Stefan Johansson

Thanks for sharing this (not uncommon!) clinical scenario. Will be interesting to follow the discussion. Actually, this topic will be one of the interactive lecture sessions on the #99nicuMeetup in Vienna next year , one of the real experts in this field has semi-confirmed. I find this tricky myself, I like to stick to our guidelines. In practise, we typically handle a case like this with an inter-collegial discussion (sometimes also involving our neighbouring level-3 NICU) and reach consensus how to act that way. In this case, I think the jury would be out for some time before deciding. What we'd decide in this case, an open question in my view.

The Dept of Brilliant Ideas proudly presents this 90 sec video about Neobiomics and the vision and mission of ProPrems®. I am grateful and also proud that what the network of people around Neobiomics has achieved. It has been a journey and now is the time to "arrive" at the point we headed for. If you want more info - send me a DM or email stefan@neobiomics.eu. Please note that we only deliver ProPrems® in Europe.

This article in NY Times came on my radar, written by a parent whom is also an obstetrician. Very well written piece and I would really recommend it. Sparkles a lot of thoughts on what we do, what we achieve, and the parental perspective. Find the article here: https://parenting.nytimes.com/newborn/prematurity-baby-burden

@M C Fadous Khalife I tend to agree, but in infants on non-invasive ventilation or in cases with no support at all but with resp distress and the x-ray shows pneumo, I have good experience. In those "lighter" cases, needle thoracocentesis is def something reducing thoracic drains, in my experience Check this ref out https://www.ncbi.nlm.nih.gov/pubmed/29799982

The new buzz word in health care is “innovation”. Which is a good thing! I have been in the ecosystem of innovation since 2016 with the startup company Neobiomics and the ProPrems® product, in the Innovation Incubator at Karolinska Institutet (KI DRIVE). There we meet with other startup companies, and we share several of the challenges of operating in the interface between innovation and “traditional” health care. Here's a few thoughts. Innovation can only benefit patients through implementation For innovations to reach out and bring value, implementation is key. No matter how brilliant an idea, it needs to be brought to life in an open-minded culture, where learning and change are core values. Health care can be conservative and resistive to change, and that may slow down, discourage or even hinder implementation. Eminence-based medicine vs evidence-based medicine I am a strong advocate of evidence-based medicine myself, but health care is still influenced a fair bit by “eminence-based medicine”. High-profile people may tell how they “feel” or “believe”. While feelings and beliefs are essential parts of the human nature, they are (IMHO) insufficient arguments in discussions about evidence. Innovations backed by evidence may not “feel right” if they change current practice. But we need to trust data, or else there is little point of doing research. (Too?) many stakeholders Health care is a complex structure, with a lot of stakeholders. While patients are more empowered now than ever before, there are a lot of “layers” between an innovation and a patient. Implementation involves staff, informal leaders, heads of departments, pharmacies, management teams, professional bodies, policymakers etc. As a consequence, implementation takes time. It can take more time than patients should need to tolerate. What to do? To take words to action, health care needs to embrace a culture of learning and change, or else “innovation” will be no more than a buzz word Research data is a valid starting point for change Innovators travel with light luggage, and need a complementary decision-making process in health care, not to delay the benefits and value that innovation bring patients With best regards from the Department of Brilliant Ideas

+1 Here the URL: https://www.nature.com/articles/jp2017140

@all - here is the URL: https://www.youtube.com/channel/UC3g3Gs_HiffehrdWiivKReg @Nathan Sundgren - also consider to share your videos directly here too, just start a topic in a forum, write a sentence or two and copy/paste the Youtube URL and it will embed automatically

Check out this great lecture by @Nathan Sundgren about recent advances in neonatal resuscitation, i.e. sustained inflation and minimal-invasive surfactant therapy.

Difficult scenario, I must admit have no personal experience. But if I'd get the phone call from the ambulance and asked for advice it would something like this - "Keep the warmer but stop ventilation. Keep everything else as is and we arrange with extubation, catheters out, cleaning/dressing etc when you and the parents has arrived safely here" Warmer and stopped ventilation - I would feel disrespectful towards the infant if he/she got cold and also to keep on ventilating. I would consider the actual death time as is (during transport) but I would feel really bad if the parents would not present when the body of the infant is taken care off after death.

Our product (Peyona) is for both oral and iv use. in the past, our generic product manufact by the pharmacy was also for both routes of admin. suggest you crosscheck with your pharmacy before using it iv, just to be sure it is not only made for oral admin

@cB23 we dont use Morfin since quite some years but fentanyl as analgetic during intub. even for LISA we give a small dose to reduce assumed pain of the laryngoskopy

Thanks for sharing this great post!

@nashwa Would be great to hear the experience by for example @Francesco Cardona , I work in a NICU with ≥28w infants now. As I understand from level3 colleagues, nCPAP with relatively high pressures is the primary mode of respiratory support, and LISA the method to give surfactant, while nCPAP is ongoing. This is said to be a successful strategy for a surprisingly large proportion of the very immature infants (also ~24-25wk), but I don't have numbers or first-hand experience myself. I have even heard discussions that staff worry about intubation skills, and how those skills are trained/kept when only a minority of ELBW infants needs intubation and invasive ventilation. A new world!

Do you refer to the 2019 European Consensus guidelines on RDS? https://www.ncbi.nlm.nih.gov/pubmed/30974433

This would be my take - if the infant seems perfectly well, I would not worry too much. On the other hand, if there are some minor clinical signs/symtom (like some reduction in muscle tone, not perfectly normal feeding behaviour etc-etc), I'd be suspicious and probably do some basic lab workup and then refer for clinical followup with the community pediatrician (and then he/she refers back in case of increased suspicion of congenital disease)

I found this link, have not looked at it in detail but maybe a starting point, and with a video https://www.jove.com/video/58990/protocol-guidelines-for-point-care-lung-ultrasound-diagnosing

For those of you having follow-up clinics with children born preterm and affected by BPD, check out these European guidelines. A very thorough document. In short, most recommendations (screen shot below) are graded as low or even very low evidence. So there are lots of room for good research! Find the full document here (and yes, it is available as open-access): http://doi.org/10.1183/13993003.00788-2019

We measure axillary temps (most often parents do it )

We also practise some manipulation in preterm infants but only if otherwise well (preterm infants with functional GI problems) - if we suspect NEC, manipulation is a no-no. This practise is usually not a doctor's decision, usually nursing staff decide to do this if they believe it helps.

Many of you already know about my engagement in Neobiomics, a startup company now launching ProPrems® in Europe. I was asked recently if there was a specific event that made me committed to close the gap between need and availability of a safe way to support the intestinal microbiota. Yes, there was a “Tipping Point” that I can share a few words about, without disclosing patient data. The photo below shows the place in my NICU where a preterm infant stayed some years back, being well on full feeds and expected to have an easy journey with us. When things went into new and unfortunate directions. Although difficulties and suffering is part of what we work with, this event made me feel that I did not provide the best care for my patients. I mean, compared to all interventions we make every other day, and the lack of good evidence for many of them, probiotics supplementation was already in 2014 a no-brainer from an EBM perspective. So, I set off to find a suitable product. But became increasingly frustrated. I thought that manufacturing probiotics could not be rocket science but I experienced that no company could provide what I was looking for. Specifically, when it came to documentation around quality. I discussed this matter with colleagues and realized that I shared my concerns with others. An idea came to my mind that maybe we should just work out a solution ourselves, within the neonatal community. Philipp Novak, a life-science entrepreneur in Austria, was brave enough to get convinced and off we went. Backed by a group of clinicians and researchers. In 2016 we founded the startup company Neobiomics and initiated our collaboration with Chr.Hansen, world-leading manufacturer of bacterial cultures. And now, after 1000s of work hours (pro bono BTW) and with very limited funds, we have now reached the first goal. With ProPrems® there is now a premium product available, with manufacturing quality as we want it (single-dose-packaging, 2y stability in room temp, tested against an extended panel of contaminants, no risk of antibiotic resistance gene transfer). What’s next? To speak in symbols, our plane is on the takeoff strip at full throttle while we are still putting the wings together. So times are both hectic and thrilling. But like when standing in front of a very ill infant in the NICU, I feel that this is something we can manage by systematic and hard work. But of course, ProPrems® needs to find the way out to NICUs. Without a costly "old-school" organization of sales rep’s etc, this may seem challenging. But given the collegial feedback so far, we feel confident our project will sustain. If you get interested to learn more, find more in the attached folder. You can also visit the web sites neobiomics.eu and proprems.eu, or get in touch with me directly at stefan@neobiomics.eu. But please note that ProPrems® will be only available in Europe (that’s why access to ProPrems.eu is restricted from non-EU countries). ProPrems_Folder.pdf

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@Rola alzir thanks for your comment. I am not aware of any data supporting the use of ranitidin (or other anti-acid drugs) with ibuprogen. In general, the use of anti-acids seems to have few (if any) positive effects, but side-effects. Read the blog post below by Keith Barrington (from 2013 but still relevant) and when it comes to GERD, check out the document by ESPGHAN https://neonatalresearch.org/2013/12/06/acid-suppression-doesnt-work-and-its-not-safe-phunny-how-we-got-here/ https://www.ncbi.nlm.nih.gov/pubmed/29470322