Recent discussions
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Kristine Karlsen
The most at-risk for moderate to severe hypothermia are preterm and low-birth-weight infants. Hypothermia can impair immune function. Rates of early-onset-sepsis should be included in any future study. Hypothermia impairs coagulation. In addition to IVH, pulmonary hemorrhage should be an outcome that is looked at. Too rapid rewarming can cause vasodilation and reduce cardiac output. Any future study should look at whether any colloids or pressors are required during or soon after rewarming has started. An ideal study for rewarming of preterm infants would use an incubator with humidity and set on air temperature mode to best control the speed of rewarming (setting the air to 1 to 1.5 deg C above the infant's core temperature - or axillary if preterm). For term infants, a therapeutic hypothermia blanket could be used to control the speed of rewarming. Becoming hypothermic after birth is one thing - but the depth of hypothermia is not likely to be as severe as the preterm infant in the pre-transport environment and retrieved by the neonatal transport team, or the preterm infant delivered at home and is severely hypothermic and admitted to the hospital. Those patients should be included in any rewarming study and randomized to slow versus rapid rates. Preterm infants may be experiencing the effects of severe hypothermia with a body temperature of 35 deg Celsius and below, whereas term infants are severely hypothermic at 32 deg. Celsius. Establishing the range for mild, moderate, severe hypothermia for preterm infants would be a wonderful outcome of any study on rewarming of preterm infants. I am glad this topic is receiving attention. The S.T.A.B.L.E. Program Temperature module has contained precautions about the risks of rapid rewarming for many years and our recommendation has been and continues to be – rewarm slowly and steadily while monitoring vital signs and intermittently blood glucose and blood gas. Knowing that we really don't know if fast is better. But, also knowing that sudden vasodilation as occurs with using a radiant warmer or applying warm packs around the body (or both) can lead to a sudden drop in cardiac output, wide swings in blood pressure, and increased risk for brain hemorrhage.
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PATRICIA LARANJEIRA
The umbilical cord clamping time, the importance of placental transfusion and the physiological changes that occur during the transition from intrauterine to extrauterine life and the possible short, medium and long term repercussions of this procedure, returned to the center of discussions in different populations. Based on existing evidence in the literature, the recommendations to indicate delayed clamping after 60 seconds in full-term and healthy newborns, vigorous at birth, and after 30 seconds in PTNBs who do not require resuscitation procedures at birth, are safe. However, more studies will be needed to evaluate whether other alternative strategies are more effective than the strategies proposed to date.
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Martin Fagan
The principal of ‘Personal defibrillators’ is valid. Whether Ultraportable devices are the answer is open for debate. There are traditional devices that will meet this need.
As a charity, we were interested in this area and have requested on many occasions over the past 18 months, and in Zoom/telephone/face to face meetings, for copies of clinical data to support the marketing claims being made. These have never been provided, whether by the manufacturer or their UK sales agents. What has been provided is marketing and sales documentation, with challengeable statements.
RCUK advise ‘caution’ over using this device due to the lack of performance data.
We do have concerns, that need addressing, before we can consider this device. Namely;
- is 70J sufficient energy to overcome TTI?
- Is having a max energy ⅔ that of other devices clinically effective?
- Is the experimental dual exponential energy curve valid?
- Is use on neonates dangerous for a community device, given their normal HR is 120-220 and some devices shock at 130 bpm, suggesting that a shock could be given to an otherwise normal baby?
- What are the pads adhesion data?
- The explanation in the manual over use on paediatrics seems to conflict with advice from elsewhere.
- Is a cellphone type battery ⅓ that of a standard cell phone going to give sufficient energy for multiple shocks, and also what are the degradation studies on the battery over time?
- What data is there to support the marketing claim of “equal or better than existing devices”?
- How does the rescue data get transmitted to the hospital?
Until the basic questions are answered with peer reviews data, these types of product should be restricted in their use. We understand the FIRST trail is not looking at clinical efficacy, and therefore further evidence needs to be provided that shows efficacy, and in particular efficacy in relation to existing equipment that is available.
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Silvia Heloisa Moscatel Loffredo
Evaluating the favorable outcomes of therapeutic hypothermia using non-servo-controlled cooling methods in limited resource settings, I agree with the preliminar recommendations, including the definition of minimum resources for the safety and effectiveness of the method, emphasizing the importance of adhering to good practice statement.
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Silvia Heloisa Moscatel Loffredo
The available evidence does not indicate optimal rewarming rates yet, but I believe that with the constantly evolving strategies in neonatal monitoring, there will be suitable opportunities for further research
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Silvia Heloisa Moscatel Loffredo
There is clarity regarding the presented interventions, valuing the inherent peculiarities of gestational age, as well as the need for more data for the umbilical cord management strategies in preterm infants. The aim is to find a balance between effective resuscitation at birth and avoiding invasive procedures, minimizing complications in the short and long term.
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Nádia Sandra Orozco Vargas
I agree nevertheless We have to study and research more on this topic.
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Kaustabh Chaudhuri
Our unit observation is increase in number of polycythemia and neonatal jaundice in few subjects. Any comments?
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Susan Niermeyer
As noted in several comments, the choice of wording in the recommendation exerts strong influence on uptake and implementation. Treatment recommendations continue to suggest that deferred cord clamping be offered only to preterm infants “who are deemed not to require immediate resuscitation at birth”. This is open to widely divergent interpretation, and often results in extremely preterm infants being assumed a priori to need immediate resuscitation. Unless the assumption is positive, that a very preterm infant can be given an opportunity to breathe spontaneously, and appropriate monitoring by delivery room staff and thermal support are routinely in place, many preterm infants will continue to miss the mortality benefit of deferred cord clamping. This tendency may be reinforced by suggesting that cord milking (often perceived as faster and easier) is a reasonable alternative for preterm infants >28 weeks ”who do not receive deferred cord clamping".
The supporting statement to part B, “There is no evidence of increased rates of adverse effects in preterm infants <37 weeks’ gestation or their mothers after umbilical cord milking compared to immediate cord clamping.” appears on the surface to contradict to the recommendation against cord milking for infants <28 weeks. Although technically accurate regarding the studies included, this statement may lead to confusion.
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Steven Gelfand
Agree with update regarding UCM in preterms when DCC not possible. Reassured by Katheria et al 2023 in Pediatrics and appreciate the simplicity of using the 28 week cutoff for our obstetric providers.