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Showing content with the highest reputation since 03/22/2019 in all areas

  1. 3 points
    Great podcast! In fact, we almost had the interviewed author Joe Kaempf as speaker at this years "Future of Neonatal Care conference (last week in CPH). Let's hope he can come next year
  2. 2 points
    A week ago, we met up at the Future of Neonatal Care conference, AKA the #99nicuMeetup, in Copenhagen, DK. There were four day intensive days for myself, @Francesco Cardona and more than 200 people travelling from 32 countries - neonatal staff members, speakers and workshop leaders, and partner representatives. Topics included outcomes and ethics at the viability border, NEC prevention, neonatal transports, use of inotropes, hyperglycemia, cord clamping, high flow and pain management. And much much more! In short, everything went really well. Given that our vision is to "make the world smaller" and create a space for networking (in addition to a great learning experience) , I would like to share our sincere Thank You to all all delegates, faculty members and Partners for making the #99nicuMeetup the event it has become. Without You coming to "share and care", there would be no dynamics, no laughter, and no #99nicuMeetup. We did our best to share the conference over Twitter (see hashtag #99nicuMeetup). We also video-recorded the lectures, and we plan publish the set of lectures on Youtube in a few weeks time. If you attended and have photos you want to share, please add to the Gallery below (or email them to info@99nicu.org and I upload). See you next year !
  3. 2 points
  4. 2 points
    The medical term for this is placentophagy and it is a real thing. If you follow the lay press you may have seen that originally this was promoted by Kourtney Kardashian who did this herself and then by Kim who planned on doing the same after delivery. See Did Kourtney Kardashian Eat Her Placenta? This is not completely without basis as many readers will be thinking already that they have heard about the health benefits of doing the same. Reports of improved mood and reductions in the baby blues following ingestion of placenta as well as improvements in breast milk production have led to this growing practice. The evidence for this up until recently though was quite old and fraught with poorly design of such studies. The bigger driver however has been word of mouth as many women having heard about the promises of better mood at the very least have thought “why not? Can’t hurt.” What I will do in this post is run through a little background and a few recent studies that have shed some light on how likely this is to actually work. Where did the idea come from? Animals eat their placentas after delivery. It turns out that unprocessed placenta is quite high in the hormone prolactin which is instrumental for breastfeeding. Given the large amount of this hormone as well as the number of other hormones present in such tissue it was thought that the same benefits would be found in humans. Eating unprocessed human tissue whether it is put in a capsule or not is unwise as unwanted bacteria can be consumed. In fact, a case of GBS sepsis has been linked to such a practice in which the source of the GBS was thought to be due to contaminated unprocessed maternal placenta that had been ingested. Buser GL, Mat´o S, Zhang AY, Metcalf BJ, Beall B, Thomas AR. Notes from the field: Late-onset infant group B streptococcus infection associated with maternal consumption of capsules containing dehydrated placenta. What happens when you process placenta by steaming and drying? This would be the most common way of getting it into capsules. This process which renders it safe to consume may have significant effects on reducing hormonal levels.This was found in a recent study that measured oxytocin and human placental lactogen (both involved positively in lactation) and found reductions in both of 99.5% and 89.2%, respectively compared versus raw placenta. I would assume that other hormones would be similarly affected so how much prolactin might actually wind up in these capsules after all? Clinical Randomized Double Blind Controlled Trial Twenty seven women from Las Vegas were recruited into a pilot trial (12 beef placebo vs 15 steamed and dried placenta) with the authors examining three different outcomes across three studies. The first study Effects of placentophagy on maternal salivary hormones: A pilot trial, part 1 looked at a large number of salivary hormones at four time points. Plasma samples were taken as well to determine the volume of distribution of the same. First samples were at week 36 of gestation then within 4 days (96 h) of birth followed by days 5–7 (120–168 h) postpartum and finally Days 21–27 (504–648 h) postpartum. All consumption of capsules was done in the home as was collection of samples. As per the authors in terms of consumption it was as follows “two 550 mg capsules three times daily for the first 4 days; two 550 mg capsules twice daily on days 5 through 12, and then to decrease the dose to two 550 mg capsules once daily for the remainder of the study (days 13 through approximately day 20 of supplementation). Outcomes No difference was found between salivary concentrations of hormones at any time point other than that with time they declined following birth. Curiously the volume of distribution of the hormones in serum was slightly higher in the placenta capsule groups but not enough to influence the salivary concentrations. It was felt moreover that the amount of incremental hormone level found in the serum was unlikely to lead to any clinical response. The second study was on mood Placentophagy’s effects on mood, bonding, and fatigue: A pilot trial, part 2. Overall there were no differences for the groups but they did find “some evidence of a decrease in depressive symptoms within the placenta group but not the placebo group, and reduced fatigue in placenta group participants at the end of the study compared to the placebo group.” The last paper published from the same cohort is Ingestion of Steamed and Dehydrated Placenta Capsules Does Not Affect Postpartum Plasma Prolactin Levels or Neonatal Weight Gain: Results from a Randomized, Double-Bind, Placebo-Controlled Pilot Study. This study specifically addressed the issue of prolactin levels and found no difference between the groups. Neonatal weight gain was used as a proxy for breastmilk production as it was thought that if there was an effect on breastmilk you would see better weight gain. About 80% in both groups exclusively breastfed so the influence of formula one can’t take out of the equation. In the end weight gain was no different between groups although a trend to better weight gain was seen in the placebo group. To eat or not to eat that is the question? What is clear to me is that the answer to this question remains unclear! What is clear is that I don’t think it is wise to consume raw placenta due to the risks of bacterial contamination. Secondly, the levels of hormones left in the placental preparation and the most common preparation of steaming and drying leave hormone levels that are unlikely to influence much at all from a biochemical standpoint. It also seems that breastmilk production and neonatal weight gain aren’t influenced much by consumption of these pills. The issue though in all of this is that while the previous research was of low quality, the current research while of better quality is at a low volume. These were pilot trials and not powered to find a difference likely. The finding in the subgroup of some effect on mood at the end of the study does leave some hope to those that believe in the power of the placenta to help. Would a larger study find benefit to this practice? My suspicion from a biochemical standpoint is not but that one may feel a benefit from a placebo response. Should you go out and have your placenta prepared for consumption? If you have Kardashian like wealth then go for it if you think it will help. If you don’t then I would suggest waiting for something more definitive before spending your money on placentophagy.
  5. 2 points
    Hi Karsten, In Southampton, UK, we have a nutritional screening tool (high risk, medium risk, low risk) which guides us for increasing feeds. ELBW infants would be increasing between 10-20mls/kg/day of EBM. We usually start colostrum as available, then 0.5ml/ 4 hourly, increasing in 10-20mls/kg/day volumes. We are trying to start breast milk fortification at 100mls/kg/day though mostly at 120mls/kg/day. I hope this is helpful. Speed of Increasing Feed trial results later this year may also help guide practice. 🙂
  6. 2 points
  7. 1 point
    Check out this blog post by Keith Barrington whether transfusions trigger NEC. Or does anemia. https://neonatalresearch.org/2019/04/16/do-transfusions-trigger-nec-or-does-anemia/ I would say that there are enough clinical research data out there to say that there seems to be NO association. Just check out the PINT trial, the RCT comparing a liberal vs a restrictive Hb level for transfusion in preterm infants. If anything, the more liberally transfused group of infant had less NEC. And read this paper by Patel et al that nicely demonstrates that there seems to be confounding of indication coming into play, i.e. it is not the transfusion but the underlying anemia is the problem. Despite research findings, this question (whether transfusions "lead to" NEC) is still troubling us. Why so?
  8. 1 point
    Thank you, Stefan, for reminding me of my one major criticism of the PINT trial: They did not include NEC (or at least surgical NEC) in their composite outcome. As for why we, as a profession, continue to worry about TANEC, it is mostly recall bias (we all remember the case of NEC shortly after transfusion but we never stop to think of all the transfusions we have given without NEC appearing) I've often wondered if there isn't already enough data out there to answer these questions (or at least get a start). Supervised learning techniques have advanced sufficient that if you were willing to invest in combining and curating multiple datasets of ELBWs you could probably train a binary classifier to predict risk of NEC with or without transfusion.
  9. 1 point
    I really liked this blog post! I guess many of us have seen devastating cases of post-transfusion NEC that stay with us and therefore add "bias" to our judgements on this topic. There are still questions though right? Like the severity of the anaemia (how low do we leave the Hb and is that threshold different for certain babies?), the duration of anaemia (how long do we leave it before we transfuse?) and then, if the mechanism is a re-perfusion injury post-transfusion, how do we prevent it?!
  10. 1 point
    Hi . the patient is already better. the problem was that it should lower the frequency to the maximum and return to high values of delta p. I think the problem is the draguer vn500 that is not powerful enough to ventilate a patient of 4500 gs by passing it to the sle500 put down the pco2
  11. 1 point
    Thanks for the share- this had been on my to-listen list. The article is an interesting read as well (link below). I am interested in the Staffing Models of high performing NICUs which include: "Neonatologists rounded on fewer patients, less nurse turnover, better nurse: patient ratios and neonatal nurse practitioners rounding on VLBW infants" Definitely someone for next years line up 😉 https://fn.bmj.com/content/104/1/F13?rss=1&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A bmj%2FqEtm %28Archives of Disease in Childhood - Fetal and Neonatal Edition current issue%29
  12. 1 point
  13. 1 point
    @Francesco Cardona great paper! And reminds me of medical studies when I struggled with the coagulation pathways... (like the embedded image below) @Marina22 Did you have something special in mind?
  14. 1 point
    I am on a committee for enteral feeds for ELBW infants. I've pulled some recent literature to see what I could find and there are conflicting viewpoints on whether feeds should advance more slowly or faster in ELBW infants. What is your guideline for enteral feeds progression in the ELBW infant? Kärsten
  15. 1 point
    I've found that Medela quick clean breastmilk removal soap works well for this.
  16. 1 point
    Stefan, this is a difficult problem for 2 reasons: uncertainty with diagnosis of NEC, and limited evidence on what constitutes adequate treatment for NEC of various degrees of severity. The diagnosis of pneumatosis intestinalis versus gas bubbles in stool is difficult; there is commonly lack of agreement on the presence of pneumatosis, and the interpretation is easily biased by other clinical findings. Sometimes, babies with questionable pneumatosis are labeled as having non-specific colitis, or (protein)-allergic colitis, and they may be treated with only bowel rest, or additionally a couple of days of antibiotics, and feedings resumed in 3-5 days if radiological and clinical exams are reassuring. Some neonatologists will have a lower threshold for diagnosing NEC (could be Bell stage 2 in the scenario you gave) and treating for at least 7 days. Even when there is consensus on the presence of pneumatosis, the extent and location of pneumatosis may be important; for example, isolated colonic pneumatosis tends to be seen in older babies and it has a milder clinical presentation. We usually treat for at least 7 days, though some babies' abnormal findings may resolve in 2 or 3 days. I have not seen evidence on gastric decompression. It makes physical sense that intestinal distension and increased intra-abdominal pressure would tend to decrease intestinal blood flow, and they might also cause discomfort to the patient, so we start gastric suction early, until distension and other signs such as bilious aspirates resolve; then, we leave the orogastric tube to gravity drainage. I hope this helps. Joaquim Pinheiro, MD, MPH Professor of Pediatrics Albany, NY, USA
  17. 1 point
    Nicutools is here to provide clinicians with a range of useful calculators to help them care for newborn infants. All of these calculators are provided free of charge in the hope of making life a little easier for those who work in Neonatal Intensive Care. Visit http://mobile.nicutools.org and save that URL as a screen bookmark on your smartphone.
  18. 1 point
    Hi all, we have published the fifth edition of our e-book “NEOQUESTIONS 1to1” . Please feel free to distribute among your other colleagues to help them gain the knowledge of neonatology. https://docs.wixstatic.com/ugd/92a170_54197b618fb34a39a7702b7679a085ec.pdf With Best Regards NAVEED
  19. 1 point
    Dear colleagues! Please share your experience regarding 2 issues about infusion in preterm infants. Unfortunately there are no solid guidelines but questions of fluid supplementation and parenteral nutrition are obviously important for premature patients. There are considerable differences in proposed volumes of fluid requirement per day in literature. For example, Avery’s Diseases of the Newborn (10th edition from 2018, freshest one) provides following numbers: From the other hand, European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2016 Update states that “Typically fluids are initiated at about 70–80 ml/kg/ day and adjustments individualized according to fluid balance, weight change and serum electrolyte levels”. From the third point of view, National Guidelines for Parenteral Nutrition of Neonates in Russian Federation has following recommendation for daily fluid requirements: Bodyweight, grams Daily Fluid Requirements (mL/kg/day) 0-24 hours 24-48 hours 48-72 hours >72 hours <750 90-110 110-150 120-150 140-200 750-999 90-100 110-120 120-140 130-180 1000-1499 80-100 100-120 120-130 120-160 1500-2500 70-80 80-110 100-130 120-160 >2500 60-70 70-80 90-100 110-160 Which numbers are closest to yours? 2. 2. Second question. Clinical case J Premature infant with sepsis on Dopamine with edema because of boluses and severe condition. Now there is a beginning of the 3rd day of life. When calculating infusion for him what bodyweight we consider: 1. actual one (plus 15% of birthweight) 2. minus 3-4,5% from birthweight (ideally we need at least 1,5% of weight loss per day) 3. birthweight 4. something else? Thanks a lot!
  20. 1 point
    This is an interesting dialogue. I just had a long disuccussion about fluid management from the delivery room with our neonatal response team nurses. They see quite a bit of variability from our physicians. When we talk about fluids on the first day, we are usually thinking of so much more than just the dextrose/ nutrition containing fluids. We have to consider the "to keep open" fluids running in additional lumens of our UVC and UAC lines. Premature babies are often on antibiotics the first 2 days. Some get saline boluses or blood products. It is very easy to give 20-40mL/kg/d of fluid above the baseline nutrition containing fluid before you even realize it. The 2014 cochrane review of fluid restriction in preterm infants (https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000503.pub3/full) includes only 5 trials done in 1980-2000. The fluid restricted arm in the individual studies ranged from 50mL/kg/d to 120mL/kg/d. "Fluid restriction" had more PDAs close and less NEC. The incidence of BPD, IVH, and death were in the right direction (favoring fluid restriction) but not significant. Trying to tie all these factors together and deliver an adequate GIR, I start with D10 fluid at 65mL/kg/d. I presume that flushes and medications will add an additional volume that will quickly put my total fluids in the range of 80 - 110 mL/kg/d, which I think is acceptable on the first day. If I have a low glucose, I first increase GIR by going up on the D10 to 80mL/kg/d, but thereafter I try to concentrate the dextrose containing fluids to deliver more GIR over increaseing the rate of administration. In subsequent days I use weight and sodium values to guide increasing total fluid targets. For almost all circumstances i use birthweight for calculations and continue to use it until the baby is back above birthweight. If the baby has edema and is above birthweight in the first week I stick with birthweight until the edema is resolved. I'm interested in others initial fluid strategies when leaving the delivery room. Where do you start - 60, 80, or more? Do you use D10 or D5 or something else? Thanks in advance for the replies.
  21. 1 point
    Most studies I know use "bundles" - so insertion with maximum sterile precautions were used in most settings, but I have not seen any study that only looks at using cap/face-mask in incubators. I would say the possible research question is also one about equipoise.. how much hassle is it to put on cap and mask for a potential higher risk of infection that can have quite deleterious effects. Is sterile material also handled outside of the incubator (i.e. unpacking the catheter etc.)? Then it probably still might make sense.
  22. 1 point
    Dear @Dr Khalil Ahmad, we would consider use up to ~14 days of life. I have some personal experiences of using it up to 21 days of life (relapses after early initial closure) but this was some 10+ years back. Nowadays we have a more conservative approach for late relapses.
  23. 1 point
    Dose & administration Initial dose: 0.05 to 0.1 microgram/kg/min via continuous IV infusion. Titrate to response, then decrease rate to provide the lowest dose while maintaining effect. Maximum dose: 0.4 microgram/kg/min. Higher initial infusion rates do not produce greater effects and are associated with more adverse effects Indications To maintain patency of the ductus arteriosus in congenital heart diseases dependent on shunting for oxygenation Contraindications and special considerations (incl incompatibilities) There are no known contraindications or incompatibilities. Adverse effects Apnea is experienced by 10-12% of infants with congenital heart defects treated with alprostadil, especially those weighing <2 kg at birth. Apnea usually occurs during the first hour of infusion. Respiratory status should be monitored during treatment. Staff trained in resuscitation and intubation should be available. Other common side-effects: fever, seizures, flushing, bradycardia, hypotension, tachycardia, leukocytosis, diarrhea, hypokalemia Uncommon side-effects (<1%): respiratory distress, wheezing, hyperbilirubinemia, anemia, bleeding, thrombocytopenia, hematuria Pharmacological aspects Alprostadil, or prostaglandin E1, causes vasodilation, inhibits platelet aggregation, and stimulates intestinal and uterine smooth muscle. As much as 80% may be metabolized in the first pass of the lungs. Metabolites are excreted via the kidneys within 24 hours. The half-life is <1 minute, thus necessitating a continuous infusion. References Arav-Boger R, Baggett HC, Spevak PJ, Willoughby RE: Leukocytosis caused by prostaglandin E1 in neonates. J Pediatr 2001;138:263-265. PMID 11174627 Browning Carmo KA, Barr P, West M, et al: Transporting Newborn Infants With Suspected Duct Dependent Congenital Heart Disease on Low-Dose Prostaglandin E1 Without Routine Mechanical Ventilation. Arch Dis Child Fetal Neonatal Ed 2007;92(2):F117-9. PMID 16905574 Cawello W, Schweer H, Muller R, et al: Metabolism and pharmacokinetics of prostaglandin E1 administered by intravenous infusion in human subjects. Eur J Clin Pharmacol 1994;46:275-7. PMID 8070511 Prostin VR Pediatric [package insert]. New York, NY: Pharmacia and Upjohn Company; 2013. Talosi G, Katona M, Turi S: Side-effects of long-term prostaglandin E1 treatment in neonates. Pediatr Int 2007;49:335-340. PMID 17532831 Document version history Created 2016-11-10 / Maegan Wells
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