Publications by authors named "Ruben S G M Witlox"

12 Publications

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Reviewing recordings of neonatal resuscitation with parents.

Arch Dis Child Fetal Neonatal Ed 2021 Jan 29. Epub 2021 Jan 29.

Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.

Background: Recording of neonatal resuscitation, including video and respiratory parameters, was implemented for research and quality purposes at the neonatal intensive care unit (NICU) of the Leiden University Medical Center, and parents were offered to review the recording of their infant together with a neonatal care provider. We aimed to provide insight in parental experiences with reviewing the recording of the neonatal resuscitation of their premature infant.

Methods: This study combined participant observations during parental review of recordings with retrospective qualitative interviews with parents.

Results: Parental review of recordings of neonatal resuscitation was observed on 20 occasions, reviewing recordings of 31 children (12 singletons, 8 twins and 1 triplet), of whom 4 died during admission. Median (range) gestational age at birth was 27+5 (24+5-30+3) weeks. Subsequently, 25 parents (13 mothers and 12 fathers) were interviewed.Parents reported many positive experiences, with special emphasis on the value for getting hold of the start of their infant's life and coping with the trauma of neonatal resuscitation. Reviewing recordings of neonatal resuscitation frequently resulted in appreciation for the child, the father and the medical team. Timing and set-up of the review contributed to positive experiences. Parents considered screenshots/copies of the recording of the resuscitation of their infant as valuable keepsakes of their NICU story and reported that having the screenshots/video comforted them, especially when their child died during admission.

Conclusion: Parents consider reviewing recordings of neonatal resuscitation as valuable. These positive parental experiences could allay concerns about sharing recordings of neonatal resuscitation with parents.
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http://dx.doi.org/10.1136/archdischild-2020-320059DOI Listing
January 2021

Survival and causes of death in extremely preterm infants in the Netherlands.

Arch Dis Child Fetal Neonatal Ed 2020 11 6. Epub 2020 Nov 6.

Department of Neonatology, Máxima Medical Centre, Veldhoven, The Netherlands.

Objective: In the Netherlands, the threshold for offering active treatment for spontaneous birth was lowered from 25 to 24 weeks' gestation in 2010. This study aimed to evaluate the impact of guideline implementation on survival and causes and timing of death in the years following implementation.

Design: National cohort study, using data from the Netherlands Perinatal Registry.

Patients: The study population included all 3312 stillborn and live born infants with a gestational age (GA) between 24 and 26 weeks born between January 2011 and December 2017. Infants with the same GA born between January 2007 and December 2009 (N=1400) were used as the reference group.

Main Outcome Measures: Survival to discharge, as well as cause and timing of death.

Results: After guideline implementation, there was a significant increase in neonatal intensive care unit (NICU) admission rate for live born infants born at 24 weeks' GA (27%-69%, p<0.001), resulting in increased survival to discharge in 24-week live born infants (13%-34%, p<0.001). Top three causes of in-hospital mortality were necrotising enterocolitis (28%), respiratory distress syndrome (19%) and intraventricular haemorrhage (17%). A significant decrease in cause of death either complicated or caused by respiratory insufficiency was seen over time (34% in 2011-2014 to 23% in 2015-2017, p=0.006).

Conclusions: Implementation of the 2010 guideline resulted as expected in increased NICU admissions rate and postnatal survival of infants born at 24 weeks' GA. In the years after implementation, a shift in cause of death was seen from respiratory insufficiency towards necrotising enterocolitis and sepsis.
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http://dx.doi.org/10.1136/archdischild-2020-318978DOI Listing
November 2020

Improving the Quality of Provided Care: Lessons Learned From Auditing Neonatal Stabilization.

Front Pediatr 2020 16;8:560. Epub 2020 Sep 16.

Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands.

Video and physiological parameter recording of neonatal stabilization was implemented at the Neonatal Intensive Care Unit (NICU) of the Leiden University Medical Center. In order to improve documentation and the quality of care provided during neonatal transition, we implemented weekly plenary audits reviewing recordings of neonatal stabilization in 2014. In audits, provided care is reviewed, discussing, among others, mask technique, compliance to the prevailing local guideline, and clinical decision making and alternative treatment options. In this perspective, we argue that auditing neonatal stabilization is a valuable tool to improve patient safety and the quality of care provided during neonatal stabilization. We, therefore, report lessons learned and areas for improvement that could be identified and addressed during audits conducted at our NICU. Important areas for improvement were guideline compliance, documentation, the usage of medical devices, the conduct of delivery room studies, and clinical decision making. By reporting our experiences, we hope to encourage other NICUs to also implement regular audit meetings, fitting to their improvement needs.
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http://dx.doi.org/10.3389/fped.2020.00560DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525009PMC
September 2020

Automated oxygen control in preterm infants, how does it work and what to expect: a narrative review.

Arch Dis Child Fetal Neonatal Ed 2021 Mar 30;106(2):215-221. Epub 2020 Jul 30.

Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands.

Background: Automated oxygen control systems are finding their way into contemporary ventilators for preterm infants, each with its own algorithm, strategy and effect.

Objective: To provide guidance to clinicians seeking to comprehend automated oxygen control and possibly introduce this technology in their practice.

Method: A narrative review of the commercially available devices using different algorithms incorporating rule-based, proportional-integral-derivative and adaptive concepts are described and explained. An overview of how they work and, if available, the clinical effect is given.

Results: All algorithms have shown a beneficial effect on the proportion of time that oxygen saturation is within target range, and a decrease in hyperoxia and severe hypoxia. Automated oxygen control may also reduce the workload for bedside staff. There is concern that such devices could mask clinical deterioration, however this has not been reported to date.

Conclusions: So far, trials involving different algorithms are heterogenous in design and no head-to-head comparisons have been made, making it difficult to differentiate which algorithm is most effective and what clinicians can expect from algorithms under certain conditions.
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http://dx.doi.org/10.1136/archdischild-2020-318918DOI Listing
March 2021

Increase in treatment of retinopathy of prematurity in the Netherlands from 2010 to 2017.

Acta Ophthalmol 2021 Feb 23;99(1):97-103. Epub 2020 Jul 23.

Leiden University Medical Center, Leiden, Netherlands.

Purpose: Compare patients treated for Retinopathy of Prematurity (ROP) in two consecutive periods.

Methods: Retrospective inventory of anonymized neonatal and ophthalmological data of all patients treated for ROP from 2010 to 2017 in the Netherlands, subdivided in period (P)1: 1-1-2010 to 31-3-2013 and P2: 1-4-2013 to 31-12-2016. Treatment characteristics, adherence to early treatment for ROP (ETROP) criteria, outcome of treatment and changes in neonatal parameters and policy of care were compared.

Results: Overall 196 infants were included, 57 infants (113 eyes) in P1 and 139 (275 eyes) in P2, indicating a 2.1-fold increase in ROP treatment. No differences were found in mean gestational age (GA) (25.9 ± 1.7 versus 26.0 ± 1.7 weeks, p = 0.711), mean birth weight (791 ± 311 versus 764 ± 204 grams, p = 0.967) and other neonatal risk factors for ROP. In P2, the number of premature infants born <25 weeks increased by factor 1.23 and higher oxygen saturation levels were aimed at in most centres. At treatment decision, 59.6% (P1) versus 83.5% (P2) (p = 0.263) infants were classified as Type 1 ROP (ETROP classification). Infants were treated with laser photocoagulation (98 versus 96%) and intravitreal bevacizumab (2 versus 4%). Retreatment was necessary in 10 versus 21 (p = 0.160). Retinal detachment developed in 6 versus 13 infants (p = 0.791) of which 2 versus 6 bilateral (p = 0.599).

Conclusion: In period 2, the number of infants treated according to the ETROP criteria (Type 1) increased, the number of ROP treatments, retinal detachments and retreatments doubled and the absolute number of retinal detachments increased. Neonatal data did not provide a decisive explanation, although changes in neonatal policy were reported.
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http://dx.doi.org/10.1111/aos.14501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7891652PMC
February 2021

Improving Guideline Compliance and Documentation Through Auditing Neonatal Resuscitation.

Front Pediatr 2019 16;7:294. Epub 2019 Jul 16.

Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands.

Evaluate whether weekly audits of neonatal resuscitation using video and physiological parameter recordings improved guideline compliance and documentation in medical records. Neonatal care providers of the Neonatal Intensive Care Unit (NICU) of Leiden University Medical Center reviewed recordings of neonatal resuscitation during weekly plenary audits since 2014. In an observational pre-post cohort study, we studied a cohort of infants born before and after implementation of weekly audits. Video and physiological parameter recordings of infants needing resuscitation were analyzed. These recordings were compared with the prevailing resuscitation guideline and corresponding documentation in the medical record using a pre-set checklist. A total of 212 infants were included, 42 before and 170 after implementation of weekly audits, with a median () gestational age of 30 (27-35) weeks vs. 30 (29-33) weeks ( = 0.64) and birth weight of 1368 (998-1780) grams vs. 1420 (1097-1871) grams ( = 0.67). After weekly audits were implemented, providers complied more often to the guideline (63 vs. 77%; < 0.001). Applying the correct respiratory support based on heart rate and respiration, air conditions (dry vs. humidified air), fraction of inspired oxygen (FiO), timely start of interventions and evaluation of delivered care improved. Total number of correctly documented items in medical records increased from 39 to 65% ( < 0.001). Greatest improvements were achieved in documentation of present providers, mode of respiratory support and details about transport to the NICU. Regular auditing using video and physiological parameter recordings of infants needing resuscitation at birth improved providers' compliance with resuscitation guideline and documentation in medical records.
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http://dx.doi.org/10.3389/fped.2019.00294DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646726PMC
July 2019

Long-Term Neurodevelopmental and Respiratory Outcome after Intrauterine Therapy for Fetal Thoracic Abnormalities.

Fetal Diagn Ther 2019 7;45(3):162-167. Epub 2018 May 7.

Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The

Introduction: The aim of this study is to evaluate long-term neurodevelopmental and respiratory outcome after fetal therapy for fetal pleural effusion, congenital cystic adenomatoid malformation, and bronchopulmonary sequestration.

Methods: Children ≥18 months of age underwent an assessment of neurologic, motor, and cognitive development. Medical records were reviewed to determine respiratory outcome. Behavioral outcome was assessed using the Child Behavioral Checklist.

Results: Between 2001 and 2016, 63 fetuses with fetal hydrops secondary to thoracic abnormalities were treated at our center. Overall perinatal survival was 64% (40/63). Twenty-six children were included for follow-up (median age 55 months). Severe neurodevelopmental impairment (NDI) was detected in 15% (4/26). Three out of 4 children with severe NDI had associated causes contributing to the impairment. Overall adverse outcome, including perinatal mortality or NDI, was 55% (27/49). Fifteen percent (4/26) had severe respiratory sequelae. Parents did not report more behavioral problems than Dutch norms.

Discussion: Our results suggest that severe NDI in this specific high-risk cohort occurs in 15%, which is above the range of the incidence of NDI reported in case series treated with other fetal therapies (5-10%). Large multicenter studies and an international web-based registry are warranted to prospectively gather outcome data at fixed time points.
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http://dx.doi.org/10.1159/000488486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482980PMC
July 2019

Neonatal management and outcome after thoracoamniotic shunt placement for fetal hydrothorax.

Arch Dis Child Fetal Neonatal Ed 2018 May 5;103(3):F245-F249. Epub 2017 Aug 5.

Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.

Aim: To evaluate the short-term neonatal outcome after fetal thoracoamniotic shunt placement for isolated hydrothorax.

Methods: Retrospective evaluation of infants with isolated hydrothorax treated with thoracoamniotic shunt placement at our fetal therapy centre between 2001 and 2016.

Results: In total 48 fetuses were treated with a thoracoamniotic shunt. All fetuses had signs of hydrops at the time of intervention. Median (IQR) gestational age at shunting was 28.7 (24.4-31.3) weeks. Forty-one of 48 (85%) fetuses were born alive at a median (IQR) gestational age of 34.4 (31.1-36.7) weeks. In one child the course of disease after birth was unknown (this child was excluded from further analyses). After birth, 24/40 (60%) children had signs of pleural effusion and 12/40 (30%) needed a thoracic shunt for continuous pleural drainage. Twenty-one (53%) children required mechanical ventilation, of whom 13 (33%) needed high-frequency ventilation as rescue therapy. Overall 30/40 (75%) infants survived the neonatal period. Neonatal survival rate was significantly higher when infants were born ≥32 weeks' gestation as compared with <32 weeks: 93% (26/28) versus 33% (4/12), p<0.01.

Conclusion: Postnatal course of hydropic fetuses treated with thoracoamniotic shunt for isolated hydrothorax is often complicated by respiratory failure and persistent pleural effusions. Neonatal survival is good provided delivery occurs at or after 32 weeks' gestation.
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http://dx.doi.org/10.1136/archdischild-2016-311265DOI Listing
May 2018

Caffeine to improve breathing effort of preterm infants at birth: a randomized controlled trial.

Pediatr Res 2017 Aug 17;82(2):290-296. Epub 2017 May 17.

Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.

BackgroundCaffeine promotes spontaneous breathing by antagonizing adenosine. We assessed the direct effect of caffeine on respiratory effort in preterm infants at birth.MethodsThirty infants of 24-30 weeks of gestation were randomized for receiving caffeine directly after birth in the delivery room (caffeine DR group) or later in the neonatal intensive care unit (control group). Primary outcome was respiratory effort, expressed as minute volume, tidal volumes, respiratory rate, rate of rise to maximum tidal volume, and recruitment breaths at 7-9 min after birth.ResultsAfter correction for gestational age, minute volumes ((mean±SD; 189±74 vs. 162±70 ml/kg/min; P<0.05) and tidal volumes ((median (interquartile range (IQR)) 5.2 (3.9-6.4) vs. 4.4 (3.0-5.6) ml/kg) were significantly greater in the caffeine DR group. Although respiratory rates were similar ((mean±SD) 35±10 vs. 33±10), RoR increased significantly ((median (IQR) 14.3 (11.2-19.8) vs. 11.2 (7.9-15.2) ml/kg/s), and more recruitment breaths were observed (13 vs. 9%).ConclusionCaffeine increases respiratory effort in preterm infants at birth, but the effect on clinical outcomes needs further investigation.
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http://dx.doi.org/10.1038/pr.2017.45DOI Listing
August 2017

Cardiorespiratory Monitoring during Neonatal Resuscitation for Direct Feedback and Audit.

Front Pediatr 2016 18;4:38. Epub 2016 Apr 18.

Division of Neonatology, Department of Pediatrics, Leiden University Medical Center , Leiden , Netherlands.

Neonatal resuscitation is one of the most frequently performed procedures, and it is often successful if the ventilation applied is adequate. Over the last decade, interest in seeking objectivity in evaluating the infant's condition at birth or the adequacy and effect of the interventions applied has markedly increased. Clinical parameters such as heart rate, color, and chest excursions are difficult to interpret and can be very subjective and subtle. The use of ECG, pulse oximetry, capnography, and respiratory function monitoring can add objectivity to the clinical assessment. These physiological parameters, with or without the combination of video recordings, can not only be used directly to guide care but also be used later for audit and teaching purposes. Further studies are needed to investigate whether this will improve the quality of delivery room management. In this narrative review, we will give an update of the current developments in monitoring neonatal resuscitation.
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http://dx.doi.org/10.3389/fped.2016.00038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4834521PMC
May 2016

Clinical and molecular characterization of an infant with a tandem duplication and deletion of 19p13.

Am J Med Genet A 2015 Aug 21;167A(8):1884-9. Epub 2015 Apr 21.

Department of Clinical Genetics, Leiden University Medical Center, Leiden, the Netherlands.

Copy number variations (CNVs) on the short arm of chromosome 19 are relatively rare. We present a patient with a tandem de novo 3.9 Mb duplication of 19p13.12p13.2 and an adjacent 288 kb deletion of 19p13.12. The CNVs were detected by genome wide SNP-array and confirmed by fluorescence in situ hybridization. Mate-pair sequencing revealed two breakpoint junctions leading to a germline tandem inverted duplication and an adjacent deletion. The patient had a major congenital heart defect and refractory edema leading to metabolic and endocrinological disturbances. Further complications occurred due to refractory chylothorax, severe inflammatory response syndrome, and repeating sepsis. After 2 months, the child died due to intractable respiratory failure. The phenotype of this patient was compared with reported patients with overlapping deletions or duplications. We conclude that the congenital heart defect, respiratory insufficiency, and abnormal neurologic examination are most likely due the contiguous gene deletion/duplication.
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http://dx.doi.org/10.1002/ajmg.a.37076DOI Listing
August 2015

Poor accuracy of methods currently used to determine umbilical catheter insertion length.

Int J Pediatr 2010 10;2010:873167. Epub 2010 May 10.

Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, P.O. Box 9600, 2300 RC Leiden, The Netherlands.

This study compares the methods of Dunn and Shukla in determining the appropriate insertion length of umbilical catheters. In July 2007, we changed our policy for umbilical catheter insertions from the method of Dunn to the method of Shukla. We report our percentage of inaccurate placement of umbilical-vein catheters (UVCs) and umbilical-artery catheters (UACs) before and after the change of policy. In the Dunn-group, 41% (28/69) of UVCs were placed directly in the correct position against 24% (20/84) in the Shukla-group. The position of the catheter-tip of UVCs in the Dunn-group and the Shukla-group was too high in 57% (39/69) and 75% (63/84) of neonates, respectively. UACs in the Dunn-group were placed directly in the correct position in 63% (24/38) compared to the 87% (39/45) of cases in Shukla-group. The position of the catheter-tip of UACs in the Dunn-group and the Shukla-group was too high in 34% (13/38) and 13% (6/45) of neonates, respectively. In conclusion, the Dunn-method is more accurate than the Shukla-method in predicting the insertion length for UVCs, whereas the Shukla-method is more accurate for UACs.
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http://dx.doi.org/10.1155/2010/873167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2866966PMC
July 2011