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About this blog

Sporadic analyses of published research

Entries in this blog

Late Surfactant may not be effective, probably.

A large multi-center trial (n=511) led by Roberta Ballard has just been published. (Ballard RA, et al. Randomized Trial of Late Surfactant Treatment in Ventilated Preterm Infants Receiving Inhaled Nitric Oxide. J Pediatr 2015.) In this trial infants had similar enrollment characteristics to the NOCLD trial; babies were between 500 and 125o grams birthweight and less than 32 weeks gestation. They had to be receiving assisted ventilation. There were the following differences to the previous s

kbarrington

kbarrington

A step forward in neonatal resuscitation. And Oh So Simple.

When you are resuscitating a baby, and you ask, how is the heart rate? What kind of answer do you get? "It's good" "pulse is a bit slow" "I think its around 80"? As Lou Halamek and his team recount (Yamada NK, et al. Impact of Standardized Communication Techniques on Errors during Simulated Neonatal Resuscitation. American journal of perinatology. 2015), such kinds of communication in an Air Traffic Control tower would see you booted out. In air traffic control, they realized that imprecise

kbarrington

kbarrington

Can we stop worrying about hypoglycemia in newborn babies?

In the same, neonatal, issue of the Formerly Prestigious New England Journal of Medicine as my recent post about inhaled steroids, is a fascinating cohort study of serial blood glucose monitoring in 404 at-risk term infants (the CHYLD study). The infants were initially enrolled in two studies, one of them examining the effects of hypoglycemia on the EEG and the other being the "sugar babies" study, an RCT looking at the use of oral glucose gel as treatment for hypoglycemia. About 75% of them had

kbarrington

kbarrington

Early Steroids to prevent bronchopulmonary dysplasia; give them directly into the lungs?

Bassler D, et al. Early Inhaled Budesonide for the Prevention of Bronchopulmonary Dysplasia. New England Journal of Medicine. 2015;373(16):1497-506. One of those ongoing trials that we have been awaiting the results of has just been published. The NEUROSIS trial was a randomized controlled trial with a very respectable sample size, 863 infants less than 28 weeks, by far the largest investigating this issue. Babies got budesonide (or placebo) twice a day by a metered dose inhaler with an aerocham

kbarrington

kbarrington

Many unethical pain studies in newborns

Carlo Bellieni and Celeste Johnston (Conflict of Interest flag, I have collaborated with both of them) have just reviewed a couple of recent years research of analgesic interventions in the newborn. Of 46 randomized studies of painful procedures, 70% had an untreated control group, either placebo or without analgesic intervention. I have ranted about this before: Pain research in the newborn, what is ethical?, well actually having re-read that post it isn't really a rant, but a lucid, well-consi

kbarrington

kbarrington

How Long is Too Long? Stopping resuscitation efforts in newborns.

When a baby is unexpectedly born without a heart beat, and resuscitation is initiated, the outcome may be a failed resuscitation. Even if everything is done correctly. If you are doing everything correctly, and the baby doesn't respond right away, how long should you continue before you "call it off"? The NRP, based on previous data which showed that survival was very rare after 10 minutes of asystole, and the few reported survivors were profoundly impaired, recommended in an older edition that

kbarrington

kbarrington

Politeness Pays

Does being rude stimulate people to do better, or does it have adverse effects on performance, and team functioning? And how to prove it on way or another? This really interesting, innovative paper from a team in Israel has performed an RCT to address the problem. Riskin A, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015. The authors created 24 NICU teams and arranged for them to receive some comments from a supposed visiting expert from the USA. H

kbarrington

kbarrington

Choosing Wisely

Many of you will have heard of the "Choosing wisely" campaign, an attempt to improve decision making, by clarifying efficacy and risks of common procedures or therapies. Many specialty societies have come up with lists of the Top-5 questionable practices that should be reconsidered. The AAP has just published a list of 5 neonatal practices that they say should be avoided. It is interesting that some of the other societies have made very clear recommendations to not do certain things (“Don’t do….

kbarrington

kbarrington

Delayed Cord Clamping re-re-visited

I have been trying to develop some sort of protocol for babies in our center, so I have been reading in some detail the studies about very preterm births and cord clamping that are in the literature. It seems from the PAS meeting that everyone is jumping on the bandwagon, hence my detailed inspection of the trials (and the Cochrane and other systematic reviews), because we are thinking of jumping on too, to make sure that we are going to do the right thing. I created a couple of tables with some

kbarrington

kbarrington

Cord milking/delayed clamping at the 2015 PAS-meeting

I have tried to go through the abstracts from PAS to find those that had new information, from controlled trials, about the efficacy and safety of cord milking and/or delayed clamping. Mercer and the group from Rhode Island presented the 18-22 month follow-up of about 200 very preterm (<32 wks) babies randomized to immediate compared to delayed (30 to 45 s, combined with one milking of the cord) clamping. There was no effect on IVH in the groups they compared here, but there were fewer babies

kbarrington

kbarrington

Delayed cord clamping or cord milking for the very preterm newborn… or both?

What should we be doing, given the current state of the evidence, for the very preterm neonate? I think the evidence is now pretty clear that full-term babies have benefits, and no significant harm, from delayed cord clamping, which could be for a defined period of time (up to 2 minutes) or until the cord stops pulsating (usually with a maximum duration of for example 2 minutes). The major benefit in the term baby is an improved (more physiologically normal?) iron status and hemoglobin. In large

kbarrington

kbarrington

A letter from a mother to neonatologists

From the blogger Alison Epps, a mother of an extremely preterm boy, who writes at the blog 22w6d. This is a letter which she has written to neonatologists everywhere, and which she gave me permission to copy from her blog. On her blog, beneath the letter, there are also before and after photos of her son James at the age of 4 1/2.   Dear NICU Doctor,   I’m writing to you with utmost respect and admiration for what you do. In my eyes you are a hero. Doctors like you saved the life of my son again

kbarrington

kbarrington

Does Gestational Age Matter?

Gagliardi L. On the importance – and unimportance – of gestational age. Acta Paediatrica. 2015;104(6):544-6. This article by Luigi Gagliardi discusses the incidence of white matter injury on head ultrasound across extremely low gestational ages. He was intrigued by Bree Andrews article from Chicago, showing no significant effect of gestational age on developmental outcomes among surviving infants.   The data he discusses shows a relatively constant incidence of white matter injury, despite major

kbarrington

kbarrington

Before 24

The latest New England Journal of Medicine has a fascinating article the first author of which was a medical student who was working with Ed Bell in Iowa (I say was a medical student as I believe he has now graduated, with an MD and an epidemiology PhD, and is going on to great things in Wisconsin). It recounts the differences in rates of active treatment of babies by their assigned gestational age at birth, and the subsequent survival and 18 to 20 month outcomes, between the hospitals in the NI

kbarrington

kbarrington

A Parent writes in the BMJ

Published recently, a brief article by a parent of a child with trisomy 18. Please read it, it won't take more than a few minutes, but it could make a difference to how you interact with the next parent who has a baby with a serious condition. I hope Alison Pearson and the BMJ won't mind if I give you a taste of her advice to medical staff, in case the article isn't freely available everywhere. I have shortened and edited her 'bottom line' but, if you have access, the longer complete versions ar

kbarrington

kbarrington

Bayley, Bayley, Bayley

That is, Bayley 3. Back from the PAS-meeting, followed by a resuscitation research workshop, and suffering from brain fatigue. One thing that fatigues my brain is a statement that I heard more than once which is that the version 3 of the Bayley scales exaggerates the performance of very preterm infants. I think that is an erroneous interpretation of what we know. The 3rd version of the Bayley scales of infant development give higher scores, when administered to the same preterm infants, on the c

kbarrington

kbarrington

Sense about Sepsis

Recent guidelines regarding the evaluation and treatment of early onset sepsis, or the baby who has risk factors, have been widely criticized. Especially by me! And by me! The AAP for example recommends antibiotic treatment for all infants born after a maternal history of chorioamnionitis. The statement I wrote for the CPS a few years ago in contrast, did not. We recommended a CBC and close observation alone in infants who had a history of chorioamnionitis, but appeared well. This was based on a

kbarrington

kbarrington

Paracetamol for the PDA?

EL-Khuffash A, et al. Late medical therapy of patent ductus arteriosus using intravenous paracetamol. Archives of Disease in Childhood - Fetal and Neonatal Edition. 2015;100(3):F253-F6. (CoI statement: The authors of this paper are friends, colleagues and collaborators of mine), the effects of intravenous paracetamol on closing the PDA in infants who were being considered for PDA ligation are reported. The dose was 60 mg/kg/day in four divided doses. Echos were done after 3 days of treatment and

kbarrington

kbarrington

Timing of MRI after HIE

Three recent articles have investigated whether we should wait until a week or so after birth to perform brain imaging in infants with encephalopathy, or whether earlier imaging might be just as predictive. The three articles have consistent findings, which is remarkable in itself! All three note that infants at high risk, most of whom have undergone hypothermia treatment, when they have MRI at 2 to 4 days of age, the results are very similar to the findings if you wait until a week or so to do

kbarrington

kbarrington

Off-label NO: No... or Yes?

Recent articles about off-label use of inhaled Nitric Oxide (iNO) in the preterm infant shows that such use is : a. extremely variable from one center to another, (Truog WE, et al. Inhaled nitric oxide usage in preterm infants in the NICHD neonatal research network: inter-site variation and propensity evaluation. J Perinatol. 2014.) and b. increasing in some places. Ellsworth MA, et al. Off-Label Use of Inhaled Nitric Oxide After Release of NIH Consensus Statement. Pediatrics. 2015;135(4):643-8.

kbarrington

kbarrington

Bevacizumab or that other more expensive one?

A very interesting and depressing group of articles in today's BMJ. Retinopathy of prematurity is a small market compared to wet macular degeneration in the elderly, in whom VEGF inhibitors are proven to be extremely effective. Ranibizumab (I will call it RBZ) is far more expensive than BVZ for the effective dose, and the company responsible refuses to apply for a licence for BVZ for this indication, despite the 6 comparative trials which show equal efficacy, and a Cochrane review showing equal

kbarrington

kbarrington

Should we be using bevacizumab for retinopathy of prematurity?

Geloneck MM, Cet al: Refractive outcomes following bevacizumab monotherapy compared with conventional laser treatment: a randomized clinical trial. JAMA Ophthalmol 2014, 132(11):1327-1333. In this follow-up of the BEAT-RoP trial, eyes randomized to have laser were more likely to have severe myopia on follow-up at about 2.5 years than those randomized to bevacizumab. The difference is very large, 51% with laser, and 4% with bevacizumab. The severe (very high) myopia was defined as worse than 8

kbarrington

kbarrington

Endotracheal Tube Positioning, getting it right, but not too far right.

Our tiny babies have very tiny tracheas. So far you are probably all with me. Putting that tube in the right position is therefore tricky. In particular avoiding the right mainstem bronchus, which is the wrong position, is important. So first of all; where should the tip be? That seems obvious, it should be in the trachea, high enough above the carina that the tube never slips into the carina, but low enough that it doesn't slip out. On a plain AP radiograph, however, it isn't always clear exac

kbarrington

kbarrington

News about Probiotics

A few things have been happening recently: first of all, the big news was that Solgar recalled ABCDophilus as a result of some contamination of the product. As many of you will probably know, there was fungal contamination of the final product which was associated with a preterm infant developing intestinal mucormycosis, which was fatal. Quality control and highly reliable products are essential for preterm infants. Complications, expected (at least in retrospect) and unexpected, have been fr

kbarrington

kbarrington

Getting Better

Brett Manley, and a group of the CAP investigators, including yours truly, have just published an article about the long term cognitive testing results of the trial subjects. (Manley BJ, Roberts RS, Doyle LW, Schmidt B, Anderson PJ, Barrington KJ, Bohm B, Golan A, van Wassenaer-Leemhuis AG, Davis PG et al: Social Variables Predict Gains in Cognitive Scores across the Preschool Years in Children with Birth Weights 500 to 1250 Grams. The Journal of pediatrics 2015). The 5 year outcomes of the CAP

kbarrington

kbarrington

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