Published online May 1, 2006
PEDIATRICS Vol. 117 No. 5 May 2006, pp. 1859 (doi:10.1542/peds.2006-0400)
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Is It Safer to Intubate Premature Infants in the Delivery Room?: In Reply

Hany Aly, MD, FAAP
Department of Newborn Services
George Washington University and Children's National Medical Center
Washington, DC 20037

In Reply.—

Dr Kribs underscores the importance of our finding of the need for experience and time to achieve reasonable success with the implementation of early nasal continuous positive airway pressure (ENCPAP) in premature infants.1 Such time is required by the staff to gain enough confidence in the delivery room to proceed with ENCPAP without tracheal intubation. We noticed a significant trend for less intubation in the delivery room over time. In addition, staff at the bedside in the NICU requires time to develop the technical experience required for meticulous suctioning of airways to maintain them open while being gentle enough not to cause any injury to the fragile mucus membranes of the nose and pharynx. Such experience leads to a significant increase in the success rate of ENCPAP. After exercising this learning curve, ENCPAP is certainly expected to succeed.2

Efficacy and safety of surfactant when administered to premature infants supported with ENCPAP is an interesting area to be studied. Use of surfactant can plausibly be synergic to ENCPAP in premature infants suffering from respiratory distress syndrome. However, tracheal intubation is not a risk-free procedure. We previously reported that premature infants who were not initially intubated were unlikely to develop higher grades of intraventricular hemorrhage.1 Is it justified to empirically administer surfactant to all premature infants before the initiation of ENCPAP, or should we save tracheal intubation to administer surfactant only for those infants in whom ENCPAP is likely to fail? What are the criteria that should be used as indicators of infants in whom ENCPAP is expected to fail? Indeed, additional investigations are urgently encouraged.

Finally, I would like to caution my respected colleagues and scientists to ascertain the experience of their NICU staff before testing the efficacy of ENCPAP with or without the administration of surfactant. Our previous report can serve (as it did for Dr Kribs) to validate the experience of personnel who are to conduct future trials. Otherwise, randomized trials that demonstrate a high failure rate of ENCPAP will not solve but rather add more mysteries to the issue.

REFERENCES

  1. Aly H, Massaro AN, Patel K, El-Mohandes AAE. Is it safer to intubate premature infants in the delivery room? Pediatrics. 2005;115 :1660 –1665[Abstract/Free Full Text]
  2. Aly H, Milner JD, Patel K, El-Mohandes AAE. Does the experience with the use of nasal continuous positive airway pressure improve over time in extremely low birth weight infants? Pediatrics. 2004;114 :697 –702[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics

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