Stefan Johansson

Seems like a baby at risk for hypoglycemia, a BW of 1850g at 34 weeks (SGA?) and signs of antepartal stress (low apgar at 1' and mec-stained waters). Although atypical, substrate deficiency could still be a possibility, although that it getting more and more unlikely as the infants gets older. How is the baby fed in ml/kg/d and what is the baby given (breastmilk/formula)? Glucose-infusion? I would vote for the following strategy: 1. ensure that the baby is well fed (I'd go up to 200 ml/kg/d and possibly also enrich the breast milk/formula) 2. help the baby to preserve energy: maintain body temp at 37C but assisted by warmth through a heated matress or blanket, and if necessary - assist feeding with tube feeding 3. if the baby is still hypoglycemic - a more thourough investigation is needed: seems that this review on UpToDate is open access: http://www.uptodate.com/contents/neonatal-hypoglycemia The further and initial metabolic/endocrine evaluation could include the tests below. Take the blood samples when the baby is hypoglycemic: * acid-base balance * Electrolytes * keton acid in urine * S-insuline * C-peptid * Lactate * Growth hormone * Cortisol * Thyroid status (fT4, TSH) * Liver enzymes * 17-OH-progesteron

This is very interesting! I must admit that I was not aware of this association. I have seen many sutures around these "extra digits", leading succesfully to necrosis. But of course, we have no long-term follow-up... Maybe a more liberal referral to surgery in local anestesia would be a better option?

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We were in the works to get the Solgar probiotic product used in the ProPrems trial (http://www.ncbi.nlm.nih.gov/pubmed/24249817) As far as we have understood - this is the product http://www.yourhealthfoodstore.co.uk/shop-by-department/supplements/pre-probiotics/pro/solgar-abc-dophilus-powder-children-and-infant-formula.html and we have been working to import it to Sweden. Now it seems that this specific product is recalled after a safety alert by the FDA http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm423277.htm Has anyone used this product and knows more about this recall? What is your strategy now, is there an equivalent product?

You can always start with the latest Cochrane reviews http://www.ncbi.nlm.nih.gov/pubmed/17636695 http://www.ncbi.nlm.nih.gov/pubmed/23633311 Just my personal experience - know where you have chest tubings. As you know - pneumothorax is common in MAS and my personal experience is that the risk if higher in those needing surfactant. Probably more due to disease severity and probably less due to the surfactant itself.

Magnesium sulfate, given to mothers in preterm labour, has been suggested to improve neurological outcomes for preterm infants. However, ,&do=embed' frameborder='0' data-embedContent> long term follow-up studies has not been confirmative. Similar to one of the major publications in 2003 (in JAMA), principally showing trend towards better short term outcomes, those did not find associations with statistical significance, although absolute numbers of outcome events were more common among infants given placebo. In other words one could interpret these findings in two ways: 1. statistical power may have been too low to detect differences 2. the non-significant "trends" are random findings It would be interesting to hear about your practise regarding magnesium sulfate - please participate in the poll and comment below!

I guess so! You can always tweet to @breilly82 and ask.

A film producer contacted us on the 99nicu Twitter account - sharing a documentary film which is not only about difficulties families sometimes go through, but also a tribute to NICU nurses. As there are so many NICU nurses being members here: this is something I want to forward to you!

Good news and congratulations!

We are happy to make the first announcement about the Internationel Conference for Evidence-based Neonatology (EbNeo)! During 9-10 September 2015, the EbNeo conference will be held in the Union League of Philadelphia, in Philadelphia, USA. The registration will open in February 2015. Planned topics Evidence based methods of facilitating extubation Antenatal steroids - evidence limits to contemporary clinical practice What we have learned from the Swedish databases of outcomes of ELBW infants An evidence based approach to tracheostomy for the chronically ventilated newborn Why should we implement early intervention in newborns? Improving value in neonatal care through economic evaluations alongside RCTs Transitions to an extra-uterine environment - good and bad Making sense of the recent saturation targeting trials in extremely preterm infants Late and moderate prematurity: evidence to guide practice Antenatal corticosteroids: where we have been and where we are going Oxygen saturation signal: use it wisely Is an evidence base for neonatal ethics possible and what does it look like The composite outcome dilemma in newborn medicine What do we know about the molecular epidemiology of BPD New wrinkles on meta-analysis An evidence based approach to probiotics in newborns Making sense of 'GRADE': what to do when there is no randomized trial Invited speakers Peter Graham Davis Alan Jobe Mikael Norman Sara DeMauro Alicia Spittle Dmitry Dukhovny Satyanarayana Lakshminrusimha Barbara Schmidt Elaine Boyle Kellie Murphy Juliann DiFiore Dominic Wilkinson Nigel Paneth Roger Soll Gordon Guyatt

I guess breastfeeding is a matter of debate outside Sweden too. I came across a very nice review on "Being baby friendly: evidence-based breastfeeding support". Naturally, the review is within the ADC paywall... but if you can't access it from your NICU - ask your hospital library to get it. http://fn.bmj.com/content/early/2014/10/07/archdischild-2013-304873.short?g=w_fn_ahead_tab

Here - an interesting commentary by Roger Soll on the Cochrane review update on "Prophylactic Systemic Antifungal Agents to Prevent Mortality and Morbidity in Very Low Birth Weight Infants" Published in Neonatology and with open access, free to read for all! I quite his take-home message below. http://www.karger.com/Article/FullText/353683#PD

I was approached by a medtech company selling such a device, and I was not impressed. Lots of marketing efforts but when I asked for documentation and publications I was later emailed only one case report about a succesful management of CO2-retention (and no need for intubation). However, we all need to tailor our management on an individual basis, i.e. I am not saying that nasal HFOV is not effective for anyone, but one a group level I suspect the story will be similar as in the study about nCPAP and nBIPAP in NEJM http://www.nejm.org/doi/full/10.1056/NEJMoa1214533

Some input from Keith Barrington and his blog www.neonatalresearch.org (a blog I advice all to follow!) http://neonatalresearch.org/2014/09/23/the-time-for-a-confirmative-necrotizing-enterocolitis-probiotics-prevention-trial-in-the-extremely-low-birth-weight-infant-in-north-america-is-well-past/ http://neonatalresearch.org/2014/09/24/probiotics-so-what-about-those-elbw-babies/

No worries, as we do not use probiotics yet I don't take any comments personal How low is your NEC incidence? I'd estimate that our incidence is similar to the pre-probiotic era in Germany and this report discussed at neonatalresearch.org (http://neonatalresearch.org/2014/06/23/probiotics-work-in-germany-also/) seems promising, that even a low incidence can be further reduced.

As I understand it: an uncut tongue tie that is still tight over the first years affects vocalisation/pronounciation. But I have not "pubmed'ed" this question... only from the sayings of this speech therapist.

Try this WHO guide (available in several languages too!) http://www.who.int/maternal_child_adolescent/documents/924159084x/en/

@selvanr4 - laser surgery?! Frenotomy seems closer to rocket science than I had thought Related to your case: a speech therapist I met said we (in neonatal care) should also consider that a cut tongue tie lead to pronounciation difficulties later in childhood. Found some good parents info about this condition here: http://www.entnet.org/content/tongue-tie-ankyloglossia

1000-dollar-question! We do it sometimes (I'd estimate 1 procedure/week among our 7500 inborn babies/year) and almost always after request from the midwife or parents when the return for the maternity care follow-up (typically around 5-7th postnatal day), if breastfeeding is not on track as expected. However, science tells that there is not much effect on a group level in terms of breastfeeding rate/length, but some proxy outcomes (such as maternal satisfaction and tongue movement measured with ultrasound) improve. We do this procedure ourselves (no ENT referral). Baby head towards the doctor, 30% glucose as "pre-med", left index finger in the baby mouth that pulls the tounge towards the palate exposing the tongue tie, and then, open scissors down to the tongue base, and one cut. My experience is that the babies react little to the cut, if anything. Here is a thorough post on a (very nice!) web site for pediatric residents: http://dontforgetthebubbles.com/tongue-tie-cut/

The updated Cochrane review comes with a clear recommendation - that preterm infants (defined as <37 weeks / BW <2500 g) should be given probiotics to reduce the risk of NEC. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005496.pub4/abstract When reading the full review (look at the tables), my impression is that the effect among infants <1000 grams is less well documented. And I came across this editorial: http://www.jpeds.com/article/S0022-3476%2814%2900431-4/abstract What is your opinion about and/or the interpretation of the Cochrane review? If you use probiotics - do you use it for all preterms regardless of gestational age (i.e. also for the most immature & tiny babies)?

Interesting question. I work in a level-2 unit now where we do INSURE procedures, and it is rare that infants need more respiratory support than cpap after the first dose of surfactant, given that "our" babies are born from 28 weeks. I believe though that the level-3-units @ Karolinska sometimes give 2 doses of surfactant, at least we read this in the records in some babies transferred to us for level-2-care. And I guess they use the same approach as when I was there, i.e. a 2nd dose can be given in more severe RDS when FiO2 and ventilatory settings "backlash" after the first dose AND x-ray still indicate RDS (and not other kind of lung disease). In other words, I believe they do not have clear-cut guidelines in terms of gestational age etc, but tailor a 2 course of surfactant therapy in each individual case.

What is your experience how the babies react upon laryngoscopy? Do they not show signs of stress/discomfort?

We don't! Just the other way around (give anti-D proph to Rh- mothers if their offsprings are Rh+)

1) no 2) no 3) As our NICU beds are relatively few we would manage asymtomatic infants with smaller subgaleal hematomas in the well baby nursery ("maternity ward"), but admit on liberal grounds, if any kinds of suspicious symtoms arise.