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  1. Yesterday
  2. The Sugar babies trial did indeed look at babies at risk of hypoglycemia, however, in our unit we have used dextrose gel as a first line treatment for hypoglycemia for many years. The Sugar babies trial and associated research provided us with the evidence that we needed to underpin this practice. We use the BD lancet for heelsticks and process the sample immediately - we are lucky enough to have a blood gas analyzer on our unit. Using dextrose gel as a first treatment, along with feeding, has meant that most babies can be managed without IV fluids. We prefer to feed breast milk whenever possible, and don't use formula without parental consent. Sometimes there will be a baby who is on IV fluids until there is enough breast milk if the parents don't want the baby to have formula, but we don't often have babies on IV fluids because of hypoglycemia.
  3. @Urban Rosenqvist do you use the Freestyle Pro?
  4. On the OT: The same here... To reduce pain we changed several years ago from heel lancing using a stationary meter to the mobile Freestyle Lite blood glucose meter. After that we had to deal with, and treat a lot more "hypoglycemias". After changing to another model of Freestyle we now see less hypoglycemias.
  5. Please, I need a protocol for treatment of neonatal hypernatremia ..
  6. Fenton Growth Curve Calculator

    Calculate z-scores on Fenton-Curve for weight, height and head circumference.
  7. Neonatal Sepsis Calculator

    Calculate risk of neonatal infection and get a recommendation for abx therapy
  8. It's going to be great!
  9. Last week
  10. During "non flu season" we have 24hr open family visiting. We have parents fill out a "sibling visiting" form attesting that the siblings have been fever, cough, congestion & rash free for the past 48hrs. The parents fill out the form once & we expect that they will not bring in children if the situation changes. No other children under 18 yrs allowed. We do have issues around the children not being monitored or contained by parents. We also have a nearby visiting room with a few toys that parents can trade off visiting the baby & containing the siblings. "Flu season" as announced by the state department of public health - likely 11/1-5/1 closes visiting to siblings. we have had a few (over many years), contained (2 babies at a time) RSV outbreaks. We have recently had to move babies into our isolation room for viral respiratory symptoms & put on droplet/ contact precautions. These babies all had ill family members. rigorous hand washing policy & constant hand gelling as modeled by staff helps, but it is a difficult balance between being family friendly & protecting our babies. We encourage FaceTime & have 2 iPads on the unit for this purpose as a visiting substitute. Best, Gayle
  11. And here... the program as of today! There will be smaller changes and updates over the coming few weeks. We will open a registration link early January PrelProgram.pdf
  12. Hello It will be great to participate in this conference I like to share my experience as NRP instructor so i can present advanced NRP simulation Thanks
  13. @JoannieO i think this thread has become a bit confusing, sorry for that. So you use sugar gel as treatment of diagnosed hypoglycemia? I thought the sugarbaby-trial was a prevention trial incl risk groups at the maternity ward (i.e. Risk groups for hypoglycemia), but I may be wrong by memory. For infants sdmitted to the nicu, Will gel also be usually succesful so you can spare a baby an iv infusion of glucose? The feeding pump discussion is a separete topic from gel admin, but I think an attractive mode of admin compared to iv infusion of glucose (and very much OT - our main concern is our glucose measurement apparatus...)
  14. There seems to be a little confusion around the use of Dextrose gel - it is used as a treatment for hypoglycemia.I believe there are other studies underway looking at other ways to use it, but this is how our unit has used it for many years now. We give 0.5ml (cc) per kg of bodyweight applied directly to the buccal membranes with a gloved finger. The baby will then be fed and the BGL checked in 30 minutes. We have not noticed any rebound hypoglycemia. I am not sure what is meant by Asymptomatic hypoglycemia - in our experience checking the blood glucose is the only way to ascertain whether a baby is hypoglycemic or not.
  15. Hot Topics in Neonatology

    until
    http://www.hottopicsinneonatology.org/ For over 30 years, Hot Topics has been THE premiere neonatal conference, with more than 1000 neonatologists and perinatologists from around the world attending each year. The conference features internationally known faculty, poster sessions, critical reviews and debate about promising new therapies, including: O2 Data - The Final Decision Breaking News - Antenatal and Postnatal Steroids Antenatal Strategies to Decrease Neonatal Morbidities and Mortality
  16. Love it!
  17. Feed - new landing page

    To improve how you can see and browse updates, the landing page on 99nicu.org is now a feed of all new content, in forums, blogs, Pharmacopedia etc, presented in a Facebookish way. You will not only have an updated timeline to browse, the web server will create it for you (i.e. reducing our work load to keep a first "News" page updated) What do you think about the new Activity Feed?!
  18. Indomethacin

    Dose & administration Closure of Ductus Arteriosus: Dose is dependent on age of infant at time of therapy and course includes three doses given IV with 12 to 24 hour intervals between doses (ref 1). Post-natal age at first dose: Less than 48 hours: 1st dose 0.2 mg/kg, followed by 2nd and 3rd doses of 0.1 mg/kg/dose 2-7 days: 0.2 mg/kg/dose >7 days: 1st dose: 0.2 mg/kg, followed by 2nd and 3rd doses of 0.25 mg/kg/dose If the ductus arteriosus closes or is significantly reduced in size after an interval of 48 hours or more from completion of the first course, no further doses are necessary. If the ductus arteriosus re-opens, a second course of 1 to 3 doses may be given, each dose separated by a 12 to 24 hour interval as described above. Prevention of intraventricular hemorrhage: Although dosing regimes of 0.1-0.2 mg/kg/dose have been studied, the largest RCT (ref 2) used the following schedule: 0.1mg/kg/dose IV over 20 minutes and every 24 hours, beginning the first day of life and for a total of 3 doses. Indications To close a hemodynamically significant patent ductus arteriosus in preterm infants. To prevent intraventricular hemorrhage in preterm infants, weighing less than 1250g. Contraindications and special considerations (incl incompatibilities) Contraindications include active bleeding, significant thrombocytopenia or coagulation defects, necrotizing enterocolitis, untreated proven or suspected infection, and significantly impaired renal function. Incompatibilities: Solution: 7.5% dextrose in water and 10% dextrose in water Injection site: calcium gluconate, cimetidine, dobutamine, dopamine, gentamicin, and tobramycin Adverse effects Bleeding problems, higher incidence of transient oliguria and elevations of serum creatinine, decreased platelet aggregation, and hypoglycemia. Further, gastrointestinal perforations may occur if used concurrently with corticosteroids. For this reason, concomitant administration of indomethacin and glucocorticoids should be avoided. If anuria or marked oliguria (urinary output <0.6 mL/kg/hr) is evident at the scheduled time of the second or third dose of, do not give additional doses until laboratory studies indicate that renal function has returned to normal. Pharmacological aspects The exact mechanism of action through which indomethacin causes closure of a patent ductus arteriosus is not known, but inhibition of prostaglandin synthesis is the suggested mechanism of action. The plasma half-life of indomethacin is variable among premature infants and has shown to vary inversely with postnatal age and weight: Postnatal age less than 7 days old averaged 20 hours Postnatal age more than 7 days old averaged 12 hours Weighing less than 1000 g averaged 21 hours Weighing more than 1000 g averaged 15 hours Monitor urine output, serum electrolytes, glucose, creatinine and blood urea nitrogen levels, platelet counts, and signs of bleeding should be monitored during treatment. References Product Information: indomethacin IV injection. APP Pharmaceuticals, LLC (per Manufacturer), Schaumburg, IL, Mar, 2010. (URL) Long-Term Effects of Indomethacin Prophylaxis in Extremely-Low-Birth-Weight Infants. N Engl J Med 2001; 344:1966-1972. PMID: 11430325 Indomethacin Prophylaxis to Prevent Intraventricular Hemorrhage: Association between Incidence and Timing of Drug Administration. The Journal of pediatrics. 2013;163(3):706-10.e1. PMID: 23522865 Effects of Indomethacin Prophylaxis Timing on IVH and PDA in Extremely Low Birth Weight (ELBW) Infants. Archives of disease in childhood Fetal and neonatal edition. 2016;101(5):F418-F422. PMID: 18661761 Managing the patent ductus arteriosus in the premature neonate: a new look at what we thought we knew. Semin Perinatol Apr, 2012; 36(2): 130-138. PMID: 22414884 Prophylactic intravenous indomethacin for preventing mortality and morbidity in preterm infants. Cochrane Database Syst Rev 2010, Issue 7. Art. No.: CD000174. PMID: 20614421
  19. Towards better and safer intubation

    We are the victims of our own success. Over the last decade, the approach to respiratory support of the newborn with respiratory distress has tiled heavily towards non-invasive support with CPAP. In our own units when we look at our year over year rates of ventilation hours they are decreasing and those for CPAP dramatically increasing. Make no mistake about it, this is a good thing. Seeming to overlap this trend is a large increase in demand by learners as we see the numbers of residents, subspecialty trainees, nurse practitioners on the rise. The combined effect is a reduction is the experience trainees can possibly hope to obtain when these rarer and rarer opportunities arise. The result of all of this is that at least by my eyes (although we haven’t documented it) the number of attempts for intubations seems to be much higher than it once was. It is not uncommon to see 3-4 attempts or sometimes more whereas in days gone by 1-2 attempts was the norm. We do our best to deal with these shortages using simulation as an example but nothing quite compares to dealing with the real thing even if it comes close. The Less Practice You Get The More Adverse Events You Can Expect This is just the way it is. Perfect practice makes perfect and it has been well documented that intubations can lead to many complications such as desaturation, bradycardia, bleeding, airway edema from multiple attempts and a host of other issues. Hatch and colleagues first described their experience with 162 intubations in which they found adverse events in 107 (39%) with 35% being classified as non-severe and severe events in 8.8%. Not surprisingly one of the factors associated with adverse events was the need for multiple intubation attempts. Based on this initial experience they determined that as a unit they could do better and soon after undertook a series of PDSA Quality Improvement cycles to see if they could reduce these events and that they did. What follows are the lessons learned from their QI project and it is my hope that some or all of these ideas may help others elsewhere who are experiencing similar frustrating rates. Steps To A Better Intubation The findings of their QI study were published last month in Pediatrics in their paper Interventions to Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. The strategies they used were threefold. Standardized checklist before intubation – This used a “do-confirm” approach in which the individuals on the team “do” what they need to prepare and then confirm with the group that they are done. An example might be an RRT who states “I have three sizes of ETT ready with a stylet already inserted, surfactant is thawed and the ventilator is set with settings of … if needed etc”. Another critical part of the checklist includes ensuring that everyone knows in advance their roles and who is responsible for what. Premedication algorithm – Prior to this project the use of premedication was inconsistent, drug selection was highly varied and muscle relaxation was almost non-existent. The team identified from the literature that a standard approach to premedication had been associated with reductions in adverse events in other centres so adopted the same here using fentanyl with atropine if preterm and muscle relaxation optional. Computerized order set for intubation – interestingly the order set included prompts to nursing to make sure intervention 1 and 2 were done as well. The results of there before and after comparison were numerous but I have summarized some of the more important findings in the table below. Outcome Period 1 (273 intubations) Period 2 (236 intubations) p Any AE 46.2% 36.0% 0.02 Severe events 8.8% 6.4% 0.04 Bradycardia 24.2% 9.3% <0.001 Hypoxemia 44.3% 33.1% 0.006 Esophageal intubation 21.3% 14.4% 0.05 # attempts 2 2 NS <10 intubations experience 15.1% 25.5% 0.001 The median number of attempts were no different but the level of experience in the second epoch was less. One would expect with less experienced intubators this would predict higher risk for adverse events. What was seen though was a statistically significant reduction in many important outcomes as listed in the table. I can only speculate what the results might have been if the experience of the intubators was similar in the first and second periods but I suspect the results would have been even more impressive. The results seem even more impressive in fact when you factor in that the checklist was used despite all of the education and order set 73% of the time and muscle relaxation was hardly used at all. I believe though what can be taken out of these results is that taking the time to plan each intubation and having a standard approach so that all staff practice in the same way reaps benefits. If you already do this in your unit then congratulations but if you don’t then perhaps this may be of use to you! What About Intubation For INSURE? We are in the process of looking in our own centre at the utility of providing premedication when planning to give surfactant via the INSURE technique. I couldn’t help but notice that this paper also looked at that very issue. Their findings in 17 patients all of whom were provided premedication were that only one could not be extubated right after surfactant. The one who was not extubated however was kept intubated for several hours without any reasoning provided in the records so it may well be that the infant could have been electively kept ventilated when they may have indeed been ready for extubation. The lesson here though is that we likely do not need to exclude such patients from premedication it will reduce the likelihood of complications without prolonging the time receiving positive pressure ventilation. Whatever your thoughts may be at this time one of the first questions you should ask is what is our local rate of complications? If you don’t know then do an audit and find out. Whatever the result, shouldn’t we all strive to lower that number if we can?
  20. Earlier
  21. Excellent link!
  22. High quality guidelines and standards produced and published by other organisations and endorsed by the RCPCH.
  23. Noninvasix, Inc.

    To reduce the incidence of neonatal mortality and morbidity, Noninvasix is developing a patient monitor to directly, accurately, and noninvasively measure brain oxygenation in preterm and low birth weight babies in the NICU. Using optoacoustics, Noninvasix’s system pulses laser light into the brain to directly measure the amount of oxygen the baby is receiving in real time. Noninvasix Technology Video Noninvasix Pitch 16x9 20161027.pdf
  24. @Urban Rosenqvist yes, a feeding pump is exactly what I was referring to. Sounds great to hear you have experience with this - maybe we should consider to make a trial (that something we would like to do, randomize to feeding pump vs iv glucose)
  25. @Stefan Johansson Not yet a protocol on it... Did I understand you correctly - you mean milk/formula given by nasogastric tube driven by a "food pump" 24h a day? Because that´s what we are doing :-) Usually when the baby is admitted we try starting with normal bolus feeding but if the baby´s having difficulties in tolerating the given amount we switch to food infusion Sometimes they don´t tolerate 150ml/kg, sometimes they tolerate 220ml/kg or more. We set it to continous infusion (over 24h) and increase it until glucose levels are under control.
  26. In 2007, when I was chair of the CPS Fetus and Newborn Committee, we published a guideline regarding the approach to term and late preterm infants with perinatal risk factors for sepsis. Obviously any infant with clinical signs consistent with sepsis needs immediate work up and antibiotics, but the management of infants with risk factors for sepsis and no clinical signs evident was the focus of that guideline. This is what we said about chorioamnionitis, based on what we thought was the most reliable literature: The risk of sepsis (which may be due to a variety of different organisms, including GBS, E coli and other Gram-negative organisms) in an infant whose mother had definite chorioamnionitis is approximately 8%, and is approximately 3% to 4% if ‘possible’ and ‘definite’ chorioamnionitis are considered together [31][32] (evidence level 2b); among all mothers with fever, the incidence is 2% to 6% depending on the height of the fever [31] (evidence level 2b). Infants who do not have signs at birth are unlikely to develop sepsis, the odds ratio for sepsis among infants who are well at birth is 0.26 (95% CI 0.11 to 0.63) [31]. The incidence of invasive infection in the present study in an initially well-appearing infant with a maternal history of fever or chorioamnionitis was less than 2%, and this is confirmed by other data [33] (evidence level 2b). Therefore, it seems reasonable to perform a CBC and closely observe such an infant, and to only perform a full diagnostic evaluation and treat with antibiotics if the CBC is strongly suggestive of infection (low total WBC count) or if clinical signs develop. A requirement for extensive resuscitation at birth should be considered a sign of possible infection in such infants [32][33]. At that time the CDC guidelines recommended cultures and empiric antibiotics for all such infants, the CDC guidelines were updated in 2010, and continue to recommend the same thing, with the clarification that you should talk to the obstetricians (always a good idea!) Well-appearing newborns whose mothers had suspected chorioamnionitis should undergo a limited evaluation and receive antibiotic therapy pending culture results (AII). The evaluation should include a blood culture and a CBC including white blood cell differential and platelet count; no chest radiograph or lumbar puncture is needed. Consultation with obstetric providers to assess whether chorioamnionitis was suspected is important to determine neonatal management (CIII). Is there anything new recently? I think you all know the answer to that question. Braun D, et al. Low Rate of Perinatal Sepsis in Term Infants of Mothers with Chorioamnionitis. Amer J Perinatol. 2016;33(02):143-50. This database analysis from Kaiser Permanent Southern California found an incidence of maternal fever in labour (38 degrees or more) at or after 35 weeks to be 9% and chorioamnionitis (based on ICD-9 codes from discharge data) to be 4%, chorioamnionitis based on a fever of 38 degrees followed by antibiotic treatment was 5%. There were around 30,000 deliveries in this cohort and in total there were 19 babies with culture positive early onset sepsis, 14 were symptomatic and 5 had bacteremia without clinical signs. That gives an overall incidence of culture positive symptomatic sepsis of 0.45 per 1000, and of culture positive bacteremia without clinical signs of 0.16 per 1000. Among mothers without fever the rate of sepsis was 0.5 per 1000, if they had fever without chorioamnionitis it was 0.6 per 1000, and if they had chorioamnionitis it was 4 per 1000. One interesting thing in this study is that many physicians do not follow the CDC guidelines, the rate of neonatal treatment with antibiotics after maternal chorio, which should be close to 100%, ranged from 7 to 76% in different hospitals. The authors don't say how many of the babies without clinical signs were from the maternal chorio group, there were 5 babies who did not have clinical signs, if all of them were from mothers with chorioamnionitis (which I think is unlikely) then you would have to treat 250 clinically well infants after maternal chorioamnionitis with antibiotics to be sure to cover 1 baby with bacteremia. Of course if some of those babies were symptomatic, then you would have to treat many more without clinical signs for each baby infected, for example if the proportion of asymptomatic babies is the same as in the next study (about 1/3) then you would have to treat over 700 asymptomatic babies to cover that 1 with bacteremia. The authors also calculated that if the CDC guidelines had been followed (for chorioamnionitis, but also for other indications for neonatal antibiotic treatment) then 8% of all the term and late preterm babies would have received 48 hours of antibiotics. Another very large study Wortham JM, et al. Chorioamnionitis and Culture-Confirmed, Early-Onset Neonatal Infections. Pediatrics. 2016;137(1). instituted prospective surveillance for early onset sepsis among nearly 400,000 deliveries. In contrast to the other study they did not collect data from mothers whose babies did not get septic, so we don't know overall incidence of chorioamnionitis in this study, and you can't make some of the same calculations. They found 389 cases of early onset, culture positive, infections, in the cohort which included both preterm and term babies. Eighty-one of those infections were in term babies (37 weeks and more; from 350,000 term deliveries) 58 of which had clinical signs at birth. Which leaves 23 term infants who had no signs at birth but had culture positive sepsis, from mothers with chorioamnionitis, and 6 preterm babies with the same combination. The authors include some babies, 1 at term and 4 preterm, who only had histological evidence of chorioamnionitis, which doesn't help our decision-making as you don't know about those unless you did placental pathology and got the results back. If the prevalence of chorioamnionitis is 4 to 5% (as in the first study), then there would have been about 16,000 cases of chorio among the term deliveries, which gives the incidence of early neonatal sepsis (81/16,000) of 5 per 1000 which is very similar to the Kaiser Permanent data. We know 23 were without signs at birth (but one of those would not have had a diagnosis of chorio) so to ensure that 22 those asymptomatic babies with sepsis received early treatment, you would have to screen, culture and treat 16,000 babies, which is a number needed to treat of over 700. I think that is too many. NICE in the UK seems to have a similar opinion in their guideline from 2012, their guidance is a little more complicated, but goes like this (the links should work to take you to the tables): Use the following framework based on risk factors and clinical indicators, including red flags (see tables 1 and 2), to direct antibiotic management decisions: In babies with any red flags, or with two or more 'non-red flag' risk factors or clinical indicators (see tables 1 and 2), perform investigations (see recommendations 1.5.1.1–1.5.1.3) and start antibiotic treatment. Do not delay starting antibiotics pending the test results (see recommendations 1.6.1.1–1.6.1.3). In babies without red flags and only one risk factor or one clinical indicator, using clinical judgement, consider: whether it is safe to withhold antibiotics, and whether it is necessary to monitor the baby's vital signs and clinical condition – if monitoring is required continue it for at least 12 hours (at 0, 1 and 2 hours and then 2-hourly for 10 hours). In their scheme chorioamnionitis is a risk factor, but not a "red flag", so if the baby does not have any of the clinical indicators they would be observed, but not treated. As I said I think that an NNT of over 700 is too many, but others may not agree, specifically the parents may not agree. Shouldn't they be involved in that decision? A decision aid may help them to decide, with the medical team, between one or multiple IV installations, antibiotics for 36 hours (you can stop them before the 48 hour dose if cultures are negative) and hospitalisation for at least that long. Depending on how your hospital is organized term newborns on antibiotics may also not be in the room with the mother. The contrasting choice is close observation with the option of starting antibiotics later if clinical signs appear (which happened in 18 of the 23 initially asymptomatic term babies with positive cultures). Also there is no difference in mortality (there was one death in the Wortham study, a baby who died soon after cultures and never had antibiotics, 2 deaths in the Braun study both of whom were symptomatic) shown in these recent studies. Very frequent use of antibiotics of course affects colonization and resistance patterns in an environment, and will affect the development of the infant's microbiome, perhaps for many months or years. I think in these days of shared decision-making and family centered care, when a term baby is born after maternal chorioamnionitis but is clinically well, we should inform the parents that the baby has a very small risk of having an infection, (1 in several hundreds) and that there are 2 options. We should also organize our care so that both close repeated observation, and/or antibiotic administration, can be performed in a mother and infant room, without interfering with breastfeeding and the evolution of the new family, and then give the parents a big place in that decision.
  27. I hope this link stays active for ever as it is a great resource... Courtney Wusthoff from Stanford has developed a web-based educational tool, designed initially, I think, for medical (pediatric) residents. Their team has evaluated whether or not this works by showing pediatric residents videos of actual examinations of asphyxiated newborn infants, and asking them to identify whether the babies were normal or had encephalopathy that was either mild moderate or severe. They repeated the process after using the web-based tool described above. They showed substantial improvements in the skills of residents in evaluation of such infants. Ivy AS, et al. Improving the Identification of Neonatal Encephalopathy: Utility of a Web-Based Video Tool. American journal of perinatology. 2016. Hey, the internet works, sometimes!
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