99nicu... Your Forum in Neonatology!

Welcome to 99nicu, the web community for staff in neonatal medicine!

Become a member for full access to all features: get and give advice in the forums, start your own blog and enjoy benefits! Registration is free :) - click here to register!

Greetings from the 99nicu HQs

Blogs

Our community blogs

  1.  

    112612_premees.jpg?w=624

    A debate broke out recently at one of our rounds when someone asked whether a recent case of NEC was possibly related to a transfusion that a baby received.  Much has been written about Transfusion Associated Necrotizing Enterocolitis (TANEC) with the pendulum swinging back and forth between it existing as a real entity or simply being an association that is not causative in the least.  Using one of my favourite sources, a retrospective analysis of the Canadian Neonatal Network database found no difference in mortality or morbidities for those who had a transfusion and NEC vs those without. Despite this we continue to see those who “hold feeds” for a few hours prior to transfusion and then resume them a few hours later.  Why does this happen?

    Risk vs Benefit

    Those who hold feeds argue that in Neonatology we hold feeds for far less.  Furthermore, what is the harm?  If a baby develops NEC within 24 hours of a transfusion and we held the feeds we feel we have done all we could.  If a baby is fed and develops NEC we are left asking “what if?”.  The purists out there would argue the contrary though, that the evidence is not strong enough to support the practice and may require the insertion of an IV which is a painful procedure and places the infant at risk of infection from one or more skin breaks.  Additionally, does the interruption of feeds potentially alter the microbiome of the patient and with it risk potential downstream consequences. In case you are wondering, I have tended to sit on the side of holding a feed although more often when I am asked about it than ordering it upfront.  The fact is I just don’t know.  The evidence has never been solid in this regard but it is hard to ignore the possibility when you have been bitten once or twice before (whether it was causative or not!).  I doubt it really exists but then again what if there is something there?

    It May Not Be The Transfusion But Anemia Itself

    A recent paper Association of Red Blood Cell Transfusion, Anemia, and Necrotizing Enterocolitis in Very Low-Birth-Weight Infants may have found a possible explanation to the ongoing debate.  Research papers associating transfusions with NEC may all have one thing in common in that they have not been able to prove causation.  When you have many papers finding the same thing it leads medical teams to begin to believe there is causation.  Something else may be at play at this paper suggests another association which again may not be causative but at least in my mind is perhaps biologically plausible.  It may be that those patients who are transfused when their hemoglobin is below a threshold of 80 g/L are at increased risk of developing NEC rather than all patients transfused.

    This study was a secondary analysis of a prospective study on transfusion transmission of cytomegalovirus in preterm infants < 1500g.  The authors chose 80 g/L as a cutoff based on previous studies suggesting this threshold as an important one for transfusion practices. Forty eight out of 60 eligible infants developed NEC and it is from this 48 that multivariable analysis sought to identify factors predisposing to the outcome in question of NEC.  The factor with the greatest hazard risk for NEC was severe anemia in a given week with an approximate 6 fold risk (range 2 – 18) while receiving an RBC transfusion in a given week of life did not meet statistical significance.

    What does this mean?

    Before embracing the result and concluding we have the answer we have to acknowledge the authors have gone on a fishing expedition of sorts.  Any secondary analysis of a study that is done carries with it some words of warning.  There may be variables that were not controlled for that are affecting the results.  As well when looking at many many variables it could be by chance that something or several things come up by chance.  Lastly it may be that again there is nothing more than an association here at play.  Having said that, there is some biologic plausibility at least here.

    1. Delivery of oxygen to the tissues is dependent on HgB level. The oxygen content of blood is described by: O2 content = (gm Hbg)(1.34 ml O2/gm Hbg)(% sat) + 0.003(pO2) = ml O2/dL.
    2. Oxygen delivery = cardiac output X O2 concentration (or content)
    3. Could RBCs become less deformable and increase viscosity in low O2 environments? This could be the case when the HgB declines below 80 g/L.  Such changes to deformability have been demonstrated at mild levels of hypoxia as might exist in low pO2 conditions at the tissue level with anemia.

    So imagine we have fewer RBCs carrying as much oxygen as they can but eventually you cross a threshold where there is not enough O2 being delivered at the tissue level and the RBCs become lodged or perhaps sluggish as they move through capillaries of the intestines. Add to this that NEC occurs in watershed areas most commonly and you have the potential setup for NEC.

    Can we use the results of this study?

    I suppose statistical purists out there will argue that it is merely an association.  The fact remains that there are many people who are holding feeds for varying amounts of time despite the lack of conclusive evidence that TANEC exists.  I wonder if a middle ground might be to be more cautious and restrict such practice to those with low HgB values below 80 g/L as the authors here have found.  To me at least there is biologic plausibility as outlined above.  It would seem to me that to hold feeds for all babies is excessive and likely without evidence but could the threshold actually matter which it comes to oxygen content.  Given that NEC is a condition related to ischemia, the authors here have provided another association that makes me at the very least scratch my head.

  2. For the 99nicu Meetup, not only the venue but also the budget is down-sized :) So, there won't be funding for the kind of web cast we originally planned. 

    Instead we plan to use Periscope, the live streaming service that (I think) is a Twitter-owned service.

    It seems from the Periscope test run below, that the image quality from using a smartphone is not superb (despite having the latest model!) but if you plan coming to the 99nicu Meetup and are experienced with Periscope Producer, please drop me a PM or an email.

    PS. The video is cropped... go to here https://www.periscope.tv/w/1ynJOWYbnaWJR to view it with the full width

  3. In this rather weird, but interesting study from Italy, 10 mothers of preterm babies (less than 32 weeks or less than 1500 grams) without ultrasound brain injury or severe retinopathy, and 11 mothers of full term babies were shown photos of their own baby or photos of an unknown baby (from one of the other mothers) while they had their head in an MRI magnet. (Montirosso R, et al. Greater brain response to emotional expressions of their own children in mothers of preterm infants: an fMRI study. J Perinatol. 2017). The photos were of their baby's face while happy, neutral, or crying. Using functional MRI the researchers determined the activation of several different brain areas, at 3 months corrected age.

    All the mothers had more activation in several areas when looking at their own baby's face than when looking at the unknown baby.

    When they compared the responses between the groups, the preterm mothers had greater activation in several areas both when looking at their own baby's face, and also when looking at the unknown baby's face, than the term mothers, and when viewing their own infant's face they showed increased activation in an emotion processing area (i.e., inferior frontal gyrus) and areas for social cognition (i.e., supramarginal gyrus) and affiliative behavior (i.e., insula). The mothers were reasonably well matched, and not suffering from postnatal depression or anxiety.

    The weeks of stress in an NICU watching their baby and being able to do little to protect them look like they change a mother's brain function.

    Now what about the dads?

    Another article (Paules C, et al. Threatened preterm labor is a risk factor for impaired cognitive development in early childhood. Am J Obstet Gynecol. 2017;216(2):157 e1- e7). and a very interesting editorial, compared 3 groups of children at 2 years corrected age. Babies born late preterm  and infants who had been  born at term, after an episode of preterm labour. And a group born at term, without a history of preterm labour. The groups were fairly small, (22, 23 and 42 respectively). The episode of threatened preterm labour occurred between 25 and 36 weeks gestation, and isn't described in this paper, in terms of actual gestational age or other complications associated, except that the membranes were not ruptured. Some of the mothers received steroids, and that was different between the late preterm born babies (55%) and the term delivering babies (100%).

    The babies born after threatened preterm labour, whether they delivered at term or late preterm had scores on the developmental/cognitive/motor function screening test which were very similar to each other in almost all domains, and also lower in almost all domains than the controls. Overall, the Odds Ratio for what they call "mild delays in development" (more than 1 standard deviation below the mean, which is really in the lower part of the normal distribution), at 2 years was about 2.0, after an episode of preterm labour.

    A very interesting editorial confirms that this is probably the first study to have published such outcomes, although previous studies have shown an increase in SGA after threatened preterm labour. In this new study, also, the threatened preterm labour babies born at term weighed 200 grams on average less than the controls despite being born only 1 day earlier. If this finding is true (and in such a small study we should be careful about relying on it too much) then the big question is: why? Why should an episode of threatened preterm labour, which resolves with eventual delivery at term have an effect on cerebral development? Is it an antenatal influence of perhaps increased intra-amniotic inflammation? Does such an episode affect the home environment? Is it related to the somewhat higher educational level of the control mothers? (Although this was included in the logistic regression model, the differences are quite large, 30% of term delivering babies after preterm labour only had primary education, compared to 14% of controls).

    If this finding is confirmed it might lead the way to further research studying the mechanisms, and help us get a handle on the impacts of preterm birth after preterm labour also.

     

  4. Presenting the 2nd Presentation of Neonatal CME @ Jamnagar on 25th October. Its : " NEONATAL JAUNDICE- Current Concepts by Dr.Maulik Shah MD. Video link on You Tube: https://www.youtube.com/watch?v=hLMP4FHOdIk. Comments and feedback most welcome.Neonatal_jaundice_maulik.thumb.png.54d6d

    • 1
      entry
    • 1
      comment
    • 1095
      views

    Recent Entries

    What is the diagnosis?

    35 gestation weeks, IUGR, preterm gemini B babygirl has dyspnoe and multiplex fibroma around both ears. She is fed via nasogastric tube, because she can not swallow. She has peripapillary pigment ring, hepato-splenomegaly with abnormal ribs, vertebrae and spine morphology (X-ray attached). Other findings were normal. Her brother is well, he only has hydronephrosis on one side without any symptoms.

    Any suggestions are welcome.

    • 1
      entry
    • 1
      comment
    • 1639
      views

    Recent Entries

    hi

    Is adrenalin better than dopamine for maintaining/elevating BP in PPHN. Please tell me about your practice

    • 1
      entry
    • 16
      comments
    • 3346
      views

    Recent Entries

    Preterm baby 35 week was admitted to NICU for total 5 days

    All investigations were normal including blood C/S , CRP CBC And serum Electrolytes

    In day 4 , Baby develop this rash only for 20 minutes then disappear without treatment

    • 1
      entry
    • 3
      comments
    • 1762
      views

    Recent Entries

    What are the indicators we can use to check the quality of care in a neonatal unit?

  5. Mortality rates of congenital heart disease has fallen dramatically over the years, nicely demonstrated by a cohort British study. The annual numbers of deaths decreased from 1460 in 1959 to 154 in 2009. Survival was especially improved in infancy. Infants comprised 63% of all CHD deaths during 1959-63, but only to 22% in 2004-08.

    Naturally, the development of pediatric cardiology, thoracic surgery and pediatric intensive care have been essential for this dramatic improvement.

    The improved situation for infants with congenital heart disease is quite similar and parallel to improved outcomes for preterm infants. Only a few decades ago, the majority of today's survivors would have had a poor prognosis.

    With this growing generation of "new survivors" comes new challenges. In neonatal and adult medicine we know little about aging individuals born preterm, and I believe the same applies to aging individuals born with congenital heart disease.

    Knowles RL, Bull C, Wren C, & Dezateux C (2012). Mortality with congenital heart defects in England and Wales, 1959-2009: exploring technological change through period and birth cohort analysis. Archives of disease in childhood, 97 (10), 861-5 PMID: 22753769

  6. Blog ali

    • 1
      entry
    • 1
      comment
    • 1660
      views

    Recent Entries

    ali
    Latest Entry
    Hi everyone,

    Blindingly obvious I know, but our visitor numbers seem to have recently exploded. Today we topped 150 at one point. I know membership is increasing but visitor numbers seem to have changed up a gear as well, very exciting. Are we recording visitor numbers? It wouldn't be neonates without a number :)

    Best wishes

    Alistair

  7. Blog JACK

    • 1
      entry
    • 1
      comment
    • 1755
      views

    Recent Entries

    It sounds simple, but actually it turns out to be very complicated and controversial.

    The question is are we improving our NICU ? Has our NICU performance remained the same for the past few years?

    What about the performance of our NICU staff members (Medical and Nursing ) ? Are they improving themselves?

    That was the easy part.

    Now the difficult part.

    We can only improve a thing which can be measured. So to improve our NICU, we have to monitor some parameters of our NICU and then trend it and then find what we want to improve in that measure and then plan an intervention and then implement that intervention and then monitor the performance after the implementation of the interventions. (phew that was difficult to type right !)

    So lets see....if we heard that NICU in XYZ hospital had mortality of ELBW babies 5 years back of 50 % and that now they are reporting ELBW mortality of 20%...we definitely know they have improved themselves. How about nosocomial infection rate in a NICU in XYZ hospital was 5 per 1000 patient-days 5 years back and now was 1.5 per 1000 patient-days...we definitely know they have improved.

    One very nice example to illustrate this improvement is here: http://www.lafayettegeneral.com/pavilion/Level-III-Neonatal-Intensive-Care-Unit-1/Key-Performance-Indicators-3

    There are so many parameters to be monitored in a NICU..I think we just have to select what is suitable in our setup balancing our resources. We have to be cautious not to overdo it...as then it will only be on paper and have no actual benefit for the NICU.

    the other (more difficult part) is to monitor the performance of NICU staff. Here also there are many options. One beloved one is compliance with infection control practices (especially ...hand hygiene). Success rate of intubations could be used for residents. How about IV infiltration (IV burns) rate for nurses? Morbidity/Mortality outcomes for consultants/attending ?

    Once staff know that they are being monitored...performance automatically improves. Once you start rewarding good performance......then people start having a healthy competition to improve themselves....the ultimate winner is the patient...NICU performance measures improve.....And thats the ultimate aim...to improve patient outcomes...

    The floor is open.

  8. selvanr4
    Latest Entry

    hello to everyone,

    we are leaving Stockholm today after a wonderful educative and progressive conference of evidence based neonatology.

    We had nice interactive sessions lectured by topclass professionals. Had a nice boat trip coupled with a nice welcome function.

    Got into touch with new friends. Personally had direct interaction with the team members who have been known to us only through cyberspace.

    Nice experience and we like to thank everyone.

    see you next time with more to learn.

    bye now

    selvan

    Lotus Hospital

    Erode, Indai

  9. hi every one happy new year where is the image library

    • 1
      entry
    • 2
      comments
    • 1609
      views

    Recent Entries

    Dear colleagues....

    Our neonat medicine started in my town Gaza in the 70's, thanks to my professor DR. salwa Aman who alone started the work that time,,,it is was a sort of primitive stuff, she started to collect donations from here and there to build ,buy incubators and other equipment....things went further but slowly on....many of our staff got the training and experience from neighbouring countriers..so we progressed further...forgot to say that i joined dr salwa inطher syruggle to build a neonatal service in early 80's....finally here we are with well-built NICU: 30 incubators, 18 are intensive care, 15 ventilators not so advanced but ok...a staff of 16 physicians, 34 nurse serving 1000 deliveries a month in our hospital,Shifa Hospital..so what do think of our professional journey?..write t o me much like to hear from you...

  10. as a traveler, you meet all kinds of people, experience all kinds of locations, learn different ways of handling the same issue, as well as being in a position to teach and share. while i have been traveling now for 3 yrs, never have i had the last part of this brought home to me as strongly as my currently ending contract, especially the teaching part.

    as a general rule, i don't mind teaching. i enjoy sharing my knowledge and experience, as long as i have time to do it. however, in the middle of coding a baby is not when i prefer to have to be giving instructions to less experienced nurses about removing drapes to maintain warmth, chosing iv sites, how fast to push amp or how to dilute gent (or reminding peds who don't frequently work with neonates about nrp guidelines for bagging...).

    i have missed the level III NICU (this being a low level II Nursery). i have missed being surrounded by peers who know how to hold a baby for iv starts and how to help tape the iv once it's in place. or who know how to mix antibiotics and administer them. or even someone who knows appropriate technique for a heelstick. the little things. and i've missed "sick" babies.

    yes, it's been an invaluable experience. i have revisited skills that i have not had an opportunity to practice as frequently being in larger units where everybody is wanting the experience. i have gained an appreciation for the new grads and their openness for learning, as well as being thankful the more experienced nurses who know when to worry and when not to about a healthy term kid.

    and i have been given the gift of thanks. from parents. from other nurses, both new and seasoned. from techs. and from the peds.

    i have been reminded of my own start in working in this specialty, often laughing at seeing myself in the new grads, and becoming disgusted with myself when i recognize some of the harsher behavior i exhibit towards ignorance that was once visited upon me by those with more experience.

    so, as another contract winds down, i stop to think, and reflect. at the people i have worked with. a few particular cases. the geographical area i'll be leaving. but mostly that i am heading back to a level III NICU where my heart is.

    • 1
      entry
    • 2
      comments
    • 1758
      views

    Recent Entries

    First time blogger!! I am finally gaining real clarity now about how I want to be a 'nurse' alongside parents and other caregivers who have babies in the neonatal unit. The concept family centred care needs to be fully integrated into my being. So how do I achieve this? I see colleagues genuinely trying to 'help' families by their nursing actions and yet it continues to frustrate me that some of these actions take away the parents choices and impacts on their ability to fully engage with their neonate. I thought empowerment was the key but that still implies I have the power to give away to the families. Whether I like it or not this may be true purely because of the nature of the NICU environment but it fails to truly show how I work alongside or with the families. I am now convinced that if I can integrate an enabling focus into how I want to be as a nurse I can then be a partner in the care. Any thoughts from colleagues??

    Marpsie

  11. Medhaw

    • 0
      entries
    • 0
      comments
    • 750
      views

    No blog entries yet

  12. shesu

    • 0
      entries
    • 0
      comments
    • 932
      views

    No blog entries yet

    • 0
      entries
    • 0
      comments
    • 352
      views

    No blog entries yet