Gustaf Lernfelt

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.

Thank you for bringing this great subject up! Would you know anything about this @Frank ? There is a neonatal hemodynamics and POCUS-course in Gothenburg in May https://99nicu.org/events/event/379-pocus-gothenburg-2025-may-21-23-2025/ arranged by @Frank and others.

Practice change can be a challenge, even if it’s evidence based! Good luck, and thank you for sharing!

This is our schedule for enteral feeds, the columns is as follows: Gestational age at birth, Bolus starting amount (ml/kg/feed), Bolus daily increase (ml/kg/feed), days until full eneteral nutrition. There was a post about this on bluesky regarding a recently published study. Where we also got a suggestion from how they do in Aarhus in Denmark. https://bsky.app/profile/padkaer.bsky.social/post/3lhgbmxkyis2y thank you @Padkaer for sharing

We used to give a combination of Hexyon and pneumococcal vaccine but saw some increased desauturations from our pneumococcal vaccine, and the Swedish National Health Agency recommended against early vaccination in preterms. As for now we give Hexyon and RotaTeq (rota only if there are no contraindications e.g born <25 W, intestinal disease or immunosuppressive treatment in mother). For children born <26 W of age at 34 W, 26-32 W at 6 weeks of age. Surveillance with apnea monitor for 48 h post vaccination is warranted. If they get their first vaccination at 10+ weeks of age they will also get Vaxneuvance, but if possible at separate days. The statement from the Swedish national health agency was as follows: ”Since the introduction of pneumococcal vaccine into the childhood vaccination programme, the incidence of invasive pneumococcal disease has decreased significantly, and there are now only a few cases in infants annually. Very few cases are caused by vaccine serotypes, probably due to both direct protection and herd effects of the vaccines. An additional dose of pneumococcal vaccine for premature infants is not currently considered to affect the incidence of severe pneumococcal disease in this age group. This may need to be reconsidered in the event of changes in epidemiology and vaccination coverage”

Hi, We were discussing the practice of eye examinations in our unit in regards to infant discomfort. Right now we give cyclopentolate 0,5% -phenylephrin 0,5% drops, 1 in each eye, at 45 and 30 minutes before examination. If the opthalmologist chooses to do a full exam with RetCam they also give local anasthetics. Since we see a lot of problems with desaturations and instability with the children post-exam, we are considering to only give 1 drop in each eye at 45 minutes pre-exam, this has been implemented at another hospital in the region. But we were also discussing the possibility of sedation during the exams to minimize discomfort of the infant. A colleague suggested clonidine as an option, is that something you use, or how do you manage these issues?

We have started with midwife-examinations for early discharge (6-12h from birth), followed by a physician eaxmination within 2 days. For infants staying at the maternity ward they will be examined once by a physcian before discharge, unless there are indications for more exams (murmurs, tachypnea, hypotonus etc.). This would be at 12-36 hours of age. Indications for staying in the maternity ward could be first born child, risk of infection, maternal health or other, but many choose early discharge with their second child. The midwives will do a basic exam but not listen to the hearth though, only do a pre-post-ductal saturation check, and they are not trained in finding more subtle finds associated with disease. I believe that for most babies it will be alright, but for some babies this could mean severe consecuenses, although they might be too few for it to be statistically significant upon review. On the other end of the spectrum I spoke with a couple of collegeues visiting from a country in south east Europe where every infant stayed for at least 5 days, and 7 days if there was a c-section. All the babies were examined once daily, and the well baby check shifts could be pretty hard in the weekends. Right now were are aiming at combining the maternity ward with our NICU at our smaller rural hospital, to be able to offer CPAP-care skin to skin and aiming at zero separation between mother and child. We have implemented this with some success at our post-op after c-sections and thereby been able to keep some newborns with TTN out of our intensive care unit.

Normalizing albumin could be aiming too high, but isn’t there a limit somewhere where you get a little uncomfortable as a doctor even though there isn’t much of an edema? I don't know where this threshold should be, how the evidence looks, or how low albumin could be accepted in relation to other functions besides oncotic pressure in a neonate, and would need to look that up. Does anyone have any thoughts on this? UpToDate recommends maintaining levels above 2 to 2.5 g/dL in this situation (article: Management of chronic pleural effusions in the neonate). As for AB-prophylaxis our immunodeficiency Professor recommended the use of trimethoprim / sulfamethoxazole in this specific case. UpToDate does not recommend routine use, but trim/sulfa in cases of severe lymphopenia (e.g. CD4 <200 c/mikroL). We have comparably few problems with antibiotic resistance in Sweden, this could possibly be insufficient in other countries. The UpToDate-article mentioned above offers a quite comprehensive review of management of chylothorax from a team at University of Alabama at Birmingham, and was last updated Oct 18 2024. I found it quite helpful! 😊 Thank you for starting this subject BTW!

We recently had a case born with hydrops secondary to chylothorax where we replaced 2/3 of losses with 50 percent plasma, 50 percent Ringer’s. Careful increase of feeding with Monogen, evaluating possible increase in fluid losses. Albumin intermittently.

Those posters were really great. I’ll add a couple of them here.

I was on Bluesky 🦋 and saw @AllThingsNeonatal share this study validating CGM-use in preterms 29-31 weeks, with an acceptable accuracy. https://www.jpeds.com/article/S0022-3476(24)00519-5/abstract For our hyperinsulinism infants, sometimes requiring glucose infusion, diazoxide and extensive carbohydrate enriched feeds, this is a very appealing approach.

In this particular case we were handling a suspected capillary leak syndrome, so I did some reading up on different treatments. Steroids was one treatment we considered. I ended up with an article form Iowa being most usefull: https://pubmed.ncbi.nlm.nih.gov/39123307/ It discussed possible treatment strategies (theophylline, IVIG, hydrocortisone) and provided a good supplemental with dosing suggestions. I also found an article on Haemodynamic effects of prophylactic post-operative hydrocortisone following cardiopulmonary bypass in neonates undergoing cardiac surgery: https://pubmed.ncbi.nlm.nih.gov/36950894/ But it was a retrospective, small sample size, with various other treatment regimes within the groups, so it didn't give that much. Except contributing to a possible dosing regime discussion. Another article proposed to give 3% NaCl boluses follwed by furosemide to treat a possible capillary leak. Due to it's fairly simple approach without too serious side effects it seemed like an attractive solution to the problem. But we never needed to try it out. https://pubmed.ncbi.nlm.nih.gov/38429824/ And since this was an overall edematous infant I also stumbled upon an article called: Neonatal fluid overload: ignorance is no longer bliss. Which covered everything we had tried (except for dialysis), it was a fairly good read. https://pubmed.ncbi.nlm.nih.gov/35348902/

Maybe @Pontus Johansson has something to add to this subject. He’s currently the chair of the pediatric section of the Swedish national resuscitation council.

There are guidelines published, here is one from France: https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2022.1075184/full Would love to hear more. Propofol is very commonly used in the PICU, but less so with our neonates. What would be the main reason to use it or not?

Don’t miss out on Neena Modi and Josef Neus recent commentary on the subject 🙂 https://jamanetwork.com/journals/jamapediatrics/fullarticle/2824556?guestAccessKey=d560b308-01e0-4d52-b7d3-ca56cfe6a51d&utm_source=twitter&utm_medium=social_jamapeds&utm_term=14866058877&utm_campaign=article_alert&linkId=617958502

I was rather surprised of the results presented in this paper form Japan the other day: https://www.nature.com/articles/s41372-024-02093-0 While there is a small group and it has only been a two year follow up, the results are also showing better outcomes than expected for the group.