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  3. Dear Colleagues, I hope this email finds you in the best of health and good spirits. For those of you who run simulation related activity in neonatology we have a website where resources can be accessed. Simulation scenarios are added every month and can be accessed here https://www.mproveacademy.com/mprove-academy/scenario-bank Moulage to improve your neonatal scenarios can be accessed here https://www.mproveacademy.com/mprove-academy/scenario-bank If you just want to access videos to teach and train your trainees and colleagues they can be accessed through the scenarios or on this website below https://www.youtube.com/channel/UC22LMIG5Bwqhreic_DFHATw?view_as=subscriber There are playlists on Neonatal Procedural Skills, QI initiatives, and Human Factors training in neonatology. Hope this helps. If anyone has any ideas about using technology enhanced learning in neonatology that we can share please dont hesitate to be in touch. Alok Sharma Consultant Neonatologist Southampton UK
  4. Thanks Zuzanna we already have. We have implemented standard practice of placing the resuscitaire temperature probe in the baby's axilla after birth. The resuscitaire is switched to servocontrol at 37 C. At 5 minutes if the baby is still hypothermic a gel matress is added. The key is there is a dedicated person monitoring the temperature throughout the resuscitation. We have had a significant improvement in our thermal outcomes over the past year. The key thing is whether this is sustained.
  5. Great job, we should standardise it accros the board and all over the world 😢 my answers are from my current hospital but I can say that 8n my previous hospital we were following NRP including standardized communication, we did mock codes almost every week. For thermomanagement we used servo control in L&D room during resuscitation tohether with NeoHelp from Vygon and heated resuscitaire. We always checked temp immediately after arrival to NICU. Also we checked room temp of our res room in L&D. Our neonates were on servo mode immediately after arrival to NICU. Good luck with your QI project.
  6. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring https://www.frontiersin.org/articles/10.3389/fped.2018.00087/full?
  7. Gayle that's fantastic. We use servocontrol as well just like you and cannot monitor in transport. We do however do a digital temperature just before we leave the delivery area to make sure it correlates and on arrival in the NICU because distances are large. It just means that if a baby is hypothermic at any point that becomes a point at which to intervene. Using this we have had only one preterm baby with a temperature under 36.5C last year. This was without increasing rates of hyperthermia on our NICU. We used a standardised protocol (www.mproveacademy.com go to scenarios and look at https://www.mproveacademy.com/mprove-academy/scenario-bank) You are looking for Thermal Care. Alok
  8. We use a servo control temperature probe during resuscitation and upon admission- transport is to only time we do not have servo control available.
  9. Atraumatic Lumbar Puncture

    This is our new needle, a sharp 22G needle with stylet, 38 mm long (Vygon product but guess there are several suppliers).
  10. Ibuprofen

    Interesting read about PDA treatment https://jamanetwork.com/journals/jama/fullarticle/2676110
  11. Dear Colleagues, I am a consultant neonatologist from Southampton United Kingdom. We have run a quality improvement initiative with regards to thermal outcomes in in preterm neonates admitted to the NICU after birth called Project SHIP. This involves standardising management of preterm birth from before delivery to admission to the NICU. As part of this we are doing a short survey on practice in this regard world wide. I would be grateful if you could answer a few questions in this regard. Dr Alok Sharma draloksharma74@gmail.com Twitter: @draloksharma74
  12. 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 presence of CO2. These are the most commonly used devices in the delivery room. Capnographs are electronic monitors that display the CO2 concentration with each breath.” The NRP program stops short of recommending one versus the other. I don’t have access to the costs of the colorimetric detectors but I would imagine they are MUCH cheaper than the equipment and sensors required to perform capnography using the NM3 monitor as an example. The real question though is if capnography is truly better and might change practice and create a safer resuscitation, is it the way to go? Fast but not fast enough? So we have a direct comparison to look at. Hunt KA st al published Detection of exhaled carbon dioxide following intubation during resuscitation at delivery this month. They started from the standpoint of knowing from the manufacturer of the Pedicap that it takes a partial pressure of CO2 of 4 mm Hg to begin seeing a colour change from purple to yellow but only when the CO2 reaches 15 mm Hg do you see a consistent colour change with that device. The capnograph from the NM3 monitor on the other hand is quantitative so is able to accurately display when those two thresholds are reached. This allowed the group to compare how long it took to see the first colour change compared to any detection of CO2 and then at the 4 and 15 mm Hg levels to see which is the quicker method of detection. It is an interesting question as what would happen if you were in a resuscitation and the person intubates and swears that they are in but there is no colour change for 5, 10 or 15 seconds or longer? At what point do you pull the ETT? Compare that with a quantitative method in which there is CO2 present but it is lower than 4. Would you leave the tube in and use more pressure (either PIP/PEEP or both?)? Before looking at the results, it will not shock you that ANY CO2 should be detected faster than two thresholds but does it make a difference to your resuscitation? The Head to Head Comparison The study was done retrospectively for 64 infants with a confirmed intubation using the NM3 monitor and capnography. Notably the centre did not use a colorimetric detector as a comparison group but rather relied on the manufacturers data indicating the 4 and 15 mm Hg thresholds for colour changes. The mean age of patients intubated was 27 weeks with a range of 23 – 34 weeks. The results I believe show something quite interesting and informative. Median time secs (range) Earliest CO2 detection 3.7 (0 – 44s) 4 mm Hg 5.3 (0 – 727) 15 mm Hg 8.1 (0 – 727) I wouldn’t worry too much about a difference of 1.6 seconds to start getting a colour change but it is the range that has me a little worried. The vast majority of the patients demonstrated a level of 4 or 15 mm Hg within 50 seconds although many were found to take 25-50 seconds. When compared to a highest level of 44 seconds in the first detection of CO2 group it leads one to scratch their head. How many times have you been in a resuscitation and with no CO2 change you keep the ETT in past 25 seconds? Looking closer at the patients, there were 12 patients that took more than 30 seconds to reach a threshold of 4 mm Hg. All but one of the patients had a heart rate in between 60-85. Additionally there was an inverse relationship found between gestational age and time to detection. In other words, the smallest of the babies in the study took the longest to establish the threshold of 4 and 15 mm Hg. Putting it into context? What this study tells me is that the most fragile of infants may take the longest time to register a colour change using the colorimetric devices. It may well be that these infants take longer to open up their pulmonary vasculature and deliver CO2 to the alveoli. As well these same infants may take longer to open the lung and exhale the CO2. I suppose I worry that when a resuscitation is not going well and an infant at 25 weeks is bradycardic and being given PPV through an ETT without colour change, are they really not intubated? In our own centre we use capnometry in these infants (looks for a wave form of CO2) which may be the best option if you are looking to avoid purchasing equipment for quantitative CO2 measurements. I do worry though that in places where the colorimetric devices are used for all there will be patients who are extubated due to the thought that they in fact have an esophageal intubation when the truth is they just need time to get the CO2 high enough to register a change in colour. Anyways, this is food for thought and a chance to look at your own practice and see if it is in need of a tweak…
  13. Workshop break

    I know you are thinking coffee :-)
  14. In our FMC we have three levels of newborn care, the 35wks+0d ~ 36wks+6d stay for one day (24hrs) in the level II (being with a BW of > or = to 2000 grams). During that time their vitals are being monitored (on a pulse oximeter: saturation and HR), blood sugar, levels bili. Next day if oral feeding and vitals show no issues, they are moved to mom. Moms are discharged 4thday after birth if NVD and 7th day if CS. All babies would receive a check up before discharge and would make reservations for their 1 month followup check. In Canada I was in a level III unit which had a section as a step down, only 35 weekrs were kept in the NICU for 6hrs under observation by the pediatrician (under Obs) in the step down section, if the newborn could control its temp. and showed no issues on feeding and bl. sugar levels, would be moved to mom. If any issue appears, the Pediatrician would consult the NICU for management or NICU admission. 36weekrs kept with mom from birth. I have the same concept as @tarekand @Stefan Johansson "Non-separation and non-medicalization" of this population, especially that we actually very rarely need to admit these babies to the NICU.
  15. In collaboration with my long-time colleague, Dr. Richard J Schanler we monitored the oral feeding performance of Late Preterm Infants (LPT) at his hospital using the Oral Feeding Skill (OFS) scale we developed a few years ago (1). The OFS scale helps differentiate between infant oral feeding skills and endurance (2). As mentioned above, depending upon individual hospital policies, LPT may be transferred to different levels of care. However, due to their relatively short hospital stay, it remains at times difficult to identify those that may be at risk for oral feeding issues. In our study, we observed that assessing the OFS maturity levels of LPTs at their first oral feeding can help identify these at-risk infants early on. We speculated that provision of evidence-based efficacious interventions that improve OFS may shorten hospital stay and decrease future re-admission. (1). Lau C, Bhat J, Potak D, Schanler RJ. Oral Feeding Skills of Late Preterm Infants are correlated with Hospital Length of Stay. J Ped Moth Care 2015; 1:102; (2). Lau C, Smith EO. A novel approach to assess oral feeding kills of preterm infants Neonatology 2011;100:64-70 (doi: 10.1159/000321987) Lau et al'15 (LPT).pdf Lau & Smith '11.pdf
  16. Workshop break

    Looks great
  17. We for maternity ward stay for infants at 35+0 wks and onwards. I don't know the exact NICU admission rate for 35+0 -- 35+6 infants but the majority stays only at the maternity ward for ~4-6 days, until feeding works and till we know there is no signif jaundice. The midwifes usually add a followup visit after another few days to check weight, jaundice, feeding etc, and then the family only goes to the regular well-baby-clinics (as any other infant) But, we need to support (from the NICU) with planning etc, sometimes we invest relatively much time to make this work. But we feel that non-separation and "non-medicalization" of this group of infants works best in the maternity ward.
  18. Hi there, we have the same policy - the concept being to prove themselves before they move to postpartum unit where there is less surveillance.
  19. We have different practice in our unit may be due to the load of work and high rate of deliveries in our hospital which may reach to 700_ 900 deliveries per month we are just keeping them with mother and monitoring RBS if the weight is below 2.5 kg Other wise we are not admitting them unless only if there is poor feeding unable to suck ,respiratory distress ,hypoglycemia or any significant problem Some
  20. Just wanted to ask about managing care of late preterm infants. Does your hospital automatically admit late preterm infants to your NICU/Special Care Nursery? If not, how is their care managed? I am a staff nurse at a Level 2E Special Care Nursery (SCN) and we are looking to change how we manage care for late preterm infants. We are interested in learning how other hospitals care for this special population. We currently admit all infants <36 weeks to our unit. Infants >/=35 weeks are observed in the SCN for 24 hours. If the infant is feeding well and glucose checks are within normal limits for 24 hours, they are transferred to Postpartum to room in with mom and stay with mom until discharge. Thank you for your help!
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  22. 99nicu meetup 2018

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    The 6th International Conference on Human Milk Science and Innovation is a distinctive international forum covering the latest discoveries and scientific and clinical research related to human milk. Renowned scientists and clinicians from around the world are invited to attend this annual event to discuss the scientific potential of human milk and raise awareness of its clinical relevance. Click for more information: http://www.humanmilkscience.org/conference
  24. Bestowed in honor of Dr. Ruth Lawrence's contribution to the field of breastfeeding medicine, the annual award will be presented in Dr. Lawrence’s name to recognize a medical fellow or postdoctoral scholar for their research in the science of human milk. The International Conference on Human Milk Science and Innovation (ICHMSI) invites potential applicants to submit an entry for Award consideration. The Award winner will be notified on August 1, 2018. The Award will be presented during the annual ICHMSI scientific meeting held each September. The Award recipient will receive US$10,000 plus travel costs to the scientific meeting, and will have the honor of presenting their research paper during the Conference. Deadline for the application is 15 June 2018. The conference ICHMSI will take place 5-7 September 2018, Pasadena, CA, US. Read more about the award here: http://www.humanmilkscience.org/award and more about the conference here: http://www.humanmilkscience.org/conference
  25. Hypoglycemia has to be one of the most common conditions that we screen for or treat in the NICU and moreover in newborn care in general. The Canadian Pediatric Society identifies small for gestational age infants (weight <10th percentile), large for gestational age (LGA; weight > 90th percentile) infants, infants of diabetic mothers (IDMs) and preterm infants as being high risk for hypoglycemia. It is advised then to screen such babies in the absence of symptoms for hypoglycemia 2 hours after birth after a feed has been provided (whether by breast or bottle). I am sure though if you ask just about any practitioner out there, they will tell you a story about a baby with “no risk factors” who had hypoglycemia. These one-off cases have the effect though of making us want to test everyone for fear that we will miss one. If that is the case though should we be recommending that all babies get at least one check? The Canadian Pediatric Surveillance Program (CPSP) The CPSP is a branch of the Canadian Pediatric Society that “provides an innovative means to undertake active paediatric surveillance and increase awareness of childhood disorders that are high in disability, morbidity, mortality and economic cost to society, despite their low frequency. I submit my surveys each month as i hope other Canadian Pediatricians do and help to determine the impact of these rare conditions in our Canadian population. Like with any survey we rely on people taking the time to submit but there is always the risk that what is being sent in under represents the true burden of illness as some cases may not be identified. Having said that, it is the best we have! Turning our attention to hypoglycemia in low risk newborns From April 2014 to March 2016 the CPSP searched for these types of patients and just published the results of their findings in Hypoglycemia in unmonitored full-term newborns—a surveillance study by Flavin MP et al. What I like about the study is that they have been able to look at a group of babies that fall outside those identified as being at risk in the CPS statement Screening guidelines for newborns at risk for low blood glucose. They were looking for severe hypoglycemia by using a threshold of < 2.0 mmol/L (36 mg/dl) and all infants must have received IV dextrose. In the end after excluding ineligible cases they had 93 babies who met criteria. Based on the Canadian birth rate this translates to an incidence of 1 in every 8378 births. These babies were all supposed to be low risk but there were in fact clues that while not strictly identified as risks in the CPS statement could have increased the likelihood of a low blood glucose. Twenty three percent of mothers had maternal hypertension and another 23% were obese while 47% had excessive weight gain during pregnancy. Furthermore, 8% of mothers were treated with a beta blocker (most likely labetalol I would think) during pregnancy which is a risk factor for hypoglycemia although not specifically cited in the current CPS statement. A concerning finding as well was the likelihood of severe symptoms in this group on presentation. Twenty percent presented with major clinical signs (seizure, apnea or cyanosis). Median glucose levels at presentation were much lower than those without major signs (median = 0.8 mmol/L, interquartile range [IQR] = 0.5 versus 1.6 mmol/L, IQR = 0.7; P < 0.001). Lastly, providers were asked about neurodevelopmental concerns at discharge approximately 20% were thought to have issues. Are these patients really low risk though? Twenty five percent of the patients submitted had a birth weight less than the 10%ile for GA. These patients as per the CPS guideline recommendations are actually considered at risk and should have been screened. The second issue to address has to do with the way we diagnose diabetes in pregnancy. All women are provided with the oral glucose tolerance test around 28 weeks of pregnancy. No test is perfect but it is the best we have. Women who have excessive weight gain in pregnancy (almost 50% of the cohort) are at higher risk of developing diabetes or some degree of insulin resistance as are those who are classified as obese. I have long suspected and think it may be the case here that some babies who do not meet the criteria for screening as their mothers do not have a diagnosis of GDM actually are at risk due to some degree of insulin resistance or perhaps their mothers develop GDM later. The evidence for this are the occasional LGA babies who are born to mothers without a GDM diagnosis but who clearly have been exposed to high insulin levels as they behave like such affected infants with poor feeding and low sugars in the newborn period. The authors here comment on those that were SGA but how many in this cohort were LGA? The effect of hypertension can also not be minimized which was present in about a quarter of patients. These babies while not being officially SGA may have experienced a deceleration in weight gain in the last few weeks but remained above the 10%ile. These infants would not have the glycogen stores to transition successfully but would not be targeted as being at risk by the current definitions. Should we be screening everyone then? If we acknowledge that about 25% were IUGR in this study (<10%ile) and should have been screened, the expected rate would be 1:1170 births alone. In Manitoba with our 17000 births a year we would capture about two extra babies a year which translates into a low of pokes for a lot of healthy babies. Given the further information that 1:5 babies who are identified may have neurodevelopmental concerns it would take about 2-3 years of testing to prevent one concern. That pick up rate for me is far too low to subject so many babies to testing. What this study though does highlight is the need to view risk factors a little less strictly. Babies who are almost meeting the criteria for being LGA or those whose mother’s have taken lebetalol should have a low threshold for screening. Should hypertension on medications, excessive maternal weight gain or obesity in the mother be considered a risk? What I didn’t see in the end of this study were patients who truly were AGA, being born to healthy non overweight mothers presenting as high risk. Maybe what is really needed based on this study is to re-evaluate what we consider at risk. In the meantime, maybe we should be testing a few extra babies who fall into these “lesser” risk categories. Better yet a study isolating such patients and looking at the frequency of hypoglycemia in these patients is warranted to get a better idea of whether they are indeed risks.
  26. Atraumatic Lumbar Puncture

    @RasmusR In fact those needles do not have a stylet that's why we are shifting to a stylet-equipped atraumatic needle. Will post a photo once I get back on clinical service!
  27. Ibuprofen

    No we don't stop feeds during PO ibuprofen. We don't use IV form as very expensive
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    • Dear Colleagues, I hope this email finds you in the best of health and good spirits. For those of you who run simulation related activity in neonatology we have a website where resources can be accessed. Simulation scenarios are added every month and can be accessed here https://www.mproveacademy.com/mprove-academy/scenario-bank Moulage to improve your neonatal scenarios can be accessed here https://www.mproveacademy.com/mprove-academy/scenario-bank If you just want to access videos to teach and train your trainees and colleagues they can be accessed through the scenarios or on this website below https://www.youtube.com/channel/UC22LMIG5Bwqhreic_DFHATw?view_as=subscriber There are playlists on Neonatal Procedural Skills, QI initiatives, and Human Factors training in neonatology. Hope this helps. If anyone has any ideas about using technology enhanced learning in neonatology that we can share please dont hesitate to be in touch.    Alok Sharma Consultant Neonatologist Southampton UK  
    • Neonatal Hemodynamics: From 
      Developmental Physiology to 
      Comprehensive Monitoring   https://www.frontiersin.org/articles/10.3389/fped.2018.00087/full?
    • This is our new needle, a sharp 22G needle with stylet, 38 mm long (Vygon product but guess there are several suppliers).