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  1. Can a chest x-ray predict the future?

    If you work in Neonatology then chances are you have ordered or assisted with obtaining many chest x-rays in your time.  If you look at home many chest x-rays some of our patients get, especially the ones who are with us the longest it can be in the hundreds. I am happy to say the tide though is changing as we move more and more to using other imaging modalities such as ultrasound to replace some instances in which we would have ordered a chest x-ray.  This has been covered before on this site a few times; see Point of Care Ultrasound in the NICU, Reducing Radiation Exposure in Neonates: Replacing Radiographs With Bedside Ultrasound. and Point of Care Ultrasound: Changing Practice For The Better in NICU.This post though is about something altogether different.

    If you do a test then know what you will do with the result before you order it.

    If there is one thing I tend to harp on with students it is to think about every test you do before you order it.  If the result is positive how will this help you and if negative what does it tell you as well.  In essence the question is how will this change your current management. If you really can’t think of a good answer to that question then perhaps you should spare the infant the poke or radiation exposure depending on what is being investigated.  When it comes to the baby born before 30 weeks these infants are the ones with the highest risk of developing chronic lung disease.  So many x-rays are done through their course in hospital but usually in response to an event such as an increase in oxygen requirements or a new tube with a position that needs to be identified.  This is all reactionary but what if you could do one x-ray and take action based on the result in a prospective fashion?

    What an x-ray at 7 days may tell you

    How many times have you caught yourself looking at an x-ray and saying out loud “looks like evolving chronic lung disease”.  It turns out that Kim et al in their publication Interstitial pneumonia pattern on day 7 chest radiograph predicts bronchopulmonary dysplasia in preterm infants.believe that we can maybe do something proactively with such information.

    In this study they looked retrospectively at 336 preterm infants weighing less than 1500g and less than 32 weeks at birth.  Armed with the knowledge that many infants who have an early abnormal x-ray early in life who go on to develop BPD, this group decided to test the hypothesis that an x-ray demonstrating a pneumonia like pattern at day 7 of life predicts development of BPD.  Screenshot-2017-10-10-21.43.36-copy-300xThe patterns they were looking at are demonstrated in this figure from the paper.  Essentially what the authors noted was that having the worst pattern of the lot predicted the development of later BPD.  The odds ratio was 4.0 with a confidence interval of 1.1 – 14.4 for this marker of BPD.  Moreover, birthweight below 1000g, gestational age < 28 weeks and need for invasive ventilation at 7 days were also linked to the development of the interstitial pneumonia pattern.

    What do we do with such information?

    I suppose the paper tells us something that we have really already known for awhile.  Bad lungs early on predict bad lungs at a later date and in particular at 36 weeks giving a diagnosis of BPD.  What this study adds if anything is that one can tell quite early whether they are destined to develop this condition or not.  The issue then is what to do with such information.  The authors suggest that by knowing the x-ray findings this early we can do something about it to perhaps modify the course.  What exactly is that though?  I guess it is possible that we can use steroids postnatally in this cohort and target such infants as this. I am not sure how far ahead this would get us though as if I had to guess I would say that these are the same infants that more often than not are current recipients of dexamethasone.

    Would another dose of surfactant help?  The evidence for late surfactant isn’t so hot itself so that isn’t likely to offer much in the way of benefit either.

    In the end the truth is I am not sure if knowing concretely that a patient will develop BPD really offers much in the way of options to modify the outcome at this point.  Having said that the future may well bring the use of stem cells for the treatment of BPD and that is where I think such information might truly be helpful.  Perhaps a screening x-ray at 7 days might help us choose in the future which babies should receive stem cell therapy (should it be proven to work) and which should not.  I am proud to say I had a chance to work with a pioneer in this field of research who may one day cure BPD.  Dr. Thebaud has written many papers of the subject and if you are looking for recent review here is one Stem cell biology and regenerative medicine for neonatal lung diseases.Do I think that this one paper is going to help us eradicate BPD?  I do not but one day this strategy in combination with work such as Dr. Thebaud is doing may lead us to talk about BPD at some point using phrases like “remember when we used to see bad BPD”.  One can only hope.

     

  2. IMG_2962.jpg

    Our every-day job is to meet parents and their preterm infants. We have our professionalism, skills and family-centered care strategies. But how do we understand the large gap those families need to bridge, and how parenthood evolves when a child arrives too early?

    For myself, music has always been important (even essential!) in my own reflections about wider scopes. When it comes to parenthood, I can strongly recommend the record Mother Tongue by Rebekka Karijord, a Norwegian composer and singer.

    Mother Tongue is a beautifully strong and moving record about parenthood complicated by a preterm delivery, about experiencing a cesarean section far too early ("...this is a riot of blood and steel/bending me open, violently..."), and how a tiny infant still could "weigh more than...the universe, to me". The lyrics, as I interpret, is also about parenthood in a deeper sense. The music itself is so delicate and precise, and yet powerful at the same time.

    This is a record we should listen to. Get it on CD. Or on vinyl if you still play such records, like I do :). And bring it to your next staff meeting. And of course, Mother Tongue is also available on Spotify.

    IMG_2964.jpgIMG_2961.JPG

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    htawakol
    Latest Entry

    3rd International Neonatal Multispecialty Conferecne

    Abu Dhabi 16th-18th November 2017

    http://www.abudhabinms.com/

    3rd Abu Dhabi Neonatal Conference .pdf

    3rd Abu Dhabi Neonatal Conference .pdf

  3. I met the author of this article at a CPS meeting a few years ago, she immediately impressed me with her unique perspective. Paige is a developmental pediatrician who does long-term follow-up of preterms, and is involved in developmental evaluation and intervention of children with other challenges, including Spina Bifida.

    Church P. A personal perspective on disability: Between the words. JAMA Pediatrics. 2017.

    As you will see if you read the article, Paige has a form of Spina Bifida herself, a Lipomyelomeningocele, with a neurogenic bladder and neurogenic bowel, requiring life-long interventions. She discusses the poor tolerance many medical people have of disability, and such how things are often discussed as black or white, whereas having a profound personal experience of disability has made her much more nuanced.

    She recounts being involved in a discussion regarding a "selective reduction" of a twin pregnancy where the twin being considered for "reduction", i.e. abortion, had a similar lesion to her own.

    That is an experience that I can barely understand: how would I react if a family was considering terminating  a pregnancy because of a condition that I had? Paige recounts the episode with tact and humanity.

    I can imagine, as I have heard them many times, the words of the other physicians involved in such a decision, I am sure they talked about handicaps and limitations, poor quality of life, pain, and restrictions on family life. Most of which is said with good intentions but with no real knowledge of the literature, or of the range of experiences of families living with the challenges.

    Just as with similar discussions regarding extreme preterm infants, a list of complications, interventions, disabilities, and long-term problems is often presented, but with no similar list of benefits, achievements, abilities, long-term adaptation, and happiness.

    Near the end of her moving piece Paige writes:

    Like most things in life, and medicine, disability is sharp, painful, humbling, as well as tremendous, giving, awe-inspiring. It is human. It is not easily distilled to an all or none discussion. Medicine sets the tone for this discussion and, to date, has done a miserable job. More is needed to appreciate the incredible opportunities that disability poses. More education is needed to provide the counselling families deserve: balanced, sensitive, thoughtful, and individualized rather than “objective.”

    I sincerely hope that this piece by Paige will be part of a new discussion about these issues.

    (Of note, even though the article is behind a paywall, JAMA lets you see the first page of the article before buying, in this case there is only one page, so you can read the whole thing for free!)

  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

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    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.

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    hi

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

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    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

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    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

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    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

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    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.

  7. 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

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

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    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...

  9. 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.

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    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

  10. Medhaw

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  11. shesu

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