Stefan Johansson

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/

Birthday cake to all!

Our (regional) guideline here in Stockholm/SE is to give 1 ml of the current product which means 180iu intramusc. The same dose is given regardless of birth weight.

We are working on getting videos online. it won’t take too long

While at the #99nicuMeetup, I and @Francesco Cardona were filmed by Miris (one of our exhibiting partners). It was a one-time shot without rehearsal, so we spoke from the heart

@Susanna FustoloGunnink thanks for posting here looking fw to hear and learn more about your experiences. Do you still use hyperconc platelet transfusions?

And we use this product from Unimedic (sorry for being in Swedish; you can probably contact the company through www.unimedic.se) https://www.kronansapotek.se/Multivitamindroppar-Unimedic-Orala-droppar%2C-lösning/p/366415

Since 2016, I have been working “off-radar” with a group of dedicated people in the startup company Neobiomics. I think we have pushed boundaries for thinking and working outside-the-box, and with only small financial support from ALMI and Karolinska Institutet Innovations. As you are aware, the intestinal microbiota is a hot topic in the neonatal community. For several years I was frustrated about the lack of a high-quality bacterial product. I shared this frustration within my closer network here. And we decided to fix that problem, “from the community, to the community”. Neobiomics We framed this idea in the startup company Neobiomics and engaged in discussions with Chr.Hansen, a world-leading manufacturer of bacterial cultures in Denmark. Backed by a group of clinicians and researchers, our collaboration with Chr.Hansen developed into the mission to provide a safe bacterial product with high-end quality. On the #99nicuMeetup in Copenhagen, we launched ProPrems®, a triple-strain product with 1 billion freeze-dried bacteria (Bifidobacterium infants, Bifidobacterium lactis and Streptococcus thermophilus). You can see my slides below ProPrems® ProPrems® will come packaged in 0.5g single dose sachets, with a shelf life of 24 months in room temperature (≤25C). Production is done under rigorous quality control (of course complying to GMP and HACCP). During the several key steps of manufacturing, ProPrems® is tested against an extended panel of microbial contaminants. While our strategy has been the high-end quality grade, we intentionally opted to classify ProPrems® as a dietary supplement to make it available as quickly and affordable as possible. What now? On proprems.eu, it is now possible to place pre-orders, for deliveries starting in September. Two small details… ProPrems® will only be available within EU, Norway and Switzerland. More info If you'd like to get more information, email me on stefan@neobiomics.eu You can also subscribe to the Neobiomics Newsletter, and follow on Twitter, Facebook and LinkedIn.

Dear @LIONEL, thanks for posting! This review by @EBNEO was posted some months ago https://ebneo.org/2019/01/nebulized-surfactant/ My interpretation - this is preferably still a question for research, i.e. not certain about the benefits. Better to instill surfactant intratracheally (standard-of-practise)

Check out this blog post by Keith Barrington whether transfusions trigger NEC. Or does anemia. https://neonatalresearch.org/2019/04/16/do-transfusions-trigger-nec-or-does-anemia/ I would say that there are enough clinical research data out there to say that there seems to be NO association. Just check out the PINT trial, the RCT comparing a liberal vs a restrictive Hb level for transfusion in preterm infants. If anything, the more liberally transfused group of infant had less NEC. And read this paper by Patel et al that nicely demonstrates that there seems to be confounding of indication coming into play, i.e. it is not the transfusion but the underlying anemia is the problem. Despite research findings, this question (whether transfusions "lead to" NEC) is still troubling us. Why so?

@juan carlos vidal sorry that I did not see that you posted this question in this thread - but have shared over our social channels now. Anyway, it seems that you have adjusted the HFV as possible, with reduced freq and a higher d-P. Does your ventilator give tidal volumes? What approx levels of PCO2 (kPa) do you have? Have you tested regular tidal support, like SIPPV?