Healthy at risk infants failing the infant car seat challenge.  Cause for concern?

Healthy at risk infants failing the infant car seat challenge. Cause for concern?

The infant car seat challenge(ICSC) is a test which most definitely fits the definition of a battleground issue in Neonatology.  After publishing the Canadian Pediatric Practice point on the same topic I received interesting feedback through the various social media forums that I frequent.  While some were celebrating the consensus of the statement as verification that a centres’ non practice of the test was acceptable, others seriously questioned the validity of the position.  The naysayers would point out that extremely infrequent events unless intentionally tracked may be difficult to pick up.  In the case of the ICSC, if a few patients were to suffer a hypoxic event leading to an ALTE or worse after discharge, could the ICSC have picked out these babies and prevented the outcome?  The evidence for adverse events associated with the use of car seats as discussed in the position statement is poor when using autopsy records over decades but when many clinicians can point to a failed ICSC picking up events, the thought goes that they “caught one”.  Does catching one make a difference though?

The Well Appearing Infant

Shah et al in their recent paper Clinical Outcomes Associated with a Failed Infant Car Seat Challenge attempt to address this very point.  They performed a retrospective study of 148 patients who were either <37 weeks GA or < 2500g at birth.  The study was made possible by the fact that all such infants in their hospital admitted to a well newborn area meeting these criteria by policy must have an ICSC prior to discharge.  Keep in mind that these were all infants who were on the well newborn service since they were asymptomatic.  The definition of an event in this group was one or more of pulse oximeter saturation ≤ 85% for > 10 seconds, apnea > 20 seconds, bradycardia < 80 bpm for > 10 seconds, or an apnea or bradycardia event requiring stimulation.  The failure rate was 4.5% which is very similar to other reported studies.

Why did they “fail”?

  • Failure of the ICSC was owing to desaturation 59%
  • Bradycardia 37%
  • Tachypnea 4%
  • Combination of 2 in 11%

What is interesting about these results is what happened to these infants after admission to the NICU in that 39% were identified with apnea (48% in preterm vs 17% in term infants).  These events were in the supine position which is a curious finding since the ICSC was designed to find risk of cardiorespiratory stability in a semi-recumbent position.  This has been shown previously though.

What does it all mean?

The infants in this study ultimately had more NG feeding, prolonged length of stay and septic workups after failing the ICSC that comparable infants who passed.  At first blush one would read this article and immediately question the validity of the CPS position but then the real question is what has this added to the “pool of knowledge”.  That infants may fail an ICSC at a rate of 4.5% is already known.  That such infants may demonstrate apneic events has also been shown before and a study like this may help to support those clinicians who feel it is still imperative to find these infants in order to achieve a safe discharge.  I think it is important to put these findings in the context of what would have happened if such a unit did not routinely test these types of babies.  As all were seemingly well and I presume feeding with their families, they would have been discharged after 24-48 hours to home.  We have no evidence (since they have not compared this sample to a group who did not have such testing) that if these babies were discharged they would have faired poorly.

The supporters of the ICSC would point to all the support these babies received by admitting them for 6-8 days, providing NG feeding and ruling out sepsis that they were unsafe for discharge.  The other possible way to look at it was that the infants were subjected to interventions that we have no evidence helped them.  Whether any of these infants had a positive blood culture justifying antibiotics or needed methylxanthine support is not mentioned.  Judging however by the short length of stay I suspect that none or few of these infants needed such medication as I would expect they would have stayed much longer had they needed medical treatment for apnea.

Conclusion

I do commend the authors for completing the study and while it does raise some eyebrows, I don’t see it changing at least my position on the ICSC.  While they have described a cohort of patients who failed the ICSC nicely, the fundamental question has been left unanswered.  Does any of this matter?  If you look well, are feeding well and free of any clinically recognizable events but are late preterm or IUGR can the ICSC prevent harm?  This has not been answered here and perhaps the next step would be for a centre that has abandoned the ICSC to follow their patients after discharge prospectively and see whether any adverse outcomes do indeed occur.  Any takers?

 

Single Patient Room NICUs: Time to Put Parents Minds At Ease

Single Patient Room NICUs: Time to Put Parents Minds At Ease

A few days ago Nick Hall from Graham’s Foundation posted the following question on Linkedin:

Private room vs open bay for the NICU. Can always get a quote from a parent saying it is great but….? At what cost? Impact on staff? Is parent time in those NICUs greater now? Other alternatives?

Included in the post was an article discussing the benefits of such a design.  Below I will look at the benefits and risks and conclude with an answer to his last question.

The NICUs of the 1970s through late 1990s have been described as “barn like” or “open concept” but in recent years the belief that single patient rooms (SPR) would offer greater benefit to infants led to the adoption of such a unit design across North America.  The imagined benefits would be related to improved parent comfort, creating a desire for families to spend more time with their children.  As we move to a “family centred” approach to care, a key goal of all units should be to make their families as comfortable and stress free as possible in order to have a positive experience.

Detractors meanwhile,  speak of concern regarding isolation of such infants when families do not visit and moreover a risk that such infants deprived of sensory experience will have impaired development.  Last year a paper was published that did not help quell such fears; Alterations in Brain Structure and Neurodevelopmental Outcome in Preterm Infants Hospitalized in Different Neonatal Intensive Care Unit Environments (full article in link).  This study which compared infants cared for in SPR to an open unit (the hospital in this study had a mixture of both in their NICU) found a worrisome finding at 2 year follow-up in that the infants in SPR had lower scores on language and a trend towards lower motor scores as well.  Additionally, partly explaining such findings may have been differences noted at term equivalent age in both the structure and activity of the children’s brains compared to those cared for in an open environment.  We were starting construction on a new NICU at the time this paper was published and I can tell you the findings sent shockwaves through our hospital as many wondered whether this was the right decision.

Devil Is in The Details

Looking further into this study, the urban population bore little resemblance to our own.  In our hospital all women are taught how to perform skin to skin care and the majority of our mothers spend a great deal of time with their infants.  To see how successful have a look at our recent Kangaroo Care drive results! The families in this study however the average hours per week of parent visitation over the length of stay ranged from 1.8-104 hours with a mean of 19+/- 19 hours. The average number of days held per week over the length of stay was 0-6 days with a mean of 2.4 +/-1.5 days. The average number of days held skin-to-skin over the length of stay ranged from 0-4 days, with a mean of 0.7 +/- 0.9 days.  In short they were hardly there.

Second Study Finds The Opposite

Later on in 2014 a second study on this subject was published; Single-family room care and neurobehavioral and medical outcomes in preterm infants. Infants < 1500g who were admitted to an NICU between 2008 and 2012 were compared with respect to medical and neurobehavioral outcomes at discharge. Participants included 151 infants in an open-bay NICU and 252 infants after transition to a SPR NICU.

Statistically significant results (all Ps ≤.05) showed that infants in the SPR NICU weighed more at discharge, had a greater rate of weight gain, required fewer medical procedures, had a lower gestational age at full enteral feed and less sepsis, showed better attention, less physiologic stress, less hypertonicity, less lethargy, and less pain. Nurses reported a more positive work environment and attitudes in the SPR NICU.

This study in fact demonstrated greater maternal involvement in a SPR with improvement in outcomes across the board.  It would seem then that in a SPR environment, provided there is enough family visitation and involvement this model truly is superior to the open concept.  Furthermore despite concerns by some nurses that the loss of line of sight to their patients will make for a more stressful working environment this does not seem to be the case.

What About Families Who Cannot or Simply Aren’t Visiting Frequently?

The reality is that there are many reasons for parents to be absent for long periods during their newborns stay. Having a home outside of the city with other children to care for, work obligations, or loss of custody and abandonment due to apprehension are just some of these reasons.  In our hospital, at least 15-20% of all patients admitted are from outside Winnipeg.  The evidence as I see it supports the move to a SPR but what do we do for those children who need more visitation?  The solution is a cuddler program.
CuddlerAs we prepare to move to the new hospital we are grateful for the generosity of our Children’s Hospital Foundation who secured a donor to pay for a coordinator of such a program.  The coordinator’s responsibility will be to ensure that no infant goes beyond a set period of time without feeling the touch or hearing the sound of a voice.  Such a program is in fact already in place at our other tertiary hospital and was featured in a lovely article attached here.

The SPR is the right design in my mind for families with many benefits that spring forth in such an environment. This need not be a win-lose scenario for your hospital. Do not underestimate the power of a cuddler and don’t hesitate to seek support to initiate such a program.  It could mean the difference from going from good to great!