Neonatal lumbar punctures are not always easy! Holding and performing! More data is emerging that the sitting up position may be more successful in the bigger babies. I'm Dr. Tala, board-certified neonatologist, and in this video, I'm sharing an honest, unsponsored review of the SMöLTAP device — a cradle designed to position babies safely in an upright sitting position during lumbar punctures (LPs).
In this video, I walk you through: — What SMöLTAP is and how it works — The 3 key benefits: gravity assist, pelvis tilt & baby comfort — Step-by-step demo of placing a baby in the device — Who can use it (34 to 50 weeks of gestational age) — Safety considerations for tiny NICU babies
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For PDF summaries of the videos, links to relevant articles (+ 50 free Multiple Choice Questions/ Answers and explanations!!), AND a bunch of other stuff, subscribe to our Neonatal Nuggets Newsletter here: https://talatalksnicu.substack.com/subscribe ---------------------------------------------------------------------- Please be sure to give us a like, comment about future topics, and subscribe to this channel to stay up to date on all things NICU! Also, click the notification bell after you subscribe to gain your weekly NICU knowledge as soon as it's loaded! --------------------------------------------------------------------- Dr. Tala is a board-certified neonatologist and has worked in busy level III and IV units for the past 18 years. She has won multiple teaching awards throughout her time as a neonatologist. ---------------------------------------------------------------------------- References: https://smoltap.com/ Improved success rates with LPs when infant sitting up NOT decubitus position: Assessment of infant position and timing of stylet removal to improve lumbar puncture success in neonates (NeoCLEAR): an open-label, 2 × 2 factorial, randomised, controlled trial Marshall, Andrew S J et al. The Lancet Child & Adolescent Health, Volume 7, Issue 2, 91 - 100 https://pmc.ncbi.nlm.nih.gov/articles/PMC10591282/ Sitting up position for LP: https://www.loc.gov/resource/ppmsca.09456/ Holding in a Side-lying position: one hand on legs & one on head: https://dontforgetthebubbles.com/how-to-perform-a-lumbar-puncture/ Sweet-Ease sucrose drops: For pain reduction prior to procedures: https://int-bio.com/developmental-care/calming-and-soothing/sweet-ease-sucrose-solution/
---------------------------------------------------------------------------- ***TIMESTAMPS*** 00:00 — Introduction 00:24 — Why Sitting Position is Better for Baby Spinal Taps 03:33 — 3 Key Advantages of the SMöLTAP Device 05:33 — Device Overview 06:11 — Step-by-Step Demo | How to Place Baby in the SMöLTAP device 08:24 — Final Thoughts
---------------------------------------------------------------------------- *Disclaimer*: This video is intended for educational purposes only and while we strive to give the most accurate information, errors may occur. Subsequently, this video should not be a replacement for medical advice.
Hello, I'm Dr. Tala, a board certified neonatologist,
and we have a little bit of an exciting video today
because I'm going to demonstrate something
that I really think might change the way
that we do things in the NICU.
We previously made a video on how to perform spinal taps,
also called lumbar punctures,
as well as actually how to hold babies
for the lumbar punctures.
And as I talked about in that video,
go watch it if you haven't seen it.
As I pointed out in those videos,
some pretty good studies have come out
that have shown that when babies are sitting up
during spinal taps,
rather than being in the lateral decubitus position,
then basically when they're sitting up,
there seems to be a higher success rate
of actually getting the spinal tap.
Also, and I think this is just as relevant,
in a recent study done in the Lancet a couple of years ago,
it showed that when babies were sitting up
during the spinal taps,
there was a higher chance of getting a successful tap,
but also the baby's baseline heart rate
and saturations were better as well.
So kind of less desaturation events,
they were more stable during the taps.
I also admitted in that video
that since the end of residency,
which is about 20 years now,
I've basically mostly been doing lateral decubitus taps,
but it is very difficult to argue with the numbers.
Recently, I got an email from the lovely people
at SmallTap and they were basically asking me
whether I was interested in checking out their device.
I do really want to emphasize this is not a sponsored post.
I am not getting anything out of it apart from this device,
which I played around with
and I kind of fell in love with a bit.
Now I'm thinking it's more like a circumcision board.
Yes, you could hold the baby down during the circumcision,
but now there's a softer, gentler,
more consistent, safer way of holding a baby
during the spinal tap.
So moving forward, I hope that it will help our babies
like it's been shown to help many other babies
around the country.
Several studies out there,
including one from the University of Toronto Emergency Room
have shown that when babies were tapped
and they were positioned using this device,
they had a much higher chance of getting a successful LP.
And the numbers are pretty significant.
It was 63% using this device versus 44% not using it.
Also, there were much lower amounts of bloody taps.
So basically it was easier to actually interpret
those LP results.
Full disclosure, I haven't actually used this in practice
since I received this little contraption a month ago.
I've only had to do one tap and it was on a tiny baby.
And so this device cannot be used in the tiny babies.
In the study in the Lancet,
where they compared the sitting up
versus the lateral DQ babies,
most of those babies were termed,
most of them were on room air,
some were on like nasal cannula.
They did go down to 27 weeks.
This device, according to the inset,
can be used for babies between 45 centimeters
and 57 centimeters in length.
And if you look at the Fenton growth curves,
then that basically ends up being a baby
that's about 34 weeks to about 50 weeks gestational age.
In the study done in the Toronto ER,
they use this device for babies up to three months of age.
Straight off the bat,
there were a few things
that I really do like about this device.
First of all, SmallTap,
I don't know if you can see that insert there, great name.
It kind of sounds like an Ikea device made for babies,
but thank goodness we don't actually have to assemble it
so you can still have a good relationship
with all your NICU colleagues
without breaking down over the assembly of an Ikea piece.
There are three great advantages about using this device.
The first one, well, the first one according to them
is that you have this gravity assist position.
So basically because the baby's sitting up like this,
you've got the force of gravity kind of pushing the CSF down
so it helps that CSF drain easily.
And this has definitely been a problem for us in the past
in all babies really,
and sometimes you end up having to like
literally massage the fontanelle
trying to get that CSF to come out,
especially if they're in the lateral decubitus position.
The second key thing is how they consider this
to be like a pelvis tilting position.
So because of the position that the baby's in,
it will basically unfold their back
and it will widen the space between the vertebrae.
This is key.
One of the biggest difficulties
when we're tapping babies in the lateral decubitus position
is that if you can get the vertebrae to open,
sometimes the babies are in such a weird position
that it's actually affecting their breathing.
Remember though, you really need to bend the back
and not flex the neck.
So what this does in a really good way
is it opens up the vertebrae,
but in no way does it kind of push down on the neck.
So it keeps the baby safe,
but it also creates an easy way
to be able to expose the gap between the vertebrae.
The third thing is,
and this is probably what we should have led with,
is that the baby will be calm
and is in a completely still position.
I'm gonna show you how we hold the baby now.
And obviously this is ideal.
We don't want a fighting baby,
but the way that the head is positioned,
obviously there's complete access to the face.
And so we can continue to give the baby sweeties
as they are in this position.
As you know, just being in an upright position
often is just very calming for babies.
So altogether, it is a safe, comfortable position for babies.
So the main cradle thing is this like plastic metal thing.
This is completely reusable.
So I kind of feel like it could be able to be used forever.
I don't see why not.
It's very cleanable and durable,
but the small tap people are like, use it for two years.
And then it comes with these infant stabilizer straps.
So two of these straps come in the package.
These are disposable.
Right, so how do we actually use this little cradle?
Well, just like every single time you're doing an LP,
make sure that you speak to the parents about it,
make sure that you are getting informed consent
and that you're having a timeout.
And then we want to put the baby in the cradle.
So key thing is undress the baby
and then just leave a diaper on.
You know how sometimes they all soil during LPs
and you don't want that going everywhere.
Generally, I generally give sucrose
or some sort of anesthetic or sedative before the procedure.
If it's an older baby,
maybe you'll use Emler already on the back.
But it's nice for the baby to be a little bit calm
even before you start the procedure.
And you know with sweeties,
you have to give it a few minutes before
for the full pain suppressing effect to actually take place.
Okay, so let's put this baby in.
So we want to slide the legs through at the bottom.
And then you want the arm hold, the arm guards
to go just below the level of the top of the shoulders.
So kind of half an inch below the level
of the top of the shoulders.
And then the forehead will be leaning
against this little plastic piece here.
So obviously my model is not as flexible
as your average baby.
So you use one of the straps here at the top,
holding the head down.
And then you use the other strap
at the level of the shoulders.
So it's like this, at this level.
So the baby's arms are kind of free.
You have access to the baby's face,
whether you want to give sucrose or whatever else.
The baby's neck is not overly bent,
but it's maximizing the back bend down here.
Baby has a hole in its back already.
And the baby's in neurosurgery.
So obviously you can have a pulse ox on the baby.
You can have a nasal cannula on the baby.
And so the baby can be monitored
all the way through the procedure as well.
And you can give more sucrose or anything else
that you need to give for the procedure.
I'm not going to go through the procedure now.
If you want to see it,
then you can go and see one of the other videos.
But like we said,
we're kind of in a very good position for it.
Right here, the vertebrae are nicer open.
You're getting all your CSF fluid.
And hopefully you are all getting champagne taps.
Okay, thanks for watching.
I'm excited to start using this, hopefully in the unit.
Thank you again so much to the small tap people
for sending me this contraption.
I'm really excited to use it.
