Stefan Johansson

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@ashok we would do it around 7 days of age (i.e. a few days after warming).

We proudly present MONIVENT as a new Supporting Partner of 99nicu! MONIVENT is a young medtech company dedicated to improve the emergency ventilatory care given to newborn babies in need of respiratory support at birth. About 3-6 % of all newborns end up in this situation, where healthcare personnel today are lacking tools to determine how effective their manual ventilation really is. Monivent® Neo is a non-invasive monitoring device to be used during manual ventilation, measuring the air volume given to the baby with sensors wirelessly built-into the face mask, providing the caregiver with continuous feedback on several critical parameters. A target volume is presented and any volume given outside the recommended interval is clearly indicated by a color change on an intuitive display. MONIVENT recently introduced its first product - Monivent Neo training - used within simulation training on a manikin while a clinical product is currently under development. Learn more about MONIVENT on: http://monivent.se/

In our Interview series, we are grateful to present this interview with @Ryan McAdams , US, a neonatologist who is also a painter. We were curious to speak with Ryan about his art work, and the intersection of neonatology, child health and arts. Our previous interviews: Mats Blennow; Sweden Ruth Davidge, South Africa - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Could you please introduce yourself and where you currently work? I am Ryan McAdams, the Neonatology Division Chief and Neonatal-Perinatal Medicine Fellowship Program Director at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin. I’m married and have two wonderful children. How did your professional career lead you to this spot? After my fellowship training in San Antonio, Texas, I worked on a naval base in Okinawa, Japan, as an officer and neonatologist in the United States Air Force. I was the Air Transport director responsible for orchestrating and often going on flights to transport critically ill neonates throughout the Western Pacific who required care in the NICU. I met some amazing people in the military and learned a lot about other cultures. While in Japan, I became passionate about global neonatal health and did volunteer medical work in Mongolia, Cambodia, Zambia, and Malawi. After leaving the Air Force, my wife and I moved to Seattle, Washington, where I accepted a job at the University of Washington and Seattle Children’s Hospital. I continued to do global health work with colleagues in Seattle, mainly working in Uganda, with a focus on using education to empower local providers to deliver quality neonatal care. This global health work helped reinforce my strong belief that every baby everywhere is valuable and deserves the best opportunities to thrive. While in Seattle, I worked with a talented team of neonatologists, and was fortunate to have numerous opportunities to conduct translational and clinical research focused on understanding perinatal lung and brain injury. After eight enlightening years in Seattle, I was recruited to be the Neonatology Division Chief at the University of Wisconsin, Madison. Since I was born and raised in Wisconsin, I was thankful to be close to my family again. You are also a painter - please tell us what led you into painting? As a child, my aunt gave me an oil paint set, which encouraged me to start painting. I have always had a keen interest in the myriad of colors and subtle details that abound in nature, so exploring the world through art has been a gratifying experience. In medical school, I decided painting would be a healthy creative outlet to stay well-rounded in the midst of intense studying. Short on money, I drove my grandmother to a local craft store and used her senior citizen discount to buy a plethora of art supplies. I built an easel and began to paint. At the time, I was a big fan of Salvador Dali, so his surrealistic style influenced my initial approach to painting. Throughout medical school, I often stayed up all night long painting, a method not always ideal for the rigorous demands of medical school. With my first big canvas painting, I entered an art contest in JAMA magazine and my painting “A Grasshopper Which Sprang From Indecision While a 3-Day-Old Peeled Banana Waited to Be Painted (JAMA. 1998; 280:1189) was a Grand Prize winner. This germinal success misinformed my understanding of how complicated, competitive, and cultivated the art world was, a realization that I learned while in my pediatric residency in northern California. I developed a quick sense of humility after peddling my painting portfolio around the art galleries in San Francisco where the exorbitant price tags of authentic Chagall and Miró prints led me to a somewhat disheartening assimilation of my place outside the circle of established artists. This epiphany led to introspection and a self-declaration that my painting needed to serve a purpose to bless others in a way unhindered by any motivation for supplemental income. While living in Japan, inspired by the woodblock masterpieces of Hokusai, I painted a contemporary series of acrylic paintings featuring a hybrid of themes from famous Japanese prints. I also began working on a collection of paintings illustrating the teachings and ministry of Christ described in the Gospel of Luke, a book written by Luke, who was a physician. As I became more involved in global health, the focus of my art centered on the plight of the impoverished and marginalized children of our world. Do you have art school training or are you an auto-didact? While I am certain formal training would have been advantageous, I am a self-taught painter. Can you expand on your themes in your paintings? As a neonatologist who has been privileged to do global health medicine and work in large medical centers NICUs, I have witnessed a substantial amount of suffering and death. I have also witnessed the incredible resilience of children and the awe-inspiring dedication and love of their families. These experiences shape why and what I now paint. Themes of social injustice, survival, pain, and grief are the basis for my art since these ageless motifs are still globally preeminent today. What messages to you want to convey to those viewing your paintings with neonatal themes? My paintings are an amalgamation of emotions constructed with colors, lines, and textures into a tangible declaration aimed at validating the importance of children who have struggled or died, regardless of the brevity of their life. My hope is that my art will validate the existence of these amazing children and provide insight for the viewer, who can contemplate the stories I have tried to capture in acrylics. Do you direct the painting to the general public or a more niched "neonatal audience"? I paint for the general public, recognizing that the medical community may be more accessible to share my work with, but hopeful that any viewer will pause to consider my art. Are those painting also part of your own processing of experiences? When I paint a subject or theme related to an intense event, such as the death of a child that I was privileged to care for, this experience provides me a way to work through my emotions and cope with grief. Engaging in this process often requires me to relive difficult experiences in a vivid and immersed manner, which can be quite overwhelming, at times resulting in tears, frustration, scrutiny, and speculation. When I paint a baby or child who died, I approach each painting with deep reverence, often engrossed in deep reflection and prayer about the child’s family, wondering what things would have been like had the child survived. In some ways, the final painting becomes a testimony that substantiates an otherwise untold story, a story that I hope will help others. After the unexpected death of my father, at a time when my neonatology work schedule was especially onerous and severe sciatica from my herniated disc was a constant torment, I used painting as I means to deal with my pain and grief. My painting, “Self-Portrait” conveys a period of darkness I experienced and now reminds me that my resilience prevailed despite my trying circumstances. I feel that all people have seasons of struggle and sorrow, so finding constructive coping mechanisms is key to overcome anticipated or unexpected adversity. Right before moving to Wisconsin, my mother, a comical and quick-witted woman who was avid reader and art lover, was diagnosed with lung cancer. A year later, after multiple bouts of chemotherapy, she died days after her birthday. Both my parents encouraged my creativity, so although I can no longer show my latest paintings to them, they still inspire me in a way that I feel I am able to share my work with them. Where have you presented your art? I have presented my work at small venues including a café, hair salon, church, and at a medical conference. No museums yet, but hopefully someday. And, those of us wanting to see more of your work - when to we go where? I have had 8 paintings published in medical journals (see links below), but I do not have a website to view my work, since I have not had sufficient time to develop and maintain a quality site. A Grasshopper Which Sprang From Indecision While a 3-Day-Old Peeled Banana Waited to Be Painted (acrylic on canvas). JAMA. 1998; 280:1189. https://jamanetwork.com/journals/JAMA/articlepdf/1838997/jms1007-5-1.pdf Original painting entitled “Transposition.” Academic Medicine 2010 Nov; 85(11): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2010/11000/Artist_s_Statement__Transposition.36.aspx Original painting entitled “Champei’s Petals.” Academic Medicine. 2012 Oct: 87 (10): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2012/10000/Artist_s_Statement___Champei_s_Petals.34.aspx Original painting and poem entitled “The Abruption.” Obstetrics & Gynecology. 2013 Dec: Cover Art (http://links.lww.com/AOG/A450). http://download.lww.com/wolterskluwer_vitalstream_com/PermaLink/AOG/A/AOG_122_6_2013_10_22_MCADAMS_000000_SDC1.pdf Original painting entitled “Wait and See.” Academic Medicine. 2014 Feb;89(2): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2014/02000/Artist_s_Statement___Wait_and_See.21.aspx Original painting entitled “The Orphans.” Academic Medicine. 2014 Sep;89(9): Cover Art. https://journals.lww.com/academicmedicine/Fulltext/2014/09000/Artist_s_Statement___The_Orphans.13.aspx Original painting entitled “The Girl in Blue.” Academic Medicine. 2016 May;91(5): Cover Art. https://journals.lww.com/academicmedicine/Pages/toc.aspx?year=2016&issue=05000 Original painting entitled “In the Face of Hunger.” Academic Medicine. 2017 Aug;92(8): Cover Art. https://journals.lww.com/academicmedicine/toc/2017/08000 For newly graduated colleagues around the world - what would be your advice for their future professional and personal development, with regards to mixing of NICU work and creative work? I encourage anyone to explore the value of painting from a wellness perspective. Painting is an amazing way to engage your mind and body in an emotional outlet that provides mechanisms to relax, laugh, grieve, reflect, share, process, and cope with the variety of experiences we face in life. I feel everyone has creativity they can express and that a blank canvas should not be a daunting endeavor, but an amicable invitation to express yourself. And finally, what about your own future plans? While living in Japan, I conceptualized a way to help support orphans using art. I would love to develop a nonprofit organization where people can purchase online prints of original paintings and then choose a non-governmental organization of their preference to dedicate 100% of the profits to benefit children in need. My grander vision is to establish an international museum dedicated to orphans that would include donated art from global artists and would feature art from orphans around the world. This museum, which would serve as a voice for our most vulnerable children and represent a place where their importance is highlighted, could generate financial resources to support constructive programs, such as academic scholarships, that will help future generations thrive. I am grateful to be a neonatologist, a husband, a father, and an artist, so I look forward to further applying my talents to advocate for children. - - - - - - - - - - - - - - - - - Please find a selection of nine paintings by Ryan McAdams below.

@Schumz we also cool infants without keeping them intubated (for the sake if it), and we have good experience (PO2- and PCO2-wise ) that infants can do just fine even without CPAP, despite cooling and relatively large doses of analgesia / sedation. But of course, one needs to think both once and twice, especially not to be keep infants "breathing" but not giving sufficient analgesia and sedation. Also, if we do use mechanical ventilation, we do not extubate during cooling even if spont breathing is restored.

@Schumz thanks for closing the loop with those good news!

We now have 13 confirmed speakers for the Copenhagen Meetup 7-10 April next year! Generally, we'll stick to the successful format we have had at the previous meetings: 45 min slots split into a 30 min lecture and a 15 min discussion. We'll continue to use the sli.do smartphone app to facilitate the discussion and allow every delegate to share questions and comments. In addition to the lecture program 7-9 April, we are also planning workhops and mini-symposia on the 10th of April. We'll share more info about those soonish, but if you want ONE cliff-hanger... we plan one symposium about the infant microbiome etc-etc Confirmed topics and speakers Neonatal transports - safe and easy, Morten Breindahl (Sweden) Treating pain in neonates, Karel Allegaert (Belgium) How to improve quality on the NICU, Joseph Kaempf (US) Hyperglycemia - how to manage and why, Kathryn Beardsal (UK) Why we should rehearse simulated scenarios, Ruth Gottstein (UK) Go with the (high) flow, Brett Manley (Australia) News in the updated ESPGHAN guidelines, Nadja Haiden ( Austria) Prevention of BPD, Christian Poets (Germany) The many inotropes - what to use when, Yogen Singh (UK) Cord Clamping, 1.0 and 2.0, Ola Andersson (Sweden) When NEC rates persist , despite everything done “Right”, Ravi Patel (US) Outcomes in infants surviving at the limit of viability, Ulrika Ådén (Sweden) Ethical decision making around the limit of viability, Gorm Greisen (Denmark)

I got this email with more input from Susan Ludington:

An interesting article just came on my radar, an international survey study on diagnosis and management of ankyloglossia (tongue-tie). The paper is Open Access in the October issue of @Acta Paediatrica, here: https://onlinelibrary.wiley.com/doi/10.1111/apa.14242 The conclusion reads On topic: here is a great article on Don't Forget The Bubbles (great web resource for ped fellows): https://dontforgetthebubbles.com/tongue-tie-cut/ Where I work, we are commonly consulted by midwifes about tongue.ties, and without knowing an actual rate, I'd say that we do relatively many frenectomies. We give sugar orally as analgesia and then one scissor "snip". What is your approach to the tongue-tie?

@Nathan Sundgren great post! I agree that the major benefit from delaying clamping seems to be *until* breathing starts off. Heard a pretty convincing talk about that on jENS. The study by Katheria et al was commented by EBNEO on: https://ebneo.org/2015/12/does-umbilical-cord-milking-result-in-higher-measures-of-systemic-blood-flow-in-preterm-infants/ We "only" practise delayed clamping (60 sec) for term and preterm infants in reasonably good shape, but we do not have trolleys to start resusc with the cord intact. BTW - at our next Meetup in Copenhagen 7-10 April 2019, Ola Andersson will lecture about "Cord Clamping , 1.0 and 2.0"

I just want to share some brief news about our next Meetup, 7-10 April 2019 at Rigshospitalet in Copenhagen/Denmark. We (i.e myself, @Francesco Cardona @RasmusR @Christian Heiring , Gorm Greisen and Morten Breindahl) are currently working on the program lectures and workshops. I just want to share the first five confirmed speakers and their topics: Morten Breindahl: Neonatal transports – how to do them safe and easy Ola Andersson: Cord Clamping, 1.0 and 2.0 Ravi Patel: How to explain when NEC rates persist – even when a NICU does everything “Right” Ulrika Ådén: Infants surviving at the limit of viability, what are the outcomes? What shall we do? Gorm Greisen: Ethical decision making around the limit of viability- lessons from Scandinavia I'll update you all with more names and topics as they are confirmed Looking forward to meet up in Copenhagen!

Thanks for a great post! But, what a challenge to replace Apgar scoring, so deeply rooted in all of us

We have a ABL900 that is managed by our hospital lab department and they say that the analyses are validated. Meaning that we should trust the values (whether it is S-electrolytes, lactate or hematocrite) as if they had run the test in the "big lab machine". So, I'd say that we generally trust our ABL (as with all tech, it sometimes fails...)