Even brief neonatal PPV indicates close monitoring

By Will Boggs MD

NEW YORK (Reuters Health) - Neonates who require positive pressure ventilation (PPV) at birth for as little as one minute still need close monitoring as part of their postresuscitation care, new data from Canada confirm.

"One size doesn't fit all, and even infants who require very brief positive pressure ventilation at birth are at risk for complications and should not be left with just 'routine care,'" Dr. Walid El-Naggar from Dalhousie University, Halifax, Canada told Reuters Health.

However, Dr. El-Naggar continued, "The level of postresuscitation care needed for these children may vary and should be tailored according to their risk factors, presentation, and support given."

Neonatal Resuscitation Program (NRP) guidelines recommend transfer of these neonates to an environment where close monitoring and anticipatory care can be provided once adequate ventilation and circulation have been established, without distinguishing between those who receive short and long periods of PPV.

Dr. El-Naggar and colleagues used the health center database to investigate whether postresuscitation care (PRC) is indicated for all infants born at or after 35 weeks' gestation who receive PPV at birth and to characterize perinatal risk factors that might influence the need for PRC.

Of more than 3,600 neonates who had positive pressure ventilation at birth, 90% were admitted to the special neonatal care unit (SNCU), including 1,425 (43%) who required PPV for less than one minute at birth and 1,876 (57%) who required it for a more prolonged period.

Infants who received PPV at birth were more likely to have neonatal morbidities and require special care measures, even if they had PPV for less than one minute, the authors reported online September 29 in Pediatrics.

Children who required more prolonged positive pressure ventilation were more likely to develop complications and require assisted ventilation, central venous catheters, and longer stays in the SNCU.

In multiple regression analysis, placental abruption, assisted vaginal delivery/cesarean delivery, small for gestational age, gestational age <37 weeks, longer duration of PPV, need for intubation at birth, and 5-minute Apgar scores of 3 or below were independent predictors of an SNCU stay of one or more days and the need for assisted ventilation, central lines, and parenteral nutrition.

"The study findings provide data from a large cohort of patients that support the NRP guidelines in providing post-resuscitation care for infants who have depressed breathing at birth," Dr. El-Naggar said. "It also highlights the risk factors most predictive for the need of this care. This can help clinicians to better decide on and tailor the level of care that should be provided for these children after the resuscitation in the delivery room."

"Ideally, the approach to these infants should differentiate between those at high risk for complications that need medical support in addition to the observation and monitoring in a special care unit and those who may be observed closely while still staying with their mothers to prevent separation and support breastfeeding," Dr. El-Naggar said. "Our study provides some risk factors that help clinicians to choose the level of care provided. Different hospitals' resources will eventually play a significant role."

Dr. El-Naggar added, "The area of providing postresuscitation care for full-term and late preterm infants needs more attention and research in order to optimize their care without compromising parents' bonding and breastfeeding or unnecessarily increase parents' anxiety."

SOURCE: http://bit.ly/1ByXqB2

Pediatrics 2014;134:e1057-e1062.

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