wackdi

What an interesting discussion!!! There is so much to learn from each other, when reading how the different centers manage these tiny infants. Only some of my aspects in this discussion: ... bag ventilation: There is a lot of data out (e.x. ERC guidelines) that the t-piece-devices are superior over bag, as the bag can not deliver PEEP and we know from studies, that the PIP is not controllable even in the hands of experienced users. We use only T-Piece-Devices in all infants. ... the enemas: That's really an interesting point. We know from many centers, that they are very active in this point, starting early with all kinds of "treatment". I know only a few articles, examine the timing of the first passing of meconium in preterm infants https://pubmed.ncbi.nlm.nih.gov/18285377/. There is one article I know that did not find an association between delayed passing of meconium and NEC https://link.springer.com/article/10.1007/s00431-023-05035-8, but as we are afraid of the obstruction syndrome and NEC a lot of "prophylactic" treatment is done. I don't know what is right or wrong, but in my opinion especially the start of enteral feeding, if feeds are mothers' own milk, donor milk or formula, the condition of the infant has significant impact on the passing of meconium. ... primary intubation in these infants: As there is a growing evidence that avoiding mechanical ventilation in these infants has advantages in terms of IVH, BPD, survival etc., I do not agree that intubating all of them by default is the right way. There are interesting numbers from the German neonatal network showing, that only half of these infants need mechanical ventilation within the first 7 days, after receiving Surfactant by LISA/MIST ( https://pubmed.ncbi.nlm.nih.gov/35943742/ ). Avoiding MV is also in line with the recent recommendations by Sweet et al. (https://pubmed.ncbi.nlm.nih.gov/36863329/). In my opinion, "soft transition" with late or physiological cord clamping, DR-CPAP, LISA/MIST, early/ DR-caffeine and intubation as the last option seems to me more promising strategies in these tiny infants. I can really recommend to look at the Cologne group of Angela Kribs how work with this strategy since many years. Wish all of you a pleasant weekend Dirk

Good morning everybody, thanks for starting this interesting discussion! As we are reviewing our own guidelines of transition support for the tiniest infants, I would like to add a question: Do you use Caffeine in the delivery room to improve breathing efforts (diaphragm activity and improvement of FRC)? With kind regards Dirk

Hi, I would also switch to a PICC line. Otherwise, I can warmly recommend using ultrasound when placing the UVC! This article is a wonderful overview of how to use it while placing the UVC. Check out the videos! Kozyak BW, Fraga MV, Juliano CE, Bhombal S, Munson DA, Brandsma E, et al. Real-Time Ultrasound Guidance for Umbilical Venous Cannulation in Neonates With Congenital Heart Disease. Pediatr Crit Care Med. 2022 May 1;23(5):e257–66. https://pubmed.ncbi.nlm.nih.gov/35250003/ With kind regards from Mainz Dirk

Thanks to Nathan for sharing this nice summary of the findings and the clinical guideline. And I fully agree to Mo7 that PTX and CPAP is rather an association than a causation. With kind regards Dirk

Hello everybody, I am wondering if you treat term or near term infants with CPAP (if they need breathing support) in the delivery room. The background of my question is an ongoing discussion whether term/near term infants (GA >=35+0) should receive postnatal delivery room CPAP. As far as I know are there three studies of two centre published describing an increase in PTX occurrence after implementing CPAP in the delivery room: https://pubmed.ncbi.nlm.nih.gov/25854822/ (Pulmonary air leak associated with CPAP at term birth resuscitation) https://pubmed.ncbi.nlm.nih.gov/31399490/ (Delivery Room Continuous Positive Airway Pressure and Pneumothorax) https://pubmed.ncbi.nlm.nih.gov/35173286/ (Decreasing delivery room CPAP-associated pneumothorax at ≥35-week gestational age) This leads me to two question: 1) Do you treat term and near term infants (GA>=35+0) needing pulmonary transition help with nCPAP in the delivery room? 2) What are the criteria to start nCPAP? Thanks for all your answers in advance With kind regards Dirk

Hello Katja, I have worked with different kind of PDMS in different countries. Mostly I have worked (and configured) the PDMS system from GE (CliniSoft in Sweden) Since four months ago, I am implementing the COPRA system at my new work in Mainz. As mentioned before, all systems have their pros and cons. After a lot of work, together with the IT and the pharmacy, we have our system up and running. I would say: It works ok and is definitely better than the paper system we had before. The V3 version of the ordinating tool has some interesting features for neonatologists. With kind regards Dirk

Hi Francesco, Thanks for the information. What a pity. Maybe the measurements are similar but than the blade is too long. For a skilled person it will be possible doing the intubation but this is not the classic procedure (different angel etc). This means (IMHO ) that the C-Mac can not be used for teaching intubation in infants below about 1200g. Have a nice weekend Dirk

Hi Francesco and Stefan, we are using a C-Mac laryngoscope. The smallest blade is 0. The company told us that a 00-blade is on the way ... but by now we haven't seen it. The view with the C-Mac is fantastic, so I hope that we could see the 00-blade soon. Greetings from Stockholm Dirk

Nutrition and feeding would be a great topic. TPN (as smaik.hiran suggested) but also feeding strategies would be of great interest. su ... and of course the question how optimal postnatal growth (catch-up) should look like. Greetings Dirk

We use Atropine, Fentanyl, thiopental and (sometimes) suxamethonium. In my opinion we have a lot of stiff chest problems even if we give the fenanyl as a two minutes slow push. In a difficult situation I would definitively go for propofol in combination with atropine and maybe fentanyl. Ghanta S, Abdel-Latif ME, Lui K, et al. Propofol compared with the morphine, atropine, and suxamethonium regimen as induction agents for neonatal endotracheal intubation: a randomized, controlled trial. Pediatrics 2007;119:e1248–55. doi:10.1542/peds.2006-2708 The babies are really relaxed and well sedated, so intubation is quite easy (even in difficult situations). Greetings Dirk

Hi RichMaus, we are using the Vygon micro site since two years ago. We use it round about 3-4 times per month in the "bigger" babies (>1200g) to insert 2F PICCs. It works perfectly well for us as we can use our "standard" 24G iv catheter to start the procedure. I is quit easy (and a very high success rate) to get in the 2F catheters. We are only using PICCs with one lumen but in my opinion it should be no difference to use it with two lumen PICCs. I is a great device and made it possible in our unit to have more babies with 2F lines. Greetings from Sweden Dirk

Very interesting! In the past I had good experience by using Sildenafil enterally (by gastic tube). As I am now working in a Level III NICU i recently found an article about using Vasopressin a adjuvant treatment: http://www.ncbi.nlm.nih.gov/pubmed/24141655 Does anyone have any experience with this drug? Greetings from Sweden Dirk

Hi, I would absolutely agree with Stefan and Naveed! A good randomized placebo-controlled trial showed no clinical relevant changes in haemodynamics in preterm infants. The only significant change was an increase in FiO2 from 0.27 to 0.29. http://www.ncbi.nlm.nih.gov/pubmed/21784442 The article gives you even a good overview on the topic. Greetings Dirk