Urban Rosenqvist

We give term formula to > w 34+6 and SGA Preterm formula (preNAN discharge) < w 32+0 until 2 months corrected age Preterm formula (preNAN discharge) w32+0 - 34+6 until w. 40+0 or until discharge

1 No 2 No 3 We dont have that many subgaleal hemorrages but a baby with typical symptoms and mildly decreasing Hct would probably have stayed in the nursery with repeated blood draws. A baby with signs of blood loss or rapidly decreasing Hct would have been admitted to our neonatal ward.

This is an interesting topic for me. We´ve just had two cases of fat necrosis with following hypercalcemia in the last 2 months. One baby had birth asphyxia 41+2, APGAR 0,2,2 (HIE I/II) and was cooled. The other baby was not so ill but had reduced peripheral circulation the first hours of life (a risk factor) due to PPHN which resolved quickly on oxygen treatment. The latter one developed subcutanoeus fat necrosis in about a week after birth and also more necrosis after a month. In this patient hypercalcemia was no more than 3,0 mmol/l (2,2-2,7) and we noted no symptoms of hypercalcemia. The former baby was in pain and tender to touch and was treated with morphine and paracetamol with some success. This baby had a higher calcium with calcium above 3 during a couple of weeks, up to 3,51 mol/l. Searching for information on this topic yields no conclusive recommendation. I´ve also talked to colleagues and the opinions vary enormously - from: "Do nothing, we have never monitored calcium in these babies and we´ve never seen any pathology because of it", to "monitor and treat!" Some studies states that fat necrosis itself is a self resolving harmelss condition but the effects of hypercalcemia can be dangerous and a cause of for example nefrocalcinosis and even death (cardiac arrythmias). We have just kept on monitoring the well baby with the lower calciums levels without any intervention. The baby with the higher calcium was constantly irritable despite pain management so we suspected that these symptoms were rather caused by the hypercalcemia (which can cause irritability) than actual pain from subcutaneous necrosis. . After discussing this with an endocrine specialist we started NaCl infusion, after a while we also added oral frusemide. We also changed the babies formula to Locasol which is low calcium/low vitamin D formula and we postponed supplementation with vitamin D (which every child in Sweden gets). This had an effect (though not immidiate) lowering s-calcium. With the hypercalcemia resolving the baby was happier and less irritable so it seemed that the symptoms had been caused by the hyperclalcemia. Our next step would have been oral prednisone 1mg/kg/day but s-calcium is returning to normal so the only treatment now is Locasol and no vitamin D for another 3-4 weeks.

Fcardona: Some references... http://www.ncbi.nlm.nih.gov/pubmed/22611116 http://neonatalresearch.org/2012/05/23/weaning-from-cpap-in-preterm-babies/

Usually we use CPAP up to 7 but when we use BiPAP pressures are higher (9-10)

Studies show that there are more benefits with weaning nCPAP by decreasing pressure than having alternating "time-on and time-off" nCPAP. We wean by lowering the pressure gradually, in the preterm to as low as 2cm H20. I know that many use 4cm H20 as a lower limit. The argument for this is that the pressure measured in the pharynx is close to zero when CPAP is set lower than 4 cm H20 (thus believed to not have any positive effects). Still, we see many babies that benefit from low pressure CPAP (2-3). Do you know any studies that show negative effects using low pressures? (Theoretically, it could give increased breathing effort without any significant CPAP effect).

I'd say the same as already mentioned: In different words: CO2 travels about 10 times easier over the alveolar membrane than oxygen. Low pO2 because the need of oxygen is not met due to low oxygenation in the lungs caused by restricted lung blood flow (hypertension).

In most cases, keeping saturation above 93% in combination with good care and keeping the baby warm will suffice. In some cases we use Sildenafil and in the most severe case we refer for NO.

Thanks! Great one.

Noone?

We´re revising our instructions on nutrition and one thing came up: Do you let your newly extubated patients eat or do you let them wait a certain time to prevent aspiration?

Thank you Stefan!

Inspired by the EBNEO meeting I asked myself: why do we give caffeine? To reduce central apnoea - yes, but does it really reduce mortality or morbidity regarding the prevention of apnea? I know caffeine has been shown to reduce BPD morbidity and other endpoints but I'm only after the positive effects on central apnea - do fewer prematures die from apnoeic spells? I don't find conclusive literature on this. Can you enlighten me on the subject?

What about leukotriene-antagonists in BPD? I only have a few reports on the treatment with these drugs. What is your experience? Are there any major studies on this topic?

I checked with a sales person so I will answer my own questions: yes, yes and yes ;-)

hamakoosha: Interesting! Will it in "Biphasic Trigger"-mode deliver the higher pressure on every triggered breath? Did I understand it correctly: In biphasic-mode e.g. 10 breaths/min. with PEEP 5 PIP 8 Ti 1s it will give a "breath" 1 second long (sigh) every sixth second and between it will act as a regular nCPAP (just keep PEEP at 5) ? During the "breath" (sigh) will it be 8 cmH20 during inspiration and 5cmH2O during expiration?

We will probably move away from our morphine + diazepam routine and instead use Propofol as a single drug, single dose in elective intubation. NICU Uppsala has quite a lot of experience on Propofol in these situations and my personal experience is also positive. I´m looking for available research results in the field and so far this is quite interesting: http://pediatrics.aappublications.org/cgi/content/full/119/6/e1248 Anyone who knows any more good articles? The neuotoxic effect still remains unclear but other studies has concluded that the clearance of propofol in newborns is slower than toddlers and older children, thus no infusion is recommended.

bebi23: http://neoreviews.aappublications.org/cgi/content/abstract/10/1/e31?fulltext=&searchid=QID_NOT_SET is the article you´re looking for. Only an abstract though....

We use pulse-oximetry screening in the maternity wards in the hospital of Västerås, Sweden since about half a year or so. We adopted this method since earlier studies had suggested better sensitivity with a combination of pulse-oximetry and clinical examination than the latter one alone. As mentioned in the article above you also have a better possibility to find non-cardiac problems (causing a lowered oxygen saturation) As far as I know, in Västerås it has´nt meant an increased amount of echocardiography. A couple of babies with infection and pulmonary hypertension was discovered this way. I´m not completely updated on cardiac malformations, also I think we have too few patients in this group.

Just a thought... Those of you using only Midazolam - remember that midazolam has no analgetic effect but only a behavioural modifying effect caused by sedation. The pain signals to the brain remains unaltered - i.e. when administered, the pain sensation remains but we don´t see the baby fighting the pain. BTW: Anyone who has experience using propofol in the newborn?

Thank you. This is very interesting! We also run a neonatal simulation training program in Västerås and I look forward to "attend" this meeting. It looks like all I have to to is provide my name and mail address on the linked page and the broadcast should be up and running...?

Morphine + diazepam

Thank you for that link!

In Uppsala they did´nt use pyridoxal phosphate but were very interested in this alternative. I guess that the hospitals in Stockholm use Pyridoxin and not pyridoxal phospahte? What about you neonatologists/pediatric neurologists in this forum? Do you have any experience on this subject?

Hej! We (Västerås) also use only pyridoxin but I´ve heard that maybe Akademiska in Uppsala uses pyridoxal phosphate. I´ll call them any day and check - I´ll let you know about it...