Gustaf Lernfelt

While my email went unanswered, and our hospital's ophthalmologists lacked the full background on the routine they are implementing, I was able to find further elaboration on the study online. I highly recommend reading Keith Barrington's excellent review, along with the discussion featuring author Ann Hellström in the comments. https://neonatalresearch.org/2026/08/11/steroid-drops-for-retinopathy/

After testing a few devices we are chose to go with a Canon aplio ME due to amazing resolution, acceptable agility and ease of use. Looking forward to start using it in practice.

Key Takeaways from the Advanced Monitoring & Point-of-Care Diagnostics SessionWe have officially wrapped up the final afternoon session of the day, and it was a fantastic glimpse into the future of neonatal intensive care! The focus was entirely on cutting-edge, non-invasive monitoring and how we can bring real-time physiological data directly to the delivery room and the bedside. Here is the breakdown of the core messages from our final three speakers: Cerebral Oxygenation Monitoring / NIRS (Gerhard Pichler) The SPO2 Disconnect: Routine parameters like arterial oxygen saturation (SPO2) and heart rate do not always reflect what is happening in the brain. Due to immature autoregulation or varying metabolic demands, a neonate can have perfectly on-target SPO2 while their brain remains dangerously hypoxic—a pattern closely associated with subsequent IVH. The COSCA Trials: Using NIRS to guide interventions (adjusting FiO2, respiratory support, or giving fluid boluses) successfully reduced the burden of cerebral hypoxia. While standard frequentist analysis showed a 4.3% increase in survival without brain injury (not statistically significant), Bayesian analysis revealed a 92% probability of improved outcomes, alongside significant reductions in cerebral palsy and sensory impairments in the 28-31 week subgroup. Clinical Protocol: Following the 2024 ILCOR guidelines, NIRS can be a powerful bedside tool: stabilize routine targets first (SPO2 80-85%), and then look at the NIRS monitor. If the brain is still hypoxic, escalate your support. Lung Ultrasound in the Delivery Room (Bernhard Schwaberger) Lung ultrasound (LUS) is highly feasible in the delivery room and serves two distinct clinical purposes without delaying essential resuscitation: Emergency Assessment: Rapidly identifying immediately actionable pathologies like pneumothorax (loss of seashore sign/barcode sign), massive pleural effusions (jellyfish sign), or unexpected congenital diaphragmatic hernias. Organ-Based Assessment (Transition Tracking): For infants with persistent respiratory distress, LUS can visualize lung aeration in real-time. Predictive Power: An LUS performed at just 15 minutes of life can accurately distinguish TTN from RDS and predict CPAP requirements at 60 minutes. Even earlier, at 5-10 minutes, LUS predicts the need for subsequent surfactant treatment better than clinical oxygen requirements alone. Lung Recruitment & Impedance Measurement / EIT (Vincent Gaertner) Electrical Impedance Tomography (EIT) utilizes a sensory belt to measure bioimpedance, allowing us to visualize breath-by-breath regional lung ventilation and volume changes (FRC) in real-time. Preterm Breathing Patterns: EIT identified three distinct breathing patterns in preterm infants on CPAP. Notably, the "holding maneuver" (where the infant halts exhalation for up to 10 seconds, closing the glottis) was the only pattern associated with a successful gain in end-expiratory lung volume (FRC). Clinical Traps Revealed by EIT: The Face Mask Illusion: EIT showed cases where a Respiratory Function Monitor (RFM) at the T-piece displayed "adequate" tidal volumes, but EIT proved zero air was reaching the lungs. The highly compliant nasopharyngeal space was simply expanding and obstructing flow. Intubation was required to actually ventilate the lung. The Cost of Interventions: EIT visualized massive, immediate drops in end-expiratory lung volume during routine nasopharyngeal suctioning (questioning the routine use of steps like VISTA-SOPA) and during laryngoscopy for LISA surfactant administration. What an incredible day of science and clinical innovation. Before we head to the evening networking events, let's bring these concepts back to our own units: NIRS at the Bedside: Gerhard's talk bridges the gap between research and practice, highlighting that SPO2 isn't always enough to protect the brain. Is your unit currently using cerebral oxygenation monitoring routinely for clinical decision-making, or is it still primarily used in a research context? LUS in the Delivery Room: Lung ultrasound is rapidly gaining traction as a predictive tool, but the delivery room is a high-stress, fast-paced environment. Do you see point-of-care LUS becoming a standard tool during the "Golden Hour" in your unit, and what are the main training hurdles? Visualizing the Invisible: Vincent's EIT data showing that RFMs can register "good" tidal volumes while the lungs receive nothing is alarming. How rely on T-piece monitors vs. clinical chest rise in your delivery room, and how close do you feel we are to using tools like EIT at the bedside? Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.

Hi everyone, checking in from the neonatal neurology sessions at CEPAS here in Lyon! We just wrapped up a fantastic morning diving deep into neurocritical care and early intervention. For those who couldn't be here, I wanted to share a quick summary of the core take-home messages from our first two speakers, along with some points to chew on. What is Neurocritical Care and who are the babies at risk? (Lina Chalak, USA) NIRS as a CO2 Proxy: Dr. Chalak highlighted using near-infrared spectroscopy (NIRS) practically to monitor CO2 levels. Keeping CO2 strictly between 40–45 during the first five days is vital; outside this window, autoregulation fails and blood pressure fluctuations directly impact the developing brain. Unsedated MRIs for Micro-preemies: Her unit routinely does term-equivalent MRIs for all infants under 1000g before discharge. By bundling the scan with feeding and swaddling, they avoid sedation and frequently catch subtle diffuse white matter injuries and cerebellar bleeds that standard serial sonography misses. Placental Pathology: They integrate placental pathology into neuro-assessments. Fetal inflammatory response (seen in 42% of her cohort) directly correlated with lower MRI scores and 2-year cognitive deficits, even in the complete absence of clinical chorioamnionitis. Telemedicine for the "Golden Hour": To reduce care variability across regional hospitals, her team uses iPad-based remote assessments by a central examiner to standardize the decision to initiate therapeutic hypothermia, allowing cooling to start immediately on transport. EI-SMART (Betty Hutchon, UK) Rethinking Therapy: Citing recent evidence, Hutchon pointed out that traditional early intervention often struggles because it isolates motor skills and relies on passive, sometimes stressful therapies (like forced tummy time) rather than fostering holistic, active exploration. The Power of Everyday Routines: EI-SMART weaves four threads of development (Sensory, Motor, Attention & Regulation, and Relationships) into the things we already do. Rather than doing a once-a-week therapy session, the framework focuses on adapting the 50+ times a day a baby is naturally handled—like optimizing supportive holds during nappy changes or feeding—to provide a constant, low-stress sensory-motor environment. Parent Co-Production: Clinicians are encouraged to drop medicalized "goals" and deficit-focused questions (e.g., "Can your baby sit?"). Instead, the approach utilizes a "Developmental Care Profile," collaborating with parents by starting with what positions or toys the baby likes, framing parents as the equal experts on their infant. Do NOT miss the excellent resources provided by the EI-SMART team ➡️ https://eismart.co.uk/r I'd love to hear your thoughts on these topics: Using NIRS as a practical proxy for CO2 and autoregulation during the first five days was a major point in Dr. Chalak's talk. How widely adopted is continuous NIRS monitoring in your units, and what hurdles have you faced in training bedside staff to actively use these trends for respiratory management? How does your NICU manage the logistics of routine term-equivalent MRIs for extremely low birth weight infants, and have you successfully adopted unsedated "feed and wrap" scanning protocols? The EI-SMART framework emphasizes turning routine bedside moments (like nappy changes) into early intervention. What practical challenges do you face in aligning therapists, bedside nurses, and parents to consistently execute this before discharge? Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.

Key Takeaways from the Pharmacology, Neurology & Neonatal Exposures SessionWe have reached the end of an incredible day at CEPAS 2026! The final session delivered fascinating insights into pharmacology, the microbiome, and early neuroprotection. We were also thrilled to see one of our very own 99nicu team members take the stage! Here is the breakdown of the core messages from the final session: Neonatal Opioid Safety Attitudes: Türkiye vs. the UK (Esra Ardahan Akgül) A cross-sectional study of 64 healthcare professionals compared knowledge and practices regarding neonatal opioid use. Common Ground: Both countries demonstrated high agreement on the importance of strict monitoring protocols, recognizing opioid-related adverse effects, and maintaining medication safety. Key Differences: Significant discrepancies emerged regarding familiarity with validated neonatal pain assessment tools, knowledge of naloxone use, and perceived adequacy of education. While safety perceptions are generally positive, there is a clear international need for standardized, evidence-based education—particularly concerning the consistent use of validated pain scales. Caffeine Exposure & TDM in Preterm Infants (Francesca Chessa) Is routine Therapeutic Drug Monitoring (TDM) necessary for caffeine? The short answer is no. Having a "therapeutic" serum level (>15 mg/L) does not guarantee therapeutic success. Treatment success was independently associated with gestational age, not serum caffeine levels or pharmacokinetic markers like AUC. Universal TDM is not supported by the data. TDM should be strictly targeted—for instance, to rule out caffeine toxicity when a baby presents with unexplained tachycardia. Additional Caffeine Doses & Hypoxic Burden (Kelly Storm) For infants experiencing recurrent apneas despite standard maintenance therapy, administering an additional dose of caffeine (typically 5 mg/kg) is highly effective. In the three hours following an additional dose, the hypoxic burden decreased by 43% and the number of desaturations decreased by 21%. Infants with a high baseline frequency of desaturations (the top quartile) experienced the most significant clinical benefit. The ALBINO Trial: Early Postnatal Allopurinol (Axel Franz) Allopurinol targets the secondary energy failure and superoxide generation that occurs upon reperfusion in evolving HIE. To be effective, it must be administered within a very tight window: under 45 minutes after birth. The ALBINO trial navigated immense logistical and ethical hurdles across 10 countries and 69 sites to enroll 526 infants, successfully treating 376 within that strict 45-minute window using deferred or two-stage consent. Primary outcome data (death or neurocognitive impairment at 24 months) will be available next year. Restoring Gut Microbiota via Maternal FMT (Noora Carpén) Cesarean sections delay the colonization of beneficial maternal bacteria (like Bacteroides) and favor hospital-associated pathobionts. The Secfort study (a double-blind RCT) safely administered a highly controlled Maternal Fecal Microbiome Transfer (FMT)—mixing 0.1g of screened maternal feces with breast milk—to C-section infants. The FMT successfully shifted the microbiome closer to a vaginal-birth profile (higher Bacteroides and E. coli) without increasing adverse infectious events, and even stimulated early immune responses (higher CXCL proteins). In Utero Stimulant Exposure (Dotan Shaniv) A huge congratulations to our very own 99nicu team member, Dotan, for a fantastic presentation closing out the day! 👏 Analyzing a massive retrospective cohort of over 7,000 pregnancies, the study looked at maternal use of ADHD stimulants (primarily methylphenidate/Ritalin) during pregnancy. Reassuring Safety Profile: There was no increased risk of preterm birth or major congenital malformations. While there was a statistically significant signal for lower birth weight, the actual mean reduction was only ~23 grams—suggesting that the clinical impact on fetal growth is highly uncertain and likely negligible. What a fantastic end to the scientific program today. Let’s bring these topics back to our own units: Pain Assessment in Practice: The data comparing Türkiye and the UK highlighted significant gaps in the use of validated neonatal pain assessment tools. Which pain scale is standard in your unit, and do you feel your team receives adequate ongoing training to use it effectively when administering opioids? The Caffeine Ceiling: Between Francesca's data showing TDM isn't the answer and Kelly's data showing extra doses work, how does your unit handle apnea of prematurity that doesn't respond to standard dosing? Are you routinely pushing additional 5 mg/kg boluses? Microbiome & Maternal Interventions: Maternal fecal microbiome transfer for C-section infants is a fascinating, expanding frontier. What are your thoughts on the practical and ethical implementation of restoring neonatal gut flora this early in life? Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.

Silke Mader opened the workshop with the parents’ perspective, speaking both as the mother of a preterm baby (four and a half months in the NICU) and as a former preschool teacher. A global study on this topic is underway but has no results yet. She therefore drew on feedback from parent organisations in different countries. Her core message: parents are not visitors. It is their baby, and real involvement starts with very basic, practical conditions. Understand the parents’ situation Parents are in a traumatic, highly stressful situation. Information often doesn’t stick, however many times it has been given, and that is not the parents’ fault. Medical, financial, social and administrative problems all arrive at once. Parents are very diverse: highly educated, critical parents who ask many questions; parents who don’t speak the local language; families from different cultural backgrounds. The basics of being a main caregiver Parents can’t be present 24/7 with visiting hours, a locked door to ring at, or an upright chair. Nobody on staff would sit on that chair for 8 hours of kangaroo care. Units need a bed to rest, food, a shower and toilet, and comfortable chairs. This applies to fathers as well as mothers. These things should be designed into new hospitals from the start. Partnership and communication Involve parents in decision-making. Use language parents understand; even a lawyer or a teacher cannot follow medical jargon. Repeat information, and give it in writing. Consistency matters. She recalled getting different messages from the morning nurse, another nurse, the weekend doctor and the Monday chief physician. When her primary nurse went on a two-week holiday, it felt like something to survive. Parents need to feel safe, and that requires one consistent message from the team. A global view: very different realities Australia (feedback from the Miracle Babies Foundation): Limited parental leave, combined with stays of four to six months or more. Huge distances, no accommodation or food for parents, and expensive daily parking. Marked inequalities for Indigenous families, including a higher preterm birth rate and a historical lack of trust in healthcare. Brazil: Families in river communities may need days to reach the hospital, and lose contact with the rest of their family. Language barriers for immigrant families in a Portuguese-speaking country. The suggested solution is regional support and stronger local and primary care, rather than relying only on centralised units. Nordic countries and Canada: centralisation means long distances, which can mean flights in Canada. Families may stay in the big city for months. After discharge, every follow-up visit can mean a full day and an overnight stay at the family’s own cost. Canada is working towards culturally safe, trauma-informed care for Indigenous families, newcomers and refugees, and towards standardised information and practice across the country. Low-resource settings (the Uganda example): Fathers are kept out entirely. Mothers wait outside the hospital, sometimes sleeping on the floor without food, and are allowed in only once a day for a few hours. USA: With no paid maternity leave, parents must choose between their income and being at the bedside, and support is being cut further. Black mothers and babies face around double the risk of dying. The UK has some data on inequalities; Germany and most of Europe have hardly looked. She believes the problem exists all over Europe. Ukraine: war-time evacuations of preterm babies, fathers at the front or missing, and a higher preterm birth rate. Family involvement under these conditions is a reality we should not look away from. Practical solutions Early, understandable information in many languages, for example the Neopedia platform. Interpreters. When they aren’t affordable, AI translation is not perfect but better than nothing. Cultural sensitivity, ideally with team members who share the families’ cultures. Family spaces and accommodation, which don’t need to be five-star: a bed near the hospital, partner hotel or Airbnb rates, Ronald McDonald House–type solutions. Practical support: lunchboxes for parents, affordable parking, social support so mothers aren’t left alone. Some German hospitals have won these battles with hospital management. Education: update curricula. The ESN already covers family involvement, but not country differences, inequality or racism. Advocacy: work with parent organisations and policymakers on parental leave. Sweden, which recently extended leave to grandparents, is her favourite example. Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.

The first afternoon session dives deep into some of neonatology's most enduring debates: managing the PDA and navigating the extreme pharmacological complexities of vasoactive drugs in premature infants. Here is a breakdown of the core messages from each speaker: Pharmacological Management of PDA (Gilles Cambonie) The debate over managing presymptomatic PDAs in extreme preterms continues. Prophylactic or early routine pharmacological treatment (within the first two weeks) is generally not recommended, as studies show it does not improve long-term outcomes (mortality or severe neurodevelopmental disability) and may increase risks of adverse events like severe BPD or infections. However, for symptomatic cases or those failing conservative management, targeted pharmacological closure remains a reasonable approach. Future research must focus on the most vulnerable subgroups (≤26 weeks) possibly using AI, multimodal physiologic monitoring, and targeted biomarkers to identify the precise window for intervention. Long-Term Outcomes: Expectant vs. Active PDA Management (Ilhaam Ouamari) A comprehensive systematic review and meta-analysis found no statistically significant difference in survival without neurodevelopmental impairment (NDI) between expectant management and active treatment groups overall. Interestingly, a small subgroup analysis of studies with follow-ups beyond two years suggested active treatment might favor survival without NDI, potentially linked to a reduction in severe IVH when prophylaxis was used in older trials. However, the data quality is limited by high heterogeneity and short follow-up periods. There is an urgent need for PDA trials to track outcomes well into school age to see if children "grow into a deficit." Dynamic Dosing of Vasoactive Drugs (Vincenzo Cannizzaro) Traditional adult-based pharmacology fails in neonates. Blood pressure changes cannot be reliably attributed to a single drug-receptor interaction, and traditional alpha/beta receptor targeting is overly simplistic for clinical shock. The Delivery Delay: The programmed pump rate does not equal immediate drug delivery. With tiny infusion volumes and significant dead space, changing the delivery time can take minutes to several hours depending on the infusion configuration. The drug might not even be reaching the baby when you are expecting a clinical response. Dynamic Dosing: Dosing must move away from linear escalation. It requires understanding the specific physiological problem and continuously reassessing the response before arbitrarily pushing the dose up. Pharmacology of Vasoactive Drugs in Neonates (Eugene Dempsey) The Data Void: There is an extreme lack of pharmacokinetic (PK) and drug clearance studies in premature infants. We are heavily relying on adult extrapolation, which is complicated given the differences in volume distribution, immature enzyme pathways, and highly variable renal clearance. For instance, most of our dopamine data comes from small cohorts 30+ years ago, and there is virtually zero PK data on adrenaline in preterms. The Rule of 5 Half-Lives: It takes 5 elimination half-lives to reach a steady-state concentration. For dobutamine, the half-life in preterms varies wildly (from 3 to 36 minutes). This means it can take anywhere from 15 minutes to 3 hours just to reach a steady state! Clearance and Escalation Traps: Steady-state concentration is dictated by the infusion rate divided by drug clearance. Crucially, increasing the infusion rate does not shorten the time to reach the new steady state—it just sets a new target that will still take 5 half-lives to achieve. Antenatal Steroids and Pulmonary Hypertension (Gonzalo Solis-Garcia) Elevated pulmonary pressures are common in extremely preterm infants during the first 72 hours. Infants who received a complete course of antenatal steroids showed significantly lower (more normal) pulmonary pressures compared to those with incomplete courses. Cardiovascular Remodeling after Fetal Growth Restriction (Celina Brunsch) In the first week of life, there was no significant difference in cardiac strain (left ventricular function) between preterm infants with FGR and those without FGR. Preterm birth itself may have a more dominant impact on early cardiac strain than the added factor of FGR, heavily influenced by the presence of a PDA. However, FGR infants did show impaired cerebral autoregulation compared to their non-FGR preterm peers, a pattern that emerges strongly after the first three postnatal days, potentially linked to a prolonged brain-sparing effect. Let’s keep the conversation going! How does your unit handle these hemodynamic challenges? The PDA Dilemma: With the ongoing debate between active pharmacological closure and expectant management for extreme preterms, how has your unit's approach to the PDA evolved over the last five years? The "Waiting Game" with Infusions: Given the extreme variability in clearance and the fact that it takes 5 half-lives (up to 3 hours for dobutamine!) to reach a steady state, how do you manage the urge to rapidly escalate doses at the bedside when the blood pressure isn't responding immediately? Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.

What an incredible morning session here at CEPAS! We just wrapped up a packed HIE-block covering everything from late-preterm cooling debates to trial integrity and family-centered neurocritical care. For those following our live reporting, here is a quick breakdown of the core messages from each talk: Therapeutic Hypothermia in Late Preterm Infants (Floris Groenendaal) Recent data highlights that there are higher risks and complications associated with cooling late preterm infants, calling into question the overall positive effect of the intervention in this population. Major cooling trials have historically underrepresented these infants, making it difficult to establish strong, uniform guidelines. Despite the risks, cooling at 35 weeks can still be considered depending on individual underlying clinical factors and severity, whereas cooling at 34 weeks presents a distinctly riskier profile. Cerebral Proton MRS and School-Age Neurodevelopment (Lorea Vicente Elcano) Early neonatal proton magnetic resonance spectroscopy (performed on days 4–6) provides strong long-term prognostic value in infants with HIE treated with hypothermia. The lactate to N-acetyl aspartate (NAA) ratio emerges as the most robust biomarker, maintaining high predictive accuracy for adverse outcomes at school age (5–8 years). This predictive power is particularly strong for cognitive outcomes compared to motor domains. Beyond Cooling: Latest HIE Trials and Precision Phenotyping (Lina Chalak) Second-generation trials attempting deeper/longer cooling or adjunctive erythropoietin did not show improved survival and pointed toward potential harm. The newly completed enrollment of the Cool Prime trial highlights that "mild" HIE carries significant risk, with many infants eventually meeting thresholds for early intervention. Future Advancements: The next frontier relies on continuous, precision physiological tracking rather than a single-point clinical exam (like an early SARNAT score). By utilizing real-time EEG (to monitor neuronal activity), broadband NIRS (to measure mitochondrial function and cerebral oxygenation), and advanced MRI, clinicians can track the dynamic trajectory of reperfusion injury. This functional phenotyping allows us to identify infants who initially present as "mild" but progressively worsen between 6 and 24 hours, paving the way for delayed or highly tailored neuroprotective strategies. Cortical Activity Mechanisms and HIE Severity (Timo Syvälahti) A multicenter validation study utilizing the ALBINO trial cohort demonstrated that automated computational EEG metrics correlate strongly with clinical HIE severity (Thompson scores). Lower local cortical amplitudes and higher large-scale network connectivity map consistently across the entire clinical severity spectrum, including mild HIE cases. These automated metrics hold strong potential as objective endpoints for future clinical trials. Cuddling During Therapeutic Hypothermia / Cool Cuddle (Ela Chakkarapani) Structured parental cuddling (up to two hours) during active therapeutic hypothermia is safe and does not clinically compromise core/surface temperature regulation or intensive care stability. Infants experienced improved comfort during cuddles, reflected by increased sleep-wake cycling on amplitude-integrated EEG and lower pain scores. Implementing Cool Cuddle fosters a sense of normality for families and significantly reduces risks of poor parent-infant bonding. Resource: You can watch a great animated explainer on the Cool Cuddle process here: https://youtu.be/dC7SriN99SA?si=P5PKrzUfc8ymUHef Trustworthiness of Trial Evidence in HIE Cooling (Anna Lene Seidler) A systematic integrity assessment of 34 randomized trials on therapeutic hypothermia revealed major concerns or potential red flags in 41% of studies. When excluding these compromised trials, overall effect estimates shift, though the core neuroprotective benefits of cooling in high-income settings remain supported. The findings underscore the critical need for rigorous trial integrity screening and individual participant data (IPD) meta-analyses in neonatal research. We would love to hear how these findings resonate with your clinical practice back home. Jump into the discussion below: Late Preterm Cooling: Given the conflicting data and nuances between 35 and 36 weeks, how is your unit currently approaching cooling eligibility for late preterm infants (35 weeks)? Future HIE Protocols: Between advanced prognostication (like MRS) and the search for adjunct therapies, what do you think will be the next major protocol shift in HIE management? Family-Centered Neurocritical Care: What practical or cultural hurdles has your team faced when considering family integration strategies like "Cool Cuddle" during active hypothermia, and how have you navigated them? Is it being used or considered at your unit? Disclosure: This is an AI-assisted summary of the session, generated from a recording made by our team in attendance. We believe it is as accurate as our own notes would be, but please refer to the speakers’ original work before applying anything in clinical practice.

WIll sure do! We will share it in our channels after CEPAS aswell. I read some very nice French recommendations a few years ago: https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2022.1075184/full?fbclid=IwY2xjawVP-_FleHRuA2FlbQIxMABwZG9mAWJyaWQRMTJ0R1V6NEw0Q3hFem96ZkZzcnRjBmFwcF9pZBAyMjIwMzkxNzg4MjAwODkyAAEfLZdxgkaZitZ0PRa1hbzeetoCmza6G1MhbWgQvP70c7nAv2jA-nPDiD5RXEA_aem_fP0fC_vKKGCw4pzHOJr5pw We succesfully use a guideline with less sedation than indicated above, especially for SALSA. Thank you for doing this excellent and clinically important work!

Hello from Lyon! 👋 The opening remarks just wrapped up, and it was a fantastic reminder of why we do this—bringing the global pediatric and neonatology communities together to connect, learn, and advocate for our patients. We have a great few days ahead of us! The program is packed with 80 sessions, and plenty of poster walks to check out. The faculty also outlined some great priorities for the future, especially around improving access to pediatric meds and devices, driving research, and protecting children's health and rights across Europe. A huge congratulations to Professor Alfred Tinova for receiving the 2026 ESPR Honorary Member Award! 🏆 And a big thank you to our local organizers for such a warm welcome to the city. Are you here at the congress? If so, please drop by the 99Nicu area! We’d absolutely love to meet you, catch up, and talk shop. Come say hi! Looking forward to all the great conversations and connections this week.

Thank you for sharing, this is very helpful! While this provides a great reference for normal values, deciding exactly when and how to intervene is always a challenge. I’d love to know how you set the threshold for when a bedside nurse should escalate a measurement and call you? What is your unit's approach to this?

Very interesting papers, thank you for sharing. We sometimes use thicken up, but I have not read much about it's use. We do not follow a strict timeline for breastfeeding; instead, our nursing staff bases the process on the individual infant's readiness. While we begin early oral stimulation using the mother's milk, actual breastfeeding is initiated when the child is ready, typically between weeks 31 and 33. Thanks to a robust social security system, parents can remain at the bedside 24/7 from 28 weeks onward. This allows us to practice skin-to-skin care aiming at eight hours a day if feasable, making the transition to the breast a very natural, minor step. If an infant struggles with swallowing, we consult a speech and language therapist for an assessment. We do frequently manage aspiration and reflux, but these issues are generally related to positioning, bowel care, or overall immaturity rather than the act of breastfeeding itself. If there is a prolonged problem with establishing feeding somebody will usually say, it's time for radiology. But it will usually be after we have tried milk protein-free fortifiers, esomeprazol or thickening.

Yes, there was a topic a couple of years ago. It’s mentioned as an option in Gomella and is used in some neonatal units.

While not methamphetamine, I recently took care of an infant whose mother was treated with daily doses of lisdexamfetamine, paroxetine, pregabalin, lamotrigine, oxazepam, zopiclone, and a couple of other medications. The child suffered from meconium aspiration syndrome and was showing signs of developing PPHN, so we needed to avoid withdrawal symptoms. Since there was no opioid exposure, we looked at using phenobarbital instead, which is recommended as a complement to morphine in polypharmacy according to the Australasian Neonatal Medicines Formulary. https://www.anmfonline.org/wp-content/uploads/2024/07/Phenobarbital-Phenobarbitone_ANMFv3.1_20270731.pdf Maybe @Dotan S has some good input when it comes to different pharmaceutical options (and I'm sorry Dotan, but this time we said no to breastfeeding due to complicating factors).

We also only do physical assesments. We rely highly on our national Swedish Child Health Services program where specially trained nurses follow all infants for regular assesments. I would say though, that these conditions are often missed, and that we find them at our routine visits for neonatal follow up with PTs aswell as neonatologists. I would be very interested in you PDF @Stefan Johansson, to share with my PT colleagues.

Does your guideline have any recommendations on when to consider Diazoxide if hyperinsulinism is confirmed?

Dear Neonatal community, We are currently in the process of acquiring a new neonatal POCUS machine, with our primary focus being on vascular access, cranial, pulmonary, and cardiovascular assessments. We would love to hear your recommendations: what is your preferred ultrasound machine for the NICU, and why? Internally, we are debating our primary goal. We are weighing the benefits of a highly agile, compact machine that lowers the threshold for frequent bedside use, versus a higher-end system optimized for comprehensive cardiovascular workups (which may sacrifice some of that maneuverability). We can still get a full cardiovascular assesment from our pediatric cardiologist with their GE vivid-machine, but it has its limitations in regards to other examinations. Personally, I am leaning toward a Mindray TE-series-like solution, as it offers a large screen while maintaining a minimal footprint at the bedside. Any insights or shared experiences would be greatly appreciated! Best regards, Gustaf

I’ve only seen the approach were you find yourself with a problematic tube that need constant suctioning, and then you take a culture to see if there is Ureaplasma present that might(?) induce increased mucus production. If present, a course of azithromycin is provided. However, a colleague mentioned that their previous unit abroad gave prophylactic azithromycin to all extreme preterms, both to target Ureaplasma and to leverage its anti-inflammatory effects.

I have reached out to one of the coauthors, and will get back to you if I get any good answer 🙂.

Thank you for the fantastic, incredibly thorough review of each drug. It is truly inspiring; we usually rush into decisions after a brief glance at clinical support tools. Based on your detailed insights, we feel confident offering the family a partial breastfeeding plan combined with regular monitoring of drug concentrations and routine labs, similar to standard antiepileptic treatment. Our plan is to let the mother establish breastfeeding while aiming for the infant to receive 50% of their intake via preterm-adapted formula, ensuring bottle feeding for at least 4 meals a day. For context, the child's initial carbamazepine concentration came back well below therapeutic levels. We have sent out a sample for Briviact analysis to an external lab and are currently awaiting those results. This has been immensely helpful for our clinical reasoning, thank you again

I'm working at one of the intervention sites in the study After the inclusion period finished we continued to use it for all affected infants according to the treatment indication of the study, and still do. Were there any particular questions you had regarding the results and the treatment? I might not be able to answer the ophthalmologic questions myself, but could get back to you with an answer from one of the authors.

Dear NICU-colleagues I would like your expertise in a patient case. We have a preterm infant born at 28+2 weeks of gestation following PPROM and chorioamnionitis, treated with SALSA for RDS, and subsequently managed on HFNC until a week ago. The infant is now at 34+0 weeks postmenstrual age and is off all respiratory support. Aside from this, the infant is very healthy, with no IVH, no PDA, and adequate growth. Enteral nutrition was initiated with donor breast milk, and the infant reached full enteral feeds of 150 mL/kg by 7 days of age. The infant’s mother has complex epilepsy and was maintained on Tegretol (carbamazepine) 800 mg + 1200 mg/day, Briviact (brivaracetam) 200 mg + 200 mg/day, and mirtazapine 45 mg once daily throughout the entire pregnancy. She began pumping early on and expressed a strong desire to feed the baby with her own milk. Initially we were hesitant, however, given her strong wishes and our goal to promote the use of mother's own milk, we have permitted partial feeding with MOM 12 mL out of 50 mL per feed, 8 times a day. The infant currently weighs 2340 g. We now need to decide whether to allow her to transition to full breastfeeding. While we do use Briviact to treat some of our pediatric patients, this scenario presents a complex preterm polypharmacy issue, and our experience with Briviact safety during breastfeeding is limited. The straightforward approach would be to transition directly to formula, but the mother has worked incredibly hard for this, and we want to support her wishes if it is safe to do so. I read @Dotan S framework on polypharmacy (https://www.nature.com/articles/s41390-025-04416-z) and I know that @Mariana Oliveira usually has great insights on this topic. What would be an acceptable approach according to you? Allt toughts are welcome to help us make the most reasonable decision. Best Gustaf

This is absolutely brilliant and should be published as an article. Thank you Brar 🙏! We do use single use sterile gel for our most vulnerable patients, like in examinations before rickham reservoir taps, and in US-guided venous puncture / picc-line insertions. In older premature infants a heated multi use-bottle is more common (which feels great for bacterial culture 😱). We do also see lack of cleaning post examinations sometimes, with residue still on the probe as you mention. It does feel reassuring that our solution still Is a viable choice, as long as staff is coherent to routines. Thank you once more, for sharing your knowledge and providing such a thorough and well thought out answer. All the best, Gustaf

We rarely send them home on caffeine unless an underlying neurological cause for central apnea is suspected. Our standard protocol involves treating extremely premature infants until 33–34 weeks gestation, followed by a 5-day observation period prior to discharge. Some mature preemies who don't need respiratory support can be discontinued earlier. Some of the infants will still have intermittent desaturations because of BPD, requiring home oxygen, or a symptomatic PDA and get a bit swollen which we manage with a short course of diuretics. But if the reason for the desaturation isn't central, no caffeine. All infants are monitored with apnea alarms until 35 weeks, provided saturations remain stable enough to discontinue extra O2 and pulse oximetry. It feels more reasonable to try and address the specific underlying etiology than everything for all.