Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular hemorrhage in preterm infants

Romantsik, Olga; Calevo, Maria Grazia; Bruschettini, Matteo

doi:10.1002/14651858.cd012362.pub2

Cited by 24 publications

(15 citation statements)

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“…Maintaining a midline head position during the early transition period has been included in GMH-IVH prevention bundles at several institutions. However, so far strong data to support the practice are lacking 23 32–34. Two RCTs have been performed by the same group 35 36.…”

Section: Discussionmentioning

confidence: 99%

Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: a multicentre cohort study

Bijl-Marcus

Brouwer

Vries

et al. 2019

Arch Dis Child Fetal Neonatal Ed

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ObjectiveTo investigate the effect of a nursing intervention bundle, applied during the first 72 hours of life, on the incidence of germinal matrix-intraventricular haemorrhage (GMH-IVH) in very preterm infants.DesignMulticentre cohort study.SettingTwo Dutch tertiary neonatal intensive care units.PatientsThe intervention group consisted of 281 neonates, whereas 280 infants served as historical controls (gestational age for both groups <30 weeks).InterventionsAfter a training period, the nursing intervention bundle was implemented and applied during the first 72 hours after birth. The bundle consisted of maintaining the head in the midline, tilting the head of the incubator and avoidance of flushing/rapid withdrawal of blood and sudden elevation of the legs.Main outcome measuresThe incidence of GMH-IVH occurring and/or increasing after the first ultrasound (but within 72 hours), cystic periventricular leukomalacia and/or in-hospital death was the primary composite outcome measure. Logistic regression analysis was used to explore differences between groups.ResultsThe nursing intervention bundle was associated with a lower risk of developing a GMH-IVH (any degree), cystic periventricular leukomalacia and/or mortality (adjusted OR 0.42, 95% CI 0.27 to 0.65). In the group receiving the bundle, also severe GMH-IVH, cystic periventricular leukomalacia and/or death were less often observed (adjusted OR 0.54, 95% CI 0.33 to 0.91).ConclusionsThe application of a bundle of nursing interventions is associated with reduced risk of developing a new/progressive (severe) GMH-IVH, cystic periventricular leukomalacia and/or mortality in very preterm infants when applied during the first 72 hours postnatally.

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Section: Discussionmentioning

confidence: 99%

Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: a multicentre cohort study

Bijl-Marcus

Brouwer

Vries

et al. 2019

Arch Dis Child Fetal Neonatal Ed

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“…Although with no definitive answer, preterm infants, because of the risk of germinal matrix-intraventricular hemorrhage and the effect of head position on jugular venous drainage, should lie with the head in midline position, at least when the risk of hemorrhage is greatest, that is, during the first three days of life [ 34 ].…”

Section: Positioning the Patientmentioning

confidence: 99%

Respiratory Care for the Ventilated Neonate

Rocha¹,

Soares

Gonçalves³

et al. 2018

Canadian Respiratory Journal

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Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.

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“…As the internal jugular veins are the major blood outflow tract of the brain, turn of the head associated compromise of the venous blood drainage might lead to venous congestion, increased intracranial pressure, reduced cerebral oxygenation, and ultimately germinal matrix IVH ( de Bijl-Marcus et al, 2017 ). Therefore, the head midline position has been advocated for many years for preventing the occurrence or extension of IVH in routine neonatal care, but an updated Cochrane systematic review was unable to support this approach due to a lack of adequate studies ( Romantsik et al, 2017 ). In routine care of the respiratory and hemodynamically stable mature infant, however, prone position is preferred for reasons of improved oxygenation (secondary to augmented functional residual capacity) ( Bhat et al, 2003 ), saturation stability ( Heimann et al, 2010 ), airway patency ( Francois et al, 1992 ), drainage of oropharyngeal secretions ( Pickens et al, 1989 ; Waisman, 2006 ), reduction in obstructive apnea ( Heimann et al, 2010 ), and improved quality of sleep ( Bhat et al, 2006 ).…”

Section: Introductionmentioning

confidence: 99%

Supine vs. Prone Position With Turn of the Head Does Not Affect Cerebral Perfusion and Oxygenation in Stable Preterm Infants ≤32 Weeks Gestational Age

2018

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Intraventricular hemorrhage (IVH) is a frequent major damage to the brain of premature babies ≤32 weeks gestational age, and its incidence (20–25%) has not significantly changed lately. Because of the intrinsic fragility of germinal matrix blood vessels, IVH occurs following disruption of subependymal mono-layer arteries and is generally attributed to ischemia-reperfusion alterations or venous congestion, which may be caused by turn of the head. Therefore, supine position with the head in a midline position is considered a standard position for preterm infants during their first days of life. We asked whether a change in body position (supine vs. prone) linked with a turn of the head by 90° in the prone position would change blood flow velocities and resistance indices in major cerebral arteries and veins of stable premature babies at two different time points (t0, day of life 2, vs. t1, day 9). Moreover, we assessed cerebral tissue oxygenation (cStO2) by near-infrared spectroscopy and determined correlations for changes in velocities and oxygenation. Twenty one premature infants [gestational age 30 (26–32) weeks] with sufficiently stable gas exchange and circulation were screened by ultrasonography and near-infrared spectroscopy. Peak systolic and end-diastolic blood flow velocities in the anterior cerebral arteries (29 ± 6 m/s vs. 28 ± 7 peak flow at t0, 36 ± 8 vs. 35 ± 7 at t1), the basilar artery, the right and the left internal carotid artery, and the great cerebral vein Galen (4.0 ± 0.8 m/s vs. 4.1 ± 1.0 maximum flow at t0, 4.4 ± 0.8 vs. 4.4 ± 1.0 at t1) did not show significant differences following change of body and head position. Also, there were no differences in cStO2 (83 ± 7% vs. 84 ± 7 at t0, 76 ± 10 vs. 77 ± 11 at t1) and in vital signs such as heart rate and blood pressure. We conclude that change in body position with turn of the head in the prone position does not elicit significant alterations in cerebral blood flow velocities or in oxygenation of cerebral tissues. Maturational changes in arterial flow velocities and cStO2 are not correlated. For this subgroup of premature infants at low risk of IVH our data do not support the concept of exclusive preterm infant care in supine position.

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Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular hemorrhage in preterm infants

Abstract: Given the imprecision of the estimate, results of this systematic review are consistent with beneficial or detrimental effects of a supine head midline position versus a lateral position and do not provide a definitive answer to the review question.

Cited by 24 publications

References 50 publications

Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: a multicentre cohort study

Neonatal care bundles are associated with a reduction in the incidence of intraventricular haemorrhage in preterm infants: a multicentre cohort study

Respiratory Care for the Ventilated Neonate

Supine vs. Prone Position With Turn of the Head Does Not Affect Cerebral Perfusion and Oxygenation in Stable Preterm Infants ≤32 Weeks Gestational Age

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