Over the last number of years clinicians have sought more and more to limit the experience of babies to painful stimuli. In the area of surfactant administration this has focused on “less invasive” strategies such as use of small catheters while on CPAP (LISA or MIST) and surfactant via LMA or Surfactant Administration Through Laryngeal or Supraglottic Airways (SALSA) as it is sometimes known. Intubation Surfactant Extubation (INSURE) while not generally included in the less invasive approach is to a degree fitting since it involves at least intubating for a very brief period after surfactant is administered. SALSA has been growing in popularity due to its “extreme” non-invasiveness since babies are receiving surfactant without instrumentation of the airway at all. It should come as no surprise then that head to head comparisons will be done to determine which should be reigned king!
The Contenders
A group out of Albany, NY has looked at SALSA vs INSURE before in which they used morphine for premedication prior to the procedure. You might ask why any premedication is needed at all but I would suggest that covering one’s airway and dripping liquid into it might cause some irritation so why not keep them calm. The authors in their paper Randomized trial of laryngeal mask airway versus endotracheal intubation for surfactant delivery found a high rate of failure in the intubation arm which more than likely was attributable to the respiratory depressive effect of the same.
This time around in the current paper Randomized Trial of Surfactant Therapy via Laryngeal Mask Airway Versus Brief Tracheal Intubation in Neonates Born Preterm they switched to remifentanil for its brief duration of action. Babies in the SALSA arm received that drug while those in the ETT group received atropine as well. The authors included infants born from 27 weeks to 36 weeks gestation who were larger than 800g at birth. This was a non-inferiority trial with the primary outcome being Our primary outcome was failure of surfactant therapy to prevent the need for invasive mechanical ventilation or its surrogate indicators, namely, more than 2 doses of surfactant therapy, sustained need for FiO2 >0.60 to maintain target O2 saturations, or a second dose of surfactant within 8 hours of the first dose.
Surfactant redosing criteria were the same for both groups: FiO2 >0.60 or FiO2 >0.30 with clinical signs of worsening RDS. If surfactant needed to be given a second time it was via intubation. The decision to ultimately intubate though was in the hands of the practitioners.
Unfortunately, the trial was stopped after only 51 patients were enrolled into the LMA and 42 into the INSURE groups respectively. Randomization was by block design and the authors were looking for 130 patients per group so they fell far short of that. The reasons for falling short were interesting as they demonstrate one of the challenges of research and changing beliefs. At the start of the trial there was equipoise among practitioners with respect to the two modes of surfactant delivery but part way through people preferred SALSA. The authors changed the randomization to try and deal with that to a 2:1 favoring SALSA but with the combination of that and COVID they had to stop. They did manage to get enough though to determine the primary outcome in spite of this.
What did they find in the end?
Well first of all it is worth noting that there were no differences in baseline characteristics between the two groups. As it turns out, while the numbers were small it didn’t seem to lead to an unbalancing of groups.
With respect to inferiority the finding was that it was in fact not inferior as per the figure below.
In table 2 some interesting findings emerge
Early failure of surfactant which was defined as within 1 hour of surfactant administration was found to be significantly increased in the intubation group. Late failure through at 5 days of age was not any different. An early failure is suggestive of the procedure not working to deliver the surfactant. When you look at the bottom half of table 2 the answer may be there. As part of the planned procedure the authors aspirated a gastric tube after surfactant administration to ensure that it went to the right place. There was no difference in surfactant volume aspirated via this route. There was however 9.7% of infants in the ETT group that experienced reflux in the ETT vs zero with observed reflux in the SALSA group (in the mouth perhaps?). Is surfactant without PPV better tolerated maybe?
There was a trend overall to more failures in the ETT arm although this was not found to be significant either in the intention to treat or per protocol analysis.
Where do we go from here?
First off it is important to look at who was chosen for this strategy. You may have noticed that there were no micropreemies in this trial. The reason for this is likely two-fold. The first is that prior trials on SALSA have found it doesn’t work as well to prevent intubations in babies below 27 weeks. This is very similar to the findings of studies using aerosolized surfactant. It may well be that there just isn’t enough of the total dose getting to the alveoli. If you can get some of the dose in deep into the lung for those with less severe RDS it may work ok for those babies. The second reason likely has to do with using LMAs in those in that weight range as they generally are designed for larger preemies although I understand smaller ones are becoming more readily available.
The second point is that this was not a blinded study. This could have become an issue as the authors acknowledge that there was a growing institutional preference for SALSA as the study went on. If the Neonatologist subconsciously believes it is better, might that have influenced some of the decisions to intubate again since one of the criteria was “clinical signs of worsening RDS”. It is quite possible this could have led to a few more intubations in the INSURE group for repeat doses. We can’t prove that but it is a weakness of the study.
At the very least it can be argued that the use of SALSA works as a small percentage overall failed the procedure. The largest groups of infants though were above 29 weeks so we also might not expect a high rate of failure after one dose though. It works but how well is tough to say.
Where I think this study is really important though is what it tells us for centers in particular who don’t intubate as often. Intubation is a skill that is declining in opportunity, both because of a turn to more use of non-invasive support as a primary mode of treatment. It also has become scarcer at an individual level due to there being more practitioners who can perform the skill. Having an option to use SALSA for those who aren’t as comfortable with intubation will no doubt be of much interest to many in this situation.
What is no doubt going to come next is the LISA/MIST vs SALSA trials. I hope that in the future pain scores are included in these sorts of analyses to really determine if in being less invasive we are also ensuring that we are also not undertreating discomfort. I suppose the lesson being learned from all of this is that less very well may be more.
Anyone who has watch the delivery of a baby knows that in some cases things go very smoothly and in others every care provider in the room would likely have tachycardia themselves. In some cases where labour is quite prolonged and some degree of cephalopelvic disproportion exists, the fetal head can become quite wedged in the pelvis. When this occurs it is not uncommon to hear of an ob/gyn having to dislodge the entrapped head from below and then perform a c-section to get the baby out safely.
In some of these cases though on the newborn exam a depression of the skull is found such as with the figure on the right. As our brains like to link things together we may jump to the conclusion that the pressure exerted on the head from below led to a fracture. This fracture in turn may lead to injury to the underlying brain. At least that is what our brains want us to think but what if the reason for the fracture has nothing to do with the maneuver as described?
Spontaneous Skull Fractures
This exact situation has been described in two cases and with a review of the literature in a paper entitled Spontaneous Intrauterine Depressed Skull Fractures: Report of 2 Cases Requiring Neurosurgical Intervention and Literature Review. In this report they describe two cases, the first of which was a term infant born via SVD without instrumentation and was described as atraumatic. The figure above was from this infant and thankfully the underlying brain was free of hemorrhage. The second case was also term and again there was no need for forceps or vacuum. In this case there was significant parietal fracture with a small amount of subdural blood collection. This infant unlike the other one due to significant depression required neurosurgical intervention to correct the skull deformity and lift the bone off the brain. As the authors go on to describe there have been 39 other such patients described in the literature with the features as shown in the table from the paper. While there are 4 more in the paper they had vacuum extractions so I wouldn’t count them.
Why Does This Happen?
The short answer in most cases is a tight fit! In the 1960s this was postulated that in the right occiput posterior and and right occiput transverse positions the fetal head becomes compressed between the sacral promontory and pubic bones. Other implicating factors have been maternal fibroids leading to chronic pressure on the developing skull along with oligohydramnios that may lead to fetal compression as well.
When you look at the above table though what stands out is failure to progress as an ethology. One can imagine the contracting uterus attempting to propel the fetus forward and if impacted in the pelvis the pressure on the skull may well lead to fracture.
The other thing of note is the overwhelming involvement of the parietal bone in these cases. A presentation in another bone might lead one to think of a different etiology.
As far as treatment, many of these as you can see are simply observed but in the presence of significant bleeding neurosurgical intervention is needed. At the outset it is sensible to consult neurosurgery as one never knows which ones need intervention and which ones do not.
As you can see, the presence of a fracture and a history of forceful pushing from below MAY be related to a fracture but on the other hand these may occur simply with protracted labours themselves. In these situations while it may be tempting to blame the ob/gyn we also need to ask ourselves what the alternative they had was. Should they have let the mother continue to push with the potential risk of asphyxia or potentially even uterine rupture? At some point the delivering physician needs to get the baby out and if that is what needs to be done to extract the baby then that is what they will need to do. At the end of the day one thing is for sure that we don’t know for sure what caused the fracture and as tempting as it may be to blame the ob/gyn or GP delivering a baby it just might have been spontaneous!
Hypoxic Ischemic Encephalopathy or HIE is a condition in which a baby presents with cord blood gases, a gas at one hour of age, low apgar scores and neurological findings which point to an event occurring that has interrupted blood flow to the brain. The Canadian Pediatric Society further defines this by looking at who may benefit from whole body cooling to mitigate the risk of an abnormal outcome for these patients. The criteria are shown below from the CPS Guideline
Invariably when HIE has occurred and there is neurological injury, two predominant patterns appear on MRI. The first is of a subacute hypoxic injury that typically involves multiple areas of the brain such as the frontal, parietal and occipital lobes but in particular the cortex. When a sentinel event has occurred, which is defined as a sudden interruption of blood supply to the fetus, the pattern is decidedly different. This may occur in such situations as an acute abruption, or umbilical cord compression as with cord presentation. When this occurs, the pattern is more typically white matter injury along with involvement of deep brain structures such as the thalami and basal ganglia (putamen and globus pallidus as examples).
Can Bloodwork Give Us Clues As To When The Injury Occurred?
One of the questions that I am often asked is to determine when such injury occurred. Is this an injury that was sustained a day or two before birth or during labor minutes or hours prior to delivery. The timing of such injury is often difficult to determine. It is said that about 90% of such injuries do not occur during labor but that of course leaves 10% that do. Alternatively, the number might be greater than 10% but it is simply difficult to really determine timing but 10% is a best guess.
I had often relied on what I felt was a logical conclusion that in the presence of an acute and profound interruption of blood supply sufficient enough to cause neurological injury that there would be similar perturbations of blood work in the newborn. The absence of renal, hepatic or coagulation disturbance would mean one of two things. Either the injury was remote and while profound, the fetus had recovered and these disturbances resolved or absence indicated to look for another etiology.
Recently the following paper has led me to a different conclusion. Broni et al published Blood Biomarkers for Neonatal Hypoxic-Ischemic Encephalopathy in the Presence and Absence of Sentinel Events. The authors performed a retrospective analysis of all neonates with HIE admitted to their NICU with sentinel events in the first three days of life and compared them to those without. All infants met the criteria for whole body cooling and were cooled for three days. The goal was to see how those infants with a sentinel event compared to those without in terms of patterns of bloodwork. Presumably those with sentinel events since they were so severe might show a different pattern of bloodwork after birth.
What Did They Find?
The authors had 277 babies with HIE treated with whole body hypothermia. The blood used to look for biomarkers was discarded blood not used for regular sampling and in all there were 68.6% of babies that had such blood for analysis. Of the babies tested 40.5% had a sentinel event and 59.6% did not.
In terms of baseline characteristics, the groups were similar with the exception (not surprisingly) that there were 32 women with abruptions in the sentinel event group and none in the no sentinel event group. Also, meconium was present at delivery about 2.5 times as common with the subacute patients than the sentinel event group.
The goal of the study was to look at biomarkers.
The authors examined a wide range of them but the only two that showed a significant difference in babies with and without sentinel events were vascular endothelial growth factor (VEGF) and IL-10. VEGF levels increase in the presence of hypoxia related to placental secretion of the factor. IL-10 levels increase during hypoxia and is protective since it inhibits secretion of IL-1β, IL-8 and TNF-α. This interrupts the production of leukocyte aggregation, and reduces inflammatory responses in the brain. Looking at the first figure you can see that VEGF levels were higher in those with sentinel events on day 2 and 3 while IL-10 levels were lower on days 1-3 in those with sentinel events. In other words, in the presence of a sentinel event there higher VEGF levels are present after hypoxia and protective IL-10 levels are lower.
Looking at Figure 2, other than initial glucose being lower in those with sentinel events (but not clinically relevant as still above normal) one cannot discern any differences between those with and without a sentinel event.
Possibly even more surprising is that my long held belief that those with a sentinel event should have significant multiorgan system involvement doesn’t appear to be true. Such things as platelet counts, white blood cell counts and initial blood gases show no difference between groups.
Putting it all together
The authors here have shown that two biomarkers display different patterns in babies born after a sentinel event than those with a subacute hypoxic course. It is possible that had they been able to test blood from all babies instead of 68.6% the results may have been different but there is biological plausibility to a more acute and severe event having this pattern of greater hypoxic injury since these babies are also at risk for significant neurological impairment later on. These tests are not routinely done but, in the future, might there be a role for drawing IL-10 and VEGF levels when trying to determine etiology?
What was also surprising was the fact that not all babies with sentinel events show a clear pattern of that demonstrates they fall into that group. The clinical appearance alone does not differ between the two groups of patients with HIE. While liver, renal and coagulation systems were not individually reported here, the lack of difference at one hour in terms of blood gases, lactates and platelet counts suggests that it would be unlikely to see a difference in those end organs. If measures of perfusion are no different as measured by gases and lactates then why would organ injury be different?
At least for me my conclusion is that laboratory measures are not able to discern whether a sentinel event occurred or not. Additionally, those who believe that the absence of laboratory markers indicate that an injury occurred remotely and the baby recovered should be careful in making such conclusions solely based on laboratory data. It will be interesting to see if anyone begins testing IL-10 and VEGF levels routinely in such patients but I guess time will tell.
It’s been a while since my last post. Like many centers across North America and worldwide the resuscitation of premature infants as young as 22 weeks is becoming more commonplace. Our own center is in the process of working towards coming up with evidence-based approaches to the care of these fragile infants. One of the questions that has long been asked is whether antenatal steroids really make a difference at these earliest gestational ages. The argument against effectiveness would be that the cards are just so stacked up against these preemies that even steroids may not help. Making matters worse is that the number of babies at this early gestational age included in antenatal steroid trials are extremely small making any conclusions difficult.
In short, the goal of the study was to look at survival and survival without major morbidities for infant born between 22 and 0 days to 23 weeks and 6 days gestational age who either received no antenatal steroids, 1 dose or 2 doses 24 hours apart. Only those mothers who received betamethasone were included and the doses were provided at either 21 or 22 weeks of gestation prior to delivery at 22 and 23 weeks of gestation. The study was retrospective and looked at NICHD neonatal research network data from January 1, 2016 to December 31, 2019. In comparison to all the previous prospective studies in existence which recruited less than 50 preterm infants this young this study managed to recruit 431 infants. In the groups analyzed, there were 25.5% infants who received no antenatal steroids, 18.6% infants receiving a partial course and 55.9% infants receiving complete antenatal steroids.
What did they find?
The authors found evidence that I believe will be reassuring to practitioners deciding whether to provide a course of steroids at these gestational ages. There are questions though that will be raised when looking at this data as well.
The data in table to show a number of interesting findings. Most notably a primary outcome of survival at hospital discharge was improved with a complete course of steroids but not with partial or none. Similarly there were reductions in severe intracranial hemorrhage and survival at 36 weeks postmenstrual age without major medical morbidities.
Figure 2 shows survival to hospital discharge and survival without major neonatal morbidities graphically. What one can more clearly see is that if you are going to give steroids the outcome is best if the mother receives both doses.
Challenges
On the one hand you might say that this is a slam dunk finding and we should be giving antenatal steroids to all women presenting at 21 and 22 weeks gestational age. I mentioned there would be questions and one of them will have to do with the avoidance of a repeat course of antenatal steroids. There is some literature that suggests repeat dosing of antenatal steroids later in pregnancy is associated with adverse developmental outcomes and also structural changes to the developing brain. This then leads the practitioner and a bit of a quagmire. If the woman presents at 21 or 22 weeks with threatened preterm labor do give her the steroids knowing that only a full course will help her versus waiting to see if she is truly in labor as you are considering whether you should save dosing for a later time in pregnancy. I have no doubt there will be some providers that we will hesitate to give the 1 course if that is their institution practice at this gestational age. This will not be an easy selection to make.
The other question that we will come up as we start to see a single dose antenatal steroid trials coming out is whether such infants will be included in prospective trials. The upcoming SNACS trial which we are participating in is one such trial that will include infants as young as these. It will be interesting to see if prospectively collected clinical trials with adequate numbers of such small infants will demonstrate similar findings that 2 doses really are required to make a meaningful reduction in adverse outcomes. As we have seen with many retrospective studies though such as this one the outcomes may in fact be different when you randomize patients in a prospective fashion.
For now I think the evidence as good as it is we will favor giving steroids to mother’s presenting at these gestational ages. Curious what you think?
In an effort to reduce the incidence of IVH many patient care bundles in the last number of years have advocated for minimal handling. As part of approach to minimal handing an effort to keep the head straight and in some centres elevated has been postulated to help with enhancing venous outflow from the head. By reducing the passive gravity aided flow from the brain back into the thorax the theory would be that this would help minimize venous pressure in the draining cerebral system. Lowering pressure would in turn theoretically reduce the risk of IVH and hopefully the most severe types. The evidence to support this practice has largely been observational in the sense that those units practising this sort of intervention have published reductions in rates of severe IVH such as reported for small baby units. The fly in the ointment however is that many changes occur in the care of these infants so definitively attributing the difference in outcomes to just one intervention such as midline head positioning with elevation of the head can be challenging.
A Study to Sort It Out
Researchers in Iran sought to answer this question with an elegant study in which 39 patients served as their own controls and had NIRS monitoring through different head positions. This study entitled The effect of head positioning on brain tissue oxygenation in preterm infants: a randomized clinical trial study by Mohamammadie et al looked at these infants over the first 48 hours of life. Each infant went through NIRS monitoring and were randomly placed in six different positions as shown in the figure.
The infants studied were those who would be most vulnerable to IVH so were all <=32 weeks and < 1500g. The authors acknowledged that they would have liked to record over the first 72 hours as this has traditionally become the period of minimal handling in care bundles but claim that they did not have enough data past 48 hours to comment.
Prior to starting positional changes ten minutes of baseline recording was done in the midline position without elevation. Each position was used for a period of 2 hours during which NIRS monitoring was performed. The goal here was to see if the amount of oxygen extraction changed with different head positions and elevations. If the extraction increased in one head position it would be thought to reflect slowed return of venous blood with further extraction of oxygen from the brain.
What did the authors find?
Since I am reporting the findings it shouldn’t surprise you that they found something here. What might surprise you though is the actual difference in what they found. If one would have to guess before sharing the results it would seem that laying the head of the bed flat would not help with venous drainage as much as a 15-30 degree elevation so let’s guess that they would find that. Also, based on a belief that the jugular veins might be kinked if you turn your head to one side or the other let’s guess that midline head positioning does make a difference. Looking at the results below, let’s see if this actually happened.
As you can see the highest NIRS recordings were found in the baseline position and in general the three positions with the head of bed elevated (Position 4-6) and when flat in the midline (Position 1). It would seem then that the anticipated benefit was shown! From a statistical standpoint the third position was found to be different as was the fourth compared to the first position.
What does it all mean though?
A statistically different finding was achieved which shows the 3rd and 4th positions are not as good as baseline for sure but what about clinical significance. The lower limit of normal for NIRS readings is about 60. The means for all of these positions were in the 70s. In fact the difference between the mean of the 3rd and 4th positions and the others were only about 2%. Is this enough to make a difference? I honestly am not sure. There is a difference that reaches statistical significance so if we accept that there may have been some disruption of venous flow is this enough evidence to totally explain the reductions in IVH that have been seen with bundles for minimal handling with positioning? There were a lot of variables here that could not be controlled such as time of day that a baby was in one position or another since it was random. Was there a lot of noise in the unit at the time of one position or another? Depending on circadian rhythms what would the cortisol levels be and might mild changes in blood pressure explain the findings since they are so small?
I don’t want to totally dismiss the findings but suspect that it isn’t just the positioning that is leading to reductions in IVH. The same units that promote small baby care are also pushing breastfeeding rates up, skin to skin care and trying to harmonize other aspects of care. If we are seeing reductions in IVH which is a wonderful thing is it all related to this? Probably not but what this study does in my mind is support the theories about enhancing venous drainage through positioning and I see no reason not to continue this practice and try to keep these infants in the mid line and avoid bothering them as much as possible as they transition from the in-utero to ex-utero environment.
