Greice Batista

I got curious on small airway malacia... do you have anything to read on that? Thank you!

I really liked this idea, Mariana! I'll definetely try to put this in practice here. We have rounds and I do believe they talk about it, but the idea of focusing "only" in breastfeeding and breastmilk might enhance the importance of it. Thank you for sharing!

We usually use NIPS, but don't it well defined what to do with every score. We use sucking and sucrose for small procedures, paracetamol for "crying babies". For continues infusion, we usually use fentanyl, but dexmedetomidine is being used more often - which I confess it concerns me a little.

Here in our nursery, we use dextrose in the first 24 hours when we identify asymptomatic newborns with low blood sugar (we always try to breastfeed and "harvest" colostrum first). After that period, if there is not enough breast milk, we use formula too. We have a form to fill when we prescribe formula. When we look at the data, we see not enough milk and excessive weight loss as the main causes for supplementation. We don't use galactogogues routinely here. If we do, I believe domperidone is the first choice.

Thank you for your answer, Dr. Stefan! I specially appreciate you saying "My personal advice to parents is to get the basic / cheapest one, there is such a big business of around formula and most more expensive variants of term formula is IMHO not backed by data showing benefits. But there are many variations on this theme, as you probably also experience", because I do the same and I don't find it very easy to discuss this topic with other colleagues. In our unit, we are trying a few things: a QI project, to start expressing milk from mothers in the first 6 hours. We noticed that most health workers "felt sorry" for the mother and thought they should wait for around 24h to start "asking for milk". We're hoping that sooner we will have to worry less about this topic, since we're going to have more MOM available. For preterm infants, we use hydrolyzed formula in the first 24 hours, expecting that hopefully after that period of time, we will have MOM available - of course, that does not happen all the time. After that period, we start regular formula - maybe if we had unlimited resources, we would keep on using hydrolyzed formula for late preterm and term infants, but I am aware that we are not sure it would reduce CPMA. For a newborn who does not have risk factors for hypoglycemia, we try to wait for hunger cues to offer formula. If the baby is already on IV fluids (i.e., late preterm or term NB), I personally try not to rush with formula if there is some perspective of offering MOM in the next 12-24 hours. We also aim for 40-60ml/kg/d, but I'm afraid maybe we, neonatologists, are less tolerant with feeding intolerance! So I believe we do better with the lower range. Hoping to be reading other units experience around here soon!

Dear colleagues, I would love to read your thoughts on how you manage moderate/late preterm infants admitted in the NICU who do not have enough mother's milk. How do you feed them? Do you prefer to keep them on IV fluids/PN until MOM is available? Do you have unlimited donor milk to use for every baby? How is your level of concern about cow's milk allergy (CMA)? I work in a teaching hospital in South Brazil and I'm an enthusiast (aren't we all?) on improving breastfeeding rates in the NICU. How things work here: we have a limited resource of human donor milk, so we prioritize it to newborns under 32 weeks (when MOM is not available, of course). For babies older than that, when MOM is not available, we are using hydrolyzed formula in the first 24 hours - as an intention to try to avoid early exposure to cow's milk protein. I am very aware that we don't have good evidence for that. In the ESPGHAN position paper on CMA (https://www.espghan.org/knowledge-center/publications/Gastroenterology/2024-Diagnois-and-Management-of-Cows-Milk-Alergy), it might seem OK to give hydrolyzed formula, and I like the thoughts on how offering this different type of formula might help parents to see it as something temporary. The thing is sometimes babies keep on receiving hydrolyzed formula for longer than 24 hours, and we also do not have enough of that. New thoughts on CMA prevention seem to go on a way that probably continue exposure to CMP might help prevent allergies. So, probably, offering hydrolyzed formula to babies who will stay longer in NICU might not be a good idea. Maybe later on I'll start a new topic on CMA in NICU too :)

I’d like to translate it to English… I think this approach is a little conservative, bur after inquire the team, I saw that there were too many concerns about progressing too fast. Let’s see how it goes.

Manual nutricão v1.2024.docx

We use Curosurf here.

This other article got me thinking too... https://jamanetwork.com/journals/jamapediatrics/fullarticle/2828319#:~:text=Most IVH occurs during the,typically unknown in individual events.&text=A 2014 meta-analysis found,weighing 1500 g or less. It also shows pretty much the same rates, but IVH appearing later.

Thank you for sharing, dr. Stefan! I think this strategy of starting with less and increasing in the next feedings seems very reasonable. As you said, all infants have their own path, so even though they are "easier" patients, they might require more thinking and more individualized approach (don't we all? 😁). Once again, there's probably no one size fits all. I too tend to start with less and, when it is feasible, tend to wait a little to offer, trying to mimic what would happen if baby and mom would be together.

Dear colleagues, I'm a neonatologist in South Brazil and we're writing a new feeding protocol... we frequently disagree about the amount of milk we should start for late preterm/term infants, who cannot breastfeed right away, but can be enterally fed. They are babies that are not so sick that need to be NPO, but still have to be in neonatal ward. Some people calculate same volume as It would be parenterally, some tend to wait to see if baby will be able to breastfeed in the next hours, some tend to start with 10ml... In my opinions and in my readings, it is not very easy to get an agreement... so I would love to read some opinions around the world to check how everybody else is doing. Best regards, Greice

Dear colleagues, In our unit, we have some disagreements on what to consider hyperkalemia in newborn and at what threshold we should do something. In my opinion (based on literature review and units protocols available), I consider an elevated potassium when it is above 5,9 – and we usually would see some repercussion when it is above 6.5. I have a lot to discuss about it, but I would like to start with this: what do you consider hyperkalemia? Best regards, Greice Batista