Recent discussions
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Jayasree Nair
We appreciate the ability to comment on this upcoming ILCOR statement . Our discussions involved Neonatal Fellows and Faculty, frontline providers at high-risk deliveries. Below represents a consensus of opinion.
We urge ILCOR to consider rewording their recommendation “begin resuscitation with more than 30% oxygen” for < 32 wk infants. A distinct change from 2020 recommendations for initiating resuscitation in <35 wk infants with 21-30% O2, this seems to be primarily based on the NETMOTION meta-analysis. This intriguing network & IPD meta-analyses showed lower mortality in >90% compared to the other 2 groups <30% & 50-65% (weak/very weak recommendations). While thought provoking, individual study limitations remain, such as heterogeneity in setting (both well and poorly resourced, with/without availability of oxygen blenders) and patient population (AGA/SGA infants etc.). Except for one study, (Oei et al) the cause/s and timing of mortality is unclear. Trying to link a few minutes of starting O2 to mortality in the absence of such data is difficult.
Practically, clinicians here have initiated preterm resuscitation with 30% O2. In most other DR`s, clinicians likely start at 21% or 30%, as recommended.. “More than 30%” implies that a clinician who starts resuscitation at 30% would not be adhering to recommendations while starting at 31% would be compatible. Could rewording the statement to “30% or higher” support current science while being less of a drastic and unclear change?
The third statement “Subsequent titration of O2 using pulse oximetry is advised” could be more impactful if included with the initial sentence as “Among newborn infants <32 wks’, it is reasonable to begin resuscitation with 30% or higher O2 with subsequent titration using pulse oximetry”. When using higher oxygen, titrating O2 delivery based on pulse oximetry is critical. If used as currently formulated, we consider the word “advise” weak. We would suggest using “recommended”. If blenders are unavailable, the word “recommended” should force guiding councils to consider making them available.
Physiologically, heart rate response is as important as O2 saturations in a resuscitation. A lower HR, eg 60-100/min, could lead to the clinician turning up the O2 even if the saturations are near target range. Is this a knowledge gap that could be explored with existing data or in future studies?
Nair J, Ahn E, DeBenedictis N, Hartman C, Lee Y, Mansfield J, Muthalaly R, Kim J, Perlman J.
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Aurimery Chermont
- Glucose therapies relevant to resuscitation include exogenous dextrose (intravenous, intraosseous, buccal) and glucagon (intramuscular, intravenous). These could be given during resuscitation in infants with poor response or in post-resuscitation care, with or without prior glucose monitoring. In post-resuscitation care, glucose therapies could be provided as part of a bundles of care.
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Aurimery Chermont
The use of videolaringoscopy is very useful in a premature less than 1000g. can be recommended.
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Aurimery Chermont
- Comparison of different devices to support resuscitation with an intact cord should be undertaken
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Aurimery Chermont
Future studies should address these outcomes. Sufficiently powered trials to investigate a difference in the critical outcomes severe intraventricular hemorrhage and periventricular leukomalacia should also be considered.
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Aurimery Chermont
Concerns persist regarding unmeasured adverse effects of hyperoxia and hypoxia, and most very preterm infants whose resuscitation has started in 21% or 100% will need prompt adjustments of inspired oxygen concentration, and as a result, two pending multicenter trials are utilizing 30% vs 60% oxygen for their treatment arms.
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Lynn Newton
Delayed cord clamping with PPV – if babe needs NRP
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Lynn Newton
Screening for glucoses during resuscitation is essential – placing a UVC for support is necessary if babe is critically ill – providing IV dextrose. Venous labs are preferred as well as acrocyanosis may have false results (capillary sample)
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Abdul Razak
I would like to urge reconsideration of the suggestion: “In term and late preterm infants who remain non-vigorous despite stimulation, we suggest intact cord milking (ICM) in preference to early cord clamping (ECC).” The evidence synthesis reveals no significant benefit or harm of ICM compared to ECC for mortality (risk ratio 0.11 [95% CI: 0.01–2.03]) & NICU admission (modeled odds ratio 0.69 [95% CI: 0.41–1.14]). However, ICM may show a potential clinical benefit in reducing moderate to severe hypoxic-ischemic encephalopathy (HIE) (RR 0.49 [95% CI: 0.25–0.97]) with moderate certainty. Notably, much of this evidence stems from a large multicenter cluster-randomized trial (Katheria 2024), which raises important concerns about the validity of these findings due to the inherent limitations of the study design. Cluster-randomized trials often face challenges as participants within a cluster tend to respond similarly, violating the assumption of independent data points. When this clustering effect is ignored, confidence intervals become artificially narrow, and p-values deceptively small, leading to potentially false-positive results. This issue was apparent in the trial by Katheria et al., where the primary outcome—NICU admission—appeared significantly lower with ICM than ECC (22.8% vs. 27.9%; crude OR 0.77 [95% CI: 0.62–0.95]). However, after adjusting for the cluster design, this effect became nonsignificant (adjusted OR 0.69 [95% CI: 0.41–1.14]). The stark difference between unadjusted and adjusted results underscores the profound impact of clustering on risk estimation, cautioning against overinterpreting crude estimates. Similarly, the study reported a significant reduction in moderate to severe HIE with cord milking compared to early clamping (1.4% vs. 3%; unadjusted RR 0.48 [95% CI: 0.24–0.96]). However, this outcome was not adjusted for the study design, likely due to low event rates. Given the absence of such adjustment and the usual lack of power to assess secondary outcomes in RCTs, it remains uncertain whether the observed effect on HIE is genuine or an artifact of the unaccounted clustering. This lack of robustness in the evidence raises concerns about the validity of prioritizing ICM over ECC based on unadjusted risks. Therefore, the recommendation to consider intact cord milking in preference to early cord clamping may be premature & potentially misleading, given the significant methodological limitations and the tenuous nature of the evidence.
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Rita de Cassia Silveira
Level of initial supplemental oxygen delivered: according gestational age and for extreme preterm ( less than 28 wks GA. My suggestion is
- 31% to 50%