Neonatology
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We review information about how the preterm lung can be injured with the initiation of mechanical ventilation at birth. Although multiple variables such as pressure, tidal volume, positive end expiratory pressure, and the gas used for ventilation may contribute to the injury, the relative contribution of each is not known. ⋯ A model for gas inflation of the fluid-filled lung may explain why even low tidal volumes may injure the preterm lung, and why the injury may initially occur to the small airways. Ventilation strategies that minimize injury need to be developed.
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Multicenter Study Comparative Study
Comparison of pain responses in infants of different gestational ages.
There is a plethora of infant pain measures; however, none of them have been validated for extremely low for gestational age (ELGA) infants (<27 weeks' gestation). To date, clinicians, researchers and parents use information gleaned from more mature infants to make inferences about pain in ELGA infants. Using physiological or behavioral pain indicators derived from more mature infants may lead to inaccurate assessments and management. ⋯ ELGA infants have similar pain responses to older infants, but the responses are dampened. Other factors such as severity of illness, frequency of painful procedures or medication use should be examined, as they may influence the pain responses in ELGA infants.
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Mechanical ventilatory support is required by a large number of neonates in respiratory failure. However, its use in preterm infants is frequently associated with acute complications and long-term respiratory sequelae. Therefore, it is recommended to avoid or limit the exposure to ventilatory support. This is a review of existing practices and novel strategies to achieve weaning of ventilatory support in this population.
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Newborn babies, even if extremely preterm, show responses to pain. The major stress responses seen with surgical pain are associated with serious adverse medical outcomes. There is an ethical imperative to consider pain relief in babies, despite the fact that they cannot verbalise their experience. ⋯ Topical anaesthetic creams reduce the pain response when used in anticipation of phlebotomy or vascular cannulation. Intra-oral sucrose is effective cover for procedures associated with mild to moderate distress, but its role in preterm infants is uncertain. Nursing interventions to reduce environmental stress, although commonly used, have not consistently been shown to be of benefit.
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Invasive ventilation via the endotracheal tube is one of the most common therapeutic interventions performed in preterm infants with respiratory failure. Respiratory distress syndrome (RDS) occurs in about 50% of preterm infants born at less than 30 weeks of gestational age. Mechanical ventilation using conventional or high-frequency ventilation and surfactant therapy have become the standard of care in management of preterm infants with RDS. ⋯ Randomized controlled trials comparing conventional mechanical ventilation and high-frequency ventilation, using 'optimal ventilatory strategies', have shown no significant difference in rates of BPD. Use of noninvasive ventilation, such as nasal continuous positive airway pressure and nasal intermittent positive pressure ventilation has shown a significant decrease in postextubation failure as well as reduced incidence of BPD. Optimal ventilatory strategy in preterm infants with RDS may begin in the delivery room with application of sustained inflation to establish functional residual capacity, followed by surfactant therapy and rapid extubation to noninvasive ventilation to decrease the incidence of BPD and improve overall outcome.