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  • Latest Blog Entries

         0 comments
      The 99nicu.org web site is built on the Invision Power Board software. 
      In the next version (v5) there will be a major overhaul of the user interface, allowing for an even better way of presenting and browsing content here.
      You can get a sneak preview in the video below (a bit techy, but still )
       
         1 comment
      I don’t need to expand on how Internet and social media have shifted the paradigm for professional discussion. You know this!
      Painful it is, but I wanted to share that I have decided to close my Twitter/X account. I will miss you tweeps. But... see you soon elsewhere!
      I started to build a network on Twitter in 2009, exploring this new channel for communication about research and medicine. Twitter was different then, compared to what X has become. In the earlier years, Twitter impersonated open, high-level and cross-professional discussions. Despite different opinions shared, the feed was a friendly gathering. If you posted something seemingly controversial (or something not at all controversial about Covid-19, liberal democracy values, suffering among immigrants, or aggressive warfare), people commented in a respectful manner. You did not get a load of automated bot replies (from "verified accounts" with like ~10 followers) telling you were a moron and should XYZ!
      Importantly, #NeoTwitter, #NeoEBM and #foamneo all grew into valuable resources. I am so grateful for connecting with you and other wonderful people there. It has indeed enriched my professional life, and often made me think twice.
      With X and the new leadership by Musk et al (btw, is there even an “al”?), I have simply taken the consequence of not compromising with my values. That’s why I will delete my X account soon, after saying good bye to comrades there. The principal reason is that I don’t want to contribute to a communication platform where hate speech, conspiracy theories, and fake news is given this much space. The world of today is complicated enough as it is.
      Although my own feed is still pretty OK, I feel that sharing a communication platform with the “dark side” (and don’t underestimate the force of it), implies that my presence there, as a person and as a professional, legitimate the bad stuff. In fact, this might even be an intentional business strategy of the X management team.
      There is certainly some “alternative cost” to rebuild a neonatal network on a new platform. But I am fine with that. For myself, this is a step worth taking to get rid off the feeling that I am also, to some symbolic extent, feeding the trolls on X.
      For the time being, I will stick to LinkedIn, while hoping to rebuild a network feed on our NICUVERSE Mastodon-server and/or on Bluesky. So, might see you there
      And of course, maybe the future holds a renaissance for 99nicu.org with its older-school web site-based discussions.
      Please note that this is a personal decision and about my own Tw/X account. However, within the 99nicu Team, we are also discussing an X-it strategy, but we need to make sure we have the organization's best interest in mind. And, with our upcoming conference, we may choose to keep the 99nicu account up and running to for sharing the word about our conference plans. After all, #NeoTwitter is still a great place for reaching out.
      Thanks to the Verge for making the graphics illustrating this post

         0 comments
      I would like to introduce to you doctor Angela Gregoraci, a Spanish neonatologist, who has just completed a two-month observership in our NICU in Turku, Finland. Our unit here in Turku, is a tertiary center, with single-family rooms and- even more importantly- with families having the possibility to stay with and care for their sick or premature infant throughout the day and night. The objective of this short training was to learn how to facilitate the implementation of family-centered care in dr Gregoraci's unit in Spain. After the internship, she decided to describe her experiences in an essay and I'm grateful she gave me the permission to publish it also here. I hope that this well-thought and beautifully written text will warm your heart on this cold, fall evening. Enjoy the read! KP
       
      FROM TARREGA'S MEMORIES OF THE ALHAMBRA TO SIBELIUS' TUONELA SWAN: EXPERIENCE OF A SPANISH NEONATOLOGIST IN TURKU
       
      I remember very well the first time I heard about developmental and family-centred care, back in 2010, when I was just a neonatologist in training, looking in awe at the pictures of the Uppsala Unit. I knew then that this was the path I wanted to follow, although at that time it seemed utopian... Years later my boss and mentor, Dr. Perapoch, told me a similar anecdote when in 2003 his colleagues visited a Danish neonatal unit: that visit opened their minds. They were there to learn about CPAP and what they brought back with them was a discovery that had an equal or greater impact on the health of the infants and their families: the kangaroo care and the supportive environment.  That was more than a decade ago and I am still walking in that direction, convinced, despite the obstacles, that there is no other possible horizon in modern Neonatology.
      In 2018, European expert group recommendations defined eight principles for newborn-centred and family-integrated care1 consistent with the European Research Network on Early Developmental Care (European Science Foundation)2. In Spain, there are two Newborn Individualized Developmental Care and Assessment Program (NIDCAP) training centres and seven neonatal units that include NIDCAP-certified professionals. Moreover, several units have started to work on different training programmes for developmental and family-centred care3.  A survey examining the eight principles previously published was sent to all Spanish level-III public neonatal units in 2018. Results indicated that none of the Spanish NICUs surveyed had completely implemented the eight principles3. Principles related to the family (parental presence and psychological support) were implemented significantly more often in units with a greater number of very low birth weight (VLBW) infants. Free 24/7 parental access with no limitations is essential for a real infant and family-centred developmental care implementation. In Spain, free parental access was present in 11% of Spanish NICUs in 20064, which increased to 82% in 20125 and 95.4% in 20183. However, although most of the units defined themselves as having an open-access visitation policy for parents, many of them imposed restrictions so that access was not in fact unlimited6,7. Indeed, even if the number of neonatal units with 24/7 access has increased in the last decade, it is not enough. We should still make an effort to remove barriers and promote facilitators to encourage parents' presence and participation during medical procedures or ward rounds. Another unresolved key point, according to the survey findings, was the scarce availability of health care professionals to provide psychological support to parents during and after their infant's admission. Skin-to-skin contact was fulfilled by almost 70% of the NICUs3.
      I came to Turku determined to find a way to overcome these barriers, not knowing that what I would find would be the closest thing to l'isola che non c'é, by the Italian singer E.Bennato. It was as if I had returned to the future and found myself looking through the eyehole of the door at what I would like to be my NICU ten years from now at the latest.
      I was convinced that in order to achieve real and sustainable change in care, the intervention should aim to change the attitudes and beliefs of each professional who work with newborns and their families rather than aiming to change single care practices of the unit. Empowering professionals to empower families, that was the challenge. And here in Turku, they had achieved it, it was not a utopia!
      Sometimes it is enough to change the direction of your gaze to see more clearly, said the French writer Saint-Exupéry. It was as easy as looking for the pole star, guided by the Chariot, as Ulysses tried to do on his return journey to Ithaca, or where the moss grows, or where the compass tells you... north.  During these two months in the NICU of the Turku University Hospital, I have had the opportunity to see with my own eyes the revolutionary power of critical training based fundamentally on practice and reflection to bring about change. Nine years after the group led by Sari Ahlqvist-Björkroth, Zack Boukydis, Anna Axelin, and Liisa Lehtonen successfully implemented and extended their training Close Collaboration with Parents Programme, the "revolutionary" idea that parents are the main facilitators of the proper development of their baby, whether healthy or sick or born prematurely, had become indisputable and inherent in the mindset of both professionals and families in this Finnish unit. I spoke with nurses, with paediatricians, with families, I observed the babies admitted there, and all of them transmitted me unequivocally the same mantra: the participation of families is indispensable in neonatal care, a critical stage of life for both newborns and parents.  How to achieve this is perhaps the next biggest challenge and it is clear that Finland is one of the countries with the most supportive and enviable social policies to do so, but it is not the only thing that is needed. Teamwork, good communication, active listening, and respect for diversity and otherness among professionals and between professionals and families are essential.
      One of the biggest lessons I learned from humanitarian work is that the necessary ingredients for a successful action are: humility, respect, and collaborative work. Without asking beneficiaries about their real needs and capacities, without empowering the development of their skills and making them active subjects of intervention and care, aid will never be sustainable over time. As the indigenous activist and artist Lila Watson said: "If you have come here to help me, you are wasting your time. But if you come here because your liberation is bound up with mine, then let us work together".
      Moving from a care model centred on the professional who relates to the patient in a vertical way, seeing and treating them as vulnerable and lacking in decision-making capacity or autonomy, to a model centred on the patient (and family in the case of neonatal care) endowed with capacities and skills, who relates to the professional in a horizontal and collaborative way, is possible and imperative for all of us to enjoy greater physical and mental health. And Turku is a clear example that it is possible.
      In my personal journey to Ithaca I have been accompanied by extraordinary people: the nurses and Sanna and Helena, with whom I had the opportunity to get to know their training programme in depth, carrying out the individual practice sessions as bedside practice, and sharing their experience as trainer-mentors from the difficult beginnings in their own unit to their current challenge to continue extending to more Finnish and European units; the psychologist Sari, one of the promoters of the programme, with whom I shared knowledge and exercised the incredible and exciting art of critical reflection in a relaxed and, at the same time, professional atmosphere; the families of N. , S., J., O., who allowed me to enter and stir emotions, memories and thoughts at such a critical and difficult time in their lives, and who confirmed to me that parents also have a voice that wants to be heard, because we need them to take better care of their babies and they need us to be able to feel and act as parents. And finally my two bosses, the one over there (Josep Perapoch) and the one over here (Liisa Lehtonen) who gave me the chance to enjoy this experience in my own way and whom I deeply admire for their tenacity and love for Neonatology in general and for families and their babies in particular.
      All these people have facilitated (and I am sure that they will continue to do so with their example and support) my particular process of gestation as a neonatologist, woman, and mother, as well as that of all neonatologists, fathers, and mothers of the present and future, because utopia is not far away, as Galeano said, but is ever closer.
      Kiitos
       
      "In dark times we are helped by those who have been able to walk in the night, showing us that the obstacle does not prevent history. Only those who are capable of embodying utopia will be fit for the decisive combat, that of recovering what humanity we have lost" (Ernesto Sabato)
       
      Angela Gregoraci, Neonatologist
      Hospital Dr. Josep Trueta, Girona, Spain
       
       
      References:
      1-Roué J-M, Khun P, Lopez-Maestro M,et al. Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2017;102(4):F364-F368
      2-Research on Early Developmental Care for Extremely Premature Babies in Neonatal Intensive Care (EDC). Secondary research on early care for extremely premature babies in neonatal intensive care units (EDC). http://www.esf.org/index.php?xml:id=1514. Accessed October 10,2019
      3- López-Maestro M, De la Cruz J, Perapoch López J, et al. Eight principles for newborn care in neonatal units: Findings from a national survey. Acta Paediatr.2020;109:1361-1368
      4- Perapoch López J, pallás Alonso CR, Linde Sillo MA, et al. Developmental centred care. Evaluation of spanish neonatal units. An Pediatr (Barc).2006;64:132-139
      5- López-Maestro M, Melgar Bonis A, de la Cruz-Bertolo J, Perapoch López J, Mosqueda Peña R, Pallás Alonso C. Developmental centred care. Situation in Spanish neonatal units. An Pediatr (Barc).2014;81:232-240
      6- Raiskila S, Axelin A, Toome L, et al. Parents' presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries. Acta Paediatr.2017;106:878-888
      7- Greisen G, Mirante N, Haumont D, et al. Parents, siblings and grandparents in the neonatal intensive care unit. A survey of policies in eight European countries. Acta Paediatr.2009;98:1744-1750
       

         1 comment
      Quick Facts:
      The sudden and unexpected death of a child younger than a year is called sudden infant death syndrome.
      Such infants usually die in their sleep.
      Infants between 2 to 4 months are more prone to SIDS.
      The doctor will declare the death of the infant as SIDS if no other cause is identified.
      The risk of SIDS can be reduced by placing an infant to sleep on his or her back.
      What Is SIDS (Sudden Infant Death Syndrome)?
      Sudden infant death syndrome, otherwise called SIDS, is the sudden and unexplained death of an otherwise healthy infant, generally during sleep. As most infants die in the crib during their sleep, it is also called crib death or cot death. It can be difficult to find the cause for SIDS. It is thought to be due to defects in the part of the infant’s brain that controls breathing and wakes up the body from sleep.
      Doctors and researchers have identified some factors that might be increasing the risk of SIDS, and there are various measures that parents can try to protect their children from SIDS. The most important advice from doctors is to put the baby to sleep on his or her back.
      SIDS is rare, but still the most common cause of death of infants under a year old in the US. Babies between the ages of 2 and 4 months are most commonly affected.
      Does SIDS Result in Any Symptoms?
      SIDS does not result in any symptoms. Babies who are sleeping die suddenly.
      What Causes SIDS?
      Researchers are yet to conclude the exact cause of SIDS. They believe a combination of the following factors might be responsible:
      1) Physical Factors:
      Brain Development - Most of these babies are born with some defects in the brain, which makes them more prone to die suddenly. The part of the brain that is responsible for breathing and sleep arousal do not mature enough.
      Premature Birth - In babies born prematurely, the chances of the brain not developing completely increases. Such babies do not have proper control over breathing and heart rate.
      Respiratory Infection - Breathing problems due to a cold or any other respiratory infection can lead to SIDS.
      2) Environmental Factors:
      Sleeping Position - Babies that are put to sleep on their stomach or side might find it more difficult to breathe.
      Bed Sharing - Babies sleeping with their parents in their bed, or any other mattress that is not specially made for them increases the chances of injury, asphyxia, and strangulation.
      Being too Warm - The risk increases if the baby is too warm while sleeping.
      Blocked Airway - If a baby rolls over while sleeping on a soft surface like a comforter or soft mattress, it can block his or her airway.
      Other Causes - Using an unsafe or old crib, using a very soft mattress, filling the crib with soft toys while the baby is sleeping, not using a pacifier, and not breastfeeding.
      What Are the Risk Factors for SIDS?
      Apart from the physical and environmental factors, the following factors also increase the risk of SIDS:
      Boy babies.
      Infants between 2 to 4 months of life. More than 80 % of babies that die of SIDS are under 6 months of age.
      Having siblings or cousins who died due to SIDS.
      Babies exposed to secondhand smoke.
      Babies with low birth weight.
      Sleep apnea (breathing stops in periods while sleeping).
      Mothers can also increase the risk of their baby dying of SIDS. Mothers who:
      Are younger than 20 years.
      Smoke cigarettes.
      Use drugs.
      Drink alcohol.
      Do not have proper prenatal care.
      Try to avoid as many of these risks as possible.
      How Does a Doctor Diagnose SIDS?
      There is no specific test to determine that the infant died due to SIDS. The doctor rules out all possible causes of death before declaring the cause to be SIDS. The tests and investigations done by the doctor include:
      Examining the infant’s body after death.
      Examining the place where death occurred.
      Evaluating the symptoms that the baby had before death.
      Is There Any Treatment for SIDS?
      Sadly, there is no treatment for SIDS. As there are no symptoms or signs that can alert the parents before the sudden death, nothing can be done. But, there are various ways to reduce the risk.
      What Can Be Done to Reduce the Risk of SIDS?
      The following tips can possibly help reduce the risk of SIDS:
      Put Babies to Sleep on Their Back - Until they are 1 year old, babies should be put on their back for sleep. While they are awake, you can put them on their side or tummy, as it will make the baby grow stronger. But always keep a close eye on them.
      Prenatal Care - Get early and regular prenatal care. Pregnant women should follow a healthy diet and avoid drinking alcohol and smoking. This can help reduce the chances of premature birth and, in turn, reduce SIDS.
      Use a Firm Mattress - Always make your baby sleep on a firm bed with a tightly fitted sheet. Avoid using fluffy comforters. Never put soft toys or pillows in the crib.
      Breastfeeding - Breastfeed your baby at least for the first 6 months. Until suggested by your doctor, do not give your baby water, sugar, or formula milk.
      Pacifier - Give your baby a pacifier while sleeping.
      Avoid Overheating - The room temperature should not be too warm, and avoid over covering or overdressing your baby.
      Do Not Share a Bed - Infants should sleep in a separate crib, that is placed close to the parent’s bed. Never share a bed, especially if you take medicines or alcohol.
      Do Not Smoke Around Your Baby - Do not smoke when you are pregnant and let any person smoke near your baby. Secondhand smoke can be bad for the baby.
      Vaccination - Regular checkups and vaccinations to prevent infections can reduce the risk of SIDS.
      Avoid using baby monitors and other devices that claim to reduce the risk of SIDS.
      Coping With the Loss of Your Baby:
      It is essential to get emotional support after losing a baby to SIDS. Most mothers feel guilty and grief. Talking to other parents who have lost their children to SIDS also helps. Communicate with your friends, family, or a counselor. Losing a child strains a relationship, so try to be open with your partner. Give yourself time to grieve.
  • Upcoming Events

    • 28 March 2024
      0  
      Dear colleague,
      We are a group of neonatologists interested in neonatal pharmacology. We have launched worldwide this survey to study neonatal analgesia & sedation management.
      We would really appreciate your expertise and input!
      We´d suggest you to reflect the current management of analgesia and sedation in your NICU.
      The name of the Hospital, that we offer to add at the end of the survey, is requested only to avoid duplicated responses and will be deleted before processing the data. No single person or institution will receive information regarding individual answers to the survey.
      The survey will take 10 minutes or less to complete.
      In case you have any questions or want to comment on something, you can do so via email carribass@unav.es .
      We really appreciate your participation in advance!

      https://es.surveymonkey.com/r/W92CYM7  
      cover letter neonatologist analgesia survey.pdf
    • 18 April 2024 Until 19 April 2024
      0  
      Check out the Nordic Perinatal Care Spring Meeting in 18-19 April 2024!
      Find program and registration info on the link below:
       
    • 18 April 2024 06:00 AM Until 19 April 2024 12:30 PM
      0  
      Dear Esteemed Perinatal Care Professionals,
      The Finnish and Swedish Perinatal Societies are delighted to invite you to the Nordic Perinatal Care Spring Meeting 2024 in Helsinki. We have curated a program that promises to engage obstetricians/gynecologists, neonatologists/pediatricians, midwives, and neonatal nurses. We extend our warm welcome to participants from all the Nordic and Baltic countries.
      Sincerely,
      Kalle Korhonen
      Chair, Organizing Committee
      kalle.korhonen@tyks.fi
       
      Registration: https://www.perinatologinenseura.fi/koulutukset/kevatkokous-2024-yhteiskokous-ruots-2/
      Nordic Perinatal Care Spring Meeting 2024_invitation and program.pdf
    • 03 May 2024 12:00 PM
      0  
      Perinatal Care of the Preterm Baby-Epidemiology and Ethics
      This is an online module being organised by the MPROvE Academy starting from the 12th of February till the end of April 2021. The content covered includes limits of viability, prenatal counselling, communication, prognostication, decision making, and a lot more as outlined below. The course has been broken up into content that can be imbibed weekly with a webinar covering that topic. The course has online content, and videos for review by the participants. Participants can access this from anywhere in the world. For more details a video of the course is attached.
      For registration please contact Dr Alok Sharma Consultant Neonatologist on draloksharma74@gmail.com 
       
       
       



    • 18 May 2024 Until 19 May 2024
      0  
      The MPROvE neonatal simulation instructor course was established in UK in the year 2012. The concept MPROvE relates to multidisciplinary education of any kind being used to improve the quality of care and/or patient outcomes. The intention is to help institutions, hospitals and teams develop faculty skilled in using simulation and technology enhanced learning as an educational tool for quality improvement, delivery of high-quality neonatal care and to improve neonatal outcomes.
       
      The MPROvE team delivers the simulation instructor course in 2 modules.
      Module 1 - The module includes a two-day face to face interactive workshop. It comprises of series of interactive lectures, demonstrations and opportunity to practice the skills needed to become a simulation facilitator.
      Module – 2:  This module is a 12-week mentored online sessions to further refine the skills. This also helps to obtain certification as simulation faculty.
      We assure you that you will be become a trained facilitator with required competencies to conduct/ train/ teach at you institutes with confidence. We strongly recommend the programme to all the teachers/trainers/faculty in healthcare to further enhance your overall training skills mainly focusing on translational learning through simulation.
      mprove simulation instructor course.pdf
    • 22 May 2024 Until 25 May 2024
      0  
      Objectives

      IPOKRaTES seminars provide high quality postgraduate education, which enables professionals to keep abreast of the most recent developments and offers participants the opportunity to discuss clinical problems or scientific issues personally with international experts.
      “IPOKRaTES under the Acropolis” will focus on specific problems and management of the cardiorespiratory system of the neonate, nutritional needs, growth and infections, particularly of the preterm infant, issues concerning neonatal neurology and topics of general interest in Perinatology.
      For further information and registration, please visit www.ipokrates.info
       
    • 29 May 2024 12:00 PM Until 31 May 2024 08:00 PM
      1  
      Join us for our 4th International Neonatal POCUS Workshop in Sweden!
      Learn all about neonatal hemodynamics and basics and advanced skills in NPE/TNE, Lung-ultrasound and vascular access POCUS.
      More info on www.neonataltraining.org
      Registration is now open and early bird until February 15th!
       
       

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  • Latest Posts

    • Thanks for sharing this @chandas - NEC is such a terrible disease but law suits like this one is just a sign of cynism IMHO, lawyers "milking" the system so to say. You raise an important question, would be interesting to hear from US staff about the implications of this law suit.
    • Adding some links for context: Reckitt charged with $60 million verdict: https://www.reuters.com/legal/reckitt-unit-hit-with-60-million-verdict-enfamil-baby-formula-case-illinois-2024-03-14/ The legal turns: https://www.law.com/2024/03/14/mead-johnson-hit-with-60m-verdict-in-first-nec-trial-over-preterm-infant-formula/?slreturn=20240224133119 As I’ve understood it they are fined for not warning about the increased risk for NEC compared to breast milk. As for breast milk, there are a number of ways to set up programmes for donor breast milk, wouldn’t that be the most reasonable approach?    
    • Many colleagues would be aware of the recent lawsuit in Illinois against Mead Johnson alleging Enamel causing NEC in a preterm baby which the US Court found in the family's favour with an award of $60 million. Whilst the allegation that any cow's milk-based formula CAUSES NEC (rather than saying that human milk protects against NEC) may not be widely held view here, I wondered if colleagues are seeing any fallout from this lawsuit. Clearly this would raise parental concerns and the professionals would find it difficult to recommend any cow's milk-based formula for a preterm baby if the mother can not or does not wish to provide her own breast milk.
    • In our NICU, in the absence of breast or human milk, we use formula for premature babies in extremely preterm babies. There is no support in the literature for the use of partially or extensively hydrolyzed formulas or amino acids. Post-enteritis, the use of an extensively hydrolyzed formula can be considered, but it is not our routine.
    • Hello everyone! I would like to ask about the choice of milk you do for an extremely premature neonate when there is not human milk or mothermilk. Here, in Greece some NICU's give EHF instead and when the baby achieves full enteral feeding they change it to premature formula.  Thanx in advance 
    • We have converted to a webinar to allow more participants to join us. Register on the link below https://us02web.zoom.us/webinar/register/WN_nRDn-K-hQA-7q3lYVZohfQ
    • Dear Colleagues We have a guest speaker session as part of the Lung Ultrasound Course we are running. In it, we will discuss consolidation, atelectasis, and pneumonia.   This webinar is being held on the 21st of March via Zoom as a webinar. If you would like to join, please register below. You are invited to a Zoom webinar. When: Mar 21, 2024 08:00 PM Dubai Topic: Lung Ultrasound-Differentiating Consolidation and Atelectasis in Neonates and Clinical Implications Register in advance for this webinar: https://us02web.zoom.us/webinar/register/WN_nRDn-K-hQA-7q3lYVZohfQ After registering, you will receive a confirmation email containing information about joining the webinar.
    • Rashida Javed and Harsha Gowda from University Hospitals, Birmingham, UK review EbNeo October Article of the Month "Kidman AM, Manley BJ, Boland RA, et al. Higher versus lower nasal continuous positive airway pressure for extubation of extremely preterm infants in Australia (ÉCLAT): a multicentre, randomised, superiority trial. Lancet Child Adolesc Health. 2023 Dec;7(12):844-851. https://doi.org/10.1016/S2352-4642(23)00235-3. Epub 2023 Oct 27. PMID: 38240784." READ HERE! Hear it discussed on the Incubator Podcast! Acta Commentary: Acta Paediatrica - 2024 - Javed - EBNEO Commentary Reducing extubation failure in extreme preterm infants higher vs.pdf Despite advances in non-invasive respiratory support, extremely preterm infants experience extubation failure frequently which can be associated with morbidity and mortality1. The increased risk of extubation failure is due to lung immaturity, poor chest compliance and immature respiratory drive2. Nasal continuous positive airway pressure (nCPAP) or high flow have been the mainstay of post extubation respiratory support3. Following extubation, nCPAP settings vary between centers. Higher set nCPAP levels post extubation may help to maintain end expiratory lung volume and reduce atelectasis. But, a small pilot RCT by Kitsommart et al in 2013 comparing high vs low nCPAP pressures showed no difference in extubation failure rates4. In the ECLAT study, extubating infants less than 28-week gestation to a higher nCPAP of 10cmH2O reduced extubation failure (35% – 24/69 infants) compared to standard nCPAP group (57% – 39/69 infants) with risk difference of -21.7%, 95% CI -38.5% to -3.7%. The number needed to treat was 5 infants meaning five infants needed to receive higher nCPAP to standard nCPAP to prevent one additional extubation failure. Stratification for gestational age subgroups (22-25 and 26-27 completed weeks) also showed a lower extubation failure rate in the nCPAP group receiving higher pressures, especially in the more mature subgroup. However, the study was underpowered for subgroup analysis. The secondary outcomes showed no significant differences between groups which was also underpowered. The most common adverse events, such as pneumothorax, pulmonary interstitial emphysema, spontaneous intestinal perforation, and death were similar in both groups. All infants had exogenous surfactant prior to recruitment which might had contributed to minimal incidence of pneumothorax in higher nCPAP group. 13(19%) infants in standard nCPAP group and 2(3%) in higher nCPAP deviated from protocol to increased nCPAP level above the prescribed level. All these infants were eventually re-intubated within the primary outcome period. Recruitment ceased at 74% of planned sample size due to recurrent pauses during COVID-19 pandemic.  Other limitations are clinicians were not blinded and actual distending pressure in alveoli was not measured. Also, there were no standardized criteria for readiness for extubation. Inspite of above limitations, it is a well-designed randomized control trial showing benefits of higher nCPAP reducing extubation failure. Buzzella et al did randomized control trial in 93 infants of less than 30 weeks gestational age to a higher nCPAP of 7-9 cmH2O or a lower nCPAP of 4-6 cmH2O and found a significant reduction in extubation failure in higher nCPAP group5. But in the ECLAT trial, a much higher nCPAP was used and more immature infants were included. All the extubation failure in higher nCPAP group occurred in first 72hours and nil between 73-168 hours compared to 12 in standard nCPAP group. Probably this suggests the importance of high alveoli end expiratory pressure after extubation to prevent later atelectasis and extubation failure. To conclude, the ECLAT study provides evidence for the use of higher nCPAP in infants less than 28 weeks’ gestation to reduce extubation failure compared to standard nCPAP. There was no difference in BPD rates observed, so the benefit of higher nCPAP (9-11 cmH2O) is questionable. Further large RCT adequately powered to compare BPD rates is required to better evaluate the safety and efficacy of higher post-extubation nCPAP levels on outcomes of greater importance to clinicians and families.' References: Razak A, Shah PS, Ye XY, Mukerji A. Post‐extubation use of non‐invasive respiratory support in preterm infants: a network meta‐analysis. Cochrane Database Syst Rev. 2021;2021(10):CD014509. Published 2021 Oct 25. Kidman AM, Manley BJ, Boland RA, Davis PG, Bhatia R. Predictors and outcomes of extubation failure in extremely preterm infants. J Paediatr Child Health. 2021;57(6):913–9. Awanti, Srinivas & Pol, Ramesh & Katti, Arun. (2023). A randomized controlled trial to compare the success rates and efficacy of high flow nasal cannulae versus nasal continuous positive airway pressure in post extubation period in neonates. International Journal of Contemporary Pediatrics. 10. 510-513. 10.18203/2349-3291.ijcp20230728. Kitsommart R, MHSc AK, Al-Saleem N. Levels of nasal CPAP applied during the immediate post- extubation phase. A Randomized Controlled Pilot Trial2013;3:9. Buzzella B, Claure N, D’Ugard C, Bancalari E. A randomized controlled trial of two nasal continuous positive airway pressure levels after extubation in preterm infants. J Pediatr 2014; 164: 46–51.
    • Vonita Chawla from University of Arkansas for Medical Sciences / Arkansas Children’s Hospital reviews the paper "Motojima Y, Nishimura E, Kabe K, Namba F. Management and outcomes of periviable neonates born at 22 weeks of gestation: a single-center experience in Japan. J Perinatol 2023; 43(11):1385-1391. PMID: 37393397" for EbNeo. READ HERE! Acta Commentary: Acta Paediatrica - 2024 - Chawla - EBNEO Commentary Management and outcomes of periviable neonates born at 22 weeks of.pdf 'In 1991, an amendment to the Eugenic Protection Act lowered the limit of viability to 22 weeks of gestation, in Japan (1). Backed by a robust prenatal care program (2), the Japanese longitudinal experience in caring for neonates born at the cusp of viability has led to improved outcomes (3). Subsequently, active resuscitation is offered to most neonates born at 22 weeks GA, i.e.>80% of these neonates are intubated at birth, according to the year 2020 report of the Neonatal Research Network (NRN) Database, Japan (4) despite a lower rate of antenatal steroid use (~50%). In this study, Motojima et al describe the experience of a single Japanese tertiary center, in caring for periviable neonates born as early as 2013. In this cohort of 29 neonates, overall favorable outcomes are noted with more than 80% survival. Strikingly, only one neonate (5%) in this group developed CP long-term, and only 2 infants (11%) had severe NDI, with the overall greatest impairment seen in the language-social domain. Key maternal/infant characteristics include universal prenatal care, a considerably higher median birth weight of 512 g (compared to median birth weight of 480 g reported by the National Institute of Child Health and Human Development NRN, 2013-2018) (5), use of C-section as the predominant mode of delivery and comparable rates (5) of antenatal steroid administration (34%), both of which are associated with increased survival in this population (6). Maternal illnesses and other prenatal exposures such as smoking and recreational drugs are not listed. Cord milking is practiced commonly, which is currently not standard of care for infants <28 weeks GA, due to an increased risk of IVH (7). Interestingly, in this study, the incidence of severe IVH remained low. Other noteworthy management strategies include early enteral feeding (100% of infants fed by day of life (DOL) 1, despite 90% of these infants requiring some inotropic support), frequent use of neonatologist-performed echocardiograms to inform decisions regarding fluid management, PDA, selection/titration of inotropes/vasopressors, etc., and lung-protective approach to ventilation. All infants are on non-invasive respiratory support by 40 weeks PMA. Postnatal steroid use is not mentioned and a distinction between early vs. late onset sepsis is not made. Probiotics are used as early as DOL 0 in some neonates and phenobarbital is the primary sedative used in the first week of life. Worldwide, several centers have well-established neonatal hemodynamics programs, however, this highly specialized area of neonatology is still evolving and many neonatal intensive care units rely on traditional clinical parameters. This may be one of many reasons for such wide variation in clinical practice and outcomes related to periviable neonates (8). Given the overall improved survival, the American College of Obstetricians and Gynecologists has provided updated recommendations to consider antenatal steroids for GA 22w 0d – 22w 6d (9). Careful consideration should be given to individual patient factors including maternal comorbidities, presence of fetal/neonatal anomalies, inborn versus outborn neonates, resource availability, and most importantly, expectations of the families when choosing active resuscitation for these infants.' References Nishida H, Ishizuka Y. Survival rate of extremely low birth weight infants and its effect on the amendment of the Eugenic Protection Act in Japan. Acta Paediatr Jpn 1992; 34(6):612-6. PMID: 1285508. Kusuda S, Hirano S, Nakamura T. Creating experiences from active treatment towards extremely preterm infants born at less than 25 weeks in Japan. Semin Perinatol 2022; 46(1):151537. PMID: 34862068. Miyazawa T, Arahori H, Ohnishi S, Shoji H, Matsumoto A, Wada YS, et al. Mortality and morbidity of extremely low birth weight infants in Japan, 2015. Pediatr Int 2023; 65(1):e15493. PMID: 36740921. Website for the Neonatal Research Network Database Japan: https://plaza.umin.ac.jp/nrndata/indexe.htm Bell EF, Hintz SR, Hansen NI, Bann CM, Wyckoff MH, DeMauro SB et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Mortality, In-Hospital Morbidity, Care Practices, and 2-Year Outcomes for Extremely Preterm Infants in the US, 2013-2018. JAMA 2022; 327(3):248-263. PMID: 35040888. Vidavalur R, Hussain Z, Hussain N. Association of Survival at 22 Weeks’ Gestation With Use of Antenatal Corticosteroids and Mode of Delivery in the United States. JAMA Pediatr 2023; 177(1):90-93. PMID: 36315137. Katheria A, Reister F, Essers J, Mendler M, Hummler H, Subramaniam A et al. Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. JAMA. 2019; 322(19):1877-1886. PMID: 31742630. Silva ER, Shukla VV, Tindal R, Carlo WA, Travers CP. Association of Active Postnatal Care With Infant Survival Among Periviable Infants in the US. JAMA Netw Open 2023; 6(1):e2250593. PMID: 36656583 Website for the American College of Obstetricians and Gynecologists: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/09/use-of-antenatal-corticosteroids-at-22-weeks-of-gestation    
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