growth failure is not without consequence and will be the topic of a future post.  One significant concern however is that failure of our VLBW infants to grow will no doubt impact the timing of discharge as at least in our unit, babies less than 1700g are unlikely to be discharged.  With the seemingly endless stream of babies banging on the doors of the NICU to occupy a bed, any practice that leads to increasing lengths of stay will no doubt slow discharge and cause a swelling daily patient census.

What if increasing volume was not an option?

Such might be the case with a baby diagnosed with BPD.  Medical teams are often reluctant to increase volumes in these patients due to concerns of water retention increasing respiratory support and severity of the condition.  While diuretics have not been shown to be of long term benefit to BPD they continue to be used at times perhaps due to old habits or anecdotal experiences by team members of a baby who seemed to benefit.  Such use though is not without it’s complications as the need to monitor electrolytes means more needle sticks for these infants subjecting them to painful procedures that they truly don’t need.  Alternatively, another approach is to restrict fluids but this may lead to hunger or create little room to add enough nutrition again potentially compromising the long term health of such infants.

Amy Hair and colleagues recently published the following study which takes a different approach to the problem Premature Infants 750–1,250 g Birth Weight Supplemented with a Novel Human Milk-Derived Cream Are Discharged Sooner

This paper is essentially a study within a study.  Infants taking part in an RCT of Prolacta cream (Prolacta being the subject of a previous post) were randomized as well to a cream supplement vs no cream.  The cream had a caloric density of 2.5 Kcal/mL and was added to donor milk or mother’s own milk when the measured caloric density was less than 19 Kcal/oz.  The study was small (75 patients; control 37, cream 38) which should be stated upfront and as it was a secondary analysis of the parent study was not powered to detect a difference in length of stay but that was what was reported here.  The results for the groups overall were demonstrated an impact in length of stay and discharge with the results shown below.

Control  (N=37) Cream (N=38) p
PDA ligation % 8.1 2.6 0.36
PDA treated medically % 27 29 0.85
Sepsis % 5.4 7.9 1
NEC% 0 0
BPD% 32.4 23.7 0.4
Death % 0 0
Length of stay, days 86+/-39 74+/-22 0.05
PMA at discharge, weeks 39.9+/-4.8 38.2+/-2.7 0.03

What about those with sensitivity to fluid?

Before we go into that let me state clearly that this group comparison is REALLY SMALL (control with BPD=12 vs cream with BPD=9).  The results though are interesting.

 

BPD control (N=12) BPD cream N=9 p
Length of stay, days 121 +/-49 104+/-23 0.08
PMA at discharge, weeks 44.2+/-6.1 41.3+/-2.7 0.08

So they did not reach statistical significance yet one can’t help but wonder what would have happened if the study had been larger or better yet the study was a prospective RCT examining the use of cream as a main outcome.  That of course is what no doubt will come with time.  I can’t help but think though that the results have biologic plausibility.  Providing better nutrition should lead to better growth, enhanced tissue repair and with it earlier readiness for discharge.

One interesting point here is that the method that was used to calculate the caloric density of milk was found to overestimate the density by an average of 1.2 Kcal/oz when the method was compared to a gold standard.  Given that fortification with cream was only to be used if the caloric density of the milk fell below 19 Kcal/oz where average milk caloric density is 20 Kcal/oz there is the distinct possibility that the eligible infants for cream were underestimated.  Could some of the BPD be attributable to infants being significantly undernourished in the control group as they actually were receiving <19 Kcal/oz but not fortified?  Could the added fortification have led to faster recovery from BPD?

Interesting question’s in need of answers.  I look forward to seeing where this goes.  I suspect that donor milk is not enough, adding a little cream may be needed for some infants especially those who have trouble tolerating cow’s milk fortification.

Parental stress in the NICU; effect of parental presence on rounds.

Parental stress in the NICU; effect of parental presence on rounds.

To many of you the answer is a resounding yes in that it reduces stress.  Why is that though?  Is it because you have had a personal experience that has been favourable, it is the practice in your unit or it just seems to make sense?  It might come as a surprise to you who have followed this blog for some time that I would even ask the question but a social media friend of mine Stefan Johansson who runs 99NICU sent an article my way on this topic. Having participated in the FiCare study I realised that  I have a bias in this area but was intrigued by the title of the paper.  The study is Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion by Abdel-Latif ME et al from New Zealand and was performed due to the lack of any RCTs on the subject specifically in the NICU.

Before I go on though I have to disclose a few biases.

  1.  I love parents being on rounds so I can speak with them directly and have them ask me any questions they may have after hearing about their infants condition.
  2. Our unit encourages the practice.
  3. We are rolling out the principles of FiCare after being part of the study which encourages parental presence at the bedside for far more than just rounds.For information on implementing FiCare click here
  4. While this study is the only reported RCT on the subject in the NICU, the FiCare results will be published before long.

What is the problem with having families on rounds?

The detractors would say that sensitive information may be more difficult to discuss out in the open for fear that the family will take offence or be hurt.  Another concern may be that teaching will be affected as the attending may not want to discuss certain aspects of care in order to prevent creating fear in the parents or awkwardness in the event that the management overnight was not what they would have done.  Lastly, when patient volumes and acuity are high, having parents ask questions on rounds may lead to excessive duration of this process and lead to fatigue and frustration by all members of the team.

So what does this study add?

This particular study enrolled 72 families of which 63 completed the study.  The study required 60 families to have enough power to detect the difference in having parents on rounds or not.The design was interesting in that the randomisation was a cross over design in which the following applied.  One arm was having parents on rounds and the other without.  The unit standard at the time was to not have parents on rounds.

≤30 weeks 1 week in one arm, one week washout period then one week in the other arm

>30 weeks 3 days in one arm, three day washout and then three days in the other arm

The primary outcome was to see if there would be a significant difference in the Parental Stressor Scale.  table 3

Surprisingly there was no difference across any domains of measuring parental stress.  When we look at questions though pertaining to communication in the NICU we see some striking differences.

Table 2

The families see many benefits to the model of being on rounds.  They appear to have received more information, more contact with the team, contributed more to the planning of the course of their babies care and been able to ask more questions.  All of these things would seem to achieve the goals of having parents on rounds.

So why aren’t parents less stressed?

This to me is the most interesting part of this post.  The short answer is I am not sure but I have a few ideas.

  1.  The study could not be blinded.  If the standard of care in the unit was to not have parents on rounds, what kind of conversations happened after rounds?  Were staff supportive of the families or were they using language that had a glass is half empty feel to it?  Much like I am biased towards having parents on rounds and thanking them for their participation were there any negative comments that may have been unintentional thrown the families way.
  2. Is a little knowledge a dangerous thing?  Perhaps as families learn more details about the care of their baby it gives them more things to worry about.  Could the increase in knowledge while in some ways being pleasing to the family be offset by the concern that new questions raise.
  3. Was the intervention simply too short to detect a difference?  This may have been a very important contributor.  This short period of either a week or two leaves the study open to a significant risk that an event in either week could acutely increase stress levels.  What if the infant had to go back on a ventilator after failing CPAP, needed to be reloaded with caffeine or developed NEC?  With such short intervals one cannot say that while communication was better the parents were not stressed due to something unrelated to communication.  In an RCT these should balance out but in such a small study I see this as a significant risk.

So where do we go from here?

I applaud the authors for trying to objectively determine the effect of parental presence on rounds in the NICU.  Although I think they did an admirable job I believe the longer time frame of the FiCare study and the cluster randomised strategy using many Canadian centres will prove to be the better model to determine effectiveness.  What the study does highlight though in a very positive way is that communication is enhanced by having parents on rounds and to me that is a goal that is well worth the extra time that it may take to get through rounds.  Looking at it another way, we as the Neonatologists may need to spend less time discussing matters after rounds as we have taken care of it already.  In the end it may be the most efficient model around!

 

A Model For Reducing Parental Stress in the NICU.

A Model For Reducing Parental Stress in the NICU.

A good idea that is for sure and stress may be what the infant in the picture is displaying as a reflection of what her parents are feeling!  A growing trend is to include parents in rounds and that is the subject of this piece?  It sounds like a great idea and may feel that way as you have had a personal experience that has been favourable, is the practice in your unit or it just seems to make sense?  It might come as a surprise to you who have followed this blog for some time that I would even ask the question but a social media friend of mine Stefan Johansson who runs 99NICU sent an article my way on this topic. Having participated in the FiCare study I realised that  I have a bias in this area but was intrigued by the title of the paper.  The study is Parental presence on neonatal intensive care unit clinical bedside rounds: randomised trial and focus group discussion by Abdel-Latif ME et al from New Zealand and was performed due to the lack of any RCTs on the subject specifically in the NICU.

Before I go on though I have to disclose a few biases.

  1.  I love parents being on rounds so I can speak with them directly and have them ask me any questions they may have after hearing about their infants condition.
  2. Our unit encourages the practice.
  3. We are rolling out the principles of FiCare after being part of the study which encourages parental presence at the bedside for far more than just rounds.For information on implementing FiCare click here
  4. While this study is the only reported RCT on the subject in the NICU, the FiCare results will be published before long.

What is the problem with having families on rounds?

The detractors would say that sensitive information may be more difficult to discuss out in the open for fear that the family will take offence or be hurt.  Another concern may be that teaching will be affected as the attending may not want to discuss certain aspects of care in order to prevent creating fear in the parents or awkwardness in the event that the management overnight was not what they would have done.  Lastly, when patient volumes and acuity are high, having parents ask questions on rounds may lead to excessive duration of this process and lead to fatigue and frustration by all members of the team.

So what does this study add?

This particular study enrolled 72 families of which 63 completed the study.  The study required 60 families to have enough power to detect the difference in having parents on rounds or not.The design was interesting in that the randomisation was a cross over design in which the following applied.  One arm was having parents on rounds and the other without.  The unit standard at the time was to not have parents on rounds.

≤30 weeks 1 week in one arm, one week washout period then one week in the other arm

>30 weeks 3 days in one arm, three day washout and then three days in the other arm

The primary outcome was to see if there would be a significant difference in the Parental Stressor Scale.  table 3

Surprisingly there was no difference across any domains of measuring parental stress.  When we look at questions though pertaining to communication in the NICU we see some striking differences.

Table 2

The families see many benefits to the model of being on rounds.  They appear to have received more information, more contact with the team, contributed more to the planning of the course of their babies care and been able to ask more questions.  All of these things would seem to achieve the goals of having parents on rounds.

So why aren’t parents less stressed?

This to me is the most interesting part of this post.  The short answer is I am not sure but I have a few ideas.

  1.  The study could not be blinded.  If the standard of care in the unit was to not have parents on rounds, what kind of conversations happened after rounds?  Were staff supportive of the families or were they using language that had a glass is half empty feel to it?  Much like I am biased towards having parents on rounds and thanking them for their participation were there any negative comments that may have been unintentional thrown the families way.
  2. Is a little knowledge a dangerous thing?  Perhaps as families learn more details about the care of their baby it gives them more things to worry about.  Could the increase in knowledge while in some ways being pleasing to the family be offset by the concern that new questions raise.
  3. Was the intervention simply too short to detect a difference?  This may have been a very important contributor.  This short period of either a week or two leaves the study open to a significant risk that an event in either week could acutely increase stress levels.  What if the infant had to go back on a ventilator after failing CPAP, needed to be reloaded with caffeine or developed NEC?  With such short intervals one cannot say that while communication was better the parents were not stressed due to something unrelated to communication.  In an RCT these should balance out but in such a small study I see this as a significant risk.

So where do we go from here?

I applaud the authors for trying to objectively determine the effect of parental presence on rounds in the NICU.  Although I think they did an admirable job I believe the longer time frame of the FiCare study and the cluster randomised strategy using many Canadian centres will prove to be the better model to determine effectiveness.  What the study does highlight though in a very positive way is that communication is enhanced by having parents on rounds and to me that is a goal that is well worth the extra time that it may take to get through rounds.  Looking at it another way, we as the Neonatologists may need to spend less time discussing matters after rounds as we have taken care of it already.  In the end it may be the most efficient model around!

 

High Flow Nasal Cannula: Be Careful Out There

High Flow Nasal Cannula: Be Careful Out There

As the saying goes the devil is in the details.  For some years now many centres worldwide have been publishing trials pertaining to high flow nasal cannulae (HFNC) particularly as a weaning strategy for extubation.  The appeal is no doubt partly in the simplicity of the system and the perception that it is less invasive than CPAP.  Add to this that many centres have found less nasal breakdown with the implementation of HFNC as standard care and you can see where the popularity for this device has come from.

This year a contact of mine Dominic Wilkinson@NeonatalEthics on twitter (if you don’t follow him I would advise having a look!) published the following cochrane review, High flow nasal cannula for respiratory support in preterm infants.  The review as with most cochrane systematic reviews is complete and comes to a variety of important conclusions based on 6 studies including 934 infants comparing use of HFNC to CPAP.

1.  No differences in the primary outcomes of death (typical RR 0.77, 95% CI 0.43 to 1.36; 5 studies, 896 infants) or CLD.

2.  After extubation to HFNC no difference in the rate of treatment failure (typical RR 1.21, 95% CI 0.95 to 1.55; 5 studies, 786 infants) or reintubation (typical RR 0.91, 95% CI 0.68 to 1.20; 6 studies, 934 infants).

3.  Infants randomised to HFNC had reduced nasal trauma (typical RR 0.64, 95% CI 0.51 to 0.79; typical risk difference (RD) -0.14, 95% CI -0.20 to -0.08; 4 studies, 645 infants).

4. Small reduction in the rate of pneumothorax (typical RR 0.35, 95% CI 0.11 to 1.06; typical RD -0.02, 95% CI -0.03 to -0.00; 5 studies 896 infants) in infants treated with HFNC but the RR crosses one so this may be a trend at best.

If one was to do a quick search for the evidence and found this review with these findings it would be very tempting to jump on the bandwagon.  Looking at the review a little closer though there is one line that I hope many do not miss and I was happy to see Dominic include it.

“Subgroup analysis found no difference in the rate of the primary outcomes between HFNC and CPAP in preterm infants in different gestational age subgroups, though there were only small numbers of extremely preterm and late preterm infants.”

In his conclusion he further states:

Further evidence is also required for evaluating the safety and efficacy of HFNC in extremely preterm and mildly preterm subgroups, and for comparing different HFNC devices.

With so few ELBW infants included and with these infants being at highest risk of mortality and BPD our centre has been reluctant to adopt this mode of respiratory support in the absence of solid evidence that it is equally effective to CPAP in these smallest infants.  A big thank you to our Respiratory Therapy Clinical Specialist for harping on this point over the years as the temptation to adopt has been strong as other centres turn to this strategy.

Might Not Be So Safe After All

Now do not take what I am about to say as a slight against my twitter friend.  The evidence to date points to exactly what he and his other coauthors concluded but with the release of an important paper in May by Taka DK et al, I believe caution is needed when it comes to our ELBW infants.

High Flow Nasal Cannula Use Is Associated with Increased Morbidity and Length of Hospitalization in Extremely Low Birth Weight Infants

This paper adds to the body of literature on the topic as it truly focuses on the outcome of infants < 1000g.  While this study is retrospective in nature it does cover a five year period and examines important outcomes of interest to this population.

The primary outcome in this case was death or BPD and whether HFNC was used alone or with CPAP, this was more frequent than when CPAP was used alone.  Other important findings were the need for multiple and longer courses of ventilation in those who received at least some HFNC.  In these times of overburdened health care systems with goals of improving patient flow, it is also worth noting that there was a significant prolongation of length of stay with use of HFNC or HFNC and CPAP.

One interesting observation was that the group that fared the worst across the board was the combination of CPAP and HFNC rather than HFNC alone.

CPAP (941) HFNC (333) HFNC +/- CPAP (1546)
CPAP d (median, IQR) 15(5-28) 7 (1-19)
HFNC d (median, IQR) 14(5-25) 13 (6-23)
HFNC +/- CPAP 15 (5-28) 14(5-25) 26 (14-39)
BPD or death % 50.40% 56.80% 61.50%
BPD % 42.20% 52.20% 59.00%
Multiple ventiation courses 51.10% 53.10% 64.70%
More than 3 vent courses 17.60% 21.00% 29.40%
Ventilator d (median, IQR) 18(5-42) 25 (6-52) 30 (10-58)

I believe the finding may be explained by the problem inherent with retrospective studies.  This is not a study in which patients were randomized to either CPAP, HFNC or CPAP w/HFNC.  If that were the case one would expect lung pathologies and severity of illness to even ou,t such that differences between groups might be explained by the difference in treatments.  In this study though we are looking though the rearview mirror so to speak.  How could we account for the combination being worse than the HFNC alone?  I suspect it relates to the severity of lung disease.  The babies who were placed on HFNC and did well on it might have had less severe chronic changes.  What might be said about those that had the combination?  Well, one could postulate that there might be some who were extubated to HFNC and collapsed needing escalation to CPAP and then failing that therapy were reintubated.  Another explanation could be those babies who were placed on CPAP after extubation and transitioned before their lungs were ready to HFNC may have failed and lost FRC thereby going back to CPAP and possibly intubation.  Exposure in either circumstance to HFNC would therefore put them at risk of further positive pressure ventilation and subsequent further lung injury.  The babies who could tolerate transition to HFNC without CPAP might be intermediary in their outcomes (as they were found to be) as they lost FRC but were able to tolerate it but consumed more calories leaving less for growth and repair of damaged tissue leading to prolonged need for support.

Either way, the use of HFNC was found to lead to worse outcomes and in the ELBW infant should be avoided as routine practice pending the results of a prospective RCT on the subject.

Is it a total ban though?

As with many treatments that one should not consider standard of care there may be some situations where there may be benefit.  The ELBW infant with nasal breakdown from CPAP that despite excellent nursing and RRT attention continues to demonstrate tissue damage is one patient that could be considered.  The cosmetic implications and potential for surgical correction at a later date would be one reason to consider a trial of HFNC but only in the patient that was close to being able to come off CPAP.  In the end I believe that if a ELBW infant needs non invasive pressure support then it should be with CPAP but as there saying goes there may be a right time and a place for even this modality.