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Home, at last

Sorry for keeping you waiting but here's finally the Home page, the landing page if you type 99nicu.org in your browser.
Here we will publish and promote stuff you should not miss. In addition to such articles, you can find out about the most recent topics and posts in the forums, as well as the latest blog entries.
Did I say that Home looks great in smartphone and tables  ?
Stefan Johansson
Stefan Johansson

Conferences on Twitter

It is great to visit a conference, but I believe I am not the only one who attends conferences infrequent. 
But one can follow conferences through new social technologies like Twitter! As many of you know, I am deeply involved in the EBNEO Society (together with others in the 99nicu Team, like Francesco Cardona and Hesham Abdel-Hady) and one strategic idea has been to live-tweet our conferences. We did so already during the 1st and 2nd EBNEO conferences in Stockholm 2011 and Istanbul 2013, and also during the recently held 3rd conference in Philadelphia. Have a look at the hashtag #ebneo2015 on Twitter.
I see know that the jENS-meeting in Budapest also has an official Twitter account @2015_jens, and there are live-tweets on the hashtag #jens2015.
So, don't miss the chance to learn about what's going on in Budapest!
Stefan Johansson
Stefan Johansson

Journal Club in the pipeline

Here come some pre-info about a 99nicu Journal Club!
By using a template for how to disentangle a paper we plan for an organized scrutiny of a paper over one hour. This recent paper in JAMA for example, about early PDA detection, would be great to discuss there! However, that paper is behind the paywall of JAMA so we will start off with open-access papers published in ADC and Acta Paediatrica.
The Journal Club will take place in the Chat room (you see the "Chat" in the menu above if you are logged in). Hopefully we also manage to make a transcript or even get a live feed going out on the @99nicu Twitter account
No date and time is set yet for the first Journal Club, but we will get back soonish
99nicu.org
99nicu.org

Technical updates and changes

We have been working with software upgrades and changes over the last week. During this time, the web site has not been running smoothly and we would like to apologize for that. The peak of problems occurred yesterday when we had to take 99nicu offline. Thanks to great support from IPB, the provider of the technology, we are up and running as usual now! We hope  
There is one big change noticeable for you - our new URL is http://99nicu.org. Previously our installation was in the folder 99nicu.org/forum, and those typing 99nicu.org was re-directed to that URL. Now, the installation is moved to the root on our server. We don't believe this change will cause problems for you, unless you have bookmarked the old URL.
If you notice problems, broken links etc - please use the Contact Us form below or email to info@99nicu.org
99nicu.org
99nicu.org

Special thanks to Acta Paediatrica

The 99nicu make-over has been a process that has included lots of work, also from professional IT consultants. As 99nicu is a free service, i.e. everyone can use everything at no charge, this re-launch had not been possible without a dedicated grant from Acta Paediatrica.
I would like to publicly thank professor Hugo Lagercrantz and the foundation of Acta Paediatrica, for this great contribution to 99nicu. Without this grant, the future had not seen so bright for us. Now, we have modern technical platform and the web site works great on all devices (computers, tablets, and smartphones). Now, we can focus on the great content 99nicu generates.
If you have manuscript for publication, consider submission to Acta Paediatrica.
Stefan Johansson
Stefan Johansson

Pediatrix posts job position on our Job Board

Pediatrix Medical Group is a leading provider of maternal-fetal, and pediatric medical services, neonatal care included.
We are therefore happy that Pediatrix has posted a NNP position on our Job Board, and hope for future postings as well.
With our Job Board we aim not only to match neonatal staff with providers of neonatal care. The Job Board will also generate some funding, as we kindly ask all posters to make a 10USD-donation for each post. 
@Pediatrix - thanks for you donation!
99nicu.org
99nicu.org

99nicu Polls are back! Do you use laryngeal masks during resuscitation?

We are back with the 99nicu Polls!
Inspired by the EBNEO review on ventilation through a laryngeal masks during resuscitation, we started a poll here!
Find the interesting review on the EBNEO website: https://ebneo.org/2015/09/airway-support-during-neonatal-resuscitation-how-effective-is-a-laryngeal-mask/
So now... visit go to our poll on http://99nicu.org/forums/topic/1878-laryngeal-masks-should-be-available-for-neonatal-resuscitation/ and share your comments on laryngeal mask ventilation!
99nicu.org
99nicu.org

Webcast on Echocardiographic Assessment of PDA

We would like to high-light an interactive webcast on the Echocardiographic Assessment of PDA Thursday 26th of November at 3pm CET
The webcast is presented by Dr Nim Subhedar, Consultant Neonatal Paediatrician NICU Liverpool Women’s Hospital, and is organized by Orphan-Europe.
Connection details
Link: meet.republic-m.com Guest code: 57876 Find more details in our Calender:

 
And here is a PDF to share within your networks: FLYERA5.pdf
99nicu.org
99nicu.org

the ROP Trial - now a Supporting Partner

The ROP Trial has become a Supporting Partner to 99nicu!
The ROP Trial needed to distribute material to potential NICUs that would be willing to enroll preterm infants to the trial on IGF-1 and whether IGF-1 would reduce the risk of ROP.
If you are interested to join the ROP trial and enroll preterm infants at risk of ROP - visit http://www.roptrial.com and find more information in the attached PDF.
In return, the ROP Trial gave an unrestricted educational grant to us, very timely as another round of technical upgrades is close in time.
@ROPTrial, thanks for considering 99nicu for a channel of communication and becoming a Supporting Partner!
10352269_ROPP_99NICU_Email_HCP_v1.027Oct2015.pdf
Stefan Johansson
Stefan Johansson

How manage malnutrition in infants with congenital heart malformations?

There is an big and relevant topic started in the forums, about how to avoid that malnutrition develops in infants with congenital heart disease.
@Aymen Eshene works in a NICU in Libya and often see that infants with congenital heart disease is becoming malnourished.
He searches for input on strategies and interventions how to reduce the risks of malnutrition. If anyone has experience or knowledge within this field, please post in the thread here:
http://99nicu.org/forums/topic/1887-malnutrition-in-chd-infant/ 
Stefan Johansson
Stefan Johansson

NeonatalStaff.com - a dedicated NICU job board

After a long sleep, I have re-launched NeonatalStaff.com, a dedicated the job board for NICU professionals! For recruiters to advertise vacant job positions related to neonatal care.
The web site is developed and maintained by myself, and any revenue is directly granted 99nicu and its maintenance and development. In other words, NeonatalStaff.com is a sort of charity project for 99nicu
It is free to post vacancies there, but it is also possible to feature jobs. Featured vacancies are cross-posted to 99nicu and its social channels.
UPDATE 2017-01-30 - as the activity on NeonatalStaff has been very small, I have closed NeonatalStaff. The URL re-directs to 99nicu.org
Stefan Johansson
Stefan Johansson

Add your flag!

Now you can tweak your signature by adding your country flag!
The flag will be displayed before your name, like the Swedish flag is seen before my name.
Just login, and in the right upper corner, choose "Account settings", and click on the "Country" tab there.
Done!


Stefan Johansson
Stefan Johansson

Join our first Journal Club!

Finally, the first 99nicu Journal Club is scheduled, on Tuesday the 24th of November, 5 PM (GMT).
The JC will be held in the Chat room on 99nicu.org. To attend, you need to log in with your membership credentials (username/password), and then you find the "Chat" in the navigation menu above.
Our current software license enables up to 20 people to attend, so there is a risk that some may not get in. If the discussions will be attracting lots of people, we could upgrade the license to allow more people in the Chat room (although that means a higher license cost).
the Topic
of the first JC is ductal shunting, and the natural evolution of the PDA and the great chance of spontaneous closure. The paper was published in ADC some time ago. A complementing paper is the findings from Epipage2, published in JAMA this summer, about the benefits of early echocardiography.
Find the papers here:
http://fn.bmj.com/content/100/1/F55.abstract
http://jama.jamanetwork.com/article.aspx?articleid=2338255
the JC Discussion
will be semi-structured. The aim is to dissect the paper and get a feeling whether the paper is good (research-wise) and relevant (clinical-wise).
Please have a look at this poster from Elsevier about how to read a paper

 
 
99nicu.org
99nicu.org

17 November is World Prematurity Day 2015

17 November is World Prematurity Day, a day to bring light on the public arena to the world-wide burden of preterm birth.
With advances in combatting infections, complications of preterm birth is now the main cause of mortality among children before 5 years of age. Of 6 millions estimated deaths among children <5y, preterm birth and its complications account for about 1 million.
In many countries, there are events set up by health care providers, parent organisations, charities and organisations.
In addition to your own local channels, we would like to promote a few web sites with information about the World Prematurity Day:
March of Dimes EFCNI The WPD Facebook group And, additionally, find tweets using the hashtag #WorldPrematurityDay (https://twitter.com/hashtag/worldprematurityday)
Finally, a video produced for March of Dimes, feel free to share it.

99nicu.org
99nicu.org

First Journal Club transcript

So, our first JC ever is over. Three people from Sweden, India and Iran met up to discuss two papers on PDA. Despite the small group, I think it was a great experience to sort-of meet IRL, although there is room for improvements, also on the technical side.
I add a transcript from the Chat room below.
******************************
Stefan Johansson
** getting ready **
Welcome to the 1st 99nicu Journal Club
Tonight we are going to discuss a paper previously publ in ADC: http://fn.bmj.com/content/100/1/F55.full.pdf+html 
on the "Natural evolution of patent ductus arteriosus in the extremely preterm infant"
** patiently awaiting others to join... **
Stefan Johansson
Hi Selvan! How are you?
@Selvan - seems that we are not attracting a crowd
@amirmasoud2012! Welcome here!
amirmasoud2012
hello
selvanr4
yes stefan .it is day one . wait for sometime
Stefan Johansson
Shall we start? Did you read the ADC paper on spontaneous PDA closure? If so, what was your general impression?
selvanr4
yes. paper questions the need for treatment to close pda since around 70% pda close on their own
amirmasoud2012
It was interesting ... the more we were treated ....     
Stefan Johansson           
PDA's are a tricky business. Interesting that the unit (in the study) did not treat PDA's at all (with drugs)
But I think the rate of spontaneous closure is a mistake... they should have included all infants "at risk", i.e. also those who died, in the denominator.
But still, the spont closure rate would be around 55-60% if all infants were included               
What is your practises regarding PDA therapy?
selvanr4
yes stefan you are correct .they have excluded babies who died.and within 72 hrs . but still 55-60 good number               
we treat if they are symptamatic           
Stefan Johansson               
We do the same. But I think our general view has changed - to a more conservative approach                     
amirmasoud2012               
Better if we treat the unstable situation ...                 
modrate to large size pda 18:26
Stefan Johansson               
@amir - I agree. A major difficulty with PDA's is that some tiny babies are severly affected (say a 24w on mech ventilation), while other more mature preterm do just fine without tx (like a 31w on CPAP)    
selvanr4        
i heard from my friend who has worked in cardiff saying they have used it very rarely.            
amirmasoud2012               
can you accept the risk of no treatment?                     
Stefan Johansson               
I would be very hesitant NOT to give a significant shunt.          
I am a PDA-believer
Did you manage to get hold on the other paper in JAMA - about early echo and its benefits? 
In fact - that paper oppose the ADC paper - that there are benefits with early investigation (less lung bleeds for example)                   
selvanr4        
i just read the abstract. as you said it is for early echo!                    
i could not get full paper   18:33
amirmasoud2012               
I remember I do not have to search again                   
Stefan Johansson               
But it is a bit strange (the JAMA paper) - because they use timing of echo as a proxy for treatment.
selvanr4        
It will be difficult for me to keep my hands tied when you see a significant pda          
Stefan Johansson               
Actually, I have heard know of plans in the US (within the NICHD trial network) that they will make a placebo-controlled (blinded) RCT. Meaning they will give NSAID or placebo to treat a duct...
Very difficult trial, and complicated with cross-overs in case a baby really need to close the duct                 
selvanr4      
An early PDA is not always a benign entity- did you read the rapid response?      

An early PDA is not always a benign entity
Martin R Kluckow, Neonatologist Nick Evans, Sydney University
We read with interest the article by Rolland et al regarding a retrospective natural history study of the PDA in a cohort of preterm infants in a unit which conservatively managed the presence of a PDA after 24 hours(1). We have concerns about the data analysis and the conclusions drawn. In particular we question the decision to exclude...
Stefan Johansson               
Nick Evans is my principal mentor in PDA-thinking
This is a good conclusion! "Concluding from the data presented that the exposure to the risk of therapeutic intervention to close a PDA is not warranted based on spontaneous closure rates of a selected surviving sub-group is not justified."              
selvanr4       
Nice argument                   
Stefan Johansson               
In short, I think Kluckow and Evans want to say that the ADC study is crap
selvanr4        
yes stefan
amirmasoud2012

selvanr4        
what do feel is a best model to study the natural evolution of pda 
Stefan Johansson               
I think the best way would be to make serial echos on a prospective cohort. In fact I think Kluckow and Evans have done that
and showing that severe early shunts is associated with lung bleeds and IVH (really significant and bad things)              
amirmasoud2012               
Our third day we echo
And before the third day if not treated pda .               
Stefan Johansson               
@amir - generally do the same, but in very instable babies our guidelines is echo typically on 1-2 day of life
Stefan Johansson               
@amir and @selvan - my time is out now
it was great chatting with you despite some techn problems        
selvanr4        
thanks stefan                     
amirmasoud2012               
thanks
good idea    
selvanr4        
thanks amir 
Stefan Johansson               
I think we need to think about how we use                 
the chat room in the future                     
i.e. the technical side. I hope we meet again here    
selvanr4        
can we have offline postings?               
amirmasoud2012               
Keep going in the future    
Stefan Johansson               
@selvan - I will try to copy & paste the conversation into a word doc and then add it on the web site
selvanr4       
yes . hoping for the best   
Stefan Johansson               
We keep in touch! Ciao!
Stefan Johansson
Stefan Johansson

New 99nicu Poll: probiotic use in the NICU

The awaited probiotics UK-trial is now published, and the results are showing that a single bacteria (Bifidobacterium breve BBG-001 in very preterm infants) does not reduce the risk of NEC, late-onset sepsis, or mortality. In short, a negative trial of good quality methodologically.
However, the results contrasts against the ProPrems trial, similarly powered and well-designed, but the probiotics in that trial included a 3-strain preparation. Also, the Cochrane review from last year expressed strong recommendations that probiotics should be offered to preterm infants.
We have started a new 99nicu Poll about probiotic use in the NICU.
Please go there, vote, and share your experience and expertise.
Here's the URL: http://99nicu.org/forums/topic/1901-probiotics-in-very-preterm-infants-how-do-you-do-now/
99nicu.org
99nicu.org

Survey on vitamin A and BPD prevention

We would like to invite all our members to join a short survey on parenteral vitamin A, as a preventive therapy against BPD in preterm infants.
We are distributing the survey on behalf of Orphanix, an Austrian start-up company that is developing innovative medicines with a strong focus on neonatology.
In return Orphanix will support 99nicu with an educational grant for 2016, a mostly welcome contribution!
Please use this URL to complete the survey: https://www.surveymonkey.com/r/W8JG8BR
 
Stefan Johansson
Stefan Johansson

View the Webcast on PDA echo assessment

Several people contacted us after the webcast on Echocardiographic assessment of PDA (broadcasted Thursday 26th), and asked if it was possible to view it afterwards.
The answer was first no... but Orphan-Europe, the company organizing the webcast, generously emailed a copy and allowed sharing here through the Vimeo-service.
The webcast was presented by Dr Nim Subhedar, Consultant Neonatal Paediatrician NICU Liverpool Women’s Hospital.
Enjoy!
 
 
99nicu.org
99nicu.org

Journal Club 12 Jan 2016: Outcomes of infants with Apgar score of zero at 10 min

We have set the date for the next Journal Club to Tuesday 12 January 2016, at 7 PM (GMT).
The topic this time is outcomes of infants with Apgar score of zero at 10 min.
Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.
The report is accompanied by an interesting editorial.
Both articles are available as Editor's Choices at the ADC web site:
http://fn.bmj.com/content/100/6/F492.full
http://fn.bmj.com/content/100/6/F476.full
ADC also produced a podcast that you can listen to here:
https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat
 
Please read those articles and join the Journal Club in the Chat room. Note that you need to log in to enter the chat room.
Stefan Johansson
Stefan Johansson

New Years Greetings!

First and foremost - I would like to wish you the best for the upcoming New Year 2016!
During 2015, I think 99nicu thrived really well. Especially memorable moments were:
our first virtual journal club the comeback of the 99nicu Polls plenty of great blog posts from Keith Barrington and Michael Narvey our upgrades that resulted in a great new interface (finally fully responsive on mobiles), made possible by educational grants from Acta Paediatrica and the ROP trial. our sharing of the Orphan-Europe webcast on PDA echo assessment For 2016, I hope 99nicu reaches its full potential as the busy community needed by professional in neonatal medicine. This is what I personally think about for 2016:
future journal clubs, (next is scheduled 12 January) more active discussions in the forums more blogs  (email me on info@99nicu.org if you need help to start a blog) a crowd-sourced Pharmacopedia (Neonatal Formulary) the 99nicu 10year anniversary, in May 2016! New Years Greetings from the early frosty winter in Stockholm!
Stefan Johansson, MD PhD
Stefan Johansson
Stefan Johansson

Latest journal club transcript

The topic for this journal club on 12 January was outcomes of infants with Apgar score of zero at 10 min.
Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.
The paper was accompanied by an interesting editorial.
Both articles are available as Editor's Choices at the ADC web site:
http://fn.bmj.com/content/100/6/F492.full
http://fn.bmj.com/content/100/6/F476.full
ADC also produced a podcast that you can listen to here:
https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat
 
Here comes the transcript of the JC!
-----------------------------------------------------------------------------
Stefan Johansson
Hi everyone and welcome to the 2nd 99nicu JC! The topic this time is outcomes of infants with Apgar score of zero at 10 min.
Commonly guidelines are that resuscitation may be stopped if an infant is till asystolic by 10 min of age and despite adequate resuscitative efforts. However, an interesting case series published in ADC concluded that a relatively large proportion of infants surviving despite Apgar score of zero at 10 minutes had a normal neurological assessment on follow-up.
You find the original article and the and the editorial: http://fn.bmj.com/content/100/6/F476.full
What was your general impressions reading the article and editorial?
Fcardona
It was definitely an eye-opener for me. I mostly considered APGAR of 10 as sure predictor of death or terrible outcome
Jonathan Davis
My overall impression that is that this is an important topic area and one that is currently under justifiable scrutiny.
I too was surprised at the survival potential
Stefan Johansson
What is your current (or previous) guidelines about resusc when the Apgar is /was zero at 10 minutes?
amirmasoud2012
The decision is difficult
Jonathan Davis
In Bristol where I currently work we don't have a specific guideline
Fcardona
neither do we here in vienna have a guideline
Stefan Johansson
The Swe guidelines has been to continue resusc until 15 min if there is asystole
Jonathan Davis
it is generally accepted that one would stop resuscitation once a consultant has at least been present
dracunculus
In Ulm where I currently work we dont have a guideline, but I think nobody would stop resuscitation here after 10 minutes
Stefan Johansson
I have felt discomforted about this (as the international guidelines are evaluation at 10 min). Have had cases with apgar0 at 10' who started going at >14 minutes... and outcomes were quite bad (severe CP)
Jonathan Davis
if out of hours that should be at max 20 minutes
Stefan Johansson
Do you generally use chest electrodes to monitor heart beats?
Jonathan Davis
I agree Stefan the push for longer resus is definitely one that shouldn't be made with haste
amirmasoud2012
Several issues must be considered
rate Population growth of the country The development level of the country Religious beliefs communities The ability of parents The health system support If the above condition is better we continue to resuscitation.
In our country under the above conditions there and I 'd rather stop after ten minutes of resuscitation
Stefan Johansson
@Amir - valid points, the context matters                  
Jonathan Davis                  
I certain agree that all the above must be taken consideration... the evidence base of survival and with or without disability is also important
Dracunculus
We are starting to use ECG electrodes.
Stefan Johansson
One thing about the case series in ADC - how certain where the authors that apgar was really zero? It does not say how heart beats were monitored.
Could the babies be Apgar=1 at 10 min?                    
Jonathan Davis
That is the flaw in these papers, the apgar is a subjective measure
who listened... and for how long and how practised where they    
fcardona
I agree stefan, it is unclear how objective heart rate was assessed
Jonathan Davis
ECG is the new european rests council guidance fcardona?            
Stefan Johansson
Thanks for support  I just think there is some problem with the internal validity of this report
After the JC I can recommend this blog post by MichaelN (All Things Neonatal) ; http://99nicu.org/blogs/entry/169-apgar-score-of-0-at-10-minutes-why-the-new-nrp-recommendations-missed-the-mark/
How do you handle the contact with parents in a situation like this? Do you give a "trial of life" on mechanical ventilation etc and discuss options thereafter? (In Sweden, we generally (I think) do not listen enough to the voices of the parents)             
Jonathan Davis                 
If heart rate was achieved, a trial of life is appropraite                  
early measures of brain injury are difficult and poorly predictive    
fcardona
yes, jonathan - ecg is suggested for use during neonatal resuscitation in the 2015 guidelines 
Jonathan Davis
parents wishes extremely important and the context as above essential
fcardona
i agree about parents wishes
Jonathan Davis                  
I had a recent case of no heart rate at 10, baby extremely unwell. Trial of life with EEG and discussion with parents at the bedside
additional colleague opinion sought also for second brain
Stefan Johansson
This is just an impression but in the "pre-cooling days" (when I was fulltime at a level3 unit) I think babies were more often given palliative care if the asphyxia was very severe. Now we are more active, start cooling shortly after birth (usually within 2-3 hours), and then there is a rolling stone of activity.
@Jonathan - good point about intercollegial support and discussion                   
Jonathan Davis
Very true re activity. Early marker of severity of asphyxia can often mislead and none are perfect... some work done by the Brain group in cork... will look for link
on early predictors from umbilical cord samples
Stefan Johansson              
One problem is the lack of models that can predict bad outcomes with good precision. How could we do better?
Jonathan Davis                  
https://clinicaltrials.gov/ct2/show/NCT02019147
fcardona
I agree, do we know anything about the EEG and MRI in the survivors of this study?
Stefan Johansson
@Francesco - I cannot find this info in the paper only that "All eight deaths were because of withdrawal of life support in view of severe encephalopathy on clinical exam- ination, electrocortical inactivity on electroencephalogram (EEG) and extensive damage to the brain on MRI”
Jonathan Davis                  
the group in cork appear to be collaborating with the Karolinska Institutet
Stefan Johansson              
@Jonathan - I see that. The current head of the Karolinska Neo Dep (Boubou Hallberg) is a co-investigator
fcardona      
in the study: i am still concerned about selection bias in the study. what is the denominator of the study population?
Stefan Johansson              
@Francesco - you mean, where is the epidemiologist  
fcardona
I guess
Jonathan Davis                  
I think the study represents a pragmatic interrogation of the data that is routinely collected and submitted to the ANZNN
fcardona      
and how many cases with apgar 10 of zero were not included because they didnt make it into the database
Jonathan Davis                  
I think we are back to the antithesis of the 'were they sure it was zero' argument
where there miscounted apgars?
Stefan Johansson              
Valid point, if we are to study outcomes, we need to know about the population base. If you look into the blog post I linked to above, I non-secretely display one of my fancy research ideas...
Jonathan Davis                  
The population as far as I can tell is all babies who were admitted to KEMH and PMH in WA..
Interesting that APGAR is now being used or certainly reported as a predictor.
In my training the APGAR score was always derided as an unreliable subjective measures
I need to confess that I will soon be a consultant in the unit that authored the paper in Australia. I haven't had anything to do with the paper however... nor any other particular bias
Stefan Johansson              
@Jonathan -  But in 2001 even NEJM had an article about that Apgar was not entierly wrong
@Jon - are you moving to Australia?!   
Jonathan Davis
The first question.... Yes I have come to the conclusion that my mentors had an anti APGAR bias... a subjective measure but potentially a useful one.. experienced hand quiet useful..
the second question.. yes starting hopefully next month... fellowship in oz previously and now appointed in Perth..
Stefan Johansson
This is off-topic... but Perth sounds great!                  
Jonathan Davis                  
yes... sorry.. needed to disclose that fact                    
Stefan Johansson              
@Jonathan - no worries!  
@all: what can we learn from the paper and editorial?
I think one important thing raised in the editorial is that "Clinicians must be guided primarily by the best interests of the infant."
Jonathan Davis                  
I think personally we can learn that perhaps 10 minutes may not be long enough... the resuscitation needs to be effective and all reversible causes need to be excluded                   
Also the suppose to me was that the outcomes are still not great but they are better then I expected and that needs to influence what we discuss with parents.        
Stefan Johansson
another important message it seems, is that noone with Apgar=0 at 20 min did survive
+1 on that last comment
Jonathan Davis
I will have to duck out of the conversation at this stage... but although involved in the podcast... the discussion with Ben Stenson and Dominic Wilkinson makes interesting listening... expands on the editorial a little..
Stefan Johansson              
And here is the link to the podcast:
https://soundcloud.com/bmjpodcasts/how-long-should-resuscitation-continue-at-birth-in-the-absence-of-a-detectable-heartbeat
Jonathan Davis
thanks for the great discussion.. I tweeted along the way!!            
Stefan Johansson
I will also need to leave now. Any final thoughts ?
amirmasoud2012
thanks
Stefan Johansson              
Thanks all for a another great experience!
Meet you next time!
Stefan Johansson
Stefan Johansson

Interview: Mats Blennow, Sweden

We are launching a new Series - interviews with interesting people within the big world-wide neonatal community. Our goal is to publish one interview per month.
First out is Mats Blennow, Stockholm, Sweden, senior consultant neonatologist at the Karolinska University Hospital and professor in neonatal neurosciences at the Karolinska Institutet. Furthermore, he was also a president for the European Society for Neonatology (2008-2014).
Mats Blennow took a break from the level-3 NICU life in Stockholm to do something extraordinary...
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Where are you working now?
I am working in Irbid, a city in the north of Jordan approximately 25 km from the Syrian border. I work here in a project run by Medecins sans Frontieres (MSF- Doctors without Borders).
This is, for MSF, a unique setting as Jordan, a middle-income country, is considered safe and developed. This in contrast to the usual MSF projects dealing with situations in war, natural and man-made disasters.
The MSF rationale for this project is that the Syrian refugees here do not have free access to the Jordanian health care. In my project we provide maternal and neonatal health care for the approximately 130,000 syrian refugees living in the Irbid Governate. We run a highly efficient maternity unit, annually providing antenatal, maternity and neonatal care for 3,500 pregnant women and their offspring. The project is housed in a private hospital, where MSF rents 2 floors.
I work as a pediatric/neonatal expat in the small neonatal unit. Recently, in matter of fact this week, we have expanded the unit from 10 to 16 cots/incubators. I would describe this as a level 2 unit, for example we do not provide ventilator care or long-term TPN. Our admission criteria include babies from 32 weeks gestation. Very preterm infants are referred to other local private or Ministry of Health facilities, and then MSF covers the costs of care also there.
 
Why did you choose to go on this mission to Jordania?
Since many years I have wanted to broaden my views on paediatrics and neonatology to other settings than working in a tertiary NICU in a high-income country, preferably by working for some NGO. The reputation of MSF is highly respected by everyone. For example, in a survey in Sweden, more than 50% of the responders expressed high confidence in the work MSF provide in more than 70 countries. The MSF charter stating the organisation is to provide medical help irrespective of race, religion, creed, or political convictions and doing this observing neutrality, impartiality and independence is to me fundamental.
The fact that my current mission is in Jordan is primarily not from my own choosing. Signing up to work for MSF, I had full confidence that the organisation would send me on an important mission.  
 
What is it like to work there? What are the largest similarities and differences compared to the NICU you normally work at in Sweden?
The work has many similarities, but also differences, to the work I usually do in Stockholm. The national staff is well educated with very good theoretical and practical knowledge. Nurses and doctors work together, although the emphasis on teamwork is not as strong as in Europe.
The organisation of health care is not as developed as back home, and a lot of attention needs to be given to organise for referrals to tertiary units, to follow-up clinics and for more advanced tests and examinations. For example, when I first arrived here we did not have access to blood cultures. Due to this, many infants with only risk factors for early onset infections were given full courses of antibiotics despite no clinical signs of infection. Consequently, this resulted in prolonged stays in the neonatal unit and mother-child separations as many families live far from Irbid and have several children at home needing attention.
Another difference is the access to respiratory support. My primary task was to start CPAP care in the project, which was successfully started after 2 weeks. Before that, infants with any respiratory distress were given nasal cannula oxygen with FiO2 of 1.0 and rather high flow rates.
Perhaps the biggest difference however was the nursing care of the infants. I was lucky to be able to recruit a neonatal nurse expat, and together we worked hard to implement as many elements of developmental care as possible, including reducing ambient noise, covering incubators, nesting and supporting the infants position, and clustering of blood sampling. We also managed to expand the area of the neonatal unit with 2 additional rooms allowing mothers to remain with their babies 24/7 in the unit.
 
What expertise have you brought to Jordania and what experience can you bring back to Stockholm?
Medically, my most important contribution has been to update the protocols on non-invasive ventilator care. This includes implementing nCPAP treatment, but also t-piece ventilation for resuscitation, guidelines for treatment of apneas, use of fractionised oxygen and emergency surfactant treatment before referral of very preterm infants with RDS unintentionally delivered at the MSF hospital.
I have also trained the staff after updating many other protocols, such as those for infants at risk of septicaemia and the use of a Neonatal Early Warning Signs (NEWS) protocol in the maternity.
To bring back home is the knowledge of good care being given also in this resource limited setting, problem solving in an environment that doesn´t have all the expertise available just around the corner. The basic principle to always have a humanitarian approach to everything we do in medicine.
Working with the dedicated MSF-expats from all over the globe is extremely rewarding. In my project we had expats from France, Scandinavia, Canada, Liberia, Sudan, Lebanon and Australia. Personally, I think I will after my mission come out as a better and more humble person J.
 
What is your advice to those wanting to go on a similar mission?
Take a good course preparing for NGO work. It was invaluable for me to take an 8-week course in Humanitarian Health Assistance and 1 week of Preparation Primary Departure (PPD) before leaving. There is also an abundance of information to be found on the webpages of UNHCR, WHO, MSF and other NGOs. There it is possible to, once the destination is decided, to get detailed information about the country, project and security issues.
Most important is to keep an open mind to new cultures and experiences, to have a great respect for the knowledge and integrity of everyone you meet; patients, locals and colleagues.
 

ISH - the hospital where the delivery unit and NICU is located.

The NICU environment at ISH

The first infant recieving nCPAP in the MSF NICU.

Umm Qais - a popular area to visit in norther Jordan - an old town with a history going back >2000 years. From this site it is possible to view (from the left): Israel, Lake Genesaret/Tiberia, Palestine (in the valley), the southern parts of the Golan mountains, and distantly Lebanon and Syria.
 
Stefan Johansson
Stefan Johansson

Book review of "Death or Disability"

Ethical questions are common in neonatal care. Dominic Wilkinson is not only a consultant neonatologist, he is also an ethicist who has written a fantastic book. The title "Death or Disability" catches questions we and parents commonly ask. I can recommend this book to everyone. It should be available in the staff book shelf in every NICU.
Leaning against examples of situations and practises over the last 2000 years, Wilkinson dissects ethical questions related to clinical care and decision-making. First, he focuses on the question of the “best interest”. I was especially caught by the chapter on competing interests, when decisions in the NICU may be complicated by imbalances between what may be considered to be in the best for the infant, in the best for the parents, and even in the best for other infants and families when resources are constrained. Then Wilkinson continues with addressing our difficulties to make predictions of later outcomes and how that uncertainty may impact our treatment decision, and the interests of the infant and parents.
You can read the full review on our review section, here!
 
Stefan Johansson
Stefan Johansson

Survey on Probiotics

We would like to invite all members to participate in a short survey on probiotics. As you know, probiotics are commonly given to preterm infants to reduce the risk of necrotizing enterocolitis. However, in many countries there is a lack of a product designed specifically for preterm infants.
99nicu was approached by an independent and non-profit project that aims to provide such a dedicated probiotics formulation for preterm infants.
The survey takes about 5 minutes to complete. All information provided will be treated confidentially.
Please use this URL to respond to the survey: https://www.surveymonkey.com/r/STFZTZD
99nicu.org
99nicu.org