The next big thing… for little things

Susan Niermeyer, MD, MPH, FAAP University of Colorado Children’s Hospital Colorado Aurora, CO USA

Womb with a view

Partridge EA et al. Nature Communications 2017; 8:15112

The next big thing?

The next big thing….for little things

Bundles of interventions around birth to reduce mortality and morbidity • Significance of supporting physiological transition • Evidence for widespread effectiveness and impact of

bundles of care • Framework of community and family

Origins of neonatal care technology and intervention

Dr. Martin Couney’s incubators – 1901

Supporting physiologic transition T + A B C

Temperature

Airway

Breathing

Circulation

Temperature

• Temperature < 36⁰C at birth is an independent risk factor for death in premature infants

• Evidence from 36 observational studies • Low quality evidence upgraded to moderate due to effect

size, dose-effect relationship, single direction of evidence

• Hypothermia is associated with morbidities • Respiratory distress • Metabolic derangements - hypoglycemia • Intraventricular hemorrhage • Late-onset sepsis

hypothermia increases risk of death and morbidity in premature infants

Mullany LC et al. Arch Pediatr Adolesc Med 2010;164:650 Laptook AR et al Pediatrics 2007119:e643

Bundles of interventions to support physiologic transition

• Maintain normal temperature Plastic wrap, hat, thermal mattress, skin-to-skin contact

• Establish an airway as non-invasively as possible

• No routine suction • No routine intubation for

meconium • CPAP instead of routine

intubation and surfactant • Support breathing with low

supplemental oxygen (21-30%) • Facilitate circulation with

delayed umbilical cord clamping

Improving delivery room care for very preterm infants in a single hospital

Axillary temperature at admission to NICU

Endotracheal intubation without trial of CPAP (%infants)

Supplemental oxygen percent at 5 minutes after birth

DeMauro SB et al. Pediatrics 2013

Prevent heat loss

Reduce supplemental oxygen exposure

Increase non-invasive respiratory support

Improving delivery room care for very preterm infants

Outcome Epoch 1 Epoch 2 P-value

Duration of invasive ventilation (days)

5 (1, 31) 1 (0, 3) 0.008

Duration of non-invasive ventilation (days)

26 (8, 39) 18 (3, 30) 0.04

Supplemental oxygen at 36 wks

16 (24%) 15 (22%) 0.76

Postnatal steroid treatment of lung disease

12 (17%) 2 (3%) 0.004

Length of hospitalization (days)

80 (59, 100) 60 (50, 80) 0.02

DeMauro SB et al. Pediatrics 2013

Data shown as n (%) or median (interquartile range)

Improving delivery room care for preterm infants in a quality collaborative

• 3 groups of hospitals in California Perinatal Quality Care Collaborative: face-to-face collaboration (20), individual QI (31), non-participating (44)

• Improvement activities focusing on reducing hypothermia and invasive ventilatory support

____ collaboration - - - - individual QI ……. non-participating

Lee HC et al. Pediatrics 2014

Evidence-based practice to improve survival without severe morbidity EPICE population-based cohort of very preterm

infants

Effective Perinatal Intensive Care in Europe • 19 regions from 11

European countries • 850,000 annual births • 7336 infants born

between 24 and 31+6 weeks gestation in 2011/12

Zeitlin J et al. BMJ 2016; 354:i2976

Evidence-based practice to improve survival without severe morbidity EPICE population-based cohort of very preterm

infants

Zeitlin J et al. BMJ 2016; 354:i2976

Evidence-based practice to improve survival without severe morbidity EPICE population-based cohort of very preterm

infants • Only 58.3% (n=4275) of infants received all

evidence-based practices for which they were eligible

• Evidence-based care associated with o Lower in-hospital mortality

(risk ratio 0.72, 95% CI 0.60 - 0.87) o Lower in-hospital mortality or severe morbidity or both

(risk ratio 0.82, 95% CI 0.73 – 0.92) • Estimated 18% decrease in all deaths without

severe morbidity if evidence-based care provided to all infants

Zeitlin J et al. BMJ 2016; 354:i2976

Wrapping bundles of care in family and community

social determinants of health

Lorch SA. JAMA Pediatrics 2017

Neighborhood Built environment

Health and Health care

Economic stability

Education Social and

community context

Delivering bundles of care in a broader systems context

Temperature Airway Breathing Circulation

Planning, collaboration, education, access

Family - integrated care

The next big thing…for little things