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  • Blog Entries

    • By AllThingsNeonatal in All Things Neonatal
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      One of the most common conditions afflicting ex-preterm infants is chronic lung disease. Through advances in antenatal steroids, surfactant and modern ventilation we have done what we can to try and prevent this condition from occurring yet despite our best efforts CLD remains a common problem among those born at less than 1500g as is shown in the 2018 Canadian Neonatal Network data.
      Primary prevention is of course the ideal strategy to reduce disease but when you try and your best and an infant still has chronic lung disease what is one to do? For now we bide our time focusing on nutrition and minimizing harm from ventilation. Something new is coming and I hope it comes soon.
      Stem Cells to Heal BPD
      My former colleague Bernard Thebaud has done much work already in this field. A recent review he was part of is a good starting point to bring you up to speed; Stem cell therapy for preventing neonatal diseases in the 21st century: Current understanding and challenges. As the field advances though and we continue to see additional animal trials such as the one I will discuss here, the interest in this field continues to grow. I was drawn to a recent paper on this topic as it is not dissimilar to another trial I wrote about in which stem cells were given via breastmilk intranasally to improve outcome after IVH; Can intranasal application of breastmilk cure severe IVH? In this new trial though instead of delivering stem cells in a cephalad direction they place the rat vertically to deliver the stem cells from wharton’s jelly to the trachea and damaged lung.
      Stem cells from Wharton’s Jelly
      Moreira A et al published the following paper in Intranasal delivery of human umbilical cord Wharton’s jelly mesenchymal stromal cells restores lung alveolarization and vascularization in experimental bronchopulmonary dysplasia This study was done in four rats divided into 4 groups. Group A were rats born and raised in room air. Group B were exposed to 60% oxygen for four days to induce BPD. Group C was given experimental BPD as in Group B and then given the vehicle for stem cell delivery without stem cells. Group D then also had BPD was actually given stem cells. The timeline for the study is shown below.
      The results are quite impressive. Looking at the histology of the four different groups reveals the curative property of these types of cells.
      In essence the lung tissue architecture at the alveolar level looks almost identical to normal rat lung on the far left if the stem cells are provided through the intranasal route.
      Moreover, when one looks at the impact on the blood vessels in the lung using Von Willebrand Factor staining similar healing is observed.
      Lastly, not only were the numbers of blood vessels recovered but the thickness of the smooth muscle was reduced to that of normal rats without BPD after such treatment.
      Why is this so important?
      Past research has delivered stem cell treatment to the alveoli through an endotracheal tube. What this demonstrates is that rats held in a vertical position can have stem cells delivered into the lung where they are sorely needed. Could one take an infant on CPAP who is developing signs of CLD and do the same? The day may be coming when we prevent such infants from being reintubated just for CLD in the future.
      The road is long though and the use of stem cells in humans has not begun yet. The effects seen in this rat model are dramatic but will they translate into the same thing in the human? I believe so and am waiting ever so patiently for such trials to start in humans. If you are looking for the next big leap in Neonatology I suspect this is what we are looking at. The question now is when.
    • By Jelli KA in Bubbly Girl in NICU
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      A article that most struck lately:
      This article by Dr. G.Moore et al researchers at the University of Ottawa, accessible #FOAM, give a good thoughtful analysis to whether chest compression & epinephrine cause more harm than good to V.preterm infants using 'principals' as an ethical framework aka the Spanish /French say does 'Encarnecimiento Terapeutico' a concept complex.
      As I understand, away to explain it what happens when you go beyond overtreatment?  When continuing treatment is medically futile, but you keep going it starts to cause more harm than it yields benefits.
      Here the author explain with explain with examples why chest compression and  justified in cases of need - concludes with a maybe.
    • By AllThingsNeonatal in All Things Neonatal
         1
      First off I should let you know that we do not do transpyloric feeding for our infants with BPD. Having said that I am aware of some units that do. I suspect the approach is a bit polarizing. A recent survey I posted to twitter revealed the following findings:
      I think the data from this small poll reveal that while there is a bias towards NG feeds, there is no universal approach (as with many things in NICU).
      Conceptually, units that are using transpyloric feeds would do so based on a belief that bypassing the stomach would lead to less reflux and risk of aspiration. The question though is whether this really works or not.
      New N of 1 Trial
      I don’t think I have talked about N of 1 trials before on this site. The trials in essence allow one patient to serve as a study unto themselves by randomizing treatments over time for the single patient. By exposing the patient to alternating treatments such as nasogastric or nasoduodenal feedings one can look at an outcome and get a sense of causality if a negative or positive outcome occurs during one of the periods consistently. That is what was done in the study Individualising care in severe bronchopulmonary dysplasia: a series of N-of-1 trials comparing transpyloric and gastric feeding by Jensen E et al from the Children’s Hospital of Philadelphia. The authors in this study determined that using a primary outcome of frequency of daily intermittent hypoxaemic events (SpO2 ≤80% lasting 10–180 s) they would need 15 patients undergoing N of 1 trials between nasogastric and nasoduodenal feeding. Included infants were born at <32 weeks and were getting positive airway pressure and full enteral nutrition at 36 0/7 to 55 6/7 weeks PMA. Infants who were felt to be demonstrating signs of reflux or frank regurgitation were enrolled.
      The findings
      Thirteen of 15 enrolled patients completed the study. The two who did not complete did so as their oxygen requirements increased shortly after starting the trial and the clinical team removed them and chose their preferred route of feeding. Randomization looked like this:
      Of the 13 though that completed and using an intention to treat analysis of the other two the findings were somewhat surprising. Contrary to what one might have thought that transpyloric would be a lung protective strategy, the findings were opposite.
      Overall the combined results from these 15 patients demonstrated that nasogastric feedings were protective from having intermittent hypoxic events.
      How can this be explained?
      To be honest I don’t really know but it is always fun to speculate. I can’t help but wonder if the lack of milk in the stomach led to an inability to neutralize the stomach pH. Perhaps distension has nothing to do with reflux and those with BPD who have respiratory distress with some degree of hyperinflation simply are prone to refluxing acid contents due to a change in the relationship of the diaphragmatic cura? It could simply be that while the volume in the stomach is less, what is being refluxed is of a higher acidity and leads to more bronchospasm and hypoxemic events.
      What seems to be clear even with this small study is that there really is no evidence from this prospective trial that transpyloric feeding is better than nasogastric. Given the size of the study it is always worth having some degree of caution before embracing wholeheartedly these findings. No doubt someone will argue that a larger study is needed to confirm these findings. In the meantime for those who are routinely using the transpyloric route I believe what this study does at the very least is give reason to pause and consider what evidence you have to really support the practice of using that route.
    • By AllThingsNeonatal in All Things Neonatal
         1
      Inhaled nitric oxide has been around for some time now. I recall it being called at one point in medical school “endothelial relaxation factor” and then later on identified as nitric oxide. Many years later it finds itself in common usage in NICUs all over the world. Our experience though has been for treatment of pulmonary hypertension and for that it is pretty clear that for those afflicted by that condition it can be lifesaving. Over the years other uses have been looked at including prevention of BPD (turned out not to be the case). Rescue approaches therefore have found to be useful but on the prophylactic side of things not so much.
      Maybe starting earlier is the key?
      A group based out of Oklahoma has published a pilot study that raised an eyebrow for me at least. Krishnamurthy et al released Inhaled Nitric Oxide as an Adjunct to Neonatal Resuscitation in Premature Infants: A pilot, double blind, randomized controlled trial . The study set out to recruit 40 infants who between 30-90 seconds of life if requiring PPV would either get iNO 20 ppm with 30% oxygen or 30% oxygen and placebo for ten minutes. At ten minutes weaning of iNO by 1 ppm per minute for a total of 17 minutes was done. The primary outcome of interest was FiO2 required to achieve target oxygen saturations. As with many studies that seek enrollment prior to delivery this study was a challenge as well with early termination of the study after 28 babies (14 in each group) were recruited.
      Did they find anything interesting?
      In spite of the low numbers in the study, the authors did find a divergence in the FiO2 needed to achieve the target oxygen saturations.
      The authors conclusions were that the cumulative exposure to FiO2 was lower in the iNO group as well as the maximum exposed FiO2 of 39% vs 48% (although this almost but not quite met statistical significance. Even then this is a pilot study so inferring too much could be a dangerous thing.
      The study though does get one thinking but we need to be wary of letting our brains do some mental trickery. Lower FiO2 seems like a good thing given what we know about oxygen free radicals. What about rapid lowering of pulmonary vascular resistance with exogenous iNO? Is this a good thing or could other things be lurking around the corner? Could a larger study for example find a higher rate of pulmonary hemorrhage with rapid reductions in PVR? The authors did not find harm in the study but again with small numbers it is hard to conclude too much.
      What this small study does though is raise many questions that I think could be interesting to answer. If a patient needs less FiO2 at 17 minutes after study entry might there be less perceived need for higher PEEP if ventilated or CPAP levels if on non-invasive support? Less pressure could lead to less risk of pneumothorax (or more perhaps if under treated but with respiratory distress. Less pressure might also influence longer term risks of BPD from barotrauma or volutrauma for that matter.
      Regardless this is only the beginning. I have no doubt there will be further trials on the way. The trick will be as in this study to obtain consent unless a deferred consent could be obtained but I have my doubts about getting that. Nonetheless, wait for more to come!
  • Upcoming Events

    • 14 March 2020 Until 15 March 2020
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      NEOANT2020
      2nd Annual National Conference
      Theme
      "Integrating Trauma Informed Practice in NICU"
      Recognizing the enormity of the challenges our society faces, Association of Neonatal Therapists (ANT) is dedicated to making a lasting impact through our programs. While our efforts are driven by our organization’s singular focus, we spread a wide net by investing in a variety of progressive strategies.
       
      Time & Location
      14 Mar, 8:00 am IST – 15 Mar, 6:00 pm IST; Surya Hospital, Mumbai, Santacruz, Mumbai
       
      About the Event
      Chief Guest : Dr. Mrudula Phadke,  Sr. Advisor, National Rural Health Mission, Govt. of India; UNICEF 
       
      Key Note of Address by Mary Coughlin
      A leader in neonatal nursing, Mary Coughlin MS, NNP, RNC-E has pioneered the concept of trauma-informed care as a biologically relevant paradigm for hospitalized newborns, infants, and their families. 
      An internationally recognized expert in the field of age-appropriate care, Ms. Coughlin has over 35 years of nursing experience beginning in the US Air Force Nurse Corp and culminating in her current role as President and Chief Transformation Officer of Caring Essentials Collaborative. 
      Ms. Coughlin authored the 2011 NANN Guidelines for Age Appropriate Care of the Premature and Critically Ill Hospitalized Infant and most recently authored the books: Transformative Nursing in the NICU: Trauma-informed, Age-appropriate Care (2014) and Trauma-informed Care in the NICU: Evidence-Based Practice Guidelines for Neonatal Clinicians (2016) - endorsed by the National Association of Neonatal Nurses. Ms. Coughlin has mentored close to 10,000 interdisciplinary NICU clinicians from over 14 countries to transform the experience of care for the hospitalized infant and family in crisis. 
       
      Reserve Your Free Seat
       
      Tentative Agenda
      First Day - 
       
      Why and What Research I should do? -
      Dr. Nandkishor Kabra, Director, Surya Hospital, Mumbai
       
      Strategies for Knowledge Translation of Developmentally Supportive Care in NICU
      Dr. Amitava Sengupta , Fellowship Neonatology (Neth) ; FNNF Director: Mother & Child Unit, Neonatology & PediatricsParas Hospitals, Gurgaon (NCR), India
       
      Demonstration : Developmentally Supportive Care 
       
       "Individual Newborn Developmental Intervention Application" Nandgaonkar Hemant
       
      Second Day - Scientific Session
      Submitted Topics (Subject to approval of Scientific Committee)
       
      Quality of care
      Trauma informed care in NICU-implications for occupational therapist.
      Development of INDIA EBUS - Brain Oriented Care in NICU
      Recent advances about Family centered care in NICU
      Neonatal Therapy Kit
      WHY, WHEN AND HOW TO POSITION IN NICU
      Article Presentation
      To analyse the effect of quality of sleep and level of fatigue in postpartum lactating mothers.
      A Systematic Review of different Pain Assessment Scales used in Neonates
      A Systematic Review of different Pain Assessment Scales used in Neonates
      Immediate effect of Diaper change Activity with Individualized Developmental Care on preterm neonates Neurobehavior.
       
       Time management during busy clinical setting 
      Dr. Ulhas Kolhatkar,
      Director, Ace Children's Hospital, Dombivili
      Ex. Governor of Mumbai District, Rotary Club
       
                          - Neonatal Therapy Certification Examination (Seperate Registration for Examination) Rs. 1000/-
       
       
      Registration 
      Members - INR 5000
      Non Members - INR 7550
      Group of five Non members - INR 25000
       
      Abstract Submission ends at 15th December, 2019
       
      Patron: Dr. Nandakishor Kabra, Director, Surya Hospital, Mumbai
       
      Organizing Chairperson - Sanika Gawade
       
      Scientific Committee Chairperson - Jyothika Bijlani, Dean Academic Council of Occupational Therapy
       
      LIMITED SEATS
       
       Payment details Payment will be accepted by NEFT 
      Bank Name :Canara Bank  Branch :Mumbai, Parel  Name of the Account holder :Association of Neonatal Therapists Account number :0110201004920  IFSC CODE :CNRB0000110  
       
      Simple Registration Process
      Pay by NEFT - Send Your details along with transaction details to neonataltherapistindia@gmail.com 
       
      For more information, please visit
      https://www.neonataltherapy.org/
    • 19 March 2020
      0  
      Stockholm Conference on Ultra-Early Intervention is a scientific conference on Infant and Family Centered Developmental Care (IFCDC) organized by Karolinska NIDCAP Training and Research Center.
      In 2020, the 11th conference is scheduled for 19 March 2020.
      Check out the web site: https://www.karolinska.se/ultraearly

      the-2020-stockholm-conference-on-ultra-early-intervention_191120.pdf
    • 15 April 2020 Until 19 April 2020
      0  
      Welcome to Vienna and the 4th Future of Neonatal Care conference AKA the 99nicu Meetup!
      Find all info here: https://99nicu.org/meetup/ 
    • 26 April 2020 Until 28 April 2020
      0  
      First 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.
      First_Announcement_01.2020.pdf
    • 25 June 2020 Until 26 June 2020
      0  
      Visit Conference website: http://www.lutonneocon.co.uk
    • 17 November 2020
      1  
      The 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.
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