"A new system for managing serum glucose with less pokes. This is a good thing."
Check out this new blog post on continuous glucose monitoring by Michael Narvey.
New IRL case in our Virtual NICU: a very preterm infants and challenges related to ventilation strategy (infant is on MV). Please note the Virtual NICU is a member's only section (ie you need to log in to read and comment).
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What are the safe option to sedate an infant with increased ICP post craniotomy?
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Physiological-based cord clamping (PBCC) in preterm infants. Experiences of resusc with intact cord?
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By AllThingsNeonatal in All Things NeonatalGlucose metabolism in the newborn can be a tricky thing to manage. Neonates can have significant fluctuation in their serum glucose in the first few days of life which can lead heels to look like pin cushions. How many times have you been asked as a physician if there is anything we can do to reduce the number of pokes? That something may have arrived at least in a feasibility study that could pave the way for this becoming the standard approach to hypo/hyperglycemia in the newborn. This is an important area to improve tightness of control as hyperglycemia has been associated in VLBW infants with such adverse outcomes as IVH, ROP and NEC.
Continuous glucose monitoring (CGM) with closed loop insulin delivery
The principle here is that a meter is inserted subcutaneously that detects blood glucose fluctuations and responds by either increasing infusion of dextrose for low glucose or delivery of insulin. The technology has been around for some time and used in the adult population but is relatively new in this population. I have written about it before in Continuous glucose monitoring in NICU may be around the corner. What follows is the latest pilot study to test this out coupled with glucose or insulin delivery in a closed loop system. The study in this case is out of Cambridge in the UK and entitled Feasibility of automated insulin delivery guided by continuous glucose monitoring in preterm infants .
What did they do?
The study was a pilot of 20 patients randomized to have an automated system to regulate glucose based on CGM data from 48-72 hours of age vs a paper based algorithm to manage dextrose or insulin infusion rates during the same period. The sample size was one of convenience to test the concept and the period was chosen to allow for time to recruit patients. The sensor used was an Enlite attached to a laptop with software capable of delivering infusion rates to two alaris pumps (one with 20% dextrose and the other with insulin). Target serum glucose levels were set to be between 4-8 mmol/L. The babies included were all under 1200g and had mean weights of 962g in the closed loop and 823g in the control arm.
The Results were fairly dramatic in my mind at least. A remarkable 91% of the infants in the closed loop system had glucose levels in the target range vs 26% in the control arm. Nutritional intakes and mean insulin dosing were not any different between groups. No harm in addition was noted from use of the CGMs. You don’t escape pokes all together though as the device does require q6h checks to calibrate and ensure it is reading properly. Every 6 hours is better though than every three for those with brittle control!
Tightly regulating blood glucose and avoiding both lows and highs has benefits on the low end to neurological preservation. On the high end some complications such as IVH, NEC and ROP may be avoided by better control. The challenge with the system as is at the moment is that it is not widely available. I am eager for a company out there to create software for mass distribution that would enable us to try this out. While the calibration is still required I can’t help but think this is an improvement over what we have at the moment. Stay tuned as I think this one is for real and will appear in NICUs sooner than you think!
By Stefan Johansson in Department of Brilliant IdeasMany of you already know about my engagement in Neobiomics, a startup company now launching ProPrems® in Europe.
I was asked recently if there was a specific event that made me committed to close the gap between need and availability of a safe way to support the intestinal microbiota. Yes, there was a “Tipping Point” that I can share a few words about, without disclosing patient data.
The photo below shows the place in my NICU where a preterm infant stayed some years back, being well on full feeds and expected to have an easy journey with us. When things went into new and unfortunate directions.
Although difficulties and suffering is part of what we work with, this event made me feel that I did not provide the best care for my patients. I mean, compared to all interventions we make every other day, and the lack of good evidence for many of them, probiotics supplementation was already in 2014 a no-brainer from an EBM perspective. So, I set off to find a suitable product. But became increasingly frustrated. I thought that manufacturing probiotics could not be rocket science but I experienced that no company could provide what I was looking for. Specifically, when it came to documentation around quality.
I discussed this matter with colleagues and realized that I shared my concerns with others. An idea came to my mind that maybe we should just work out a solution ourselves, within the neonatal community. Philipp Novak, a life-science entrepreneur in Austria, was brave enough to get convinced and off we went. Backed by a group of clinicians and researchers.
In 2016 we founded the startup company Neobiomics and initiated our collaboration with Chr.Hansen, world-leading manufacturer of bacterial cultures. And now, after 1000s of work hours (pro bono BTW) and with very limited funds, we have now reached the first goal. With ProPrems® there is now a premium product available, with manufacturing quality as we want it (single-dose-packaging, 2y stability in room temp, tested against an extended panel of contaminants, no risk of antibiotic resistance gene transfer).
What’s next? To speak in symbols, our plane is on the takeoff strip at full throttle while we are still putting the wings together. So times are both hectic and thrilling. But like when standing in front of a very ill infant in the NICU, I feel that this is something we can manage by systematic and hard work. But of course, ProPrems® needs to find the way out to NICUs. Without a costly "old-school" organization of sales rep’s etc, this may seem challenging. But given the collegial feedback so far, we feel confident our project will sustain.
If you get interested to learn more, find more in the attached folder. You can also visit the web sites neobiomics.eu and proprems.eu, or get in touch with me directly at email@example.com.
But please note that ProPrems® will be only available in Europe (that’s why access to ProPrems.eu is restricted from non-EU countries).
By AllThingsNeonatal in All Things NeonatalThe story around cord management after birth continues to be an evolving one. I have certainly posted my own thoughts on this before with my most recent post being Delayed cord clamping may get replaced. Time for physiological based cord clamping. While this piece demonstrated that there are benefits to longer times till clamping is done, it also showed that if you go too long hypothermia becomes a real risk and with it possible complications. At least in our centre the standard that we have tried to reach is DCC for one minute for our infants. As you will no doubt know from the literature reviewed here before, this is likely not long enough!
One or Three Minutes?
This study caught my eye this week. Effect of early versus delayed cord clamping in neonate on heart rate, breathing and oxygen saturation during first 10 minutes of birth – randomized clinical trial What struck me in particular about this paper was not just the physiologic outcomes it was looking at. What is remarkable is the size of the study. So many articles that are published in Neonatology have under a hundred patients. On occasion we see studies with hundreds. In this case the authors included 1510 patients who were randomized to early ≤60 s of birth and ≥ 180 s for time of clamping. What is also interesting here is that early which used to be considered right after delivery of the infant is now 1 minute in this study. I like that this is the accepted new norm for this type of study.
Inclusion criteria were such that these were all low risk vaginal deliveries with fetal heart rate (FHR) ≥100 ≤ 160 bpm and all infants were ≥33 weeks. Although 1510 were randomized (power calculation for sample size found there should be 566 per group based on an expected loss of 25% per arm. In the end there were 670 in the ECC and 594 in the DCC groups that adhered to the protocol. In the ECC group the mean duration of time till clamping occurred was 31.2 s (+/-14.4) vs 198.5s (+/-16.9).
The goal after delivery is to increase blood flow to the lungs as PVR drops. In order to do so this requires adequate ventilation but it also requires adequate perfusion of the myocardium. If you clamp too early and pulmonary blood flow has not yet increased you run the risk of having a sudden drop in coronary blood flow with oxygenated blood from the placenta and with that bradycardia. A longer time on “heart lung bypass” from the placenta should allow for a smoother transition. That is what was seen here. At 1, 5 and 10 minutes infants randomized to the DCC had better oxygen saturations. Heart rates interestingly were lower in the DCC group but that could also be related to better oxygenation leading to less compensatory tachycardia. In other studies in which the cord was clamped immediately bradycardia was more common. This difference here may reflect timing of the clamp on heart rate. Lastly, time to first breath was much faster in the group randomized to DCC. Might this be an effect of better oxygenation?
What they didn’t measure?
There was no comment on risk of hypothermia or other markers of illness such as rates of admission to NICU, hypoglycemia, lethargy or other markers of an infant who became cold. If this is to become standard practice measures need to be in place to prevent these concerns from becoming reality. It is also worth noting the population studied. These are healthy late preterm and term pregnancies. More work is needed on younger infants and those with risk factors in pregnancy. How would mothers with poor tracings, diabetes or hypertension fare as well as those who have growth restricted infants?
This field is growing and I will continue to follow this evolving story and share information as it becomes available. One thing in my mind is fairly certain though and that is that clamping right after delivery for routine births should be a thing of the past.
01 July 2019 06:00 AM Until 30 September 2019 05:00 AM
0It is an online course which lasts 3 months, starting in July, 2019. 28 topics avilable 24/24 and 7/7. 22 mexican professors and 8 international ones.
20 October 2019 Until 23 October 2019
0Investing in a Healthy Future for All: Research, Education, Policy.
Participate in the 11th DOHaD World Congress which will be held in Melbourne, Australia in October 2019. The Congress is hosted by the DOHaD Society of Australia and New Zealand.
The Congress theme is Investing in a Healthy Future for All: Research, Education, Policy. The Congress will bring together basic and clinical researchers and health care professionals from around the world to address the many challenges that currently impact the health of mothers and fathers, babies in the womb, infants, children and adolescents, as well as explore solutions, interventions and policies to optimise health across the lifespan.
Click here to reach the conference web site!
14 November 2019 Until 15 November 2019
1The European Neonatal Ethics Conference is one of the premier events discussing issues involving ethical care around a variety of aspects in neonatal care. It is held every 3 years and is being held in Southampton United Kingdom this year. Besides addressing a number of different topics including issues of neonatal palliative care, organ donation and extremes of viability it is opportunity to share ethical practice across Europe.
Venue -St Mary's Stadium Southampton UK Dates 14th & 15th November 2019
Call for Abstracts-We are calling for abstracts for oral presentations, poster presentations, debates and round table discussions. More details are available here
17 November 2019
1The 17th of November each year is the World Prematurity Day. Originally started by parent organisations in Europe in 2008, the World Prematurity Day is an international event aiming at high-lighting the ~15 million infants born preterm each year.
Read more about this day on the March of Dimes web site, and on Facebook.
26 April 2020 Until 28 April 2020
0First announcement of
Recent advances in neonatal medicine
IXth International symposium honoring prof. Richard B. Johnston, MD, Denver, US
26-28 April 2020, in Würzburg, Germany
Find more information in the attached folder.