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Showing content with the highest reputation since 10/21/2013 in Blog Entries

  1. It has to be one of the most common questions you will hear uttered in the NICU. What were the cord gases? You have a sick infant in front of you and because we are human and like everything to fit into a nicely packaged box we feel a sense of relief when we are told the cord gases are indeed poor. The congruence fits with our expectation and that makes us feel as if we understand how this baby in front of us looks the way they do. Take the following case though and think about how you feel after reading it. A term infant is born after fetal distress (late deceleration to as low as
    7 points
  2. It’s been some time since I last posted here. Many things have changed in my life since then- the most important transition being my decision to move to Finland to work as a research fellow with the Baby-friendly Ventilation Study Group in Turku. The life of a beginning clinical researcher deserves a separate post here (it may even come at some point). To celebrate my first anniversary in Finland I would like to share 3 things I wish somebody had told me before I moved here. Enjoy! 1.Get nylon pants. The weather in Finland is truly whimsical. We have had a kind spring, warm summer, and
    6 points
  3. Our tiny babies have very tiny tracheas. So far you are probably all with me. Putting that tube in the right position is therefore tricky. In particular avoiding the right mainstem bronchus, which is the wrong position, is important. So first of all; where should the tip be? That seems obvious, it should be in the trachea, high enough above the carina that the tube never slips into the carina, but low enough that it doesn't slip out. On a plain AP radiograph, however, it isn't always clear exactly where the tube tip should be. In general ,studies have suggested that on the radiograph the tip
    6 points
  4. The professional communication during the Covid-19 pandemic really shows the potential to share expertise and experience through web-based channels. Journals, societies, regular news media, social media platforms etc-etc play an important role for us to keep updated, and many web sites have also opened up their content free of charge. We will learn many things from facing and tackling this pandemic, but one major change will certainly be our communication channels. Many are discovering the web-based possibilities to learn and discuss. We will do our best to facilitate profession
    5 points
  5. I must admit that it is a bit exciting to think about that 99nicu.org went live 12 years ago, at a time when Facebook and other “social media” web sites was yet to be invented. (@Zuckerberg, no offense here. Obviously, you created something far greater than 99nicu, still a grass rot project. BTW – could we apply for funding from you Foundation?) When starting 99nicu.org in 2006, we nourished an idea that experiences and expertise should not be hindered by geographical boundaries. In some sense, this was a statement, that we as medical professionals could help each other through other
    5 points
  6. I just want to share some brief news about our next Meetup, 7-10 April 2019 at Rigshospitalet in Copenhagen/Denmark. We (i.e myself, @Francesco Cardona @RasmusR @Christian Heiring , Gorm Greisen and Morten Breindahl) are currently working on the program lectures and workshops. I just want to share the first five confirmed speakers and their topics: Morten Breindahl: Neonatal transports – how to do them safe and easy Ola Andersson: Cord Clamping, 1.0 and 2.0 Ravi Patel: How to explain when NEC rates persist – even when a NICU does everything “Right” Ulrika Ådé
    5 points
  7. The lungs of a preterm infant are so fragile that over time pressure limited time cycled ventilation has given way to volume guaranteed (VG) or at least measured breaths. It really hasn’t been that long that this has been in vogue. As a fellow I moved from one program that only used VG modes to another program where VG may as well have been a four letter word. With time and some good research it has become evident that minimizing excessive tidal volumes by controlling the volume provided with each breath is the way to go in the NICU and was the subject of a Cochrane review entitled Volume-t
    5 points
  8. Originally posted at: https://winnipegneonatal.wordpress.com/ Facebook Page: https://www.facebook.com/allthingsneonatal/ As I read through the new NRP recommendations and began posting interesting points on my Facebook Page I came across a section which has left me a little uneasy. With respect to a newborn 36 weeks and above who is born asystolic and by ten minutes of age continues to remain so and has an apgar score of zero the recommendation that has been put forward is this: An Apgar score of 0 at 10 minutes is a strong predictor of mortality and morbidity in late-preterm an
    5 points
  9. Intubate-Surfactant- Extubate or INSURE has been around for awhile. The concept is to place an ETT while an infant is first on CPAP and then after pushing surfactant in quickly remove the ETT and put back on CPAP. This does not always go as planned though. If after surfactant the FiO2 remains above 30% many people would keep the ETT in place as they would surmise that the infant would fail if the tube was removed. They would probably be right. Sustained inflations have fallen out of favour ever since the SAIL trial results were published and written about here . Having said that, the c
    4 points
  10. First off I should let you know that we do not do transpyloric feeding for our infants with BPD. Having said that I am aware of some units that do. I suspect the approach is a bit polarizing. A recent survey I posted to twitter revealed the following findings: I think the data from this small poll reveal that while there is a bias towards NG feeds, there is no universal approach (as with many things in NICU). Conceptually, units that are using transpyloric feeds would do so based on a belief that bypassing the stomach would lead to less reflux and risk of aspiration. The ques
    4 points
  11. If you are to read one paper on neonatal ethics this year, I'd argue that this is the one. Late last year, John Lantos, pediatrician and a leading medical ethicist, published a review in NEJM on the ethics around decision-making in the NICU. The paper is not open-access... but you can surely get it from within your hospital intranet or your university/hospital library. We have a fantastic toolbox in the NICU. We can provide live-saving treatments and support. Most newborns in the NICU survive to good long-term health. However, we also operate in a high-risk environment where som
    4 points
  12. This has been a question that has befuddled Neonatologists for years. Get ten of us in a room and you will get a variety of responses ranging from (talking about caffeine base) 2.5 mg/kg/day to 10 mg/kg/day. We will espouse all of our reasons and question the issue of safety at higher doses but in the end do we really know? As I was speaking to a colleague in Calgary yesterday we talked about how convinced we are of our current management strategies but how we both recognize that half of what we think we know today we will be questioning in 10 years. So how convinced should we really be ab
    4 points
  13. I have never been convinced that fluid restriction is a good thing for kids with BPD. I think the common practice came about because of the short-term improvements in lung function that sometimes follow if you start diuretics. The idea being that if diuretics improve lung function, then giving less fluid will also. But this is a false equivalency, diuretics cause sodium depletion, and therefore decrease total body water, and probably lung water content also. Fluid restriction in contrast leads to a reduction in urine output, and, within clinically reasonable limits, will not have an impac
    4 points
  14. I know - many of us want less emails... But the emails from Evidence Updates are great! Evidence Updates (a collaboration project by the BMJ Group and McMaster University) assists your reading of new research by grading articles by "Relevance" and "News-worthiness". For example, this trial on D-vitamin supplementation of preterm infants showed up in an email alert, an article I had missed otherwise. 1. You need to Register (here!) 2. Choose your clinical interest ("Pediatric Neonatology", I guess) 3. Set a minimum score for new articles you want to read about (set a
    4 points
  15. It is one of the first things that a medical student pledges to do; that is to do no harm. We are a fearful lot, wanting to do what is best for our patients while minimizing any pain and suffering along the way. This is an admirable goal and one which I would hope all practitioners would strive to excel at. There are times however when we can inadvertently cause more harm than good when we try to avoid what we perceive is the greater harm. This is the case when it comes to collecting a sample of urine for culture as part of a full septic workup. If you ask most healthcare providers they will
    4 points
  16. Three recent-(ish) articles examining how we should ventilate babies and monitor what we are doing. Milner A, Murthy V, Bhat P, Fox G, Campbell ME, Milner AD, et al. Evaluation of respiratory function monitoring at the resuscitation of prematurely born infants. Eur J Pediatr. 2014:1-4. In this study, respiratory function monitoring with tidal volume, airway pressure and exhaled CO2 was routinely introduced in 2 London hospitals. The authors then asked trainees whether they found it useful, and what they thought the right tidal volume should be. As you might imagine the answers were quite var
    4 points
  17. In recent years we have moved away from measuring and reporting gastric residuals. Checking volumes and making decisions about whether to continue feeding or not just hasn’t been shown to make any difference to care. If anything it prolongs time to full feeds without any demonstrable benefits in reduction of NEC. This was shown in the last few years by Riskin et al in their paper The Impact of Routine Evaluation of Gastric Residual Volumes on the Time to Achieve Full Enteral Feeding in Preterm Infants. Nonetheless, I doubt there is a unit in the world that has not had the following situation h
    3 points
  18. I recently had the honour of being asked to present grand rounds at the University of Manitoba. My former Department Head during the question period stumped me when he asked me what role angiotensin converting enzyme 2 receptor (ACE2) has in pediatric COVID19. Like all great teachers, after I floundered and had to confess that while I was aware there is a role in COVID19 I wasn’t sure of the answer, he sent me a paper on the subject. The reality is that a very small percentage of COVID19 illness is found in children. Some estimates have it at 2%. Why might that be? It’s what’s in the n
    3 points
  19. Dear fellow Ph.D. students, full-time researchers, and other fellow scientists, please #staythefuckhome. In many grant proposals, we write "this research has the potential to save lives, because... ". Let's face it- most of our research won't save lives (or at least not at once)*. No matter how fantastic our research projects are, science takes time. But what can actually save lives immediately is US STAYING HOME. This way we - the (relatively) young people in big academic campuses- won't be spreading the virus that might be deadly for others: for an old lady in the shop (who takes care o
    3 points
  20. After watching a documentary in ARTE about bacteriophages it made me think about how else is antibiotic resistance in NICU.? It available french / German Here the story phages was told. First discovered use by Felix Derrel to combat infections in the pre-antibiotics era and was later discredited and forget about in the western world Historically they worked rather well, so there is an attempt to bring them back in the light of increasing antibiotics resistance. This rediscovery started with lab study that showed that the phages were effective at clearing infection in rats pop
    3 points
  21. Oral immune therapy (OIT) has really taken off at least in our units. The notion here is that provision of small amounts (0.2 mL intrabucally q2or 24 hours) can prime the immune system. Lymphoid tissue present in the oropharynx and intestine exposed to this liquid gold in theory will give the immune system a boost and increase levels of IgA. Such rises in IgA could help improve the mucosal defence barrier and therefore lessen the incidence of late onset sepsis. Rodriguez et al described this in their paper Oropharyngeal administration of colostrum to extremely low birth weight infants: theoret
    3 points
  22. Just about all of our preterm infants born at <29 weeks start life out the same in terms of neurological injury. There are of course some infants who may have suffered ischemic injury in utero or an IVH but most are born with their story yet to be told. I think intuitively we have known for some time that the way we resuscitate matters. Establishing an FRC by inflating the lungs of these infants after delivery is a must but as the saying goes the devil is in the details. The Edmonton group led by Dr. Schmolzer has had several papers examined in these blogs and on this occasion I am
    3 points
  23. While at the #99nicuMeetup, I and @Francesco Cardona were filmed by Miris (one of our exhibiting partners). It was a one-time shot without rehearsal, so we spoke from the heart
    3 points
  24. Recent statements by the American Academy of Pediatric’s, NICHD, the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and recommend selective approaches to mothers presenting between 22 0/7 to 22 6/7 weeks. The decision to provide antenatal steroids is only recommended if delivery is expected after 23 weeks. Furthermore the decision to resuscitate is based on an examination of a number of factors including a shared decision with the family. In practice this leads to those centres believing this is mostly futile generally not resuscitat
    3 points
  25. One of the first things a student of any discipline caring for newborns is how to calculate the apgar score at birth. Over 60 years ago Virginia Apgar created this score as a means of giving care providers a consistent snapshot of what an infant was like in the first minute then fifth and if needed 10, 15 and so on if resuscitation was ongoing. For sure it has served a useful purpose as an apgar score of 0 and 0 gives one cause for real worry. What about a baby with an apgar of 3 and 7 or 4 and 8? There are certainly infants who have done very well who initially had low apgar scores and co
    3 points
  26. July was very eventful for me and that had caused my on-line silence. I had a chance to visit again my beloved Finland and now I'm back with fresh thoughts and ideas (and also hundreds of photos). Enjoy! Kotiloma is a word in Finnish that means „vacation at home”. But in some NICUs around Finland it has grown into a bit different meaning. Kotiloma is a practice of arranging a little vacation at home for NICU patients before their final discharge. The routine is quite simple. On the kotiloma day parents come to the unit with a car seat and a set of clothes. When the seat is warm and
    3 points
  27. I had an amazing opportunity to visit NICU in the Turku University Hospital in 2016. They admit around 550 problematic newborns per year. About 10% of them are born below 30 weeks of gestation. The whole unit is practically based on 11 family rooms (single family rooms when possible) and additionally one larger room for 4 patients. The larger room is usually used for babies who are admitted due to transient issues (tachypnea, hypoglycemia, hyperbilirubinemia etc). Single family rooms are equipped with an incubator/open warmer bed/cot, one adult bed, one reclining armchair and a nappy changing
    3 points
  28. I met the author of this article at a CPS meeting a few years ago, she immediately impressed me with her unique perspective. Paige is a developmental pediatrician who does long-term follow-up of preterms, and is involved in developmental evaluation and intervention of children with other challenges, including Spina Bifida. Church P. A personal perspective on disability: Between the words. JAMA Pediatrics. 2017. As you will see if you read the article, Paige has a form of Spina Bifida herself, a Lipomyelomeningocele, with a neurogenic bladder and neurogenic bowel, requiring life-long
    3 points
  29. The human body truly is a wondrous thing. Molecules made from one organ, tissue or cell can have far reaching effects as the products take their journey throughout the body. As a medical student I remember well the many lectures on the kidney. How one organ could control elimination of waste, regulate salt and water metabolism, blood pressure and RBC counts was truly thought provoking. At the turn of the century (last one and not 1999 – 2000) Medical school was about a year in length and as the pool of knowledge grew was expanded into the three or four year program that now exists. Where
    3 points
  30. This may sound familiar as I wrote about this topic in the last year but the previous post was restricted to infants who were under 1000g. High Flow Nasal Cannula be careful out there had a main message that suggested the combined outcome of BPD or death was more prevalent when HFNC is used alone or with CPAP than when CPAP is used alone. The question remains though whether this applies to larger infants. Without looking at the evidence for that combined outcome most people would say there is unlikely to be a difference. Larger more mature babies have a much lower risk of BPD or death so p
    3 points
  31. This publication appeared on-line a couple of months ago, and still isn't in print. Prentice T, et al. Moral distress within neonatal and paediatric intensive care units: a systematic review. Arch Dis Child. 2016. It is a systematic review from Melbourne, with the help of Annie Janvier, of the literature surrounding moral distress in health care workers in the NICU and the PICU. All of the studies included nurses, and some of them also studied other health care workers. Moral Distress refers to subjective feelings of distress in response to the ethical challenges of health care work. It i
    3 points
  32. As I was preparing to settle in tonight I received a question from a reader on my Linkedin page in regards to the use of sustained inflation (SI) in our units. We don't use it and I think the reasons behind it might be of interest to others. The concept of SI is that by providing a high opening pressure of 20 - 30 cm H2O for anywhere from 5 to 15 seconds one may be able to open the "stiff" lung of a preterm infant with RDS and establish an adequate functional residual capacity. Once the lung is open, it may be possible in theory to keep it open with ongoing peep at a more traditional level
    3 points
  33. We live in a world at the moment where the public has become increasingly aware of the dangers of antibiotic overuse. Parents are more than ever requesting no erythromycin for the eyes after birth, and even on occasion questioning the need for antibiotics after delivery for the infant with risk factors for sepsis. The media has latched on to the debate as well by publishing the sensational articles about superbugs and medicine running out of the last lines of defence such as this article from the CBC. As teams caring for newborns both preterm and term we are also increasingly aware of t
    3 points
  34. I don't know about you but I have deeply rooted memories from the 1990s of donning a yellow gown and gloves before examining each and every patient on my list before rounds. This was done as we firmly believed such precautions were needed to prevent the spread of infections in the NICU. As time went on though the gowns were removed and not long after so went the gloves as priority was placed on performance of good hand hygiene to reduce rates of infection in our units. You can imagine that after having it entrenched in my mind that hand hygiene was the key to success that I would find i
    3 points
  35. I have often wondered why my obstetrical colleagues would often induce labour once a woman with ruptured membranes reached 34 weeks. I wasn't aware of any data to support doing this, or, on the other hand, any good data to say that you shouldn't. It turns out that I was well-informed, there just wasn't any good data, until now. Morris JM, et al. Immediate delivery compared with expectant management after preterm pre-labour rupture of the membranes close to term (PPROMT trial): a randomised controlled trial. Lancet. 2015;387(10017):444-52. In this study over 1800 women with singleton pregn
    3 points
  36. Many of you will have heard of the "Choosing wisely" campaign, an attempt to improve decision making, by clarifying efficacy and risks of common procedures or therapies. Many specialty societies have come up with lists of the Top-5 questionable practices that should be reconsidered. The AAP has just published a list of 5 neonatal practices that they say should be avoided. It is interesting that some of the other societies have made very clear recommendations to not do certain things (“Don’t do….” a particular test, for example). The AAP list instead states to “Avoid Routine…” for each one of t
    3 points
  37. All food is brain food when your brain is making 250,000 new neurones every minute. In a small two-center trial first published in 2013 50 very preterm babies were randomized to different parenteral nutritional intakes. The main differences between the groups were that the controls started at 2 g/kg/d of protein, compared to 3.5 in the intervention group. The controls started at 0.5 g/kg/d of lipid given as ClinOleic, the intervention group started at 2 of SMOFLipid; both gradually increased to a max of 3.4. One they were receiving 110 mL/kg/d of milk the fortification was different between
    3 points
  38. Necrotizing Enterocolitis remains a devastating disease. One of the major causes of mortality in Very Low Birth Weight Infants, it often strikes when babies are starting to do well. Because it is relatively unpredictable, observational studies are potentially useful, but can easily be misleading. In particular, observational studies which are performed as a result of a perceived change in incidence might easily be biased. One recent study that was published has received some publicity, I myself received some links on Linked-In pointing to this study, which at first sight seems to show that ad
    3 points
  39. One of Annie Janvier's first research projects was a case control study of the influence of prophylactic indomethacin on intestinal perforations. Under my supervision she analyzed cases of spontaneous intestinal perforation (SIP), and we analyzed the influence of prophylactic indomethacin, which was highly significantly related. As we knew at the time, there are numerous biases in this type of research. For one, we decided to do the study because we had just had a run of SIP; often such studies are stimulated by just this kind of phenomenon. Which immediately introduces bias: what you should
    3 points
  40. Call me prescient, OK, you won't, but I will. Two recent observational studies suggest that the recent NICE guidelines have had adverse effects on infants evaluated for potential early neonatal sepsis. 'NICE' of course is not an adjective for how good the guidelines are, but the acronym for the National Institute of Health and Care Excellence in the UK. Any long time neonatalresearch watchers will remember vividly my perceptive analysis and critique of those guidelines. Which included the good (to stop antibiotics at 36 hours if no signs of sepsis) and the questionable; universal measurement
    3 points
  41. Neil Marlow has published a thoughtful, and thought provoking, article to address the issue outlined in the title. What are the appropriate outcomes when designing neonatal research studies? It has become almost a rule, that a multi-center trial of an intervention in neonatology, especially if it is planning to enroll very preterm infants, has to have 'survival without neurological or developmental disability' as the primary outcome, with the 'disability' part measured at about 2 years. There is some value to this outcome, very preterm infants have high mortality and high morbidity in those
    3 points
  42. A catchy title for sure and also an exaggeration as I don’t see us abandoning the endotracheal tube just yet. There has been a lot of talk about less invasive means of giving surfactant and the last few years have seen several papers relating to giving surfactant via a catheter placed in the trachea (MIST or LISA techniques as examples). There may be a new kid on the block so to speak and that is aerosolized surfactant. This has been talked about for some time as well but the challenge had been figuring out how to aerosolize the fluid in such a way that a significant amount of the surfactan
    2 points
  43. 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 elect
    2 points
  44. It would seem that the Opioid crisis is continuing to be front and centre in the news. Just today the President of the United States declared an Opioid Epidemic Emergency. Of course he was speaking primarily about the damage these drugs do on the family unit and those around them, the impact on the unborn child is significant as well. If this sounds familiar it is because I have written about this topic recently and in the past in the posts A Magic Bullet to Reduce Duration of Treatment and Hospital Stays for Newborns With NAS and Mandatory Drug-Testing ni PRegnancy: Lesson learned. I suppo
    2 points
  45. A 28 week preterm infant now two weeks of age develops bilious emesis and abdominal distension. An x-ray reveals an intestinal perforation and surgery is consulted. Arrangements are made to go to the operating room for a laparotomy and due to apnea and hypotension the baby is both intubated and placed on dopamine. The resident on service ensures that blood is available in the operating room and an hour after presentation the baby is found to have a HgB of 102 g/L with a HcT of 35%. I don’t know about you but if I am then asked whether we should give blood now or in the OR I might say
    2 points
  46. It has been some time since I wrote on the topic of point of care ultrasound (POC). The first post spoke to the benefits of reducing radiation exposure in the NICU but was truly theoretical and also was really at the start of our experience in the evolving area. Here we are a year later and much has transpired. We purchased an ultrasound for the NICU in one of our level III units and now have two more on the way; one for our other level III and one for our level II unit. The thrust of these acquisitions have been to reduce radiation exposure for one but also to shorten the time to di
    2 points
  47. Choosing wisely is an initiative to “identify tests or procedures commonly used whose necessity should be questioned and discussed with patients. The goal of the campaign is to reduce waste in the health care system and avoid risks associated with unnecessary treatment.” The AAP Section on Perinatal Pediatrics puts the following forth as one of their recommendations. “Avoid routine use of anti-reflux medications for treatment of symptomatic gastroesophageal reflux disease (GERD) or for treatment of apnea and desaturation in preterm infants. Gastroesophageal reflux is normal in i
    2 points
  48. It seems the expression "(insert a group) lives matter" is present everywhere these days so I thought I would join in after a moving experience I had today. For those of you who have been with the blog since the beginning you would have seen a number of posts that if you follow them in time, provide a glimpse into the transformation that Winnipeg has seen over the last year or so. Prior to that point, 24 weeks was a cutoff for resuscitation that had been in place for some time and after a great amount of deliberation and thought was changed to 23 weeks. This did not come without a great
    2 points
  49. Bassler D, et al. Early Inhaled Budesonide for the Prevention of Bronchopulmonary Dysplasia. New England Journal of Medicine. 2015;373(16):1497-506. One of those ongoing trials that we have been awaiting the results of has just been published. The NEUROSIS trial was a randomized controlled trial with a very respectable sample size, 863 infants less than 28 weeks, by far the largest investigating this issue. Babies got budesonide (or placebo) twice a day by a metered dose inhaler with an aerochamber until they were 14 days of age then once a day until they were 32 weeks or off oxygen. The resul
    2 points
  50. I have been trying to develop some sort of protocol for babies in our center, so I have been reading in some detail the studies about very preterm births and cord clamping that are in the literature. It seems from the PAS meeting that everyone is jumping on the bandwagon, hence my detailed inspection of the trials (and the Cochrane and other systematic reviews), because we are thinking of jumping on too, to make sure that we are going to do the right thing. I created a couple of tables with some of the details of the studies that have been done, both those in the Cochrane review, and some done
    2 points
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