[Effect of preterm infant position on weaning from mechanical ventilation]. Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding. Weaning of premature infants from the incubator to an open crib. Oxygen-saturation targets and outcomes in extremely preterm infants. Randomized, controlled trial comparing synchronized intermittent mandatory ventilation and synchronized intermittent mandatory ventilation plus pressure support in preterm infants. Randomized, controlled trial of nasopharyngeal continuous positive airway pressure in the extubation of very low birth weight infants. Patterns of physiologic and behavioral response of intermediate care preterm infants to intervention. Early minimal feedings promote growth in critically ill premature infants. Decreased lipid intake reduces morbidity in sick premature neonates.
To determine the effects of prone positioning on cardiorespiratory stability and weaning outcome of preterm infants during weaning from mechanical ventilation.
                From January to December 1999, a sample of 42 preterm infants, with birthweight < 2,000 g, mechanically ventilated in the first week of life, were randomly divided, in the beginning of the weaning process, into two groups according to the position: supine position (n = 21) or prone position (n = 21). Heart rate, respiratory rate, transcutaneous oxygen saturation and ventilatory parameters were recorded every one hour. Length of the weaning process and complications were also assessed.
                In both groups the mean gestational age was 29 weeks, most of the patients presented very low birthweight and respiratory distress syndrome. The mean length of the weaning process was 2 days. There were no differences between the groups regarding respiratory rate, heart rate and transcutaneous oxygen saturation, however, oxygen desaturation episodes were more frequent in supine position (p = 0.009). Ventilatory parameters decreased faster and reintubation was less frequent in the prone group (4% versus 33%). No adverse effects of prone positioning were observed.
                These results suggest that prone position is a safe and beneficial procedure during weaning from mechanical ventilation and may contribute to weaning success in preterm infants. The impact of cup-feeding or bottle-feeding on weight gain, oxygen saturation, and breastfeeding rates of preterm infants was studied in 34 bottle-fed and 44 cup-fed preterm infants. At initiation of oral feeding, postconceptional age and weight were 37.2 +/- 2.2 weeks and 1676 +/- 83 g for the bottle-fed group (BF) and 37.0 +/- 1.6 weeks and 1637 +/- 40 g for the cup-fed (CF) group, respectively. No significant differences between groups were found with regard to time spent feeding, feeding problems, weight gain, or breastfeeding prevalence at discharge or at 3-month follow-up. Possible beneficial effects of cup-feeding were lower incidence of desaturation episodes (13.6% vs 35.3%, CF vs BF, P = .024) and a higher prevalence of breastfeeding at 3 months among those still breastfeeding at the first follow-up visit (68.4% vs 33.3%, CF vs BF, P = .04). Thirty pairs of healthy, growing preterm infants were included in this randomized prospective study comparing thermal weaning at 1700 g with that at 1800 g. Based on an intention-to-treat analysis, infants weaned at 1700 g were discharged 1.1 days sooner than those weaned at 1800 g. However, this result was not statistically significant (p = 0.13). On the other hand, differences are apparent between treatments in some strata based on birth weight (p = 0.0056). Evidence also existed that time from entry (at 1500 g) to discharge depended on birth weight stratum (p = 0.010). No infant in either group lost weight after successful weaning, and mean 24-hour weight gains were similar for both groups. Two infants were weaned at 1800 g requiring return to the incubator due to hypothermia, and four infants weaned at 1700 g likewise requiring return to the incubator. The number weaned at 1700 g who had birth weight of 1000 g or less and who developed hypothermia appeared substantial (three of six such infants). Thus, it appears that thermal weaning at 1700 g may be safe and effective only for prematures with birth weight above 1000 g. Additional study appears needed. Physiological studies have shown that chronic hypoxemia may occur in preterm infants who require supplemental oxygen for extended periods and that this hypoxemia may contribute to poor growth and development. Anecdotal reports and uncontrolled observational studies have suggested that a higher oxygen-saturation range may be beneficial in terms of growth and development.
                We conducted a multicenter, double-blind, randomized, controlled trial involving 358 infants born at less than 30 weeks of gestation who remained dependent on supplemental oxygen at 32 weeks of postmenstrual age. They were randomly assigned to a target functional oxygen-saturation range of either 91 to 94 percent (standard-saturation group) or 95 to 98 percent (high-saturation group); this target was maintained for the duration of supplemental-oxygen therapy. The primary outcomes were growth and neurodevelopmental measures at a corrected age of 12 months.
                There were no significant differences between the groups in weight, length, or head circumference at a corrected age of 12 months. The frequency of major developmental abnormalities also did not differ significantly between the standard-saturation group and the high-saturation group (24 percent and 23 percent, respectively, P=0.85). There were six deaths due to pulmonary causes in the high-saturation group and one such death in the standard-saturation group (P=0.12). The high-saturation group received oxygen for a longer period after randomization (median, 40 days vs. 18 days; P<0.001) and had a significantly higher rate of dependence on supplemental oxygen at 36 weeks of postmenstrual age and a significantly higher frequency of home-based oxygen therapy.
                Targeting a higher oxygen-saturation range in extremely preterm infants who were dependent on supplemental oxygen conferred no significant benefit with respect to growth and development and resulted in an increased burden on health services.
                Copyright 2003 Massachusetts Medical Society Prolonged mechanical ventilation is associated with lung injury in preterm infants. In these infants, weaning from synchronized intermittent mandatory ventilation may be delayed by their inability to cope with increased respiratory loads. The addition of pressure support to synchronized intermittent mandatory ventilation can offset these loads and may facilitate weaning.
                The purpose of this work was to compare synchronized intermittent mandatory ventilation and synchronized intermittent mandatory ventilation plus pressure support in weaning from mechanical ventilation and the duration of supplemental oxygen dependency in preterm infants with respiratory failure.
                Preterm infants weighing 500 to 1000 g at birth who required mechanical ventilation during the first postnatal week were randomly assigned to synchronized intermittent mandatory ventilation or synchronized intermittent mandatory ventilation plus pressure support. In both groups, weaning followed a set protocol during the first 28 days. Outcomes were assessed during the first 28 days and until discharge or death.
                There were 107 infants enrolled (53 synchronized intermittent mandatory ventilation plus pressure support and 54 synchronized intermittent mandatory ventilation). Demographic and perinatal data, mortality, and morbidity did not differ between groups. During the first 28 days, infants in the synchronized intermittent mandatory ventilation plus pressure support group reached minimal ventilator settings and were extubated earlier than infants in the synchronized intermittent mandatory ventilation group. Total duration of mechanical ventilation, duration of oxygen dependency, and oxygen need at 36 weeks' postmenstrual age alone or combined with death did not differ between groups. However, infants in synchronized intermittent mandatory ventilation plus pressure support within the 700- to 1000-g birth weight strata had a shorter oxygen dependency.
                The results of this study suggest that the addition of pressure support as a supplement to synchronized intermittent mandatory ventilation during the first 28 days may play a role in reducing the duration of mechanical ventilation in extremely low birth-weight infants, and it may lead to a reduced oxygen dependency in the 700- to 1000-g birth weight strata. We conducted a prospective, randomized controlled trial to determine whether extubation of very low birth weight infants was facilitated by the use of nasopharyngeal continuous positive airway pressure (CPAP). Eligible infants included patients weighing 600 to 1500 gm at birth who required tracheal intubation within 48 hours of birth and who met specific predetermined criteria for extubation by day 14 of life. We also sought to determine whether varying the duration of nasopharyngeal CPAP influenced the likelihood of successful extubation. Infants underwent random assignment to receive nasopharyngeal CPAP until resolution of lung disease (n = 40), 6 hours of nasopharyngeal CPAP (n = 42), or oxygen supplementation delivered by hood (n = 42). Extubation failure was predefined as a requirement for > or = 80% oxygen, pH < or = 7.20, severe apnea, or predefined clinical deterioration, and extubation success was predefined as the ability to remain free of a requirement for mechanical ventilation for 7 days and a 66% reduction in the need for supplemental oxygen. Each group was similar with regard to race, sex, and birth weight. Extubation was successful in 62%, 61%, and 60% of infants. After stratification by birth weight, there were no significant differences in the rates of successful extubation among the treatment groups. We conclude that nasopharyngeal CPAP does not improve the likelihood of successful extubation of very low birth weight infants who are ready for extubation within the first 2 weeks of life. To determine the safety of a developmental intervention for use with preterm infants and feasibility of a time sampling procedure.
                An experimental design was used to test an intervention with clinically stable 33-34-week postconceptional age infants over a 4-day period. Repeated outcome measures included pulse rate, oxygen saturation levels, and infant behavioral state.
                The intervention resulted in significant differences in infant behavioral state with the experimental group achieving more alertness. Physiologic parameters remained within normal limits both during and after the intervention.
                The protocol was found to be safe for implementation with clinically stable preterm infants. Behavioral state findings suggest the potential for the intervention to promote alertness. Results suggest that changes in oxygen saturation and pulse rate were dependent upon changes in behavioral state. Critically ill premature infants requiring mechanical ventilation and an umbilical artery catheter usually do not receive enteral feedings during the acute phase of their illness. We studied the safety and benefit of early minimal enteral feedings during this time in a prospective, controlled, and randomized study. Twenty-nine infants were randomly assigned to receive only standard intravenous fluid and nutrition (nothing per OS, NPO group; n = 13), or in addition to receive small-volume hypocaloric continuous feedings (1 ml/kg/h), beginning at 24 h of age (early-feeding group; n = 16). Standard enteral feedings were begun in both groups at the resolution of the acute phase of the illness and advanced by protocol. The two groups were of comparable birth weight, gestational age, and Apgar scores. There were no significant differences in the episodes of feeding intolerance. Two infants in the NPO group developed clinical signs of necrotizing enterocolitis. Serum diamine oxidase and somatomedin C were measured weekly until 30-60 days of age and were not different between the two groups. The early-feeding group required fewer days to reach 120 ml/kg/day enteral intake (early-feeding group 10 +/- 3 days, NPO group 13 +/- 4 days; p < 0.05). On day 30 of life the early-feeding group was 223 +/- 125 g above birth weight, while the NPO group was 95 +/- 161 g above birth weight (p < 0.05). The average intake (kcal/kg/day) from day 6 to day 30 was not different between the two groups. We conclude that early minimal feedings in critically ill very-low-birth-weight infants requiring mechanical ventilation are well tolerated and result in reduced time to reach 120 ml/kg/day of enteral feeding and in a greater weight gain by day 30 of life. For an investigation of the clinical sequelae of parenteral lipid infusions during the first week of life, 42 neonates (less than 1750 gm birth weight) were randomly assigned to receive parenteral alimentation with (IL) (Vitrum) or without a parenteral lipid infusion (NL) for 5 days. Follow-up clinical status was monitored and compared, and plasma prostaglandin levels were analyzed. Chronic lung disease was increased in duration and tended to be more severe after lipid administration. The number of days of mechanical ventilation (37 +/- 35 vs 21 +/- 18) and supplemental oxygen therapy (51 +/- 39 vs 28 +/- 23) was significantly increased in the IL group. Five IL infants developed stage 3 bronchopulmonary dysplasia, in comparison with none of the NL infants. Seven IL infants were discharged on a regimen of supplemental oxygen therapy versus none of the NL infants. Thromboxane B2 levels were significantly increased in the babies receiving Vitrum. We conclude that early administration of Vitrum in the premature neonate is associated with increased respiratory difficulty in the ensuing weeks of life.
The results of this systematic review do not provide strong evidence for either the benefits or harms of early oxygen weaning in preterm/LBW infants. Future research should be directed toward addressing the question of what are the most appropriate target levels of oxygenation, in both the early and late neonatal periods, rather than whether oxygen should be weaned early or late.