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Any surgery as a neonate carries increased risk of adverse neurodevelopmental outcomes and any neonatal study should include them. They are different from overall quality of life.
Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.
Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.
Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).
References
1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001
2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and many of our research participants – also think moral distress may not always be avoidable nor negative.
Disproportionate or aggressive medical treatments considered not in a patient’s best interests are commonly cited as key causes of moral distress(Prentice, Janvier et al. 2016). This may occur when there is disagreement between the treating team and the family, due to differently held beliefs and values. Though principles of harm draw some guidance around the role of parents in decision-making, many of these cases still fall within the broad ‘zone of parental discretion’(Gillam 2016, McDougall, Gillam et al. 2016). If we accept that parents have a significant role in decision-making and are ethically permitted to choose options for their child that are not (in our opinion) ideal, then a degree of moral distress is ‘inevitable’. This inevitability stems from differences in subjective beliefs and values and does not necessarily reflect an organisational failing as Epstein suggests(Epstein and Hurst 2017). The experience of moral distress in these situations – in accordance with standard definitions– can be traumatic and we do not mean to downplay this in any way. Yet as Dudinski notes “[m]oral intuitions should not be ignored, nor are they definitive. They must bear the weight of ethical scrutiny”(Dudzinski 2016). If we do not accept that moral distress can lead to constructive discussions, patient advocacy and a mechanism for progressive thought then we are left with moral distress acting as a vehicle for blame(Dudzinski 2016), often inferring that the clinical lead either is failing to listen to the concerns of others or lacks the moral courage to change the current management plan(Prentice 2017). Both of these may be unfair assumptions amidst the complex end-of-life considerations and decision-making dynamics. More worrisome is that the net effect may be to place undue pressure on the family to acquiesce to a particular treatment plan to resolve the net moral distress of the treating team – what we have elsewhere referred to as ‘moral transference’(Prentice, Gillam et al. 2017). The moral distress experienced by families is too often neglected in such conversations.
Moral distress is a burden, but it can also be something from which we can grow and learn, and our patients can benefit from. Should we not therefore be willing to accept some of its positive attributes along with all the bad? Is it fair for our patients’ families to bear the burden if we cannot?
Dudzinski, D. M. (2016). "Navigating moral distress using the moral distress map." Journal of Medical Ethics 42(5): 321-324.
Epstein, E. and A. Hurst (2017). "Looking at the Positive Side of Moral Distress: Why It's a Problem." Journal of Clinical Ethics 28(1): 37-41.
Gillam, L. (2016). "The zone of parental discretion: An ethical tool for dealing with disagreement between parents and doctors about medical treatment for a child." Clinical Ethics 11(1): 1-8.
McDougall, R., L. Gillam and H. Gold (2016). The zone of parental discretion. When Doctors and Parents Disagree. R. McDougall, C. Delany and L. Gillam, The Federation Press: 17.
Prentice, T. (2017). Accepting the Good with the Bad when Living with Moral Distress. AAP Section on Bioethics, American Academy of Pediatrics.
Prentice, T., A. Janvier, L. Gillam and P. G. Davis (2016). "Moral distress within neonatal and paediatric intensive care units: a systematic review." Archives of Disease in Childhood 101(8): 701-708.
Prentice, T. M., L. Gillam, P. G. Davis and A. Janvier (2017). "The use and misuse of moral distress in neonatology." Seminars in Fetal and Neonatal Medicine.
We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...
We thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dramatically over the last 10 years, from the use of static levels of pure oxygen without SpO2 monitoring to blending oxygen to meet SpO2 values derived from full-term, healthy infants (3). Much more information is required before we can be confident that any SpO2 or FiO2 recommendations are in the best interest of the infant, especially one that is as physiologically complex as the extremely preterm infant.
In conclusion, we agree with Dr Hewson that the practice of SpO2 targeting and FiO2 titration for preterm infant resuscitation deserves further (and urgent) study. Until such data are available, we advise caution when using oxygen during preterm infant resuscitation and that clinicians should remember to tailor their resuscitation practice to meet the needs of each infant.
1. Wilson A, Vento M, Shah PS et al. A review of international clinical practice guidelines for the use of oxygen in the delivery room resuscitation of preterm infants. Acta Paediatr. 2018;107(1):20-27.
2. Dawson JA, Kamlin CO, Vento M et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics. 2010;125(6):e1340-7.
3. No authors listed. Co-publishing of the Pediatric and Neonatal Portions of the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations and the 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2015;136 Suppl 2:S83-7.
This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .
The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.
It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.
The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).
This study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .
The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.
It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.
The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).
I suggest a target of 90-95% pre-ductal oxygen saturation for resuscitation of the extremely low birth weight newborn from the first acquisition of a saturation signal and through to NICU admission and beyond. Targeting 90 – 95% accords with recommended management of oxygen saturations in the NICU(4) and thus has the added benefit of being familiar to clinical staff. In practice such a simplified target still leaves clinicians with decisions around titration of inspired oxygen and in particular the optimal size of each incremental step in oxygen percentage.
Optimising the titration of oxygen once a saturation target has been decided upon probably requires consideration of individual patient factors such as airway patency, ventilation adequacy, and co-morbidities.
Individual patient analysis of the study data already available may allow the individualized prediction of optimal startingFiO2 to more reliably reach the saturation target in the first few minutes.
1. Oei JL, Finer NN, Saugstad OD, et al. Outcomes of oxygen saturation targeting during delivery room stabilisation of preterm infants. Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 07 October 2017. doi:10.1136/archdischild-2016-312366
2. Gluck PA. Medical Error Theory. Obstet Gynecol Clin North Am. 2008 Mar;35(1):11-17.
3. Bornhorst B, Peter CS, Poets CF. Detection of hyperoxaemia in neonates: data from three new pulse oximeters. Arch Dis Child Fetal Neonatal Ed. 2002 Nov;87(3):F217-9
4. Martin A. Neonatal target oxygen levels for preterm infants. In UpToDate, Post, TW (Ed), UpToDate, Waltham,MA,2017.
It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...
It is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left with gnawing, nebulous distress without adequate ways to root out and rectify its causes" (p. 324). So before moral distress is declared as beneficial and inevitable, a clear definition of the concept must be set forth and adhered to.
Dudzinski, D. M. (2016). Navigating moral distress using the moral distress map. Journal of Medical Ethics, 42(5), 321-324. doi:10.1136/medethics-2015-103156
Epstein, E. G. & Hurst, A. R. (2017). Looking at the Positive Side of Moral Distress: Why It's a Problem. Journal of Clinical Ethics, 28(1), 37-41.
Rambur, B., Vallett, C., Cohen, J. A., & Tarule, J. (2010). The moral cascade: Distress, eustress, and the virtuous organization. Journal of Organizational Moral Psychology, 1(1), 41-54.
Selye, H. (1974). Stress without distress. Philadelphia, PA: Lippincott, Williams, and Wilkins.
Wocial, L. D., & Weaver, M. T. (2013). Development and psychometric testing of a new tool for detecting moral distress: the Moral Distress Thermometer. Journal of Advanced Nursing, 69(1), 167-174. doi:10.1111/j.1365-2648.2012.06036.x
We are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
The first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstru...
We are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
The first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstrual age and 33.6 ± 0.7 weeks respectively. This would be in keeping with premature newborn physiology, when efficient coordination of suck, swallow and breathing occurring between 32 and 36 weeks of gestation.(2, 3) In fact this result compares favorably to previous reports. Hwang et al. in their cohort of infants born below 32 weeks of gestation reported first oral feed at 33.9 ± 1.7 weeks of postmenstrual age. Their group included all infants born below 32 weeks who achieved full oral feeding before discharge.(4) The infants included in our cohort were more premature (born below 30 weeks of gestation). We also excluded the ‘healthiest’ infants who were off respiratory support (63 in total, which would be over 40% of eligible infants). On the other hand we excluded also the ‘sickest’ infants with high respiratory support (19 infants) and infants who were not established on full enteral feeds at 32 weeks of gestation (5 infants). Shetty et al. in their cohort of infants similar in profile to our population reported first oral feed at median of 35 weeks of postmenstrual age (range 33 to 44 weeks) in CPAP group and 34.4 (range 33 to 37.86) in HF/CPAP group.(3) A physiological study undertaken by Amaizu et al. showed ability of infants born between 26 and 29 weeks of gestation to tolerate 1 to 2 oral feeds in 24 hours at 34.0 ± 1.0 weeks of postmenstrual age, this ability improved with gestational age at birth (34.4 ± 1.2 weeks at 26 to 27 weeks of gestation versus 33.6 ± 0.6 weeks at 28 to 29 weeks of gestation). It is worth noting that these were stable infants without chronic lung disease.(5) We would therefore believe that our results fully reflect the physiology of oral feeding in preterm newborns and would be fully justifiable for clinical practice.
We are using non-nutritive sucking in our unit as a standard practice.
We would like to thank you for the correction of our terminology used in reference to the important work of Shetty et al., however we believe that their work was a retrospective cohort study (retrospectively comparing two cohorts of infants managed differently in different time epochs).(3)
We firmly believe that our conclusion was justified that there was no difference in the duration to reach full oral feeds between stable preterm infants managed on HF Nasal Cannula and those managed on nasal CPAP, and that oral feeding was feasible and safe regardless of the method used for non-invasive respiratory support.(6)
1. Watson J, McGuire W. Responsive versus scheduled feeding for preterm infants. Cochrane database of systematic reviews (Online). 2016(8):CD005255. Epub 2016/09/01.
2. Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane database of systematic reviews (Online). 2016;10:CD001071. Epub 2016/11/02.
3. Shetty S, Hunt K, Douthwaite A, Athanasiou M, Hickey A, Greenough A. High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia. Archives of disease in childhood Fetal and neonatal edition. 2016;101(5):F408-11. Epub 2016/02/18.
4. Hwang YS, Ma MC, Tseng YM, Tsai WH. Associations among perinatal factors and age of achievement of full oral feeding in very preterm infants. Pediatrics and neonatology. 2013;54(5):309-14. Epub 2013/05/11.
5. Amaizu N, Shulman R, Schanler R, Lau C. Maturation of oral feeding skills in preterm infants. Acta paediatrica. 2008;97(1):61-7. Epub 2007/12/07.
6. Glackin SJ, O'Sullivan A, George S, Semberova J, Miletin J. High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial. Archives of disease in childhood Fetal and neonatal edition. 2017;102(4):F329-F32. Epub 2016/12/25.
I congratulate the authors for putting the results of this much needed study together and exploring the differences in survival for extremely preterm babies at 22-23 weeks. The outcome for babies born at < 26 weeks hasn't been looked at nationally since the EPICURE 2 study in 2006.
It is interesting to note the regional variation in survival at 22-23 weeks and it warrants further exploring the following issues:
1. Is there a variation nationally in administering antenatal steroids at <24 weeks gestation? The NICE guideline 2015 advocates:
For women between 23+0 and 23+6 weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P-PROM, discuss with the woman (and her family members or carers as appropriate) the use of maternal corticosteroids in the context of her individual circumstances. This is open to interpretation and may not provide consistency in administration of antenatal steroids at 23 to 23+6 weeks. There is no guidance for <23 weeks. It will be useful to explore the practice nationally.
2. The practice for resuscitation at <23 weeks is likely to be variable. The latest national guideline BAPM 2008 advocates If gestational age is certain and less than 23+0 (i.e. at 22 weeks) it would be considered in the best interests of the baby, and standard practice, for resuscitation not to be carried out. The units who were resuscitating babies <23 weeks were deviating from...
I congratulate the authors for putting the results of this much needed study together and exploring the differences in survival for extremely preterm babies at 22-23 weeks. The outcome for babies born at < 26 weeks hasn't been looked at nationally since the EPICURE 2 study in 2006.
It is interesting to note the regional variation in survival at 22-23 weeks and it warrants further exploring the following issues:
1. Is there a variation nationally in administering antenatal steroids at <24 weeks gestation? The NICE guideline 2015 advocates:
For women between 23+0 and 23+6 weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P-PROM, discuss with the woman (and her family members or carers as appropriate) the use of maternal corticosteroids in the context of her individual circumstances. This is open to interpretation and may not provide consistency in administration of antenatal steroids at 23 to 23+6 weeks. There is no guidance for <23 weeks. It will be useful to explore the practice nationally.
2. The practice for resuscitation at <23 weeks is likely to be variable. The latest national guideline BAPM 2008 advocates If gestational age is certain and less than 23+0 (i.e. at 22 weeks) it would be considered in the best interests of the baby, and standard practice, for resuscitation not to be carried out. The units who were resuscitating babies <23 weeks were deviating from the national guidance and it would be useful to explore the reasons to do so.
3. It will be important to monitor the developmental outcomes of babies < 23 weeks gestation. This will be useful to influence decision making in resuscitation and management for this group nationally.
The authors may already be looking to explore these issues as it will be important to put in context the variation in practice for management of extremely preterm babies at 22-23 weeks gestation.
Thank you for your interest in our study and your comment. When you read the 6th paragraph of the discussion of the article, you will find that we completely agree that Oxytocin could have influenced the observations. This was an observational study and moment of oxytocin was given to the discretion of the midwife. Nevertheless, we still observed umbilical circulation much longer than previously described. This study was performed in 2015, but our local guideline has recently been changed to administering oxytocin after cord clamping. A new study is currently undertaken using the same methodology.
We thank dr. Kumar and dr. Yadav for their interest in our study. We hope that by stating ‘delayed cord clamping may not be advisable in second-born MC twins after vaginal birth’, we expressed that gynecologists could consider to deviate from the international guidelines in some cases. It is possible that not all babies will benefit from placental transfusion in a similar way. However, we certainly agree with dr. Kumar and dr. Yadav that the optimal timing of umbilical cord clamping in twins warrants further investigation.
Any surgery as a neonate carries increased risk of adverse neurodevelopmental outcomes and any neonatal study should include them. They are different from overall quality of life.
Physiologically based cord clamping stabilises cardiac output and reduces cerebrovascular injury in asphyxiated near-term lambs.
Graeme R Polglase, Douglas A Blank, Samantha K Barton, Suzanne L Miller, Vanesa Stojanovska, Martin Kluckow, Andrew W Gill, Domenic LaRosa, Arjan B te Pas, Stuart B Hooper.
Polglase and colleagues have shown that in near term asphyxiated lambs physiologically based cord clamping (PBCC) may be a more suitable option for the resuscitation of the asphyxiated newborn compared with the current standard practice of immediate cord clamping (ICC). This inevitably requires that the newborn remains close enough to its mother for the cord to remain intact. They showed evidence that brain injury was greatly reduced compared with ICC followed by resuscitation. This study in lambs suggests that delayed cord clamping may benefit most human infants, term and preterm, healthy and asphyxiated. Readers will wish to know how it is possible in practical terms to provide resuscitation at the side of the mother with an intact cord and this information is available from Katheria et al (1) and Batey et al (2).
References
1. Katheria AC, Brown MK, Rich W and Arnell K (2017) Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front. Pediatr. 5:1. doi: 10.3389/fped.2017.00001
2. Batey N, et al. Arch Dis Child Educ Pract Ed 2017;102:235–238. doi:10.1136/archdischild-2016-312276
We agree that conceptual clarity is of great value. Furthermore we acknowledge that some ‘distress’ experienced by our clinicians was not of a moral nature – such as the distress that results from tragic circumstances. We believe that in practice, distress and moral distress overlap. It can be difficult for clinicians to isolate the precise aetiology of their distress. We have furthermore acknowledged that these factors mean that the frequency of ‘moral distress’ may be overestimated in this study. However we are unclear why the ‘distress’ experienced by our clinicians is better labelled as ‘moral stress’. We maintain that conceptual clarity must be of clinical significance and be meaningful to those experiencing it. The clinicians participating were not uncomfortable with the idea that good things could arise from ‘distressing’ situations. It seems a disservice to the healthcare professionals in our study experiencing it to relabel it as ‘stress’ rather than ‘distress’ for the purpose of a less unsettling conclusion. We assume that Mr Hickox remains sceptical that moral distress, as strictly defined (that is, where a clinician feels anguish due to being constrained from acting in accordance with his/her moral judgement), may have some positive attributes. We will outline why we believe that in addition to decreasing moral distress and it’s negative consequences, we – and...
Show MoreWe thank Dr Hewson for his interest in our paper and for raising several intriguing points that challenges current practice about the use of oxygen during the very important first minutes of life of a sick preterm infant. There are several points we would like to clarify in response to his questions.
Firstly, in our study, only 12% (n=96) of preterm infants from the 8 studies reached the recommended SpO2 range (80-85%) and not the lower limit (80%) of this range, as stated by Dr Hewson. The majority of infants were either below (46%) or above (42%) this range at 5 minutes of age.
We agree that neither hyperoxia or hypoxia, even for a few short minutes, is in the best interest of any newborn infant. We concur with Dr Hewson that the current SpO2 recommendations are not evidence-based, especially for sick preterm infants and for either improved short or long-term outcomes. Currently, most clinical practice guidelines recommend the same SpO2 targets for both term and preterm infants (1) and do not take into account, differences in physiological needs. Indeed, Dawson et al showed that even healthy preterm infants needed several minutes more than term infants to achieve SpO2 >90% (2).
We therefore suggest that caution should be exercised before any specific SpO2 target can be recommended (e.g. 90-95% as suggested by Dr Hewson) without a sufficiently large study that is designed to assess both short and long-term outcomes. Clinical practice has swung dram...
Show MoreThis study(1) of outcomes of oxygen saturation targeting during delivery room stabilisation or preterm infants, and other data indicating that low saturations are suboptimal for preterm infants requiring resuscitation should now lead to a review of the currently recommended saturation targets. The recommended graduated targets over the first few minutes are not based on evidence of improved outcomes and also add a significant degree of complexity to what is already a challenging resuscitation environment. Complexity is a contributing factor to error in health care(2) .
The authors incorrectly state that only 12% of preterm infants who were resuscitated with blended oxygen in eight RCTs reached the lower limit of expert committee SpO2 (80%) at 5 min of age. As is made clear elsewhere in the paper, over 50% of newborns reached or exceeded 80% at 5 minutes of age.
It is possible that the relatively small percentage of infants exactly hitting the saturation target zone (80 – 85%) at 5 minutes is due at least in part to the steep slope of the oxygen dissociation curve at that range of saturation. A relatively modest change in pO2 will lead to a significant change in saturation.
The physiologically goal should be to avoid hypoxia and avoid hyperoxia. Hypoxia is increasingly likely with pre-ductal saturations below 90%. Hyperoxia is readily avoided by maintaining saturations below 96% for infants in supplemental oxygen(3).
I suggest a target of 90...
Show MoreIt is a deleterious proposition to declare benefits to moral distress. In their recent response, Epstein and Hurst (2017) eloquently articulated many reasons for this. A better approach may be to invoke the work of Hans Selye (1974) and the parallels drawn by Rambur, Vallett, Cohen, and Tarule (2010) in advocating for the potential benefits of moral stress; not moral distress. The authors of the present article effectively revealed clinicians' general misunderstanding and misapplication of the concept of moral distress. Indeed, the authors acknowledged this explicitly: "This study demonstrates the importance of asking what clinical providers mean by 'moral distress' and/or what researchers mean when investigating this phenomenon" (p. F4). The authors' conclusions about frequency of moral distress and "inevitability" of moral distress are based on clinician self-report; not on a generally accepted definition of moral distress. Likewise, the authors do not use a validated, reliable tool to quantify moral distress (such as the Moral Distress Thermometer, Wocial & Weaver, 2013). Much qualitative research has been done that has clarified the concept of moral distress; it is not simply whatever the clinician says it is. As ethicist Denise Dudzinski (2016) stated, "clinicians benefit by distinguishing between distress and moral distress" and "without mapping the ethical dimensions of distress, clinicians are left...
Show MoreWe are delighted that our work received the attention of the neonatal community. The protocol in the study was exactly as stated in our paper, oral feeds were offered at least once in 72 hours, more often if cues were evident. As cue-based feeding depends on individual infants’ physiological wellbeing and readiness to feed a traditional feeding guideline based on volume and time would be contradictory. The cue based feeding might have some effect on earlier achievement of the full oral feeding.(1) Usual total feeding volume in our unit is between 120 ml/kg/day to 180 ml/kg/day and this depends on several factors: co-morbidity (e.g. patent ductus arteriosus, chronic lung disease), type of milk (maternal breast milk, donor breast milk, different type of formulas), weight gain. The total enteral intake would not be feasible to protocolize. The volume taken orally (volume per feed and hike of feeds) was determined by the effort and energy of each individual baby as opposed to following any particular schedule (as mentioned earlier cue-based or infant-led feeding). As our cohort consisted of infants on full enteral feeding, there was no specific definition of feeding intolerance and indeed we did not identify any problems with feeding intolerance in the trial.
Show MoreThe first oral feed in our trial was 9.3 ± 6.5 days after randomization in High Flow (HF) group and 10.9 ± 4.8 days in nasal Continuous Positive Airway Pressure (CPAP) group, that is 33.3 ± 0.9 weeks of postmenstru...
I congratulate the authors for putting the results of this much needed study together and exploring the differences in survival for extremely preterm babies at 22-23 weeks. The outcome for babies born at < 26 weeks hasn't been looked at nationally since the EPICURE 2 study in 2006.
Show MoreIt is interesting to note the regional variation in survival at 22-23 weeks and it warrants further exploring the following issues:
1. Is there a variation nationally in administering antenatal steroids at <24 weeks gestation? The NICE guideline 2015 advocates:
For women between 23+0 and 23+6 weeks of pregnancy who are in suspected or established preterm labour, are having a planned preterm birth or have P-PROM, discuss with the woman (and her family members or carers as appropriate) the use of maternal corticosteroids in the context of her individual circumstances. This is open to interpretation and may not provide consistency in administration of antenatal steroids at 23 to 23+6 weeks. There is no guidance for <23 weeks. It will be useful to explore the practice nationally.
2. The practice for resuscitation at <23 weeks is likely to be variable. The latest national guideline BAPM 2008 advocates If gestational age is certain and less than 23+0 (i.e. at 22 weeks) it would be considered in the best interests of the baby, and standard practice, for resuscitation not to be carried out. The units who were resuscitating babies <23 weeks were deviating from...
Thank you for your interest in our study and your comment. When you read the 6th paragraph of the discussion of the article, you will find that we completely agree that Oxytocin could have influenced the observations. This was an observational study and moment of oxytocin was given to the discretion of the midwife. Nevertheless, we still observed umbilical circulation much longer than previously described. This study was performed in 2015, but our local guideline has recently been changed to administering oxytocin after cord clamping. A new study is currently undertaken using the same methodology.
We thank dr. Kumar and dr. Yadav for their interest in our study. We hope that by stating ‘delayed cord clamping may not be advisable in second-born MC twins after vaginal birth’, we expressed that gynecologists could consider to deviate from the international guidelines in some cases. It is possible that not all babies will benefit from placental transfusion in a similar way. However, we certainly agree with dr. Kumar and dr. Yadav that the optimal timing of umbilical cord clamping in twins warrants further investigation.
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