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Clinical Paper

Changes over time in delivery room management of extremely low birth weight infants in Italy Daniele Trevisanuto a,∗ , Irene Satariano a , Nicoletta Doglioni a , Giulio Criscoli b , Francesco Cavallin c , Camilla Gizzi d , Claudio Martano e , Fabrizio Ciralli f , Flaminia Torielli g , Paolo Ernesto Villani h , Sandra Di Fabio i , Lorenzo Quartulli j , Luigi Giannini k , on Behalf of Neonatal Resuscitation Study Group, Italian Society of Neonatology a

Children and Women’s Health Department Medical School, University of Padua, Azienda Ospedaliera Padova, 35128 Padua, Italy Italian Army – Signals and Information Technology HQ – C4 Systems Integration Development, Treviso, Italy c Independent Statistician, Padua, Italy d Neonatal Intensive Care Unit, Pediatric and Neonatal Department, “S.Giovanni Calibita” Fatebenefratelli Hospital – Isola Tiberina, 00186 Rome, Italy e Neonatal Intensive Care Unit, Pediatric Department, Medical School, University of Turin, Azienda Ospedaliera, OIRM-S.Anna, 10126 Torino, Italy f Neonatal Intensive Care Unit, Department of Mother and Infant Science, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, University of Milan, 20122 Milan, Italy g Neonatology Unit, University of Genova, Azienda Ospedaliera San Martino IRCCS – IST National Institute on Cancer Research, 16100 Genova, Italy h Neonatal Intensive Care Unit, Maternal and Pediatric Department, Carlo Poma Hospital, Mantova, Italy i Neonatal Intensive Care Unit, Department of Mother and Infant Science, “San Salvatore” Hospital, L’Aquila, Italy j Neonatology Unit, “A. Perrino” Hospital – ASL, 72100 Brindisi, Italy k Pediatric Department, Medical School University “La Sapienza” Rome, Azienda Ospedaliera Policlinico Umberto I, 00161 Rome, Italy b

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Article history: Received 30 January 2014 Accepted 26 April 2014 Keywords: Delivery room Guidelines, infant, newborn Premature Resuscitation Survey

a b s t r a c t Aim: To identify changes in practice between two historical periods (2002 vs. 2011) in early delivery room (DR) management of ELBWI in Italian tertiary centres. Methods: A questionnaire was sent to the directors of all Italian level III centres between April and August 2012. The same questionnaire was used in a national survey conducted in 2002. Among the participating centres, those that filled the questionnaire in both study periods were selected for inclusion in this study. Results: There was an 88% (n = 76/86) and 92% (n = 98/107) response rate in the 2 surveys, respectively. The two groups overlapped for 64 centres. During the study period, the use of polyethylene bags/wraps increased from 4.7% to 59.4% of the centres. The units using 100% oxygen concentrations to initiate resuscitation of ELBWI decreased from 56.2% to 6.2%. The approach to respiratory management was changed for the majority of the examined issues: positive pressure ventilation (PPV) administered through a Tpiece resuscitator (from 14.0% to 85.9%); use of PEEP during PPV (from 35.9% to 95.3%); use of CPAP (from 43.1% to 86.2%). From 2002 to 2011, the percentages of ELBWI intubated in DR decreased in favor of those managed with N-CPAP; ELBWI receiving chest compressions and medications at birth were clinically comparable. Conclusions: During the two study periods, the approach to the ELBWI at birth significantly changed. More attention was devoted to temperature control, use of oxygen, and less-invasive respiratory support. Nevertheless, some relevant interventions were not uniformly followed by the surveyed centres. © 2014 Published by Elsevier Ireland Ltd.

1. Introduction

Abbreviations: CPAP, continuous positive airway pressure; DR, delivery room; ELBWI, extremely low birth weight infant; PEEP, positive end expiratory pressure; PIP, positive inspiratory pressure. ∗ Corresponding author at: Children and Women’s Health Department Medical School, University of Padua, Azienda Ospedaliera di Padova, Via Giustiniani, 3, 35128 Padua, Italy. E-mail address: [email protected] (D. Trevisanuto).

Approximately 5–10% of newborns require some assistance to begin breathing at birth; about 3% are managed with positive pressure ventilation (PPV) and less than 1% requires extensive resuscitative measures; these percentages noticeably rise when referred to preterm infants.1–3 Some interventions, such as the use of polyethylene/ polyurethane wrapping,4,5 titrating inspiratory fraction of oxygen,6

http://dx.doi.org/10.1016/j.resuscitation.2014.04.024 0300-9572/© 2014 Published by Elsevier Ireland Ltd.

Please cite this article in press as: Trevisanuto D, et al. Changes over time in delivery room management of extremely low birth weight infants in Italy. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.024

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and the use of non-invasive ventilation have been recently evaluated in prospective randomized clinical trials.7 An increasing body of evidence suggests that these interventions in the delivery room (DR) management of extremely low birth weight infants (ELBWI) may have a direct influence on the immediate survival and also on long-term morbidity.3,8,9 Therefore, the general outcome might be improved throughout a structured and well coded approach starting from the first minutes of life. International clinical guidance describes a standardized approach to newborn resuscitation in the DR and national clinical algorithms are guided by these consensus statements.1,10,11 However, a few large studies have examined the consistency of practice and the adherence to the International Guidelines in early DR management.11–15 In 2002, we conducted a survey on the approach to neonatal resuscitation of ELBWI at the Italian level III centres.15 The data showed that the DR management of these infants was very different across the Italian tertiary centres, reflecting a paucity of evidence and consequent uncertainty among clinicians. Since then, two iterations of the International Liaison Committee on Resuscitation (ILCOR) guidelines for neonatal resuscitation have been released, the most recent of which in 2010.1,16 In these versions, the body of recommendations devoted to neonatal resuscitation of ELBWI has been progressively increasing. In 2012, we conducted a second national survey in order to verify the compliance of level III centres with the new guidelines. To obtain a reliable comparison in overall attitude over time, we focused on those centres that participated in both surveys. Our aim was to identify changes in early DR management of ELBWI in Italy over a period of approximately ten years (2002–2011).

2.2. Statistics Categorical data are expressed as number and percentage, continuous data as median and interquartile range (IQR). Statistical analysis was performed using R 2.12 language. Statistical comparisons between the two periods were not performed due to the nature of the study. In fact, it can be defined as “voluntary inquiry with presence of non-respondents”. It’s neither a sample for an infinite population nor a sample chosen from a finite population (a proper survey). Therefore, comparisons using statistical inferential methods are not needed. The study was approved by the Human Research Ethics Committee of the Azienda Ospedaliera di Padova, University of Padua. 3. Results A total response rate of 87% (n = 76/86) and 92% (n = 98/107) was obtained for the first (2002) and second (2011) historical period, respectively. 3.1. Characteristics of centres Sixty-four centres participated in both surveys. Their characteristics are shown in Table 1. There was an increase of the total number of ELBWI from 2002 to 2011. Medical staff (physicians and nurses) also increased, but it was proportional to ELBWI increment, as shown by the relative ratios in Table 1. The organizational aspects were similar in the two periods. A Pediatrician/Neonatologist was the team leader for neonatal resuscitation in both periods in most centres (57/64, 89.1%). 3.2. Temperature management

2. Methods 2.1. Participants and evaluation instrument A structured 73 item questionnaire in Italian and an accompanying introductory letter were sent by email to the directors of the 107 Italian level III centres provided with on site delivery (Italian Society of Neonatology database). A reminder was sent to non responders every 2 weeks for a maximum of three times. At that point, if we had not received an answer yet, the participant was contacted by phone by an investigator (IS) and a new email was sent. Participation was entirely voluntary. The survey was conducted between April and August 2012. The survey focused on establishing the current DR practices in the domains of neonatal resuscitation: thermal control, oxygen therapy, positive pressure ventilation (PPV), surfactant treatment, chest compressions and medications. The questionnaire included items on the epidemiological and organizational characteristics of the centre, the equipment and practice of the centre, and questions referred to the neonatal resuscitation of the ELBWIs during the period 1 January to 31 December 2011. Participants gathered the data using local medical records or databases. The questions included multiple choice, fill in, and yes/no questions. The same questionnaire was used in a national survey conducted in 2002, with the exclusion of 3 questions about “Use of cap”, “Use of saturation targets” and “Use Sustained Lung Inflation”.15 In the two study periods (2002 and 2011), there were two different populations (n = 86 and n = 107) of the Italian level III centres based on the Italian Society of Neonatology database. Among the participating centres, those that filled the questionnaire in both study periods were selected for inclusion in this analysis.

DR temperatures were comparable between the two periods, with a median of 24 ◦ C (Table 2). The use a polyethylene bag/wrap for the management of ELBWI at birth increased from 4.7% (3/64) in 2002 to 59.4% (38/64) in 2011. A cap was widely used to cover the head of the patients at birth in 2011 (43/64, 67.2%), but this information was not available in 2002 (Table 2). 3.3. Oxygen therapy The rate of centres using 100% oxygen to initiate resuscitation decreased from 56.3% (36/64) to 6.3% (4/64) and the rate of those using >40% oxygen decreased from 76.6% (49/64) to 9.4% (6/64). The use of pulse oxymeter increased from 71.9% (46/64) to 95.3% (61/64). Most centres (58/64, 90.6%) declared to use saturation Table 1 Characteristics of centres in the two study periods. Period of study

2002

2011

Participating centres Total births at surveyed centres Total VLBWI born at surveyed centres Total ELBWI born at surveyed centres Births/centre* ELBWI admitted* Physicians* Nurses* Ratio physicians/ELBWI* Ratio nurses/ELBWI* Team leader for neonatal resuscitation: Pediatrician/Neonatologist Anesthesiologist

64 126,897 2796 1169 1560 (1278–2594) 17 (10–23) 9 (7–12) 26 (17–30) 0.61 (0.40–0.80) 1.51 (1.18–2.29)

64 137,504 3608 1388 1850 (1349–2664) 19 (13–27) 11 (8–12) 27 (21–34) 0.57 (0.41–0.78) 1.45 (1.03–1.96)

59 (92.1) 5 (7.9)

62 (96.8) 2 (3.2)

Data expressed as n (%) or *median (IQR).

Please cite this article in press as: Trevisanuto D, et al. Changes over time in delivery room management of extremely low birth weight infants in Italy. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.024

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2002

2011

64 64 Participating centres 24 (22–25) 24 (23–25) DR temperature (◦ C)* Use polyethylene bags/wrap Do not use in both surveys 26 (40.6) 3 (4.7) Use in both surveys Started using after 2002 35 (54.7) NA 43 (67.2) Use cap to cover head Start resuscitation with oxygen concentrations 40% Use pulse oxymeter Do not use in both surveys 3 (4.7) 46 (71.9) Use in both survey Stopped using after 2002 0 15 (23.4) Started using after 2002 NA 58 (90.6) Use of saturation targets Data expressed as n (%) or median (IQR). NA: not available.

targets during neonatal resuscitation of ELBWI in 2011, but this information was not available in 2002 (Table 2). 3.4. Ventilatory support The approach to ventilation also showed important changes from 2002 to 2011 (Table 3). There was an increase in using T-piece device for PPV administration (from 15.6% to 85.9%) and in using the facial mask as initial interface (from 79.0% to 96.8%). The use of PEEP during PPV rose from 2002 to 2011 (from 35.9% to 95.3%), as well as PEEP and PIP values (numerical data in Table 3). The use of sustained lung inflation was reported by 49 centres (76.6%) in 2011, but this information was not available in 2002. Only three centres stated to monitor the delivered tidal volume during PPV in 2011. The use of continuous positive airway pressure (CPAP) showed a recent large increment from 44.8% in 2002 to 86.2% in 2011. The strategy and the route of intubation were substantially unchanged from 2002 to 2011. The first was based on individual characteristics in 49 centres (76.6%) in both periods; the second held steady in 56 centres (90.3%) in both periods. There was a decrease of the percentage of ELBWI intubated at birth (from a median of 82.5% to 60.0%) and an increase of the percentage of ELBWI receiving only N-CPAP at birth (from a median of 0.0% to 20.0%), whereas the percentage of ELBWI left without any respiratory support at birth was similar in the two periods (median of 0.0% and 4.0%, respectively). 3.5. Chest compressions and medications

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Our data show that many of the new recommendations from the International Guidelines for Neonatal Resuscitation, especially those regarding respiratory management and monitoring, have been implemented by a large number of units during the two study periods. This improvement could be explained by some factors: (a) DR care for preterm infants has received little attention in original newborn-resuscitation protocols in the past, but since 2006 the Neonatal Resuscitation Program textbook included a chapter dedicated to DR care of preterm infants with several new recommendations related to resuscitation practices;17 (b) some interventions, such as the use of polyethylene/polyurethane wrapping,4,5 titrating inspiratory fraction of oxygen,6,8 the use of non-invasive ventilation have been recently evaluated in prospective randomized clinical trials allowing to reach recommendations with high level of evidence reported in the last versions of International Guidelines for Neonatal Resuscitation;1 (c) the Study Group on Neonatal Resuscitation of the Italian Society of Neonatology has strongly supported educational programs in this field over the past decade.10 Nevertheless, some interventions with a strong evidence base are not uniformly adopted and need to be reinforced. The important data gathered during this study will allow individual units to review their practice over time and to compare their approach to ELBWI at birth with similar units across Italy. 4.1. Thermal control Although International Guidelines for Neonatal Resuscitation and Word Health Organization recommend to maintain delivery room temperature at ≥26 ◦ C,1,18,19 the median temperature in involved tertiary centres was 24 ◦ C. These data are similar to those reported in a recent Canadian survey where only 61% of responders declared to adjust DR temperature to 25–26 ◦ C.11 It is encouraging to see that the management of preterm infants, arguably those likely to benefit the most from good DR practice, shows some convergence in several areas, but it’s surprising that a simple, lowcost, and evidence base practice, such as the use of a polyethylene bag/wrap for thermal loss prevention, was routinely used in only half of the surveyed units. The use of polyethylene bags/wraps increased from 2002 (4.7%) to 2011 (59.4%), but this practice needs to be further implemented since the positive effect of a polyethylene bag/wrap on reducing thermal loss in DR has been clearly demonstrated by randomized clinical trials.4,5 A recent survey in UK showed that almost the totality of the responding centres used occlusive plastic bags/wraps to reduce the risk of hypothermia.14 It’s interesting to note that the majority of the centres (67.2%) declared to cover the infant’s head with a cap, but this practice (and the best material of the cap) has not been studied specifically.20 4.2. Oxygen

Techniques for chest compressions and routine placement of an intravenous line were quite similar in the two periods, as well as the percentage of ELBWI who received chest compressions at birth (median of 12.5% in 2002 and 11.8% in 2011). The percentage of ELBWI who received medications at birth slightly increased from a median of 3.7% in 2002 to 7.1% in 2011 (Table 4).

For the majority of the centres, oxygen supplementation during initial PPV and oxygenation monitoring were in agreement with the 2010 International Guidelines for Neonatal Resuscitation and the national Italian recommendations.1,10 Furthermore, these data were similar to those reported by a recent Canadian survey.14 Of note, only 6.2% of centres still use 100% oxygen suggesting that this recommendation has been widely accepted by neonatologists.

4. Discussion

4.3. Positive pressure ventilation

This study explores the changes in ELBWI management at birth in Italian tertiary centres during a period of ten years.

A recent study showed that many obstetric and neonatal care practices used in the management of infants 501 to 1500 g changed

Please cite this article in press as: Trevisanuto D, et al. Changes over time in delivery room management of extremely low birth weight infants in Italy. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.024

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2002

2011

Participating centres PPV administered through a Self-inflating bag in both surveys T-piece in both surveys Switched from self-inflating bag to T-piece Switched from T-piece to self-inflating bag Initial interface for PPVa Facial mask in both surveys Endotracheal tube in both surveys Switched from tube to mask Switched from mask to tube Use PEEP with PPV Do not use in both surveys Use in both survey Stopped using after 2002 Started using after 2002 PEEP value* PIP value* Use sustained lung inflation Use CPAP to avoid intubationb No in both surveys Yes in both surveys Stopped after 2002 Started after 2002 Intubation based on individual strategy No in both surveys Yes in both surveys Stopped after 2002 Started after 2002 Route of intubationa Nasal in both surveys Oral in both surveys Switched from nasal to oral Switched from oral to nasal Percentage of ELBWI intubated at birth* Percentage of ELBWI receiving only N-CPAP at birth* Percentage of ELBWI left without any respiratory support*

64

64

8 (12.5) 9 (14.0) 46 (71.9) 1 (1.6) 48 (77.4) 1 (1.6) 12 (19.4) 1 (1.6) 3 (4.7) 23 (35.9) 0 38 (59.4) 4 (3–4) 18 (15–20) NA

5 (4–5) 20 (18–20) 49 (76.6)

7 (12.1) 25 (43.1) 1 (1.7) 25 (43.1) 3 (4.7) 49 (76.6) 4 (6.2) 8 (12.5) 27 (43.5) 29 (46.8) 4 (6.5) 1 (3.2) 82.5 (70.0–98.5) 0.0 (0.0–10.0) 0.0 (0.0–8.0)

60.0 (42.5–76.0) 20.0 (5.0–44.0) 4.0 (0.0–8.0)

Data expressed as n (%) or median (IQR). NA: not available. a Data not available in 2 centres. b Data not available in 6 centres.

between 2000 and 2009. In particular, less-invasive approaches to respiratory support increased.21 Also in this study we found a significant shift to a “gentle” approach between the two study periods: use of T-piece devices instead of self-inflating bags; decrease in the use of endotracheal tube as initial interface for PPV, use of CPAP to avoid intubation. In agreement with recent clinical studies evaluating the DR respiratory management of very preterm infants,7,21 there was an increment of nasal-CPAP support. Although there is insufficient evidence to recommend an optimum inflation time,1 the majority of the centres (76.6%) declared to use sustained lung

inflation for initial respiratory support. More evidence is needed to recommend this practice.22 4.4. Chest compressions and medication Our data show that a relatively large proportion of the ELBWI born at Italian tertiary centres received chest compressions. These percentages did not change over time. As they are higher than those reported in other studies,21,23 this approach needs further evaluation.

Table 4 Chest compressions, medications and fluid management. Period of study

2002

2011

Participating centres Chest compression techniquea BT/TT in both surveys TF in both surveys Switched from BT/TT to TF Switched from TF to BT/TT Percentage of ELBWI who received chest compressions at birth* Percentage ELBWI who received medications at birth* Routine placement on IV line in DR NO in both surveys YES in both surveys Stopped after 2002 Started after 2002

64

64

35 (59.3) 2 (3.4) 10 (17.0) 12 (20.3) 12.5 (0.0–23.3) 3.7 (0.0–25.0)

11.8 (4.0–25.9) 7.1 (0.0–15.4)

48 (75.0) 2 (3.2) 7 (10.9) 7 (10.9)

Data expressed as n (%) or median (IQR). a BT = both techniques, TT = Two Thumbs technique, TF = Two-Finger technique; data not available in 5 centres.

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There are some limitations to this study design. Although the response rates were high in both surveys (87% and 92%, respectively), we included in the analysis only the data of the two overlapping subsets (n = 64). With this approach, we understand that the results do not necessarily reflect the management of ELBWI at birth in whole country. However, we have obtained reliable information on changes in overall attitude over time. In fact, almost a quarter of all births and half of ELBWI births in Italy occurred in this group of 64 delivery wards. Because we involved only the directors of the participating centres, the actual practices of individual providers may not be represented. However, a consistent part of the information obtained in this survey is related to available equipment and intent to use different practices. This study involved only tertiary units; the approach to DR management of ELBWI can be different in level I and II Italian centres. However, the majority of ELBWI in Italy was born at tertiary units. The data on ELBWI who were resuscitated in the centres were retrospectively collected limiting the quality of this information. 5. Conclusions In conclusion, our study is the first to assess the consistency of practice and the adherence to the International Guidelines in early DR management of ELBWI over time. During the two study periods, the approach to the ELBWI at birth significantly changed suggesting a good compliance with the International Guidelines for Neonatal Resuscitation. More attention was devoted to temperature control, use of oxygen, and less-invasive respiratory support. The availability of new evidence based recommendations and national protocols may have contributed to these results. Nevertheless, some relevant interventions were not uniformly followed by the surveyed centres. Factors contributing to such discordance remain unclear and need to be investigated in future studies. Contributors DT conceived and designed the study. He drafted the initial manuscript, revised it for important intellectual content, and approved the final manuscript as submitted. IS and ND prepared the questionnaire and sent it to the Centres, contributed to interpretation of data, revised the manuscript and approved the final manuscript as submitted. GC, FC carried out the analyses, contributed to interpretation of data, revised the manuscript and approved the final manuscript as submitted. CG, CM, FC, FT, PEV, SdF, LQ and LG designed the data collection instruments, contributed to data collection at the sites, contributed to interpretation of data, critically reviewed the manuscript, and approved the final manuscript as submitted. Conflict of interest statement None. Funding The project was done with no specific support.

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Acknowledgements We acknowledge Dr Matteo Parotto for revising the manuscript, and the heads of the participating centres for their assistance with this survey. References 1. Kattwinkel J, Perlman JM, Aziz K, et al. American Heart Association. Neonatal resuscitation: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics 2010;126:e1400–13. 2. Perlman JM, Risser R. Cardiopulmonary resuscitation in the delivery room: associated clinical events. Arch Pediatr Adolesc Med 1995;149:20–5. 3. Vento M, Cheung PY, Aguar M. The first golden minutes of the extremely-lowgestational-age neonate: a gentle approach. Neonatology 2009;95:286–98. 4. Vohra S, Roberts RS, Zhang B, Janes M, Schmidt B. Heat Loss Prevention (HELP) in the delivery room: a randomized controlled trial of polyethylene occlusive skin wrapping in very preterm infants. J Pediatr 2004;145:750–3. 5. McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S. Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Syst Rev 2010. CD004210. 6. Gandhi B, Rich W, Finer N. Achieving targeted pulse oximetry values in preterm infants in the delivery room. J Pediatr 2013;163:412–5. 7. Carlo WA. Gentle ventilation: the new evidence from the SUPPORT, COIN, VON, CURPAP, Colombian Network, and Neocosur Network trials. Early Hum Dev 2012;88(Suppl. 2):S81–3. 8. Davis PG, Dawson JA. New concepts in neonatal resuscitation. Curr Opin Pediatr 2012;24:147–53. 9. Vento M, Saugstad OD. Resuscitation of the term and preterm infant. Semin Fetal Neonatal Med 2010;15:216–22. 10. Trevisanuto D, Gizzi C, Martano C, et al. Oxygen administration for the resuscitation of term and preterm infants. J Matern Fetal Neonatal Med 2012;25(Suppl. 3):26–31. 11. El-Naggar W, McNamara PJ. Delivery room resuscitation of preterm infants in Canada: current practice and views of neonatologists at level III centers. J Perinatol 2012;32:491–7. 12. O’Donnell CPF, Davis PG, Morley CJ. Positive pressure ventilation at neonatal resuscitation: review of equipment and international survey of practice. Acta Paediatr 2004;93:583–8. 13. Leone TA, Rich W, Finer NN. A survey of delivery room resuscitation practices in the United States. Pediatrics 2006;117:e164–75. 14. Mann C, Ward C, Grubb M, et al. Marked variation in newborn resuscitation practice: a national survey in the UK. Resuscitation 2012;83:607–11. 15. Trevisanuto D, Doglioni N, Ferrarese P, Bortolus R, Zanardo V, on behalf of the Neonatal Resuscitation Study Group, Italian Society of Neonatology. Neonatal resuscitation of extremely low birthweight infants: a survey of practice in Italy. Arch Dis Child Fetal Neonatal Ed 2006;91:F123–4. 16. American Heart Association, American Academy of Pediatrics. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: neonatal resuscitation guidelines. Pediatrics 2006;117:e1029–38. 17. Kattwinkel J, editor. Textbook of neonatal resuscitation. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics and American Heart Association; 2006. 18. Department of Reproductive Health and Research, World Health Organization. Maintaining normal body temperature (Section C-1). In: Managing newborn problems: a guide for doctors, nurses, and midwives. Geneva: World Health Organization; 2003. 19. Kent AL, Williams J. Increasing ambient operating theatre temperature and wrapping in polyethylene improves admission temperature in premature infants. J Paediatr Child Health 2008;44:325–31. 20. Trevisanuto D, Doglioni N, Cavallin F, Parotto M, Micaglio M, Zanardo V. Heat loss prevention in very preterm infants in delivery rooms: a prospective, randomized, controlled trial of polyethylene caps. J Pediatr 2010;156:914–7. 21. Soll RF, Edwards EM, Badger GJ, et al. Obstetric and neonatal care practices for infants 501 to 1500 g from 2000 to 2009. Pediatrics 2013;132:222–8. 22. Dani C, Lista G, Pratesi S, et al. Sustained lung inflation in the delivery room in preterm infants at high risk of respiratory distress syndrome (SLI STUDY): study protocol for a randomized controlled trial. Trials 2013;14:67. 23. Finer NN, Horbar JD, Carpenter J. Cardiopulmonary resuscitation in very low birth weight infants: The Vermont Oxford Network Experience. Pediatrics 1999;104:428–34.

Please cite this article in press as: Trevisanuto D, et al. Changes over time in delivery room management of extremely low birth weight infants in Italy. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.04.024

Changes over time in delivery room management of extremely low birth weight infants in Italy.

To identify changes in practice between two historical periods (2002 vs. 2011) in early delivery room (DR) management of ELBWI in Italian tertiary cen...
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