Gustaf Lernfelt

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.

I had a discussion with our IPC-nurse. After spending a year at our nearest level-4 unit where there was a problem with intermittent spread of nosocomial infections (viral as well as kleb and serratia), I wanted to change our routines regarding cleaning of ultrasonography probes. Currently, we are using 45 vol% isopropyl alcohol with added tensides.I tried to change into a combination of Kiilto Pro Cleanisept wipes ( with Didecylmetylammonium chloride, Alkylbensyldimetylammonium chloride and Alkyletylbensyldimetylammonium chloride) and 70 percent ethanol disinfection—wipes, as adopted in the other unit to limit nosocomial spread of pathogens in our unit. But since our IPC-nurse said it was not necessary they decided to continue with our current protocol because it was cheaper. Do you have any specific knowledge on how to approach the possible spread of nosochomial infections through ultrasound devices as POCUS becomes more established in every unit? Are there any good guidelines? I have a worry that our IPC-unit does not have the full neonatal perspective on things. All the best,

Very welcome! This sounds great, I do have a NeoIPC-question I would need to consult you about! Or at least two! Do we have a dedicated forum for this?

Swedish guidelines are Fluconazole 3 mg/kg every 3 days in <27W with central lines or / and during treatment with antibiotics. To be removed when neither is present. Can also be considered in cases where broad spectrum antibiotics are used in <30W when suspected intentestinal injury (or recent surgery). References are here, newest publication from 2017: https://pubmed.ncbi.nlm.nih.gov/28285752/ https://pubmed.ncbi.nlm.nih.gov/27298330/ https://pubmed.ncbi.nlm.nih.gov/27350534/ https://pubmed.ncbi.nlm.nih.gov/17943803/

My limited experience, from rotation at a Level 4 center in Sweden that uses Premiloc-dosing for all infants <28W, is that the results are generally positive. It seems to help with stabilising BP, and when maternal infection is a factor, there’s often a need for extra hydrocortisone. Side effects like hyperglycemia are usually manageable with fluid adjustments, but in some cases the infant will need supplemental insuline. The Swedish experience was published not long ago ( https://pubmed.ncbi.nlm.nih.gov/41712209/ ), though it’s hard to reach statistical significance in the micropreemie group given the small numbers, and to correct for differences in ventilation strategies between centers, the overall outcome was positive. While my experience with these patients is very limited, I do trust my seniors who’s says it’s a solid strategy. The only Swedish center involved in the Tiny Baby collaboration has not adapted this strategy as far as I know. I attended a course in extreme prematurity there a few years ago, and the recommendation then was that supplemental corticosteroids should be avoided.

I would say this is what Linkedin is for.

I rarely see this in my own unit, but I came across a case during my rotation at the Level 4 NICU, linked to a traumatic birth. One of our most experienced consultants noted that while it used to be more common, better nursing care during hypothermia treatment has made it a rare occurrence today. We diagnose it clinically and monitor ionized calcium levels every two weeks. If severe hypercalcemia, we restrict vitamine-D and start treatment with prednisone, not sure about dosing though.

While not doing any car seat tolerance screening in Sweden, we have had an issue with being able to refer a baby to home care, due to our car seats not being approved for infants less than 1500 g. This was an extremely small for gestational age infant, who was quite ”mature” in every other sense. And to use neonatal transport services was not an option, since the family needed to be able to come back for check ups, or if there was any other issue with the infant. So we do have great respect for car seats in Sweden aswell 😊

I would say that this is @Roland NNP s expert field! Do you have any comments? 😊

We are seeing a change in practice toward allowing more medications in breastfeeding. Lately I came across an infant whose mother was on Lithium, this has been a no for us in the past, but she insisted on wanting to breastfeed, and while doing a literature search (with the help of OpenEvidence 😁). I found an article in Acta Pediatrica with a reasonable follow-up schedule. PubMedLithium use during breastfeeding was safe in healthy full...Serum lithium concentrations in breastfed infants were stabilised at barely measurable levels after the first weeks of life. Before that, concentrations higher than the mothers were found. Lithium treWhile questions about breastfeeding while taking various medications are common - and we do have a great Swedish resource that Stefan referred to above - most answers tend to be ”we don’t know” or possibly some effect.” there are only a few medications that are a clear no. For me, several immunosuppressants have fallen into that category, so hearing about your practical approach is really valuable!

This is great, we were having trouble in dealing with a wound in a micro preemie the other day, and this would have helped a lot. Thank you!

Outstanding is the correct word! ⭐

We discussed this the other day, and a colleague who recently worked in the Netherlands gave us some explanation on how they practiced at the hospital where she worked there versus here. First of all, we all kind of use our own algorithm when it comes to risk for infection, even if it’s not put into a score. How long was it since the water broke, maternal fever, known GBS-status or was it an elective C-section? Second to that, the region I work in use IL-6 in combination with CRP in newborns, high levels of IL-6 is a strong marker for bacterial infection. On the other hand a low IL-6 at the start of symptoms makes an infection less likely. It reacts very fast at the start of an infection, but fades down within 24 h. But at that time a CRP would be significantly high. So let’s say that you have an infant 3 hours of age, no risk factors, with a high respiratory rate (70). IL-6 and CRP is negative, —> no AB, follow RR. If you would do a new CRP at 24 h and it would be 40 mg/L, this could still be considered possibly normal due to vaginal birth, and would prompt further follow up, but no Ab. If there were any risk factor, and the child showed symptoms we might have started antibiotics, but stopped if the CRP went down again and there were no positive blood culture in 48-72 h. In the Netherlands where she worked everyone with a CRP above 20 mg/L would be treated with Ab. Possibly due to other organisational issues. I know how studies have showed that CRP is CRaP, but I guess it kind of depends on how you use it. This way I find it useful, as a sign of inflammation and not patognomic for infection (depending on the level, we would say around 60 mg/L is a possible limit).

Bringing an old subject back again due to a recent publication in Journal of Perinatology: https://www.nature.com/articles/s41372-025-02348-4 Have we gotten any wiser since this subject was discussed 16 years ago?

As this subject comes up! May I also recommend a revisit to the @EBNEO commentary on an earlier article from a single center in Japan: https://99nicu.org/forums/topic/2688-ebneo-commentary-management-and-outcomes-of-periviable-neonates-born-at-22-weeks-of-gestation-a-single-center-experience-in-japan/#comment-12727 and @piatkat and @Ryo s post in this thread on how to manage micropreemies, with the complete guide on the japanse approach: https://99nicu.org/forums/topic/2661-how-do-you-manage-micropremies/#comment-12636 And last but no least the talk from Fumihiko Namba at our latest 99nicu Meetup: https://youtu.be/-0D6nBwN4_g?si=e0GbxaSAa6pTdJ22

Just out of curiosity, do you have a pH-limit where you would always admit for observation? Where I usually work we admit and observe children with umbilical cord pH <7. But when doing my rotation a baby with an ok APGAR at 5 and 10 minutes would go to the maternity ward with UA-pH 6,9 if no signs of distress. You would feed, check glucose and do a follow up blood gas to monitor normalisation, but not have any closer observation for possible seizures. This could have to do with limited access to ward beds (e.g. staff) though,

I really liked this webinar from The Tiny Baby Collaborative: I believe it headlighted the different approaches of dry heating to speed up keratinization vs humidification to reduce fluid loss in the incubator. Or it could have been their webinar on fluid management, both well worth watching.

Dear Mohan, We currently have a partnership with @Neobiomics who are arranging a free webinar on this on April 1st: ZoomVälkommen! Du är inbjuden att delta i ett möte: NeoMega36...ARA and DHA Supplementation: Pioneers & First Experiences in European NICUs **NeoMega36 Webinar** By Neobiomics - Karolinska Institutet Science Park DATE: 1 April TIME: 15.00-16:00 CET AGENDA:...May I also suggest listening to this recent episode of the Incubator podcast: https://podcasts.apple.com/se/podcast/the-incubator/id1566031191?i=1000685040875 It doesn’t add much to the discussion, but possibly gives some food for thought. best, Gustaf

Where I do my Level-4 rotation (Queen Silvias in Gothenburg) they implemented a strategy for the first few days of ventilating ELGANs with RDS aiming at higher frequency to minimize tidal volumes. After the acute phase of RDS is over and lung compliance is improved, a change of strategy is warranted (at latest at 5-7 days of age). But they start at: Setting Start Target MAP 10 – 12 cmH2O 8 – 10 cmH2O Amplitude (ΔP) 40 cm H2O (Max amplitude) 15 – 25 cm H2O (by ventilator) Frequency 15 Hz 16 – 17 Hz Volume 1,7 ml/kg as low as possible, normocapnea I:E 1:1 1:1 If normocapnia (pCO2 5.0 – 6.0 kPa) Note DCO2; increase Hz 1 – 2 and decrease volume 0,1 – 0,2 ml/kg – target equal DCO2 If hypocapnia (pCO2 < 5.0 kPa) Only decrease volume 0,1 – 0,2 ml/kg If hypercapnia (pCO2 > 6.0 kPa) Only increase frequency by 1 – 2 Hz The rationale behind using 1:1 is that if frequency >14 Hz with I:E 1:2 the ventilator will not be able to provide sufficient tidal volumes. After the first few days the HFO-strategy (if you choose to continue with HFO) will change to ventilating at a lower frequency and aiming at 10-12 Hz with the tiniest infants. This might require somewhat increased volumes but with reduced amplitudes. At this stage, in cases that would require longer expiration and where increasing MAP is contraindicated (pulmonary interstitial emphysema, overdistension), I:E of 1:1,5 can be considered. The strategy is compiled by Juliús Kristjansson, he did an amazing work with this. I have only cited the PM. As for the I:E reasoning he cited another Sanchez-Luna article than mentioned above: PubMedEffect of the I/E ratio on CO2 removal during high-freque...•The tidal volume on HFOV is determinant in CO 2 removal, and this is generated by delta pressure and the length of the inspiratory time. What is New: •HFOV combined with VG, an I/E ratio of 1:2 is... aswell as https://pubmed.ncbi.nlm.nih.gov/35136198/ and https://www.draeger.com/Content/Documents/Content/jane-pillow-hfov-br-9102693-en.pdf I hope this could help you in your reasoning, I'm not very knowledgeable in this myself, but it's at least something.