Stefan Johansson

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.

I share your views, that PICC lines in inferior vena cava above L4-L5 is a good position. As we commonly insert PICC lines in the arms, I have less experience with leg sites, but I have not seen a PICC line entering the liver. When it comes to PICC lines I personally feel that there is sometime a trade-off between a really optimal position and what's possible to achieve for an individual baby. For example - although we aim for an intrathoracic position for a line coming through cubital veins, sometimes the line reaches only the subclavicular vein. Also a reasonably large vessel but not as intended. If the baby is believed to be on parenteral nutrition for a short while or has few/no alternative vessels, we accept that position.

As Internet is everywhere (sort of), 99nicu.org has become a truly global network! From Google analytics we could see that people browsing 99nicu the past month (May 9 - June 8) comes from all over the world. The final goal for our outreach is Greenland and countries in Central Africa.

We still use the INSURE procedure ("intubation, surfactant, extubation") (For those not familiar with "LISA" it means "Less invasive surfactant administration" http://www.ncbi.nlm.nih.gov/pubmed/23446061 I am not certain but I guess that LISA is the same procedure as MIST, i.e. "Minimally-invasive surfactant therapy" http://www.ncbi.nlm.nih.gov/pubmed/22684154 )

While most of my colleagues would go for an oral tube in an emergency situation (like during resuscitation after birth), we prefer nasal endotracheal intubation for babies we believe will need to be intubated for some time (semi-planned intubations). With the exception of small preterm infants that are usually intubated nasally at birth, if they are likely to need MV/HFOV initially. My personal opinion is that nasal tubes are not more difficult to insert, especially in smaller infants that can have little room orally and the tube can partly "hinder" view of the tracheal entrance. Nursing-wise I guess there are lots of opinions and experiences that differ. Our take is that nasal tubes are better fixated, making nursing easier. But I am sure that units using mostly oral tubes don't consider nursing difficult. Here are two rather recent and interesting references, the first one is a survey of practise from PICUs (maybe not so applicable to NICUs, but interestingly almost all children have oral tubes), the other one a review from Cochrane concluding that one route of intubation does not seem to be preferable to the other. http://www.ncbi.nlm.nih.gov/pubmed/23328260 http://www.ncbi.nlm.nih.gov/pubmed/10796391/

Here are two interesting links: a Cochrane review and a clinical protocol from New Zealand: http://www.adhb.govt.nz/newborn/guidelines/Cardiac/Hypotension.htm http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005090.pub2/abstract;jsessionid=DBEFF0EF81F0658DAC56D184FD0149D4.f04t01 You can also see a good lecture here: http://web22.abiliteam.com/ability/show/khcichp/abbott_ebneo/speed.asp (just submit email and name, and then choose day 2, the inotrope lecture comes first)

I know that the academic setup for PhD varies between countries, so you would need to check with the university you intend to defend your thesis. First of all, you need one/several supervisors. I guess the regulations are similar in this regard, that you have one main supervisor and 1-2 co-supervisors. Together with your supervisors you set the topic and work plan for doing projects that ultimately results in your PhD-thesis. You could probably work on anything related to neonatology (basic science, clinical trials, epidemiology etc) - writing a PhD is much about training to become a researcher. A PhD becomes your "driver's license" to be a researcher and be able to design and perform your own projects "postdoc"

@drakjaleel - I guess it depends on the epidemiology of germs in your setting. If you see gonococcal and chlamydia eye infections from time to time - your strategy should be different than others (see below) We do not use any prophylactic eye drops in Sweden. Slight eye irritation is common in our well babies in the maternity ward. Our first-line treatment is frequent washing with physiological sodium chloride which is usually enough for most cases, likely due to the fact that much of the minor problems do not represent "real infections" but just tear canal congestions and slight inflammatory processes after birth. However, if there is an aggressive conjunctivitis we always take cultures and treat with antibiotic eye drops, usually directed towards staph aureus.

Our dietician often suggests that we should use preterm formula "some time" after 40 weeks corrected age, in the more preterm born babies (typically <28 weeks) In practical terms we usually switch over to regular formula at the first follow.up visit, i.e. usually at 3 months corrected age.

This a great topic, we all see theses babies often and yet I have come across many different approaches What we usually do: 1. if babies are asymmetrically growth retarded and especially if there is a history of maternal illness (like preeclampsia): we usually do nothing BUT consider nutrition as a catch.up-growth can be expected 2a. if the baby is symmetrically growth retarded and more than -3 SD from the expected BW - we usually do TORCH titers on the mother, urinary CMV on the infant, and head ultrasound to look for calcifications 2b. if these tests are all normal and the baby looks well besides being small, we generally follow-up growth and development for these being < -3SD in our policlinic (until 24 months of age) 2c. if the baby have stigmata or being unwell, we usually do a "syndrome" evaluation, including charyotype / micro-array, possible echocardiography and renal ultrasound, and an eye investigation Would be great to hear from more members about their approaches.

Dear Martin and Zuzana Galcik, thanks for your post here and I am sorry to hear about your daughter's start in life. As JACK writes, we refrain from giving medical advice to parents. The main reason being that it is hard to give good advice when not seeing the whole picture and context. Parental advice is also (yet) beyond the scope of this community. Generally speaking - hypothermia is currently the treatment used for perinatal asphyxia. Whether there are experimental research (such as clinical trials) where your daughter Sara is staying - you will need to discuss with the doctors that knows you and Sara. To my knowledge there are no additional clinically available therapies (than hypothermia) that are "neuroprotective". In our units we have no such treatments and we have no ongoing trials either. The most important that we focus on after the acute phase is nutrition and growth, as for all babies, and of course a regular follow-up visits after discharge from hospital. Sending my thoughts to you and Sara.

Hi and welcome back! I like the supporting cushion most and voted for it. I think - a major spinoff would be that people would also take more steps on how to manage the airway. Great idea and wish you have luck with it!

Interesting to hear, especially the short injection time. Do you use the same dose regardless of gestational age (23-43 weekers). My thoughts about our (sporadic) problems are that we use a too low dose (usually around 3 mikrog/kg) and give it too slowly (over a few minutes). The general belief in our unit is that lower dose, and a more "gentle" administration would reduce the risk of stiff chest/laryngospasm. But, I start to think that babies gets too little analgesia, that the reaction we see is due to discomfort.

Hi all! I was trained to use morphine as premed before (semi-planned) intubation but our protocol and practise has changed to fentanyl as analgesic drug (in addition to atropin, pento and +/- celocurin) What is your experience with stiffening of the chest and laryngospasm? If you use fentanyl, what is your dose and over how many minutes do you inject it?

We give it as a slow bolus, body lying flat and head/nose straight up.

I agree with @rehman_naveed. No diuretics unless the baby is really unwell and have instable hemodynamics and renal function. But, I believe people have different opinions on this. For example, I was taught to give diuretics after blood transfusions (when the goal is to increase Hb/EVF)

Ichtiosis has been discussed before, maybe these two threads will give some advice:

@satyen75 - to be honest I don't know the AAP curves, but I suppose curves differ between countries, as interpretation of research and experience probably leads to slightly different conclusions regarding safe levels etc. The work by NICE that resulted in their curves seems very thorough, and the full document is extensive (http://guidance.nice.org.uk/CG98). Still, I personally believe their work was probably also influenced/biased by some degree of subjectivity/consensus/"tradition", as there is no gold standard for these curves.

These curves should be what you're looking for, as you set gestational age and the graph's adjusted. See the screen shot.