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  • Blog Entries

    • By AllThingsNeonatal in All Things Neonatal
         2
      Use of caffeine in the NICU as a treatment for apnea of prematurity is a topic that has certainly seen it’s fair share of coverage on this blog. Just when you think there is an aspect of treatment with caffeine that hasn’t been covered before, along comes a new paper to change my mind.
      The Caffeine for Apnea of Prematurity study or CAP, demonstrated that caffeine given between 3-10 days of age reduced the incidence of BPD in those treated compared to those receiving placebo. As an added benefit, in follow-up studies of these patients there appeared to be a benefit to neurodevelopmental outcomes as well at 18-21 months but this was lost by school age with groups being equivalent. In recent years evidence has mounted that starting caffeine earlier in the time course (<3 days and in many cases in the first hour after birth) has led to less need for intubation and BPD. What has really not been known though is whether the use of caffeine in this way might have any long term benefits aside from these short term outcomes.
      Dr. Abhay Lodha from Calgary and a group of researchers led by Prakesh Shah from the Canadian Neonatal Network using our robust Canadian network data have tried to answer this with their paper Early Caffeine Administration and Neurodevelopmental Outcomes in Preterm Infants
      The group studied were <29 weeks’ gestation born between April 2009 and September 2011 and admitted to Canadian Neonatal Network centres. As defined in the paper “Neonates who received caffeine were divided into early- (received within 2 days of birth) and late-caffeine (received after 2 days of birth) groups. The primary outcome was significant neurodevelopmental impairment, defined as cerebral palsy, or a Bayley Scales of Infant and Toddler Development, Third Edition composite score of <70 on any component, hearing aid or cochlear implant, or bilateral visual impairment at 18 to 24 months’ corrected age.”
      There were 2018 neonates included in the analysis with 1545 in the early group and 563 in the late. It is worth noting that there were 473 infants lost to follow-up meaning that there was about an 80% follow-up rate. Looking at the characteristics of those infants lost to follow-up there were no striking differences that one would expect between them and the group followed.
      What did they find?

      The odds of BPD (aOR 0.61; 95% CI 0.45–0.81), PDA (aOR 0.46; 95% CI 0.34–0.62), and Severe Neurologic Injury – parenchymal injury or GR III/IV IVH or PVL (aOR 0.66; 95% CI 0.45–0.97) were reduced in the early- caffeine group. The primary outcome was also found to be significantly different as per the table below demonstrating the odds after logistic regression analysis.
       
      So early caffeine seems to be good. Is that all then?
      I am very happy to see these results but a few questions remain. Before we get too enthusiastic, I find myself thinking back to the early 2000s after the initial CAP results showed an apparent difference in outcome. The question is whether the reduction in odds seen here for the primary outcome will persist as these children age. Will we see a tendency for the differences to vanish as these children enter school age? I suspect we might but that doesn’t mean all is lost here. What the authors have demonstrated clearly is that early caffeine is not harmful as there is no suggestion of those infants exposed to caffeine so shortly after birth fare worse than those treated later.
      Also as the authors state, what isn’t clear is how caffeine works to decrease the risk of developmental impairment. In the discussion they offer some insightful thoughts as to what may be at play and I agree that certainly an anti-inflammatory effect may be responsible for some of the effect. I do wonder though if one could tie the reductions to the lower likelihood of BPD. Development of BPD has been shown many times over to be associated with worse developmental outcomes. Aside from the anti-inflammatory effect mentioned, could the avoidance of early intubation and therefore reduced risk of BPD from positive pressure ventilation be the reason?
      In the end if the results persistent into school age, the reason won’t really matter and I hope it does. Will see what happens when we revisit this cohort in a few years but in the meantime I think this paper certainly confirms in my mind the need to give caffeine and make sure it’s provided early!
    • By Jelli KA in Bubbly Girl in NICU
         0
      Several tweet posted on the subject of music therap­y, namely by Fiona Lawson and Dr. Michae­l Narvey. It prompted me to share  paper on the on the Music therapy(MT) in NICU as I was abl­e to research for my posgrad as a way of­ humanizing NICU experience. I had a top­ic on my mind for a while since I used t­o work in the NICU. I First heard of this kind of therapy  from a french television TV5. Here I saw how music was used in a neurological ward for its appeasing edge.    Music therapy i­n Medicine has been around since ancient time.­es.In the NICU it has been used as a therapeutic tool for more than 25 year The US is a pioneer in the field ­, a good example is a Florida University where Dr.Jayne Stanley [1] developed the Lullaby dummy­  -©PALS - by the company Power Devices.      There are many initiative­ exploring the benefits of music therapy around the World. Most i­nitiatives center their studies using the *NIDCAP* Neon­atal framework. The location spans from Spain to Brazil passing by Canada back to Sweden.For example, I found 5 Spanish initiatives, like "Música en­ vena"  which is still on going in the NICU-La­ Paz Hospital-. Together with research studies I also used testimonials of professionals  (music therapist and clinicians), such as the o­ne described in the blog *the amia musica* .      
           Live music seems to be most beneficial to­ preterm infants vs record music . They also established that the n­oise level should be under 55dB.Music therapy has been shown to pro­vides several benefits.To summ up they are as follows :
      #-Firstly,  🎶therapy provides a reduction ­of heart and breathing rate proving the ­ calming effect.of therapy.
      #-Secondly, ­addition 🎶 therapy can help form mother-­baby bond especially when done in conjun­ction with kangaroo care,as well reducing parental stress #-Third and fina­l, studies suggests that the cumulative effe­ct in preterm belongings to the music therapy group­ where discharged earlier compared to­ the control group.     
       .   . .This conclusion are ­backed up by research studies reviewed. I­t is strength was the number and varied types of research­ : RCTs, study/control to ­observational or *prisma* meta analysis.All studies reported on or more positive results.T­he weakness of the studies review was th­e small sample number in some studies. T­he other was some quality sta­ndards were not ideal. Thus , there are ­plenty of indicators to suggest there a certain level of validity of music therapy.    
           . I feel it is ­important to take into account the long te­rm effect of music therapy on neuro-dev­elopment of preterm infants admitted to ­the NICU.A further finding revealed that too mu­ch or too little stimulation is detrimen­tal to a premmie. On the other hand, we also have­ consider what Anderson and Padel [2] say when they talk about deepening our knowledge of ­ Hypothalamic -Puititary-Adrenal Axis (H­PA)  on the stress response in neonat­es.   
         In this posgrad assignment were ­asked to propose a specific proposal .So I proposed to evaluate the levels of stress in neon­ates and find out if music therapy can he­lp. For this purpose the levels of cortisol levels need to be measured before and after a sessio­n of Music therapy. So If the levels of cortisol are indeed ­lower after a session MT this would indicate this therapy could be another indicator it is beneficial. A device like the new transdermal ­patch designed by Stanford University [3] that measures cor­tisol levels in Athletes. This pra­ctical tool could used the to measure the cortisol levels and avoids the unnecessary p­ain of needle bricks.
       
       
       
       
      References:
      [1]Tom Butler: FLORIDA STATE UNIVERSITY.New musical pacifier helps premature babies get healthy.Eureka Alerta , Florida [ Internet] May 2012 . Disponible en: https://www.eurekalert.org/pub_releases/2012-05/fsu-nmp052112.php
      [2]Anderson DE1 and Patel AD2. Infants born preterm, stress, and neurodevelopment in the neonatal intensive care unit: might music have an impact? Dev Med Child Neurol. [Internet] 2018 [Consultado 27 de Julio 2018 ] Mar;60(3):256-266. Disponible en: https://onlinelibrary.wiley.com/doi/abs/10.1111/dmcn

      *.Loewy, J et al.The effects of music therapy on vital signs, feeding, and sleep in premature infants. Pediatrics. [Internet] 2013 [ Consultado 24 de Julio 2018] May;131(5):902-18. Disponible en: http://www.pediatrics.org/cgi/doi/10.1542/peds.2012-1367
      [3]Kubota,T .Wearable device from Stanford measures cortisol in sweat.Stanford News. [ Internet] Julio 2018 [ Consultado 20 Julio 2018] Stanford University, Stanford, California. Disponible en: https://news.stanford. edu/2018/07/20/wearable-device-measures-cortisol-sweat/
       
    • By AllThingsNeonatal in All Things Neonatal
         0
      This post is very exciting to me.  All of us in the field of Neonatology are used to staring at patient monitors.  With each version of whatever product we are using there seems to be a new feature that is added to soothe our appetites for more data.  The real estate on the screen is becoming more and more precious as various devices such as ventilators, NIRS and other machines become capable of displaying their information in a centralized place.  The issue though is that there is only so much space available to display all of this information but underneath the hood so to speak is so much more!
      Come Along For The Ride
      One of our Neonatologists Dr. Yasser Elsayed has been very aware of these features embedded in the patient monitor. 
      Through teaching on rounds, some of our staff have become aware of these features but delivering this content to the masses has been an issue.  That is where this post and it’s linked content come into play.  I have created a new Youtube playlist where all of this great content can be found.  Each video is very watchable with most being 5-7 minutes long with the longest being 14:16.  Each video starts with a demonstration on the patient monitor of the lesson being taught and how to access the data using the patient monitor (in this case a Phillips but I have no doubt many other monitors have the same tech – just ask your rep how to get it) followed by a brief voice-over powerpoint to deliver the essential concepts.
      However you wish to digest the information is up to you but as they are short we hope that you will be able to find the content you need quickly and apply the knowledge to patient care.  How can you use the information?  The next time a patient is giving you cause to worry try looking into some of the deeper trends that the monitor is hiding from plain sight. Is there a trend towards becoming hypotensive for the patient that can be revealed in their blood pressure histogram?  Maybe the issue lies with the way the patient is being ventilated and examining trends in the pleth waveforms may reveal where the underlying problem lies.
       
      The Topics (click the links to go to Youtube)
      Complete List of Videos
      Part 1 – Using Histograms
      Part 2 – How to interpret blood pressure histograms
      Part 3 – Using vital signs as trends
      Part 4 – Impact of ventilation on pleth waveforms
      Part 5 – How to interpret arterial pressure waveforms
      Part 6 – Near Infrared Spectroscopy
       
    • By AllThingsNeonatal in All Things Neonatal
         0
      A recent post on the intranasal application of breast milk Can intranasal application of breastmilk cure severe IVH? garnered a lot of attention and importantly comments.  Many of the comments were related to other uses for breast milk (almost all of which I had no idea about).  A quick search by google uncovered MANY articles from the lay press on such uses from treating ear infections to diaper dermatitis.  One such article 6 Surprising Natural Uses For Breast Milk certainly makes this liquid gold sound like just that!  This got me thinking as I read through the claims as to how much of this is backed by science and how much is based on experience of mothers who have tried using breast milk for a variety of unconventional treatments.  I was intrigued by the claim about acne as with several family members nearing that wonderful period of the teenage years I wondered might there have been a treatment right under my nose all this time?  Before going on I will tell you what this post is not.  This is not going to be about telling everyone that this is a terrible idea. What this is about is breaking down the science that is behind the articles that have surfaced on the internet about its use.  I thought it was interesting and I hope you do too!
      The Year Was 2009
      The story begins here (or at least this is the point that I found some evidence). A group of nanoengineering researchers published a paper entitled The antimicrobial activity of liposomal lauric acids against Propionibacterium acnes.  The authors examined the antibacterial effect of three fatty acids one of which was lauric acid (which is found in coconut oil but also in breast milk) against Propionibacterium acnes (P. acnes) the bacterium responsible for acne in those teen years.  The results in terms of dose response to lauric acid was quite significant.

      This is where the link in the story begins. Lauric acid kills P. Acne and it is found in high concentrations in breast milk so might topical application of breast milk treat acne?  From what I can see this concept didn’t take off right away but a few years later it would.
      Next we move on to 2013
      This same group published In vivo treatment of Propionibacterium acnes infection with liposomal lauric acids. in 2013.  This time around they used a mouse model and demonstrated activity against P. Acnes using a liposomal gel delivery system to get the Lauric acid onto the skin of the mouse.  Interestingly, the gel did not cause any irritation of the mouse skin but using the traditional benzoyl peroxide and salicylic acid caused severe irritation.  From this it appears that the news story broke about using breast milk to treat acne as I note several lay press news stories about the same after 2013.  Let’s be clear though about what the state of knowledge is at this point.  Lauric acid kills P. Acne without irritating skin in a mouse model.  As with many early discoveries people can get very excited and apply the same to humans after extrapolation.
      What Happened Since Then?
      Well, in late 2018 this study was released Design, preparation, and evaluation of liposomal gel formulations for treatment of acne: in vitro and in vivo studies. This is another animal study but this time in the rat which demonstrated application of the gel led to “∼2 fold reduction in comedones count and cytokines (TNF-α and IL-1β) on co-application with curcumin and lauric acid liposomal gel compared to placebo treated group.”  Essentially, comedones were reduced and markers of inflammation.  So not only do we see an antimicrobial effect, once the bacteria are erradicated, there is a clinical reduction in acne lesions!
      Where do we go from here?
      This story is still evolving.  Based on the animal research thus far here is what I believe.
      1. Lauric acid a fatty acid found in breast milk can kill P. Acne.
      2. Lauric acid provided in a gel form and topically applied to rodents with acne can achieve clinical benefits.
      3. Whereas current standard treatments of benzoyl peroxide and salicylic acid cause inflammation of the skin with a red complexion, lauric acid does not seem to have that effect.
      These are pretty incredible findings and I have no doubt, pharmaceutical companies will be bringing forth treatments with lauric acid face creams (they already exist) with a target for acne soon enough.  The question though is whether families should go the “natural route” and apply expressed breast milk to their teenagers face.  Aside from the issue of whether or not your teenager would allow that if they knew what it was the other question is what might grow on the skin where breast milk is left.  I am not aware of any further studies looking at other bacteria (since P. Acnes certainly isn’t welcome around breast milk) but that is one potential concern.
      In the end though I think the research is still a little premature.  We don’t have human trials at this point although I suspect they are coming.  Can I say this is a terrible idea if you are currently using breast milk in such a fashion?  I suppose I can’t as there is some data presented above that would give some credibility to the strategy.  I am curious for those who read this post what your experience has been if you have used breast milk for acne or for other skin conditions.
      Does it really work?!?
    • By AllThingsNeonatal in All Things Neonatal
         0
      Hypoglycemia has been a frequent topic of posts over the last few years. Specifically, the use of dextrose gels to avoid admission for hypoglycemia and evidence that such a strategy in not associated with adverse outcomes in childhood. What we know is that dextrose gels work and for those centres that have embraced this strategy a reduction in IV treatment with dextrose has been noted as well.
      Dextrose gels however in the trials were designed to test the hypothesis that use of 0.5 mL/kg of 40% dextrose gel would be an effective strategy for managing hypoglycemia. In the Sugar Babies trial the dextrose gel was custom made and in so doing an element of quality control was made possible.
      In Canada we have had access to a couple products for use in the newborn; instaglucose and dex4. Both products are listed as being a 40% dextrose gel but since they are not made in house so to speak it leaves open the question of how consistent the product is. Researchers in British Columbia sought to examine how consistent the gels were in overall content and throughout the gel in the tube. The paper by A. Solimano et al is entitled Dextrose gels for neonatal transitional hypoglycemia: What are we giving our babies? As an aside, the lead author Alfonso was just announced as the 2019 recipient of the Canadian Pediatric Society Distinguished Neonatologist award so I couldn’t see a better time to provide some thoughts on this paper!
      What did they find?
      The study examined three tubes each of instaglucose and dex4. For each tube the researchers sampled dextrose gel from the top, middle and bottom and then the dextrose content per gram of gel determined as well as gel density. Glucose concentrations were analyzed high-pressure liquid chromatography tandem mass spectrometry (HPLC-MS/MS) and gas chromatography mass spectrometry (GCMS) were used to determine glucose concentrations and identify other carbohydrates, respectively. In terms of consistency the gels were found to be quite variable with dextrose content that for instaglucose could be as much as 81% and 43% different for dex4. Differences also existed between the different sections of the tubes so depending on the whether it was a fresh tube you were using or not the amount of dextrose could vary.
      The authors also discovered that while dex4 contained almost exclusively dextrose, instaglucose contained other carbohydrates not listed on the manufacturer’s ingredient list.

      What does it all mean?
      The differences are interesting for sure. If the glucose gels are not consistent though should we stop using them? I think the answer to that at least for me is no. Although the data is unpublished, our own centres experience has been that admissions for hypoglycemia have indeed fallen since the introduction of dextrose gel usage (we use instaglucose). What I can only surmise is that in some cases patients may be getting 40% but perhaps in others they are getting as little as 20% or as much as 60% (I don’t know exactly what the range would be but just using this as an example). In some cases of “gel failure” perhaps it is for some babies, receipt of low dextrose containing gel that is at fault or it may be they just have high glucose requirements that gel is not enough to overcome. Other infants who respond quickly to glucose gel may be getting a large dose of dextrose in comparison. Overall though, it still seems to be effective.
      What I take from this study is certainly that there is variation in the commercially prepared product. Producing the gel in the hospital pharmacy might allow for better quality control and would seem to be something worth pursuing.
  • Upcoming Events

    • 07 April 2019 Until 10 April 2019
      1  
      Our 3rd 2019 Meetup will take place at Rigshospitalet in Copenhagen, Denmark,  7-10 April 2019.
      While we have the dates and venue set, we have just started to brainstorm about the program.
      Share your input on topics and speakers here! As previous years, we are specifically interested in topics with a high clinical relevance, shared by dedicated speakers.
      And yes, we will keep the same format, i.e. a rather short lecture of ~30 minutes, and a ~15 minutes interactive part with polls, questions and discussions IRL and through the sli.do smartphone app.
      See you in Copenhagen!

    • 05 May 2019 12:00 AM Until 07 May 2019 12:00 PM
      0  
      Council of International Neonatal Nurses Conference 2019 to be held in Auckland, New Zealand from 5th to the 8th May.  www.coinn2019.com 
       
    • 05 September 2019 06:00 AM Until 09:00 PM
      0  
      After (another) successful meeting with NAVA enthusiast from several countries, we are ready to announce the date of the next workshop!
      The goal of this event is to increase skills on the use of NAVA ventilation in the NICUs, which already have some experience with NAVA and they have a Servo-i or Servo-n ventilator.
      Date: 05-06.09.2019
      Location: Turku, Finland
      Registration fee: 600€ + taxes (incl. lunches and refreshments during the workshops) 
      How to register: contact Hanna Soukka (hanna.soukka@utu.fi or NAVA@tyks.fi before June 30, 2019)
      The preliminary program is attached below.  In case of any questions, don't hesitate to ask here or email!
      We've received approval from Ethical MedTech.
       
      On behalf of Hanna Soukka and Baby Friendly Ventilation Study Group,
      CathFriday
      NAVA workshop September 2019 invitation letter and preliminary program.pdf
    • 17 September 2019 Until 21 September 2019
      0  
    • 18 September 2019 Until 22 September 2019
      0  
      the 3rd Congress of Joint European Neonatal Societies (jENS)
      18. Sep 2019 – 22. Sep 2019
      Maastricht, Netherlands
      URL will be posted later.
       


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