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About this blog

I am a Neonatologist trained in Winnipeg, Manitoba and Edmonton, Alberta.  My current position is Section Head of Neonatology in Manitoba and over my career my interests have meandered from time to time.  I have been a past Program Director of Neonatology and Medical Director for a level II Intensive Care Unit prior to relocating to Winnipeg become a Section Head.

Welcome to my blog which I hope will provide a forum for discussion on topics that are of interest to Neonatologists, trainees, all health care professionals and in some cases parents of those we care for.  My intent is to post opinions and analysis on both items from the media and literature that pertain to neonates.  While I have many interests, my particular motivation is to find ways to reduce discomfort for the patients that we care for.  Whether it is through the use of non-invasive testing or finding a way to improve the patient experience this is where I find myself most energized.

I chose the picture for this site as since the inception of this site there is hardly a country that has not had an individual or many people view posts.  Moreover I have received comments from many people from so many different countries that have inspired me to think not just about the impact of these posts in North America but more globally as well.

If you like what you see and would like updates to be sent to you as they are published feel free to follow the site by clicking the follow button on the sidebar to the bottom right.  You can also follow both my Twitter (@NICU_Musings) and Facebook feeds for additional content and discussion by clicking the additional links found there.

My Facebook page serves as a better means of expanding dialogue on a variety of topics and posts

https://www.facebook.com/allthingsneonatal

Please share and like to help expand the circle of knowledge

Entries in this blog

 

Can video laryngoscopes reduce risk of harm from intubation?

The modern NICU is one that is full of patients on CPAP these days. As I have mentioned before, the opportunity to intubate is therefore becoming more and more rare is non-invasive pressure support becomes the mainstay of therapy. Even for those with established skills in placing an endotracheal tube, the number of times one gets to do this per year is certainly becoming fewer and fewer. Coming to the rescue is the promise of easier intubations by being able to visualize an airway on a screen us

AllThingsNeonatal

AllThingsNeonatal

 

Was adding placement of EKG leads to NRP a good idea after all?

It is hard to believe but it has been almost 3 years since I wrote a piece entitled A 200 year old invention that remains king of all tech in newborn resuscitation. In the post I shared a recent story of a situation in which the EKG leads told a different story that what our ears and fingers would want us to believe. The concept of the piece was that in the setting of pulseless electrical activity (where there is electrical conductance in the myocardium but lack of contraction leaves no blood fl

AllThingsNeonatal

AllThingsNeonatal

 

You don’t plan to fail. You fail to plan

I am fortunate to work with a group of inter-professionals who strive for perfection.  When you connect such people with those with skills in multimedia you create the opportunity for education.  I can’t say enough about the power of education and moreover the ability to improve patient outcomes when it is done well. With this post I am going to be starting to share a collection of videos that I will release from time to time.  The hope with any release like this is that you the reader w

AllThingsNeonatal

AllThingsNeonatal

 

Can’t intubate to give surfactant? Maybe try this!

Intubation is not an easy skill to maintain with the declining opportunities that exist as we move more and more to supporting neonates with CPAP.  In the tertiary centres this is true and even more so in rural centres or non academic sites where the number of deliveries are lower and the number of infants born before 37 weeks gestational age even smaller.  If you are a practitioner working in such a centre you may relate to the following scenario.  A woman comes in unexpectedly at 33 weeks gest

AllThingsNeonatal

AllThingsNeonatal

 

It’s time to approach nutrition in extreme preemies as if it were a drug

One of the benefits of operating this site is that I often learn from the people reading these posts as they share their perspectives.  On a recent trip I was reunited with Boubou Halberg a Neonatologist from Sweden whom I hadn’t seen in many years. I missed him on my last trip to Stockholm as I couldn’t make it to Karolinska  University but we managed to meet each other in the end.  As we caught up and he learned that I operated this site he passed along a paper of his that left an impact

AllThingsNeonatal

AllThingsNeonatal

 

The days of the Apgar score may be numbered

One of the first things a student of any discipline caring for newborns is how to calculate the apgar score at birth.  Over 60 years ago Virginia Apgar created this score as a means of giving care providers a consistent snapshot of what an infant was like in the first minute then fifth and if needed 10, 15 and so on if resuscitation was ongoing.  For sure it has served a useful purpose as an apgar score of 0 and 0 gives one cause for real worry.  What about a baby with an apgar of 3 and 7 or 4 a

AllThingsNeonatal

AllThingsNeonatal

 

Don’t let the cord gas fool you

It has to be one of the most common questions you will hear uttered in the NICU.  What were the cord gases?  You have a sick infant in front of you and because we are human and like everything to fit into a nicely packaged box we feel a sense of relief when we are told the cord gases are indeed poor.  The congruence fits with our expectation and that makes us feel as if we understand how this baby in front of us looks the way they do. Take the following case though and think about how yo

AllThingsNeonatal

AllThingsNeonatal

 

At 22 weeks of gestation does your faith matter most to outcome?

Recent statements by the American Academy of Pediatric’s, NICHD, the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and recommend selective approaches to mothers presenting between 22 0/7 to 22 6/7 weeks. The decision to provide antenatal steroids is only recommended if delivery is expected after 23 weeks. Furthermore the decision to resuscitate is based on an examination of a number of factors including a shared decision with the fami

AllThingsNeonatal

AllThingsNeonatal

 

Has the Magic Bullet to Prevent Kernicterus Been (Re)Discovered?

As the saying goes "What is old is new again" and that may be applicable here when talking about prevention of kernicterus.  In the 1990s there was a great interest in a class of drugs called mesoporphyrins in the management of hyperbilirubinemia.  The focus of treatment for many years had been elimination of bilirubin through the use of phototherapy but this shifted with the recognition that one could work on the other side of the equation.  That is to prevent the production of bilirubin in the

AllThingsNeonatal

AllThingsNeonatal

 

Just Text Me! Enhancing Communication With Families

When you mention electronic medical records to some physicians you get mixed responses.  Some love them and some…well not so much.  These tech heavy platforms promise to streamline workflows and reduce error with drop down menus, some degree of artificial intelligence in providing warnings when you stray too far from acceptable practice but for some who are not so tech savvy they are more of a pain.  I have to admit I am in the camp of believing they are a good thing for patient care as I work i

AllThingsNeonatal

AllThingsNeonatal

 

NEC & Anemia: Is the truth out there?

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

AllThingsNeonatal

AllThingsNeonatal

 

An Old Drug Finds A New Home In The Treatment of BPD.

What is old is new again as the saying goes.  I continue to hope that at some point in my lifetime a “cure” will be found for BPD and is likely to centre around preventing the disease from occurring.  Will it be the artificial placenta that will allow this feat to be accomplished or something else?  Until that day we unfortunately are stuck with having to treat the condition once it is developing and hope that we can minimize the damage.  When one thinks of treating BPD we typically think of pos

AllThingsNeonatal

AllThingsNeonatal

 

Intubating to give surfactant is so 2017!

A catchy title for sure and also an exaggeration as I don’t see us abandoning the endotracheal tube just yet.  There has been a lot of talk about less invasive means of giving surfactant and the last few years have seen several papers relating to giving surfactant via a catheter placed in the trachea (MIST or LISA techniques as examples).  There may be a new kid on the block so to speak and that is aerosolized surfactant.  This has been talked about for some time as well but the challenge had be

AllThingsNeonatal

AllThingsNeonatal

 

Aerosolized surfactant. Can we finally do away with intubation?

I have written about non-traditional methods of providing surfactant to newborns previously. The practice of intubating a preterm infant to administer surfactant and leaving the endotracheal tube in with a slow wean of ventilation is mostly a thing of the past (at least in my units). Strategies have evolved and have seen the development of the INSURE technique, LISA methods, use of an LMA to delivery surfactant and even simple deposition into the pharynx all with variable success. The Holy
 

Apgar score of 0 at 10 minutes: Why the new NRP recommendations missed the mark.

Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ As I read through the new NRP recommendations and began posting interesting points on my Facebook Page I came across a section which has left me a little uneasy. With respect to a newborn 36 weeks and above who is born asystolic and by ten minutes of age continues to remain so and has an apgar score of zero the recommendation that has been put forward is this: A

AllThingsNeonatal

AllThingsNeonatal

 

Dextrose gel for hypoglycemia: Safe in the long run?

The Sugar Babies trial was the subject of a post earlier this year as the largest trial to date examining the effects of using dextrose gel to treat hypoglycemia.  For an analysis of the use of gel in this situation please see the original post Glucose Gel For Neonatal Hypoglycemia: Can We Afford Not To Use It? In summary though, the trial involved 118 infants who received 40% dextrose gel vs 119 who received a placebo gel. All of the infants in this study were selected based on risk factor

AllThingsNeonatal

AllThingsNeonatal

 

Does High Flow Really Have A Place in the NICU At All?

This may sound familiar as I wrote about this topic in the last year but the previous post was restricted to infants who were under 1000g.  High Flow Nasal Cannula be careful out there had a main message that suggested the combined outcome of BPD or death was more prevalent when HFNC is used alone or with CPAP than when CPAP is used alone.  The question remains though whether this applies to larger infants.  Without looking at the evidence for that combined outcome most people would say there is

AllThingsNeonatal

AllThingsNeonatal

 

Perhaps it is time to change the way we use caffeine in the NICU.

This has been a question that has befuddled Neonatologists for years.  Get ten of us in a room and you will get a variety of responses ranging from (talking about caffeine base) 2.5 mg/kg/day to 10 mg/kg/day.  We will espouse all of our reasons and question the issue of safety at higher doses but in the end do we really know?  As I was speaking to a colleague in Calgary yesterday we talked about how convinced we are of our current management strategies but how we both recognize that half of what

AllThingsNeonatal

AllThingsNeonatal

 

Maybe we shouldn’t be in such a rush to stop caffeine.

Given that many preterm infants as they near term equivalent age are ready to go home it is common practice to discontinue caffeine sometime between 33-34 weeks PMA.  We do this as we try to time the readiness for discharge in terms of feeding, to the desire to see how infants fare off caffeine.  In general, most units I believe try to send babies home without caffeine so we do our best to judge the right timing in stopping this medication.  After a period of 5-7 days we generally declare the in

AllThingsNeonatal

AllThingsNeonatal

 

Gentle ventilation must start from birth

The lungs of a preterm infant are so fragile that over time pressure limited time cycled ventilation has given way to volume guaranteed (VG) or at least measured breaths.  It really hasn’t been that long that this has been in vogue.  As a fellow I moved from one program that only used VG modes to another program where VG may as well have been a four letter word.  With time and some good research it has become evident that minimizing excessive tidal volumes by controlling the volume provided with

AllThingsNeonatal

AllThingsNeonatal

 

Capnography or colorimetric detection of CO2 in the delivery suite. What to choose?

For almost a decade now confirmation of intubation is to be done using detection of exhaled CO2. The 7th Edition of NRP has the following to say about confirmation of ETT placement “The primary methods of confirming endotracheal tube placement within the trachea are detecting exhaled CO2 and a rapidly rising heart rate.” They further acknowledge that there are two options for determining the presence of CO2 “There are 2 types of CO2 detectors available. Colorimetric devices change color in the p

AllThingsNeonatal

AllThingsNeonatal

 

Does size really matter when weaning from an incubator?

Look around an NICU and you will see many infants living in incubators. All will eventually graduate to a bassinet or crib but the question always is when should that happen? The decision is usually left to nursing but I find myself often asking if a baby can be taken out. My motivation is fairly simple. Parents can more easily see and interact with their baby when they are out of the incubator. Removing the sense of “don’t touch” that exists for babies in the incubators might have the psycholog

AllThingsNeonatal

AllThingsNeonatal

 

Caffeine. Give it and give it early.

Use of caffeine in the NICU as a treatment for apnea of prematurity is a topic that has certainly seen it’s fair share of coverage on this blog. Just when you think there is an aspect of treatment with caffeine that hasn’t been covered before, along comes a new paper to change my mind. The Caffeine for Apnea of Prematurity study or CAP, demonstrated that caffeine given between 3-10 days of age reduced the incidence of BPD in those treated compared to those receiving placebo. As an added ben
 

Question solved? Why HFNC appears to be inferior to nCPAP for preemies.

To be sure there are fans of both HFNC and CPAP out there. I have often heard from other Neonatologists that they use HFNC and find positive results while other centres refuse to use it in favour of the tried and true CPAP. Turning to the literature you will find some conflicting results with some studies suggesting equity and others more recently favouring CPAP. There has been speculation as to why one would be superior to the other and now we appear to have some answers as to where the differe
 

Why do we keep treating reflux in preemies?

Choosing wisely is an initiative to “identify tests or procedures commonly used whose necessity should be questioned and discussed with patients. The goal of the campaign is to reduce waste in the health care system and avoid risks associated with unnecessary treatment.” The AAP Section on Perinatal Pediatrics puts the following forth as one of their recommendations. “Avoid routine use of anti-reflux medications for treatment of symptomatic gastroesophageal reflux disease (GERD) or for

AllThingsNeonatal

AllThingsNeonatal

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