The APTS (Australian placental transfusion study) trial has just appeared on line. This was a high-quality multicenter, international RCT of immediate cord clamping (less than 10 seconds) compared to delayed clamping (60 seconds) for babies born less than 32 weeks gestation. (Tarnow-Mordi W, et al. Delayed versus Immediate Cord Clamping in Preterm Infants. the FPNEJM 2017.)
Another trial arriving almost simultaneously is a smaller trial from the UK, which compared cord clamping at less than
The group in Newcastle in the UK has studied parents who suffered the loss of a twin. This is an unfortunately common experience in the NICU, twins and higher order multiples are much more likely to be born prematurely (for triplets it is actually quite rare to be born at full term), and for one twin to die, while the other is still being cared for in the NICU, happens frequently.
Richards J, et al. Mothers' perspectives on the perinatal loss of a co-twin: a qualitative study. BMC Pregnancy
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 h
The PREMILOC trial was a multi-center RCT of hydrocortisone, 0.5mg/kg twice per
day for 7 days followed by 0.5 mg/kg per day for 3 days, given starting within 24 hours of age to infants of 24 to less than 28 weeks gestation.
Neurological and developmental follow-up has just been published (Baud O, et al. Association between early low-dose hydrocortisone therapy in extremely preterm neonates and neurodevelopmental outcomes at 2 years of age. JAMA. 2017;317(13):1329-37.)
There were 523 in
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
I have never been convinced that fluid restriction is a good thing for kids with BPD. I think the common practice came about because of the short-term improvements in lung function that sometimes follow if you start diuretics. The idea being that if diuretics improve lung function, then giving less fluid will also.
But this is a false equivalency, diuretics cause sodium depletion, and therefore decrease total body water, and probably lung water content also. Fluid restriction in contrast le
In 2007, when I was chair of the CPS Fetus and Newborn Committee, we published a guideline regarding the approach to term and late preterm infants with perinatal risk factors for sepsis. Obviously any infant with clinical signs consistent with sepsis needs immediate work up and antibiotics, but the management of infants with risk factors for sepsis and no clinical signs evident was the focus of that guideline.
This is what we said about chorioamnionitis, based on what we thought was the mos
I hope this link stays active for ever as it is a great resource... Courtney Wusthoff from Stanford has developed a web-based educational tool, designed initially, I think, for medical (pediatric) residents. Their team has evaluated whether or not this works by showing pediatric residents videos of actual examinations of asphyxiated newborn infants, and asking them to identify whether the babies were normal or had encephalopathy that was either mild moderate or severe. They repeated the process
When there is a threatened delivery in the periviable period, one of the decisions that have to be made is about the mode of delivery. In my opinion (IMHO, I think those young'uns say) we should consider the different parts of the decision-making to be linked but separate. A decision to give antenatal steroids, for example, does not mandate a cesarean delivery or intensive care of the baby. A decision to not perform a cesarean does not mean that fetal heart rate monitoring should not be performe
Acupuncture is nonsense. There I have said it. I'll probably get at least a few comments for this post, but I'm not backing down. Acupuncture is based on pre-scientific ideas about how the body works, believing that some sort of vital energy flows along meridians in the body, and that sticking a needle into the skin at certain specific points can have distant effects, by letting out the Xi.
Xi is non-existent, meridians are non-existent and there are no acupuncture points, they just don't e
There is a reason we don't perform pupillary reactions to light in preterm babies, and that is that they don't react. They also tend to be large. This post is in response to my trying to find out what had been published about this phenomenon, when a case in our NICU raised a teaching point. I decided to go back through the literature to find out what was actually documented in peer-reviewed publications, and found, for a change, some good quality data.
The first of these, chronologically, i
This publication appeared on-line a couple of months ago, and still isn't in print. Prentice T, et al. Moral distress within neonatal and paediatric intensive care units: a systematic review. Arch Dis Child. 2016. It is a systematic review from Melbourne, with the help of Annie Janvier, of the literature surrounding moral distress in health care workers in the NICU and the PICU. All of the studies included nurses, and some of them also studied other health care workers.
Moral Distress refer
In the UK an "intensive care" day for a newborn is defined as a day where the baby is intubated and ventilated, or is on non-invasive respiratory support (CPAP of non-invasive ventilation) AND parenteral nutrition, or on the day of surgery, or on the day of death, or a day when they have any of the following:
Presence of an umbilical arterial line
Presence of an umbilical venous line
Presence of a peripheral arterial line
Presence of a chest dra
Singh N, et al. Comparison of animal-derived surfactants for the prevention and treatment of respiratory distress syndrome in preterm infants. Cochrane database of systematic reviews (Online). 2015;12:CD010249.
This is the sort of systematic review that I find really helpful. Some (including some of my own) end up finding little good evidence, and summarizing the results of only one or 2 small trials. That may help to point out the lack of evidence, and to stimulate future trials, but doesn
The trial this time is from Japan, Nakamura T, et al. Early inhaled steroid use in extremely low birthweight infants: a randomised controlled trial. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2016. 211 babies with a birth weight less than 1000 grams were randomized between June 2006 and Dec 2009; if they were still intubated at 24 hours they received a metered-dose inhaler with either fluticasone or placebo, from which they had 2 'puffs' (total dose of 100 microgams) per day
Humans, after they are born, are supposed to receive their nutrition via the gut. Before that of course, they receive a continuous infusion of nutrition via the umbilical vein. We are far from having an intravenous nutrition mixture for sick preterm infants which closely reflects what the fetus receives from the placenta, but it is clear that we can affect the usual catabolic state of an unfed newly born preterm infant by initiating intravenous nutrition immediately. Whether this is safe and whe
An important high quality trial has just been published, it has taken me a bit longer than usual to process the new info. Among other reasons a nice review was posted on the "other neonatal blog", but I wanted to try and put this in context of the other similar published trials. The new trial is Baud O, et al. Effect of early low-dose hydrocortisone on survival without bronchopulmonary dysplasia in extremely preterm infants (PREMILOC): a double-blind, placebo-controlled, multicentre, randomised
Ohls RK, et al. Preschool Assessment of Preterm Infants Treated With Darbepoetin and Erythropoietin. Pediatrics. 2016;137(3):1-9.
Robin Ohls has been working on Erythropoietin, and its longer acting analogue darbepoietin, for many years now. As well as demonstrating that it stimulates the bone marrow in preterm babies, it now is clear that erythropoietin in some models is neuro-protective. In 2014 she reported the developmental follow up of a randomized trial in infants of 500 to 1250 g bir
Two recent randomized trials, one from our group, and another one from Melbourne have evaluate the role of the videolaryngoscope (VL) in teaching trainees in neonatology to perform endotracheal intubations. The two trials are structured differently and tell us different things about the use of the VL in teaching.
The first, from the Melbourne group, (O'Shea JE, et al. Videolaryngoscopy to Teach Neonatal Intubation: A Randomized Trial. Pediatrics. 2015;136(5):912-9) used the VL for all intub
A couple of weeks ago I discussed a new multicenter RCT which examined the effects of multiple repeated doses of steroids, given by inhalation starting on the first day of life, and continuing, at least until the infants reached 14 days of age. That study showed an improvement in the primary outcome of survival without BPD with the inhaled steroids.
A newly published trial Yeh TF, et al. Intratracheal Administration of Budesonide/Surfactant to Prevent Bronchopulmonary Dysplasia. Am J Respir
The long-running epic of the oxygen saturation targeting trials is nearing completion. This publication of the joint results of the Australia and UK trials now includes the primary outcome for the trials, the combined rate of death or "disability". Australia Boost-II and United Kingdom Collaborative Group. Outcomes of Two Trials of Oxygen-Saturation Targets in Preterm Infants. The New England journal of medicine. 2016. Disability is defined as being a cognitive or language score on the Bayley-3
Azzopardi D, et al. Moderate hypothermia within 6 h of birth plus inhaled xenon versus moderate hypothermia alone after birth asphyxia (TOBY-Xe): a proof-of-concept, open-label, randomised controlled trial. The Lancet Neurology. 2016;15(2):145-53. Babies who undergo therapeutic hypothermia for perinatal encephalopathy are still at high risk of significant long term impairments. Other therapies to add to hypothermia are being sought and tested, one of them being Xenon. Inhaled xenon gas has neur
I have often wondered why my obstetrical colleagues would often induce labour once a woman with ruptured membranes reached 34 weeks. I wasn't aware of any data to support doing this, or, on the other hand, any good data to say that you shouldn't.
It turns out that I was well-informed, there just wasn't any good data, until now. Morris JM, et al. Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised
The oxygen saturation targeting trials showed more retinopathy with higher oxygen saturation targets. Will this translate into more retinopathy in actual practice? Many units have increased their saturation targets as a result of those studies. This may indeed lead to more RoP, and the expected result seems to have happened, in Melbourne at least. A before and after study showed that there was an increase in retinopathy, both overall and of stage 2 or more. They evaluated the outcomes in babies
Which is no surprise, I hope, to any of us.
Neil Finer has been a leader in the field of recognizing and quantifying the adverse physiologic effects of endotracheal intubation, and of finding ways to reduce those effects using premedication.
It was largely as a result of his work that professional societies now recommend using medications prior to intubation; medications that reduce pain, help to stabilize the babies physiology and facilitate the intubation.
We have recently, in o