Stefan Johansson

This is funny (and IMHO - because it is somewhat true)

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@ChantalNICU thanks for posting! Wished I could share my own experience but it is very small... and now I work in a level-2 context. Just wanted to share 1) the video from the 2019 Meetup (below), 2) the hyperglycemia protocol from Sydney (https://www.slhd.nsw.gov.au/RPA/neonatal/protocols.html) and 3) the Auckland insulin guideline (http://www.adhb.govt.nz/newborn/DrugProtocols/InsulinPharmacology.htm) I can check with my level-3 colleagues in Stockholm after the summer vacation, if they have their own local guideline.

We practise pre-med for INSURE (atropin+fentanyl+pento and some use celo) - my experience is good with regards to cardiovasc and respiratory stability. But as @Nathan Sundgren says, we don't premed if we need to do INSURE right after delivery. Around here, the INSURE procedure also means pre-med, while LISA/MIST is the term used when surfactant is given without pre-med. Originally, when LISA/MIST was first done and studied by Angela Kribs and co-workers (https://www.ncbi.nlm.nih.gov/pubmed/17359406; https://www.ncbi.nlm.nih.gov/pubmed/18298776; https://www.ncbi.nlm.nih.gov/pubmed/18298776) I think their idea was to minimize any drug-related impact on the breathing drive. So they tested with no drugs and it worked well for them. I know many share this experience, that surfactant can be instilled without any pre-med. I personally feel concerned about the laryngoscopy as such, I believe atropine and analgesics would still have a place also in LISA/MIST. And for younger colleagues less experienced with laryngoscopy and intubation, I think the procedure may also be more uncomfortable for infants not given analgesia.

I'd just like to bump this survey :)

@bimalc Yes, we use the Miris milk analyzer. Our hospital runs the Milk Bank for the Stockholm region , so we have all this inhouse (and do milk analyses for all other hospitals as well). Mothers start pumping usually day.1 so after a week or so, most preterm infants get their own mother's milk. Until then, from the milk bank. All milk bank batches are analysed, and mother's own milk is analysed after ~10 days and then weekly or bi-weekly. A small amount of each pumping (1-2 ml I think) is collected during 24h and this selection is analysed. With the software Nutrium (https://www.nutrium.se/, also a small Swe company BTW, started by a neonatologist in Umeå) we input the milk spec's and then "add" the fortifications in the software, to tailor it per baby. We are directed by the growth curve and also the recommendations (ESPGHAN etc). The software gives a very detailed feedback, all macro and micro-nutrients are marked red, yellow and green depending if ("too little/much", "close", and "within recommendations"). If milk is not analysed, we use a "sham" specification, one for "immature/early" and one for "mature/late" breast milk until we have data on the actual batch of breast milk. So, we spend a some time and resources on nutrition although it sometimes feel we over-engineer, we really aim to optimize nutrition on an individual basis. And the whole setup has become integrated in our daily routines, so it works smoothly. There are some publications where this detailed nutrition data (extracted from this software) has been used, the second ref also showing that many extrem preterm infants get malnourished during the first weeks of life. https://www.ncbi.nlm.nih.gov/pubmed/26690864 https://www.ncbi.nlm.nih.gov/pubmed/23855971

Dear @Akash Sharma, thanks for posting about this! We spend much time on nutrition, but personally, I tend to feel confused on this higher level. Some infants grow well, while some infants grow poorly whatever we do... We use a computerized program (https://www.nutrium.se/) and make individual fortification to every preterm infant. Weights are plotted on a growth curve (starting at 24 wks) and we aim to achieve a "normal growth velocity". For SGA infants we tend to think about the patophysiology, if it is IUGR due to placental reasons (like pre-eclampsia), we think there is a potential for this baby to be AGA. So we expect catch-up growth and (if needed) try to promote that with fortifications. We don't use the term EUGR in our unit, but we strive to get all infant withn the "normal" weight range, for us that means that we want infants within +/- 2 SD on the growth chart. Coming to your question... we tend to use the growth-chart-definition of poor growth rather than body-composition analyses or clinical endpoints (which are also more like outcomes of growth)

To my knowledge: around here, parental feedback is not collected in a structured way. However, we have a strategy for cross-checking with parents after arrival to us. Our experience is that it takes some time for parents to "overcome" a transfer, even when their infant is well and doing fine and transferred to a lower-level NICU.

@Francesco Cardona thanks for sharing this! I I posted this URL on our FB page (https://www.facebook.com/99nicu) and that post has already been shared 60 times and reached 3000 people (new impact record I think!)

If you are to read one paper on neonatal ethics this year, I'd argue that this is the one. Late last year, John Lantos, pediatrician and a leading medical ethicist, published a review in NEJM on the ethics around decision-making in the NICU. The paper is not open-access... but you can surely get it from within your hospital intranet or your university/hospital library. We have a fantastic toolbox in the NICU. We can provide live-saving treatments and support. Most newborns in the NICU survive to good long-term health. However, we also operate in a high-risk environment where some infant may suffer, some infants will die, and some infants will survive with difficult sequele. Which raises the question, by staff and by parents, what is the "right" thing to do in complex situations. When withholding and withdrawing life-sustaining therapies becomes a option to decide upon. How could we navigate in this landscape? IMHO, the review by Lantos is a good starting point on how to form a local practise. Lantos shares his reasoning about we cannot "solve" these discussion with "information" as such. Despite how hard we try, data alone does not lead the whole way. Outcomes is hard to measure, they change over time and we all percieve risks differently. Therefore, information is difficult to standardize. Furthermore, those of us sharing the information will filter our presentation through our subjective selves, coping with opinions, experiences and our expertise in different ways. The better alternative around ethical questions is shared decision-making. Two central quotes of the review is that and that Certainly, the future of neonatal care will bring more ethical questions to us. Refined prenatal diagnostics, the down-shifting boundary of viability and new treatment technologies in the future (like the artificial placenta) will impact how we think about fetal life and postnatal life, what is the "periviable grey zone" and what our fantastic toolbox can do. While improving our skills, from a medical/technical viewpoint, we also need to improve how we cope with the ethics around decision-making processes. Besides reading the review by John Lantos, I can recommend you to see this lecture from theh #99nicuMeetup in Copenhagen 2019, by Eduard Verhagen. (Feature Photo : Cropped photo by Liane Metzler on Unsplash)

Just read this editorial in JAMA Peds - about screening/tx against neonatal hyperbili phototherapy and reported long-term risks (excess risk of childhood epilepsy, at least in boys) Although confounding (factor X related to both risk of phototherapy and risk of epilepsy) may well be operating, the First Do No Harm-argument is valid IMHO. Of course, highly elevated s-bili is also something that we fear. Anyone discussing/handling these questions in clinical practise and how to balance? https://jamanetwork.com/journals/jamapediatrics/fullarticle/2733861

As you probably know, I also work for Neobiomics - a startup company centered around a dedicated group of clinicians/academics. We would like to learn more about current use / non-use of probiotics and would love to get your feedback. If you complete the survey (takes ~2 min), we will donate 100 SEK (~10€) to Médecins Sans Frontières (MSF), UNICEF or European Foundation for the Care of Newborn Infants (EFCNI) Please note that the survey is only open for respondees based in Europe. https://forms.gle/tbS3f7RbDigT3jEL7

We also come across infants that clearly have slightly elevated s-insulin (with low blood sugars) despite hypoglycemia. My limited experience is - diazoxide has worked very well and we have been succesfully withdrawing diazoxide before discharge (like after a week or so).

@selvanr4 are you thinking about early physiotherapy interventions and risk of later motor problems like CP? Maybe this would be of interest: https://www.pedneur.com/article/S0887-8994(17)30782-8/fulltext Also found twosystematic reviews (the latter from India): https://www.ncbi.nlm.nih.gov/pubmed/27925172 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6394183/