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How do you manage micropremies?


Katja

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Fantastic Delphi Talk from F. Namba

I would be very interested to know what our differences are in terms of care for micropremies? how do you manage? what are your key points or differences? 

F. Namba, maybe you want to join the discussion? Would be great! 

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I can't say much about the subject itself, but there is a webinar series from the Tiny Baby Collaborative that might give some insights in our differences. The last one isn't up yet, but there were two presentations on respiratory management, how they do in Iowa compared to Köln (Cologne). It really was a significant difference. Prof. Namba is also a member of the TBC-team.

https://www.tinybabycollaborative.org/webinars

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Good morning everybody,

thanks for starting this interesting discussion!

As we are reviewing our own guidelines of transition support for the tiniest infants, I would like to add a question:

Do you use Caffeine in the delivery room to improve breathing efforts (diaphragm activity and improvement of FRC)?

With kind regards

Dirk

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I think this presentation by Prof Namba is so interesting, he will also come to our conference in Lisbon in April, so then we will have an opportunity to meet up and discuss with him personally.

Several interesting things and different compared to the "minimal handling" strategy we aim for:

  • frequent ultrasounds (but I suppose the idea is to really to optimise hemodynamics)
  • lots of inotropia, volume and steroids for hemodyn management (!)
  • regular enema treatments (I think this would be seen as a No-No in our context @wackdi do you agree?)
  • phenobarb to most infant to prevent IVH
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I find the different strategies of initial lung recruitment to be very interesting. I went to a course on extreme prematurity in Uppsala, a center resuscitating all att 22W. They intubated almost all micropreemies, and recruited the lung with a ventilator straight away (correct me if I understood this wrong please). This way you could control the pressures and minimise barotrauma, I saw that Iowa and Japan used manual bag ventilation and would like to hear more about why to choose this approach. 

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We have a  different approach concerning fentanyl and inotropes. My thoughts were: less is more, don’t touch. But maybe I am wrong. And no phenobarb.


In my experience, they all lack strength and are eventually intubated in the first hours. The approach of intubating immediately is probably better to avoid barotrauma. We dont bag mask

@wackdiyes, we give caffeine in the delivery room.

 

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I heard a fantastic talk in a recent conference by dr Ryo Itoshima from Nagano Children's Hospital in Japan. He shared plenty of insights into their practice (eg. prophylactic antifungal medicine, does anybody practice it?), and shared this manual of Neonatal Research Network of Japan describing handling of infants born <28 weeks of GA: https://plaza.umin.ac.jp/nrndata/pdf/NICUManual.pdf :) It's freely available online, almost 100 pages of knowledge :) Enjoy! 

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Hi, all. I heard about this topic from Kasha, my colleague in Finland.

I can share some differences between Japan (or at least Nagano Children's Hospital, my home hospital) and some other European NICUs from my own experience.

 

Resuscitation

  • As Gustaf mentioned in the post, manual bag ventilation is commonly used to resuscitate a baby, which allows us to "feel" the baby's lung condition.
  • Some (as far as I know) NICUs resuscitate very preterm infants "in" an incubator. All the procedures including intubation or umbilical lines insertion are done in the incubator.
  • Cord milking is still a common practice instead of delayed cord clamping. We do it very gently after their respiratory circulation has established, which we think is comparable with delayed cord clamping.

 

Acute phase

  • We tend in many ways to evaluate and stabilize their circulation: using ultrasound (every 8-12 hours?) to find the appropriate water intake and any supportive medications (catecholamines or corticosteroid), in many NICUs, using sedative drugs (fentanyl and/or phenobarbital), and use prophylactic indomethacin.
  • The initial target water intake (the first 24 hours), 60-80 ml/kg/day, may be smaller than other countries. Of course, we would adjust the amount by assessing the necessary water volume by physiological signs, physical examinations, and ultrasound. This is available because we maintain 95% humidity in the incubator at least for the first 72 hours and minimize the time to open their windows. We also seldom offer skin-to-skin opportunities during this period, which might be our challenge in the future.
  • Minimum handling may be more "minimum" than other NICUs who have similar outcomes regarding 22-23 weekers: we won't move the baby's trunk (or only a little bit) and keep it in a supine position, no weight measurement for the first 72 hours, no ECG monitor, and insert a urinary catheter to minimize diaper change opportunity.

 

After a very acute phase

  • We use HFOV to cope with respiratory difficulties more often than other countries. Some NICUs (or more than that) consider HFOV as not only a rescue use but also a long-term support method. Nowadays, NAVA has also become more common.
  • Always be prepared for late-onset circulatory collapse, which sometimes happens to very preterm infants in Japan, at least.

 

You may be able to understand something about our common practice in Japan by the following articles. However, it is difficult to summarize our practice because we have about 400 NICUs in Japan.

https://pubmed.ncbi.nlm.nih.gov/34862068/

https://pubmed.ncbi.nlm.nih.gov/35154903/

 

Please note that I am not telling you that these managements are better than others. On the contrary, I am thinking that we still have many things to learn from your NICUs, especially, to improve their long-term outcomes.

I might forget something important, but hope that this might help you think more about these infants' management in NICUs.

I am happy to have your questions or comments.

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Hello group, very interesting how the care of premature babies in Japan is presented, surely with a lot of experience and very good results. I really liked reading the experiences of other nicus and doing a benchmark and getting new ideas.

It really caught my attention how they emphasize glycerin enemas.
Does any of you do it? Could you tell me your experience?

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We use enemas on regulat base, for years glycerin and now Sodiumchloride every 12 hours. No problems and both safe to use. Only exception, where it is forbidden, is in NEC ( which we see rarely these days).

 

What do you think about circulation? especially when you look at the data to blood pressure standards that favor the fifth percentile. I think it's actually less about the altitude and more about preventing circulatory fluctuations. Any opinions on this?

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What an interesting discussion!!!

There is so much to learn from each other, when reading how the different centers manage these tiny infants.

Only some of my aspects in this discussion:

... bag ventilation: There is a lot of data out (e.x. ERC guidelines) that the t-piece-devices are superior over bag, as the bag can not deliver PEEP and we know from studies, that the PIP is not controllable even in the hands of experienced users. We use only T-Piece-Devices in all infants.

... the enemas: That's really an interesting point. We know from many centers, that they are very active in this point, starting early with all kinds of "treatment". I know only a few articles, examine the timing of the first passing of meconium in preterm infants https://pubmed.ncbi.nlm.nih.gov/18285377/. There is one article I know that did not find an association between delayed passing of meconium and NEC https://link.springer.com/article/10.1007/s00431-023-05035-8, but as we are afraid of the obstruction syndrome and NEC a lot of "prophylactic" treatment is done. I don't know what is right or wrong, but in my opinion especially the start of enteral feeding, if feeds are mothers' own milk, donor milk or formula, the condition of the infant has significant impact on the passing of meconium.

... primary intubation in these infants: As there is a growing evidence that avoiding mechanical ventilation in these infants has advantages in terms of IVH, BPD, survival etc., I do not agree that intubating all of them by default is the right way. There are interesting numbers from the German neonatal network showing, that only half of these infants need mechanical ventilation within the first 7 days, after receiving Surfactant by LISA/MIST ( https://pubmed.ncbi.nlm.nih.gov/35943742/ ). Avoiding MV is also in line with the recent recommendations by Sweet et al. (https://pubmed.ncbi.nlm.nih.gov/36863329/). In my opinion, "soft transition" with late or physiological cord clamping, DR-CPAP, LISA/MIST, early/ DR-caffeine and intubation as the last option seems to me more promising strategies in these tiny infants. I can really recommend to look at the Cologne group of Angela Kribs how work with this strategy since many years.

Wish all of you a pleasant weekend

Dirk

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