Can we reduce severe IVH with elevated midline head positioning for ELBWs?

Can we reduce severe IVH with elevated midline head positioning for ELBWs?

Recently the practice of keeping ELBW infants with a midline head position for the first three days of life has been recommended to reduce IVH as part of a bundle in many units.  The evidence that this helps to reduce IVH has been somewhat circumstantial thus far.  Studies finding that decreased sagittal sinus blood flow, increased cerebral blood volume with increased intracranial pressure all occur after head turns would theoretically increase the risk of IVH.  Raising the head of the bed would help in theory with drainage of the venous blood from the head  and in fact systemic oxygenation has been shown to improve with such positioning.  This presumably is related to increased cardiac output from better systemic venous return.

Bringing it to the bedside

Interestingly, some of the above studies are from over thirty years ago.  We now have some evidence to look at involving this practice.  Kochan M et al published Elevated midline head positioning of extremely low birth weight infants: effects on cardiopulmonary function and the incidence of
periventricular-intraventricular. The study involved maintaining ELBW infants in an elevated midline head position (ELEV- supine, head of bed elevated 30 degrees, head kept in midline) versus standard head positioning (FLAT–flat supine, head turned 180 degrees every 4 h) during the first 4 days of life to see if this would decrease in the incidence of IVH. Ninety infants were randomized into both arms of the study.  In terms of baseline characteristics, BW of 725g in the FLAT vs 739 in ELEV were comparable as well as GA both at 25 weeks. Two differences on the maternal side existed of 40% ELEV vs 24.4% FLAT of mothers having preeclampsia and 23.3% FLAT vs 10% ELEV having prolonged rupture of membranes both of which were statistically significant.

What did they find?

Ultrasounds were performed at entry into the study and then daily for days 1-4 and then on day 7 with abnormal scans repeated weekly.  In terms of IVH the authors noted no overall difference in rate of IVH.  What they did find however was a statistically significant reduction in the rate of Grade IV IVH.  The p value for the finding of lower rates of Grade IV IVH was 0.036 so not strikingly significant but different nonetheless.  Given that the venous drainage of the head is also dependent on the resistance to flow from the pressure in the thorax one can’t infer that the intervention alone is responsible for this without ensuring that that respiratory findings are similar as well.  Similarly without knowing inflow of blood into the head as measured by blood pressure it is difficult to say that the reduction in IVH isn’t related to differences in blood pressure.

The authors helpfully looked at both of these things.  For those infants on high frequency ventilation the mean airway pressure was higher on day one being 11.5 cm H2O (FLAT) vs 9.9 cm H2O (ELEV) neither of which are high although different.  The rest of the three days were no different.  For those on conventional ventilation the only difference was on day 4 where the MAP was higher for ELEV at 8 vs 7.4 cm H2O which again is fairly mild. Interestingly, as was found in other studies that oxygenation was improved with elevation of the head, the maximum FiO2 for the two groups was different on day 1 being 46% in the FLAT vs 37.5% in the ELEV.

Looking at the hemodynamic side of things there were differences in the lowest mean BP recorded on day 1 and 3 but otherwise the groups were similar. It would have been nice to see mean results during this time rather than lowest but this is what we have.

In terms of complications of preterm birth there were no differences found in rates of sepsis (important given the increase rate of prolonged rupture in the FLAT group), NEC or ROP.

Although length of stay was no different 92 vs 109 days ELEV (NS), survival to discharge was at 88% vs 76% (p=0.033) which also may explain the longer length of stay.

What Can We Learn From This

Don’t worry.  I am not about to throw the results out.  There are a couple observations though that need to be addressed.  The first is the increased rate of preecampsia in the ELEV group.  This finding could have impacted the results.  We know that fetuses exposed to this condition are stressed and are often born with better lungs than their non-exposed counterparts.  The endogenous increase in steroids due to this stress is attributable and may explain the better oxygenation and lower mean airway pressures needed in the ELEV group rather than improvements in flow alone from positioning.  The second issue is adherence to the protocol as there were some infants in the ELEV group who were placed flat for the final 1-2 days of the study.  Having said that, this would serve to dilute the effect rather than strengthen it so perhaps it makes the results more believable.

So where does this leave us?  This study demonstrates improved survival and a reduction in Grade IV IVH without an overall reduction in IVH.  There was nothing found to suggest that the intervention is harmful.  Given the background studies demonstrating improved systemic oxygenation, reductions in ICP and cerebral blood volume the finding of reduced severe IVH seems plausible to me. This could be a practice changing study for some units who have perhaps only adopted midline positioning in the first few days of life.  It will be interesting to see if this takes off but is certainly worth a good look at.

Keeping up with the Kardashians: Should you eat your placenta after delivery?

Keeping up with the Kardashians: Should you eat your placenta after delivery?

The medical term for this is placentophagy and it is a real thing. If you follow the lay press you may have seen that originally this was promoted by Kourtney Kardashian who did this herself and then by Kim who planned on doing the same after delivery. See Did Kourtney Kardashian Eat Her Placenta?

This is not completely without basis as many readers will be thinking already that they have heard about the health benefits of doing the same. Reports of improved mood and reductions in the baby blues following ingestion of placenta as well as improvements in breast milk production have led to this growing practice. The evidence for this up until recently though was quite old and fraught with poorly design of such studies. The bigger driver however has been word of mouth as many women having heard about the promises of better mood at the very least have thought “why not? Can’t hurt.”

What I will do in this post is run through a little background and a few recent studies that have shed some light on how likely this is to actually work.

Where did the idea come from?

Animals eat their placentas after delivery. It turns out that unprocessed placenta is quite high in the hormone prolactin which is instrumental for breastfeeding. Given the large amount of this hormone as well as the number of other hormones present in such tissue it was thought that the same benefits would be found in humans. Eating unprocessed human tissue whether it is put in a capsule or not is unwise as unwanted bacteria can be consumed. In fact, a case of GBS sepsis has been linked to such a practice in which the source of the GBS was thought to be due to contaminated unprocessed maternal placenta that had been ingested. Buser GL, Mat´o S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the field: Late-onset infant group B streptococcus infection associated
with maternal consumption of capsules containing dehydrated placenta.

What happens when you process placenta by steaming and drying?

This would be the most common way of getting it into capsules. This process which renders it safe to consume may have significant effects on reducing hormonal levels.This was found in a recent study that measured oxytocin and human placental lactogen (both involved positively in lactation) and found reductions in both of 99.5% and 89.2%, respectively compared versus raw placenta. I would assume that other hormones would be similarly affected so how much prolactin might actually wind up in these capsules after all?

Clinical Randomized Double Blind Controlled Trial

Twenty seven women from Las Vegas were recruited into a pilot trial (12 beef placebo vs 15 steamed and dried placenta) with the authors examining three different outcomes across three studies. The first study Effects of placentophagy on maternal salivary hormones: A pilot trial, part 1 looked at a large number of salivary hormones at four time points. Plasma samples were taken as well to determine the volume of distribution of the same. First samples were at week 36 of gestation then within 4 days (96 h) of birth followed by days 5–7 (120–168 h) postpartum and finally Days 21–27 (504–648 h) postpartum. All consumption of capsules was done in the home as was collection of samples. As per the authors in terms of consumption it was as follows “two 550 mg capsules three times daily for the first 4 days; two 550 mg capsules twice daily on days 5 through 12, and then to decrease the dose to two 550 mg capsules once daily for the remainder of the study (days 13 through approximately day 20 of supplementation).

Outcomes

No difference was found between salivary concentrations of hormones at any time point other than that with time they declined following birth. Curiously the volume of distribution of the hormones in serum was slightly higher in the placenta capsule groups but not enough to influence the salivary concentrations. It was felt moreover that the amount of incremental hormone level found in the serum was unlikely to lead to any clinical response.

The second study was on mood Placentophagy’s effects on mood, bonding, and fatigue: A pilot trial, part 2. Overall there were no differences for the groups but they did find “some evidence of a decrease in depressive symptoms within the placenta group but not the placebo group, and reduced fatigue in placenta group participants at the end of the study compared to the placebo group.”

The last paper published from the same cohort is Ingestion of Steamed and Dehydrated Placenta Capsules Does Not Affect Postpartum Plasma Prolactin Levels or Neonatal Weight Gain: Results from a Randomized, Double-Bind, Placebo-Controlled Pilot Study. This study specifically addressed the issue of prolactin levels and found no difference between the groups. Neonatal weight gain was used as a proxy for breastmilk production as it was thought that if there was an effect on breastmilk you would see better weight gain. About 80% in both groups exclusively breastfed so the influence of formula one can’t take out of the equation. In the end weight gain was no different between groups although a trend to better weight gain was seen in the placebo group.

To eat or not to eat that is the question?

What is clear to me is that the answer to this question remains unclear! What is clear is that I don’t think it is wise to consume raw placenta due to the risks of bacterial contamination. Secondly, the levels of hormones left in the placental preparation and the most common preparation of steaming and drying leave hormone levels that are unlikely to influence much at all from a biochemical standpoint. It also seems that breastmilk production and neonatal weight gain aren’t influenced much by consumption of these pills.
The issue though in all of this is that while the previous research was of low quality, the current research while of better quality is at a low volume. These were pilot trials and not powered to find a difference likely. The finding in the subgroup of some effect on mood at the end of the study does leave some hope to those that believe in the power of the placenta to help. Would a larger study find benefit to this practice? My suspicion from a biochemical standpoint is not but that one may feel a benefit from a placebo response.
Should you go out and have your placenta prepared for consumption? If you have Kardashian like wealth then go for it if you think it will help. If you don’t then I would suggest waiting for something more definitive before spending your money on placentophagy.

Is Prophylactic Hydrocortisone The Magic Bullet For BPD?

Is Prophylactic Hydrocortisone The Magic Bullet For BPD?

I feel like this has been a story in the making for some time. Next to caffeine, the story of prophylactic hydrocortisone must be one of my more popular topics and has been covered more than once before as in A Shocking Change in Position. Postnatal steroids for ALL microprems or Early Hydrocortisone: Short term gain without long term pain. and the last post Hydrocortisone after birth may benefit the smallest preemies the most!  After reporting on this topic about once a year, a recent paper may wrap it all up in a bow for the holidays and present to us the conclusion after all this work on the topic.  I was extremely interested in this topic not just because I believe this therapy may have a future in the standard approach to neonatal care for VLBWs but because I have served on the CPS Fetus and Newborn committee with two of the authors of the paper.  Dr. Lacaze and Dr. Watterberg have an exceptional understanding of this topic and so when they band together with other experts in the field I take notice.  In fact here I am with Dr. Lacaze in case you doubted our history together (we also worked in Edmonton together but that is another story).

An Individual Patient Data Meta-Analysis

If you have read my previous posts then you know the story of why hydrocortisone given over the first 10-12 days of life might help those born before 30 weeks or < 1250g.  In essence the concept is that it has been shown previously that many infants with relative adrenal insufficiency may go on to develop BPD.  If you treat all such infants at risk you could theoretically reduce BPD.  Typically after a few studies examining a similar topic come out, one can combine them in a meta-analysis using aggregate data (averages of effect sizes for the individual studies) and see what the larger sample shows.  Another way to do it though is to go back to the original data and examine the infants at a more granular level allowing a greater identification and control of variables that might influence outcomes.  This is what the authors led my Michele Shaffer did here in the paper Effect of Prophylaxis for Early Adrenal Insufficiency Using Low-Dose Hydrocortisone in Very Preterm Infants: An Individual Patient Data Meta-Analysis.  There were a total of 5 studies on this topic but one study of 40 patients no longer had individual data so was excluded from analysis leaving 4 to look at.  The details of the four studies are shown below.  You can see that the inclusion criteria differed slightly but in general these were all infants up to 27 – 29 completed weeks and 500 – 1250g maximum who were treated with regiments as shown in the table.

 

 

 

 

 

 

What were the results?

Treatment with early low-dose hydrocortisone was associated with greater odds of survival without BPD at 36 weeks PMA after adjustment for sex, gestational age, and antenatal steroid use (aOR, 1.45; 95% CI, 1.11-1.90; I 2 = 0%). Also found were lower individual odds of BPD (aOR, 0.73; 95% CI, 0.54-0.98; I 2 = 0%), but not with a significant decrease in death before 36 weeks PMA (aOR, 0.76; 95% CI, 0.54-1.07; I 2 = 0%). Importantly although death by 36 weeks was not different, a decrease in death before discharge (aOR, 0.70; 95% CI, 0.51-0.97; I 2 = 0%) was found.  Also noted and important was a reduction in medical treatment for PDA OR 0.72 (0.56-0.93)

All of these outcomes sound important but in a subgroup analysis other interesting findings emerged.

When dividing the patients into those less then 26 weeks and those at or greater than that gestational age, the benefits appear to be limited to those in the latter group.  Levels of significance are high once you reach that GA suggesting that issues affecting those at younger gestational ages are less amenable to treatment.  On the other hand one could say that the benefits seen at 26 – 29 weeks GA are relatively strong using a glass is half full approach.  An important outcome worth noting is that while spontaneous intestinal perforation is noted to be a risk with prophylactic hydrocortisone, when you remove indomethacin from the equation the risk disappears.  For those units using prophylactic hydrocortisone one would likely need to choose between the two but if you are like our unit where we don’t have that option this may be one strategy to consider.

In terms of risk to giving such therapy the big one noted in the paper was an increase in risk for late onset sepsis.  Interestingly, this was limited though to the group under 26 weeks GA.  In essence then the messaging would appear to be that under 26 weeks there may be less benefit to such treatment and therefore the increased risk of late onset sepsis without such benefits on BPD would suggest not using it in this GA group.

Where do we land then?

It would be easy to cast this aside I suppose as the group you are most worried about (22-25 weeks) doesn’t seem to really benefit but has a risk of late onset sepsis.  That leaves us though with the group from 26-29 weeks.  They do seem to benefit and may do so to a significant degree.  They do develop BPD and to be honest we don’t have much outside of trying our best to use gentle ventilation to ameliorate their course in hospital.  It is worth noting that the one group that does seem to show the greatest benefit are those exposed to chorioamnionitis.  It is this group in particular that may be the best target for this intervention and I gather this has been discussed at a recent EPIQ meeting.

If one says no to trying this approach then the question that needs to be asked is whether doing nothing for this group is better than supporting them with hydrocortisone?  If your centre’s rates of BPD are top notch then maybe you don’t want to add something in.  If not though maybe it is time to rock the boat and try something different.  Makes me think of the following saying and might be something to think about.

 

What secrets are hiding in your patient monitor?

What secrets are hiding in your patient monitor?

This post is very exciting to me.  All of us in the field of Neonatology are used to staring at patient monitors.  With each version of whatever product we are using there seems to be a new feature that is added to soothe our appetites for more data.  The real estate on the screen is becoming more and more precious as various devices such as ventilators, NIRS and other machines become capable of displaying their information in a centralized place.  The issue though is that there is only so much space available to display all of this information but underneath the hood so to speak is so much more!

Come Along For The Ride

One of our Neonatologists Dr. Yasser Elsayed has been very aware of these features embedded in the patient monitor.  Through teaching on rounds, some of our staff have become aware of these features but delivering this content to the masses has been an issue.  That is where this post and it’s linked content come into play.  I have created a new Youtube playlist where all of this great content can be found.  Each video is very watchable with most being 5-7 minutes long with the longest being 14:16.  Each video starts with a demonstration on the patient monitor of the lesson being taught and how to access the data using the patient monitor (in this case a Phillips but I have no doubt many other monitors have the same tech – just ask your rep how to get it) followed by a brief voice-over powerpoint to deliver the essential concepts.

However you wish to digest the information is up to you but as they are short we hope that you will be able to find the content you need quickly and apply the knowledge to patient care.  How can you use the information?  The next time a patient is giving you cause to worry try looking into some of the deeper trends that the monitor is hiding from plain sight. Is there a trend towards becoming hypotensive for the patient that can be revealed in their blood pressure histogram?  Maybe the issue lies with the way the patient is being ventilated and examining trends in the pleth waveforms may reveal where the underlying problem lies.

 

The Topics (click the links to go to Youtube)

Complete List of Videos

Part 1 – Using Histograms

Part 2 – How to interpret blood pressure histograms

Part 3 – Using vital signs as trends

Part 4 – Impact of ventilation on pleth waveforms

Part 5 – How to interpret arterial pressure waveforms

Part 6 – Near Infrared Spectroscopy

Was resetting the threshold for hypoglycaemia a good thing?

Was resetting the threshold for hypoglycaemia a good thing?

In 2015 the Pediatric Endocrine Society (PES) published new recommendations for defining and managing hypoglycaemia in the newborn. A colleague of mine and I discussed the changes and came to the conclusion that the changes suggested were reasonable with some “tweaks”. The PES suggested a change from 2.6 mmol/L (47 mg/dL) at 48 hours of age as a minimum goal glucose to 3.3 mmol/L (60 mg/dL) as the big change in approach. The arguments for this change was largely based on data from normal preterm and term infants achieving the higher levels by 48-72 hours and some neuroendocrine data suggesting physiologically, the body would respond with counter regulatory hormones below 3.3 mmol/L.

As it turned out, we were “early adopters” as we learned in the coming year that no other centre in Canada had paid much attention to the recommendations. The inertia to change was likely centred around a few main arguments.

1. How compelling was the data really that a target of 2.6 and above was a bad idea?

2. Fear! Would using a higher threshold result in many “well newborns” being admitted to NICU for treatment when they were really just experiencing a prolonged period of transitional hypoglycaemia.

3. If its not broken don’t fix it. In other word, people were resistant to change itself after everyone was finally accustomed to algorithms for treatment of hypoglcyemia in their own centres.

What effect did it actually have?

My colleagues along with one of our residents decided to do a before and after retrospective comparison to answer a few questions since we embraced this change. Their answers to what effect the change brought about are interesting and therefore at least a in my opinion worth sharing. If any of you are wondering what effect such change might have in your centre then read on!

Skovrlj R, Marks S and C. Rodd published Frequency and etiology of persistent neonatal hypoglycemia using the more stringent 2015 Pediatric Endocrine Society hypoglycemia guidelines. They had a total of 58 infants in the study with a primary outcome being the number of endocrine consults before and after the change in practice. Not surprisingly as the graph demonstrates the number went up.  Once the protocol was in place we went from arbitrary consults to mandatory so these results are not surprising.  What is surprising though is that the median critical plasma glucose was 2.2 mmol/L, with no significant difference pre or post (2.0 mmol/L pre versus 2.6 mmol/L post, P=0.4)  Ninety percent of the infants who were hypoglycemic beyond 72 hours of age were so in the first 72 hours.  Of these infants, 90% were diagnosed with hyperinsulinemia.  What this tells us is that those who are going to go on to have persistent hypoglycemia will demonstrate similar blood sugars whether you use the cutoff of 2.6 or 3.3 mmol/L.  You will just catch more that present a little later using the higher thresholds.  How would these kids do at home if discharged with true hyperinsulinemia that wasn’t treated?  I can only speculate but that can’t be good for the brain…

Now comes the really interesting part!

Of the total infants in the study,  thirteen infants or 40% had plasma glucose values of 2.6 to 3.2 mmol/L at the time of consultation after November 2015.  Think about that for a moment.  None of these infants would have been identified using the old protocol.  Nine of these infants went on to require treatment with diazoxide for persistent hyperinsulinemia. All of these infants would have been missed using the old protocol.  You might ask at this point “what about the admission rate?”. Curiously an internal audit of our admission rates for hypoglycemia during this period identified a decline in our admission rates.  Concurrent with this change we also rolled out the use of dextrose gels so the reduction may have been due to that as one would have expected admission rates to rise otherwise.  The other thing you might ask is whether in the end we did the right thing as who says that a plasma blood glucose threshold of 3.3 mmol/L is better than using the tried and true 2.6 mmol/L cutoff?

While I don’t have a definitive answer to give you to that last question, I can leave you with something provocative to chew on.  In the sugar babies study the goal glucose threshold for the first 7 days of life was 2.6 mmol/L.  This cohort has been followed up and I have written about these studies before in Dextrose gel for hypoglycemia. Safe in the long run? One of the curious findings in this study was in the following table.

Although the majority of the babies in the study had only mild neurosensory impairment detectable using sophisticated testing the question is why should so many have had anything at all? I have often wondered whether the goal of keeping the blood sugar above 2.6 mmol/L as opposed to a higher level of say 3.3 mmol/L may be at play.  Time will tell if we begin to see centres adopt the higher thresholds and then follow these children up.  I don’t know about you but a child with a blood sugar of 2.7 mmol/L at 5 or 6 days of age would raise my eyebrow.  These levels that we have used for some time seem to make sense in the first few days but for discharge something higher seems sensible.