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  • Blog Entries

    • 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!
    • By Stefan Johansson in Department of Brilliant Ideas
         0
      The Dept of Brilliant Ideas proudly presents this 90 sec video about Neobiomics and the vision and mission of ProPrems®.
      I am grateful and also proud that what the network of people around Neobiomics has achieved.
      It has been a journey and now is the time to "arrive" at the point we headed for.
      If you want more info - send me a DM or email stefan@neobiomics.eu.
      Please note that we only deliver ProPrems® in Europe.
       
    • By Stefan Johansson in Department of Brilliant Ideas
         0
      The new buzz word in health care is “innovation”. Which is a good thing! 
      I have been in the ecosystem of innovation since 2016 with the startup company Neobiomics and the ProPrems® product, in the Innovation Incubator at Karolinska Institutet (KI DRIVE). There we meet with other startup companies, and we share several of the challenges of operating in the interface between innovation and “traditional” health care.
      Here's a few thoughts.
      Innovation can only benefit patients through implementation
      For innovations to reach out and bring value, implementation is key. No matter how brilliant an idea, it needs to be brought to life in an open-minded culture, where learning and change are core values. Health care can be conservative and resistive to change, and that may slow down, discourage or even hinder implementation.
      Eminence-based medicine vs evidence-based medicine
      I am a strong advocate of evidence-based medicine myself, but health care is still influenced a fair bit by “eminence-based medicine”. High-profile people may tell how they “feel” or “believe”. While feelings and beliefs are essential parts of the human nature, they are (IMHO) insufficient arguments in discussions about evidence. Innovations backed by evidence may not “feel right” if they change current practice. But we need to trust data, or else there is little point of doing research.
      (Too?) many stakeholders
      Health care is a complex structure, with a lot of stakeholders. While patients are more empowered now than ever before, there are a lot of “layers” between an innovation and a patient. Implementation involves staff, informal leaders, heads of departments, pharmacies, management teams, professional bodies, policymakers etc. As a consequence, implementation takes time. It can take more time than patients should need to tolerate.
      What to do?
      To take words to action, health care needs to embrace a culture of learning and change, or else “innovation” will be no more than a buzz word Research data is a valid starting point for change Innovators travel with light luggage, and need a complementary decision-making process in health care, not to delay the benefits and value that innovation bring patients With best regards from the Department of Brilliant Ideas
  • Upcoming Events

    • 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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