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Placing preterm infants on their side appears to improve oxygenation and breathing patterns after1 ,2 and at birth.3 Current neonatal guidelines do not recommend any particular position,4 but previous guidelines5 ,6 suggested that infants could either be placed on their back or their sides during resuscitation or stabilisation. Preterm infants have floppy airways that may exacerbate respiratory distress leading to the assumption in this randomised controlled trial (RCT) that placing preterm infants on their left side would increase aeration and oxygenation even if advanced respiratory care, including continuous positive airway pressure (CPAP) and intubation, were required.
The RCT was conducted in the delivery rooms of three tertiary-level hospitals in Ireland, the Netherlands and Australia. Infants below 32 weeks of gestation were randomised in a 1:1 ratio to be placed on their backs or the left side after birth. They were stratified by gestation (<28 and 28–31+6 weeks) and by mode of delivery (caesarean and vaginal birth). At birth, preductal SpO2 was monitored and babies were stabilised according to recommended ILCOR4 and local guidelines. Infants requiring respiratory support were either placed on CPAP or positive pressure ventilation (PPV) with the Neopuff T-piece device, set at 25 cm H2O peak inspiratory pressure (PIP) and 5 cm H2O positive end-expiratory pressure (PEEP). FiO2 delivery was initiated at 0.30 and not increased until 5 min of age, regardless of SpO2. At 5 min, if SpO2 was <70%, FiO2 was increased by 0.10 every minute, aiming for SpO2 of ≥90% at 10 min of age. Infants were placed on their back for intubation and/or external cardiac massage (ECM) but returned to their assigned positions after they were stabilised. Two brands of oximeters were used: Masimo Radical and Nellcor Oximax (in the Netherlands).
The primary outcome of this study was SpO2 at 5 min of age. A total of 87 infants (41 back and 46 left side, LS) were recruited. The groups were similar in gestation (mean 28 weeks), birth weight (mean 1.1 kg) and delivery methods. There were three protocol violations where one back and two LS infants received FiO2 of 0.21 and one back and two LS infants received FiO2 of 1.0. PPV was given to 18 back and 16 LS infants (p=0.293) whereas 13 back and 22 LS infants were intubated (p=0.336) and 1 back and 2 LS infants were given ECM (p=1.000). The primary outcome of SpO2 at 5 min was not different (back=72%, LS=71%, p=0.956). Seven back and four LS infants died before hospital discharge (p=0.345). No difficulties were reported in providing CPAP or PPV to the LS infants.
This is a novel RCT examining a physiologically sound hypothesis. Older children and adults who need resuscitation are placed on their sides (ie, the recovery position) if spontaneously breathing. Coupled with the lax airways and pulmonary immaturity, one would have expected that this strategy to have improved SpO2 in preterm infants. However, there were no differences found in this study, which was initially powered to examine a 10% higher SpO2 at 5 min for LS infants. Optimum SpO2 targets for preterm infants during the first critical minutes of life are some of the biggest knowledge gaps in current resuscitation practice.4 The SpO2 targets used in this study, which were based on a previous study by the same group,7 are lower than that were recommended by most of current expert committees.8 In McCarthy et al,7 FiO2 was started at 0.30 following the results of a study by Escrig et al,9 which showed reduced oxidative stress in infants resuscitated with FiO2=0.3 compared to FiO2=0.9. Escrig et al, however, increased FiO2 by 0.1 every 60–90%, targeting for an SpO2 of 85% in contrast to this study, which maintained FiO2 at 0.3 for the first 5 min regardless of infant's FiO2. The amount of oxygen used in this current study may have been too low to show any difference in SpO2, especially for preterm infants with respiratory disease. Differences may not be evident until a larger number of patients are studied, as demonstrated by the To2rpido study, which showed an increase in death after resuscitation with FiO2=0.21 when compared to FiO2=1.0 after recruitment of 292 infants aged <32 weeks.10
Implications for practice
There are multiple influences on the trajectory of a preterm infant's SpO2 in the first critical 10 min of life. This study may not have been powered to show differences in SpO2, especially if levels of FiO2 were kept at a constant level for the first 5 min of life. There is also increasing evidence that lower SpO2 may be associated with adverse consequences, including death and severe intraventricular haemorrhage.10–12 Nevertheless, the authors must be commended for demonstrating that the LS placement is physiologically plausible. Further study of this concept (ie, placing infants on the left side at birth) is recommended.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.