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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

 

Delayed cord clamping may get replaced. Time for physiological-based cord clamping?

Much has been written on the topic of cord clamping.  There is delayed cord clamping of course but institutions differ on the recommended duration.  Thirty seconds, one minute or two or even sometimes three have been advocated for but in the end do we really know what is right?  Then there is also the possibility of cord milking which has gained variable traction over the years.  A recent review was published here. Take the Guessing Out of the Picture?

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

 

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

 

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

 

Using the printed word to treat apnea of prematurity

As the saying goes, sometimes less is more.  In recent years there has been a move towards this in NICUs as the benefits of family centred care have been shown time and time again.  Hi tech and new pharmaceutical products continue to develop but getting back to the basics of skin to skin care for many hours and presence of families as an integral team member have become promoted for their benefits.  The fetus is a captive audience and hears the mother's heart beat and voice after the development

AllThingsNeonatal

AllThingsNeonatal

 

Advice for Parents Regarding Hemangiomas: Time to change our approach in Pediatrics?

The story is typical.  A family notices a small red spot in the weeks following delivery which enlarges over the next month.  They present to their family doctor or Pediatrician who identifies the most common skin lesion in childhood; a hemangioma affecting about 3-10% of all children depending on the population observed.  As a resident I was given the following advice regarding hemangiomas; "As long as the hemangioma is not of cosmetic concern, sight threatening, multiple in number or causing a

AllThingsNeonatal

AllThingsNeonatal

 

Partnering With Parents: One Size Does Not Fit All

Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ The journey from conception to the labour floor and then for some to the NICU is not a straight one.  There are times of joy, interspersed with sadness, denial, anger and eventually acceptance, as initial news of being pregnant leads to complications in pregnancy and then eventual admission of an infant to the NICU. Much has been said in recent years about

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

 

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

 

Still performing awake intubations in newborns? Maybe this will change your mind.

If I look back on my career there have been many things I have been passionate about but the one that sticks out as the most longstanding is premedicating newborns prior to non-emergent intubation.  The bolded words in the last sentence are meant to reinforce that in the setting of a newborn who is deteriorating rapidly it would be inappropriate to wait for medications to be drawn up if the infant is already experiencing severe oxygen desaturation and/or bradycardia.  The CPS Fetus and Newborn c

AllThingsNeonatal

AllThingsNeonatal

 

Giving surfactant through an LMA. Time to ditch the endotracheal tube?

In the spirit of full disclosure I have to admit I have never placed a laryngeal mask airway (LMA) in a newborn of any gestational age.  I have played with them in simulated environments and on many occasion mentioned that they are a great alternative to an ETT especially in those situations where intubation may not be possible due to the skill of the provider or the difficulty of the airway in the setting of micrognathia for example. In recent years though we have heard of examples of surf

AllThingsNeonatal

AllThingsNeonatal

 

Every drop counts

As a Neonatologist, there is no question that I am supportive of breast milk for preterm infants.  When I first meet a family I ask the question “are you planning on breastfeeding” and know that other members of our team do the same.  Before I get into the rest of this post, I realize that while breast milk may be optimal for these infants there are mother’s who can’t or won’t for a variety of reasons produce enough breast milk for their infants.  Fortunately in Manitoba and many other places in

AllThingsNeonatal

AllThingsNeonatal

 

High Flow Nasal Cannula: Be Careful Out There

As the saying goes the devil is in the details.  For some years now many centres worldwide have been publishing trials pertaining to high flow nasal cannulae (HFNC) particularly as a weaning strategy for extubation.  The appeal is no doubt partly in the simplicity of the system and the perception that it is less invasive than CPAP.  Add to this that many centres have found less nasal breakdown with the implementation of HFNC as standard care and you can see where the popularity for this device h

AllThingsNeonatal

AllThingsNeonatal

 

The Eyes Have It. No Not Really

Every now and then I come across an instance when I discover that something that I have known for some time truly is not as well appreciated as I might think. Twice in my career I have come across the following situation which has been generalized to eliminate any specific details about a patient.  In essence this is a fictional story but the conclusions are quite real. Case of the Flat Baby A mother arrives at the hospital with severe abdominal pain and in short order is diagnose

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

 

Can't Intubate To Give Surfactant? No Problem!

A common concern in the NICU these days is the lack of opportunity to intubate. A combination of an increasing pool of learners combined with a move towards a greater reliance on non-invasive means of respiratory support is to blame in large part. With this trend comes a declining opportunity to practice this important skill and with it a challenge to get a tube into the trachea when it really counts. One such situation is a baby with escalating FiO2 requirements who one wishes to provide surfac

AllThingsNeonatal

AllThingsNeonatal

 

Parental stress in the NICU; effect of parental presence on rounds.

To many of you the answer is a resounding yes in that it reduces stress.  Why is that though?  Is it because you have had a personal experience that has been favourable, it is the practice in your unit or it just seems to make sense?  It might come as a surprise to you who have followed this blog for some time that I would even ask the question but a social media friend of mine Stefan Johansson who runs 99NICU sent an article my way on this topic. Having participated in the FiCare study I realis

AllThingsNeonatal

AllThingsNeonatal

 

Is there really a place for standard phototherapy in the NICU anymore?

I have been mulling over this piece for some time.  In my own practice I have long questioned the role for standard phototherapy (the equivalent of a single light source) vs intensive phototherapy (delivering >30 microwatts/cm2/nm and usually two light sources) when treating jaundice for all patients. I have bolded that last part to emphasize that I am not just talking about newborns with severe hyperbilirubinemia but rather all infants with treatable jaundice based on local treatment curves

AllThingsNeonatal

AllThingsNeonatal

 

High frequency nasal ventilation: Ready for prime time?

I will admit it.  I resist change at times just like many others.  This may come as a surprise to some of you who have worked with me and accused me of bringing too much change at times to the units.  The truth though is that when one understands something and is enthusiastic about implementation the change does not seem so difficult.  When it isn't your idea though we may find ourselves a little uneasy about adopting this unfamiliar practice. Such has been my experience with nasal HFOV.  I

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

 

How long should we treat preterm infants with caffeine?

Much has been written about methylxanthines over the years with the main questions initially being, “should we use them?”, “how big a dose should we use” and of course “theophylline vs caffeine”. At least in our units and in most others I know of caffeine seems to reign supreme and while there remains some discussion about whether dosing for maintenance of 2.5 -5 mg/kg/d of caffeine base or 5 – 10 mg/kg/d is the right way to go I think most favour the lower dose. We also know from the CAP study

AllThingsNeonatal

AllThingsNeonatal

 

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

 

Screening for congenital heart disease; will early discharge be its ruin?

In 2017 the Canadian Pediatric Society published the practice point Pulse oximetry screening in newborns to enhance detection of critical congenital heart disease.  In this document we recommended universal screening for CCHDs but stressed the following: “Recognizing that delivery and time of discharge practices vary across Canada, the timing of testing should be individualized for each centre and (ideally) occur after 24 hours postbirth to lower FP results. And because the intent is to

AllThingsNeonatal

AllThingsNeonatal

 

A New Years Wish. Are We Up to It?

I have been at this writing thing for almost a year and as I was approaching the end of 2015 my thoughts turned to asking myself what I have learned.  There have been so many posts, in fact so many between the blog and Facebook posts that I have truly lost count.  Having said that the posts have generally fallen into two dominant categories; those promoting a therapy or diagnostic tool and those suggesting that we should avoid certain practices. If I had to have one wish though it would be

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

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