Stefan Johansson

Great to bump this topic! I made a screen shot of the photo you referred to (below), did those infants have such marked "out-stamped areas" at the iris margin? I also looked into the first suggestion Ectropion uvae, and found something that seemed to look like your first drawing. Which one best illustrates your clinical finding?

Is this something you are looking for: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3653511/

My colleague Ewa Henckel defended her thesis at Karolinska Institutet on "Cellular consequences of preterm birth : telomere biology, immune development and oxidative stress" last week, including four projects on telomere length, inflammation and lung function viral respiratory infections and cellular aging immune system development and environmental exposures hyperoxia-induced lung damage and the capacity to counter-act surfactant inactivation with a novel antioxidant A great thesis, available for download here: https://openarchive.ki.se/xmlui/handle/10616/46531 For the table seating at the dissertation party, her husband had made clever and funny personal drawings for all guests. I translate mine for you below, it is on the spot Best regards from Mr Conference Organiser PS. BTW, hope to meet up with you at the next "Future of Neonatal Care" conference in Copenhagen. Click here to find out more.

Our guidelines are to cool infants with HIE of grade 2-3, or if seizures develop within 6h of life. But I know there are some discussions ongoing, check this paper out (https://www.ncbi.nlm.nih.gov/pubmed/26352683) that is also discussed in a blog post ~2 years back by Keith Barrington: https://neonatalresearch.org/2016/09/29/its-only-mild-encephalopathy-now-can-we-stop-worrying/

We are now moving to a dedicated email service for our newsletter. From now on, we will use Sendinblue. With this professional provider of email services, including dedicated IP's, we will be more certain that members actually recieve our emails Given that our terms of use also includes that members need to have a valid email address, we will also be clearing the members' database from those with invalid email addresses. If you want to quit your email subscription, there will be bullet proof link in every email. If you also want to close your membership, you can also email info@99nicu.org and we'll erase your membership data promptly

Thanks @Andrej Vitushka for posting about this every-day NICU question! In Stockholm, I think we are mostly following the table 30.1 from Avery (in the first post), i.e. a rather high fluid intake in the smallest infants, typically ~100/110 ml/kg/d in the most immature infants and going down to 60 in term infants. @Nathan Sundgren - with regard to what to give: we tend to start with parenteral nutrition right away, in infants that we judge will not take much enterally: in practise all infants <1500g. As already pointed out - it is always a question about fluids from medications, boluses, low-flow infusions keeping catheters open etc. The principle is easy (count everything that is not fluid therapy due to hypovolemia) but in practise there is variation. My experience from infants above the extremely preterm range (i.e. ≥28 weeks) is that it is hard to know what is the right thing. Even with slightly different fluid regimes, they mostly seem to do good in terms of water balance.

What a great training resource!

Given recent results from placebo-controlled trials on inhaled budenoside and systemic hydrocortisone, how do you practically approach the questions on steroid use in your NICU? As you are probably well aware, the NEUROSIS trial (inhaled budenoside) showed some reduction in BPD among survivors, but the 2y followup showed a increased nb of deaths in the budenoside group and no benefit with regards to neurodevelopment (NEJM 2015 and NEJM 2018). The PREMILOC trial found that systemic low-dose hydrocortisone reduced the BPD risk, without a clear benefit on neurodevelopmental outcomes (Lancet 2016 and JAMA 2017). Further, a meta-analysis came out just the other week (J Ped 2018) that also concluded that survival without BPD was increased with this strategy. With regards to clinical practise in Sweden, the latest report from our national quality register (info from 2017) presents that systemic steroids are used i ~50% of infants <25 weeks, and in ~30% of infants 25-27 weeks. The corresponding figures for inhaled steroids are ~35% and ~25%. Yet the "national" BPD rate (oxygen need at 36w) is reported as high as ~75% in infants <25 weeks, and ~45% in infants born between 25-27 weeks. (full report here, but in Swedish) So, what do you in practise? Do you use either, neither or both inhaled/systemic steroids to reduce BPD? I personally feel a confused how to navigate in this landscape 🤔

@Numan hameed please post your question about CPAP in this forum: https://99nicu.org/forums/forum/49-ventilators-and-care-of-the-ventilated-infant/

I have no personal experience. In very severe cases of BPD we sometimes try sildenafil and/or inhal iloprost, assessing pulm pressure before/after with echo.

Am curious to hear your stories later We dont have iNO so I have nothing to share. But in term infants we have sometimes used epoprostenol - I shared a story ⤵️

Hello in Canada! If time allows and circumstances looks complicated / bad; we def would 1) prepare for a UVC, 2) prepare syringes with sodium chloride bolus and 3) order O- blood to the resusc room. Better safe than sorry! I would argue that the volume may be more important than the erytrocytes, but I think the "jury is out" and that other people argue differently. Let's see what others respond!

As you have heard, our 3rd conference aka "99nicu Meetup" and "Future of Neonatal Care", will take place 7-10 April 2019, at Scandic Sluseholmen in Copenhagen, Denmark. We are very glad to open the registration today! Given that we already have 100+ pre-registrations from 30+ countries, we recommend you to sign today! From the pre-registrations, we also know that workshops will be popular. As workshops have a limited number of places, you should register ASAP if you plan to attend a workshop. Click here to register! Click here to download the program folder! If you have any questions about the registration, please email reg@meetingplanners.dk See you in Copenhagen!

Dear Edgar, we rarely use that diagnosis (ICD-10, P91.4) , but do it sometimes if a baby has had somewhat low apgar (like 6-7) and has been admitted due to some irritability. Like an "asphyxia light" diagnosis. However, I would regard it the diagnosis as a bit subjective. Am not aware of any formal definition of "Neonatal Cerebral Depression".

While preparing a lecture on the normal transition from intra- to extrauterine life, I also choosed to include a slide on cord-clamping, and the timing of it. As the umbilical vein blood contributes significantly to the systemic cardiac output (through shunting of umbilical vein blood through foramen ovale), there is a physiological reason to clamp/cut the cord once breathing is initiated. While reading up on some details, I came across a feasibilty study on a resuscitation table intended for preterm infant: https://fn.bmj.com/content/early/2018/10/03/archdischild-2018-315483 Just recently - this research group also published that this approach of physiological-based cord clamping (PBCC) do increase cardiac output and cerebral oxygenation. Proxy outcomes, but still shows that the concept seems right: https://fn.bmj.com/content/103/6/F530 Just curious to hear: does anyone have experience from stabilization with intact cord (preterm or term)? Update: also found this review by the same research group: https://fn.bmj.com/content/103/5/F493, also published in ADC FN.

Since the October issue of Neonatology Today, I and @Francesco Cardona will alternate in writing a column where we will share bits and pieces from the 99nicu community, mixed with more general reflections. This column is the start of a extended partnership between 99nicu and Neonatology Today. In case you don't know, Neonatology Today is a peer-reviewed monthly newsletter that is available free of charge, and has a mission to provide timely news and information the care of newborns and the diagnosis and treatment of premature and/or sick infants. Subscribe here! Maybe you have already read my first column in (here on page 46-47), but I also want to share my text here, on why 99nicu has a great future despite that there is "an app for everything" - - - - - - - - - - - - - - - - - - - - "As a starting point, I would like to share some background for those who are not familiar with 99nicu. The online community 99nicu.org started off with a few colleagues in my kitchen in late 2005. This was a time before the social web was on everyone’s fingertip. Instead, Internet-savvy people gathered on so-called Bulletin Boards or Discussion Forums, often niched to specific topics or interests and managed by enthusiasts. Being an active member of a computer forum, I got the idea to bring neonatal staff together online. After plenty of hours, fiddling with software and web stuff, we opened the 99nicu web site on May 11, 2006. But what did the “99” stand for? That people would gather to discuss 99% of neonatology, and 1% of everything else Since the launch in 2006, I think we have reached the main purpose: to create an international neonatal community for sharing experience and expertise, not restricted by geographical boundaries. We now count more than 7.000 registered members. Although the majority are doctors, members represent all neonatal staff categories. Moreover, our server gets a lot of traffic! During the latest 3-month period, there were 42.000 pageviews, from all over the world (Fig 1.) What’s the future of online forums, when there’s an app for everything? Will 99nicu be out-competed by the big players of the social web? Services like WhatsApp and Twitter do offer great tools for discussions in closed and open groups. But still, I believe that niched forums will outlive social media platforms when it comes to professional content. For two principal reasons. First, I assume that professionals will want to keep out of the business model of the social media companies, where free-of-charge turns users into data-for-sale (“if it is free online, you are the product”). Second, social media companies, despite smart algorithms, will not bring enough focus to your feeds. If you are primarily interested in neonatal medicine, your content will still be diluted with images of pets and food plates. On the contrary, “old-school” communities are comprehensible and focused. You know why you are there, you know why other people are there, and you know what content to expect. While 99nicu gravitates around the website, we have also realized the potential in meeting up IRL. Getting to know each other online is fantastic, but personal meetings will always be very powerful for networking and sharing. That is why we are now preparing our third conference “Future of Neonatal Care.” At our previous conference in Vienna, we had 150 delegates from 33 countries. When we meet up in Copenhagen, 7-10 April 2019, we hope to bring more than 250 people together, from an even larger number of countries. Interested in joining us in Copenhagen? Keep updated on 99nicu.org! Figure 1 The geographical distribution of 42.000 pageviews on 99nicu.org during 1 July – 30 Sept 2018. The color coding represent the number of pageviews.

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?

One of our fellows showed me these two videos on Youtube, on how to learn brain ultrasound. Both videos are very good! Enjoy Part 1 - anatomy and protocol Part 2 - IVH and PVL

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.

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