In This Issue
November Neonatal News 2016
by Pat Scheans, DNP, NNP-BC
Optimum Cord Clamping: Delayed, Timed, Physiologic!
The American College of Nurse Midwives (ACNM), the American College of Obstetrics (ACOG), the American Academy of Pediatrics (AAP), and the World Health Organization (WHO) recommend physiologic cord clamping as the standard of care.
Physiologic cord clamping (also called optimal, delayed or timed cord clamping) is associated with improved cardiovascular transition as it maintains venous return and cardiac output. Approximately 30% more blood volume is transfused than immediate clamping, preventing hypovolemia. Allowing a more gradual transition in cardiac output to the lungs during inflation while changes in pulmonary and systemic blood flow occur promotes organ perfusion, blood pressure and cerebrovascular circulatory stability. Neonatal benefits include reduction of intraventricular hemorrhage, necrotizing enterocolitis, and need for blood transfusion. There is no increase in morbidities such as maternal blood loss, neonatal jaundice or symptomatic polycythemia. Immediate cord clamping is indicated in the case of placental issues such as abruption.
Emerging evidence about the timing of cord clamping when resuscitation is needed has shown that umbilical cord milking (UCM) may be of benefit if physiologic clamping is not possible, particularly for preterms.
TAKE HOME MESSAGE: Optimum cord clamping improves outcomes.
Need inspiration? Watch this TED talk: TICC TOCC https://www.youtube.com/watch?v=Cw53X98EvLQ&feature=y
- American Academy of Pediatrics. (2013). Statement
of endorsement: timing of umbilical cord clamping after birth. Pediatrics, 131:e1323. DOI:
- American College of Nurse Midwives (2014). Position statement on delayed umbilical cord
clamping. Retrieved from http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000290/Delayed-Umbilical-Cord-Clamping-May-2014.pdf
- American Congress of Obstetricians and
Gynecologists Committee on Obstetric Practice. (2012). Committee opinion no.
543: timing of umbilical cord clamping after birth. Obstetrics and
gynecology, 120(6), 1522. doi: 10.1097/01.AOG.0000423817.47165.48.
This Will Only Hurt for a Second: Antenatal Corticosteroids on the Rise
“A single course of betamethasone is recommended for pregnant women between 34 0/7 weeks and 36 6/7 weeks of gestation at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids.” (ACOG, 2016, p. 1)
Antenatal corticosteroids have been in use since the 1990s to reduce the incidence and severity of surfactant insufficiency related respiratory distress syndrome in preterm newborns. RDS rates increase with decreasing gestational age, but that doesn’t mean that late preterms are immune. We’ve all seen biggish babies with embarrassing respiratory distress. Based on improved respiratory outcomes, the guideline for administration of betamethasone has been extended to 36 6/7 weeks of gestation. The Antenatal Late Preterm Steroids (ALPS) double-blinded, placebo-controlled, randomized clinical trial found a large decrease in severe respiratory complications, from 12.1% in the placebo group to 8.1% in the betamethasone group as well as significant decreases in the rates of transient tachypnea of the newborn, need for postnatal surfactant, and need for immediate postnatal resuscitation. The data showed no increase in neonatal sepsis, chorioamnionitis, or endometritis. Hypoglycemia (without adverse events and that did not prolong hospital stay) was more common in the betamethasone group: 24.0% versus 14.9%, but the rates of hypoglycemia found in the trial were similar to the general population of late preterm infants, who are screened routinely since they are a high risk group. (Keep up the good work and see the sweet news below).
- Late preterm administration of antenatal steroids is not indicated if there is a diagnosis of chorioamnionitis (intrauterine infection)
- Tocolysis should not be used in order to administer late preterm antenatal steroids
- Indicated late preterm delivery (such as severe preeclampsia) should not be postponed for corticosteroid administration
- Populations not studied were: multiple gestation, maternal pregestational diabetes, previous course of corticosteroids, cesarean delivery at term
TAKE HOME MESSAGE: Keep those needles handy, and carry on with corticosteroids!
- American College of Obstetricians and
Gynecologists. (2016) Practice Advisory:
Antenatal Corticosteroid Administration in the Late Preterm Period.
Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co677.pdf?dmc=1&ts=20161017T0044144801
- Kamath-Rayne, B. D., Rozance, P. J., Goldenberg,
R. L., & Jobe, A. H. (2016). Antenatal corticosteroids beyond 34 weeks
gestation: What do we do now? American Journal of Obstetrics and Gynecology,
215(4), 423-430. doi: 10.1016/j.ajog.2016.06.023
- Gyamfi-Bannerman, C., Thom, E., Blackwell, S.,
Tita, A., Reddy, U., Saade, G., et al. (2016). Antenatal betamethasone for
women at risk for late preterm delivery. NICHD Maternal-Fetal Medicine Units
Network. N Engl J Med,374(14), 1311–20.
Retrieved from http://www.nejm.org/doi/pdf/10.1056/NEJMoa1516783
Sweet News About Hypoglycemia Treated with 40% Dextrose: 2 years Later
Many of you have started treating babies with neonatal hypoglycemia with 40% dextrose gel. A recent Cochrane review published a statement which said that compared to placebo gel, 0.5 mL/kg of 40% dextrose rubbed into the buccal cavity reduces separation of the mother-baby dyad and increases the likelihood of full breast feeding compared with placebo gel. They also note that there is no evidence of adverse effects during the neonatal period or two years later.
The Cochrane review was based on the Sugar Babies Study (2011) and a recently published follow up study looking at neurodevelopmental outcome at 2 years corrected age in children who had been randomized to treatment with dextrose gel or placebo in the first 48 hours of life for neonatal hypoglycemia. The follow up assessments included neurologic function, cognitive, language, behavior, and motor skills (Bayley Scales of Infant and Toddler), function (clinical assessment and Behavior Rating Inventory of Executive Function-Preschool Edition), and vision (clinical examination and global motion perception).
The study group’s mean birth weight was 3093 ± 803 grams and mean gestation was 37.7 ± 1.6 weeks. Sixty-six children (36%) had neurosensory impairment (1 severe, 6 moderate, 59 mild) with similar rates in both groups (dextrose 38% vs placebo 34%). Processing difficulty also was similar between groups (dextrose 10% vs placebo 18%).
The authors’ conclusion is that use of the gel did not result in poorer neurodevelopmental outcomes- dextrose gel is safe for the treatment of neonatal hypoglycemia, and it reduces the need for intravenous dextrose and separation of mom and baby. Of note, neurosensory impairment is common in this population.
TAKE HOME MESSAGE: Be sure to administer the 40% dextrose by drying the inner cheeks and rubbing the gel in small aliquots into the buccal mucosa for rapid absorption into the bloodstream.
- Harris, D. L., Alsweiler, J. M.,
Ansell, J. M., Gamble, G. D., Thompson, B., Wouldes, T. A., ... & with
Hypoglycaemia, C. (2016). Outcome at 2 years after dextrose gel treatment for
neonatal hypoglycemia: follow-up of a randomized trial. The Journal of
Pediatrics, 170, 54-59.
- Weston, P., Harris, D., Battin,
M., Brown, J., Hegarty, J., Harding, J. (2016). Oral dextrose gel for the
treatment of hypoglycaemia in newborn infants. Cochrane Database of Systematic
Reviews, Issue 5. Art. No.: CD011027. Doi: 10.1002/14651858.CD011027.pub2. Retrieved from http://www.cochrane.org/CD011027/NEONATAL_oral-dextrose-gel-treatment-newborn-infants-low-blood-glucose-levels
It’s Still Cool: No Changes to Neuroprotective Hypothermia
The practice of neuroprotective cooling for newborns (over 35-36 weeks of gestation) with moderate to severe hypoxic ischemic encephalopathy (HIE) has been a standard of care for over a decade. Hypothermia at 33.5°C for 72 hours reduces death or disability with a sustained benefit into middle childhood.
A recent study was completed to determine if a longer duration of cooling (120 hours), deeper cooling (32.0°C), or both are superior to cooling at 33.5°C for 72 hours in neonates who are full-term with moderate or severe hypoxic ischemic encephalopathy.
The trial was interrupted due to safety and futility concerns- the likelihood of the benefit of longer cooling, deeper cooling, or both was found to be small. Outcomes were not improved; deeper or longer cooling may be associated with an increase in mortality. Longer duration of cooling was associated with more arrhythmia and anuria, and longer hospital lengths of stay. Deeper cooling was associated with higher use of inhaled nitric oxide therapy, ECMO, more days of oxygen, and higher incidence of bradycardia.
The researchers conclude that, longer cooling, deeper cooling, or both compared with hypothermia at 33.5°C for 72 hours did not reduce NICU death. This is reassuring and implies that no change is needed to our current practice.
TAKE HOME MESSAGE: Remember that neuroprotective cooling must begin by 6 hours of age. After consultation with NICU, passive cooling may be initiated while awaiting transfer to NICU. Monitor temperature closely, as cooling can occur very rapidly.
- Laptook, A. R. (2016). Birth Asphyxia and
Hypoxic-Ischemic Brain Injury in the Preterm Infant. Clinics in Perinatology,
43(3), 529–545. doi:10.1016/j.clp.2016.04.010
- Shankaran, S., Laptook, A. R., Pappas, A.,
McDonald, S. A., Das, A., Tyson, J. E., ... & Pedroza, C. (2014). Effect of
depth and duration of cooling on deaths in the NICU among neonates with hypoxic
ischemic encephalopathy: a randomized clinical trial. JAMA, 312(24),
2629-2639. doi: 10.1001/jama.2014.16058
Mid-Willamette Valley Chapter Meeting
Southern Willamette Valley Chapter Meeting
The Southern Willamette Valley Chapter will be hosting a "Nurses Leading Implementation of Nitrous Oxide Use in Obstetrics" webinar by Michelle Collins on November 10 from 4:30 - 6pm.
We will be meeting in Room 22Y at PeaceHealth RiverBend.
RSVP is encouraged. RSVP to Kathy Nice at email@example.com.
Central Oregon Chapter Meeting