Stefan Johansson

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.

The first that comes into my mind is that you and your colleagues in Libya need to organise yourselves, in a national society. The main reason I see is that despite current ”evidence” for this and that, you will need to bring knowledge and experience into your context. In a national society, you will be able to do this, and also set priorities, what projects and issues that are most important. A national society will also facilitate development of national guidelines, training programs of neonatal fellows, arrange postgraduate meetings, help to set “work flows” between NICUs and other health care facilities etc-etc. My second and principal thought for all your work is… start simple! For example: you probably want some system for collection and registration of morbidity and mortality data. Don’t begin to complicated and aim to register “everything”. If you manage to get national data on NICU admissions and their infant gender, gestational age, birth weight, a handful diagnoses (yes/no, coded as ICD10-codes http://www.icd10data.com/ICD10CM/Codes/P00-P96), and mortality, that would be a good start. Regarding data collection: contact Vermont Oxford Network (http://www.vtoxford.org/) or dr Ian Callander, an Australian neonatologist, who has developed “Neonatal Database” ( http://home.iprimus.com.au/callanders/ and http://www.jcdr.net/neodb/NeoDB_Questionaire.asp ) When it comes to specific domains of neonatal care, a few topics would be worth to explore early: Promotion of nasal CPAP (as it can potentially reduce the need for mechanical ventilation) Identification and (light) treatment of jaundice Infection control and prevention Nutrition, in particular how to promote breast feeding and the use of breast milk for preterms Kangoroo (skin-to-skin) care and parental involvement You have a journey to make in Libya, but I am hope you will be able to learn from colleagues around the world to develop your neonatal care fast and efficiant. My best and warmest wishes, Stefan

Take a look at the curves you can download from NICE / UK. http://guidance.nice.org.uk/CG98/treatmentthresholdgraph/xls/English The direct URL (download) is: http://www.nice.org.uk/nicemedia/live/12986/48683/48683.xls

You need separate brands from technology. The main point by the meta-analysis is that volume-targeted/-controlled mechanical ventilation has some advantages. But, as always, one needs to consider the performance of both the driver and the machine. I mean that regardless which ventilator you use/purchase, you need to learn how to master it. What machine you ultimately get will most likely depend on other things than infant outcomes. Direct and indirect costs, spare parts and service agreements, user interfaces, your previous experiences and preferences, and other similar aspects will probably be more important.

Thanks for posting your questions here, I hope you will get some valuable input from several members. Starting from scratch with setting up a structure for clinical workflows and research is a major task. The first and immediate thought that comes into my mind is to begin with simple things and add more complicated aspects as time goes. I will try to share more thoughts, I just need to think it over first.

UPDATE 2014-11-03: THIS POSITION IS NO LONGER AVAILABLE. There is a position of for a postdoc fellow in perinatal epidemiology, in Stockholm/Sweden, at the Karolinska Institutet, Department of Medicine, Solna, Unit of Clinical Epidemiology. Perinatal epidemiology focus on factors influencing health of the fetus and newborn infant. As the start of life is important for future health, there is also a focus on long-terms risks of diseases and disability in perinatal epidemiology. The proposed work will include collaboration between obstetricians, pediatricians, epidemiologists and statisticians working within perinatal epidemiology at the Clinical Epidemiology Unit. Data sources include cohorts from national registers and data the counties of Stockholm, Uppsala, and Gotland. The work will include studies of hereditary and environmental (related to both mother’s life style, pregnancy and delivery complications) factors and health of offspring at delivery, during infancy (the first year of life) and later in life. More specifically, some of the projects involve: 1. associations between maternal obesity and offspring health; 2. asphyxia in the newborn: definitions, risk factors, short and long-term consequences; 3. The maternal and paternal contribution to pregnancy and delivery complications Read more about the position and submit your application here: https://ki.mynetworkglobal.com/en/what:job/jobID:33180/where:4/ Deadline for application is 31 March (possibly extended).