Stefan Johansson

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).

I am sorry but we do not have financials to purchase such resources for members. I wished we could build a collection of really good links (i.e. purchasing access to various resources) but it is not possible for the time being.

I agree that these babies are often just well term and breast-fed babies. Breast milk is often blamed to be the cause of prolonged jaundice, but we seldom paus breastfeeding on this indication (any longer) but monitor s-bilirubin and relative often do a liver function work-up. Regarding levels: my personal take is that the baby should be clearly under the limit for photo-therapy, BUT that the most important aspect is the dynamics of the bilirubin-level, i.e. that the level decreases over time. A persisting high unconjugated s-bilirubin should lead to further investigations (liver function tests, metabolic screens etc) The NICE document (which is really good!) about neonatal hyperbili gives only vague guidelines on prolonged hyperbili (http://guidance.nice.org.uk/CG98) but I still want to high-light the the threshold graph (excel-based, http://guidance.nice.org.uk/CG98/treatmentthresholdgraph/xls/English)

Sorry, but I have no experience. We will promote your question in the next newsletter!

@wackdi - great input! we would just need something that works Either of us should take the local train for a coffee IRL! We just need to do a little more of think-tank work!

I am interested to learn more about microdialysis in newborns, for monitoring of subcutaneous glucose monitoring. We have an idea for a research project and would need a good way to monitor glucose homeostasis contineously. Microdialysis would be an option(?). This article here catches well what we want to learn more about: http://www.ncbi.nlm.nih.gov/pubmed/11694701 If you have experience from technologies (commercially available or DIY) and the use if such technologies, please share!

I know - many of us want less emails... But the emails from Evidence Updates are great! Evidence Updates (a collaboration project by the BMJ Group and McMaster University) assists your reading of new research by grading articles by "Relevance" and "News-worthiness". For example, this trial on D-vitamin supplementation of preterm infants showed up in an email alert, an article I had missed otherwise. 1. You need to Register (here!) 2. Choose your clinical interest ("Pediatric Neonatology", I guess) 3. Set a minimum score for new articles you want to read about (set a higher minimum score to get fewer emails ) 4. Watch your inbox! Link to like: Evidence Updates.

This article was recently published in ADC, a systematic review about volume-targeted vs pressure-limited ventilation. The message is that volume-targeting has advantages, as this mode is associated with... Personal reflection: finally there is enough research data to show that volume-targeting seems to be superior over pressure-limited ventilation there are a lot of less good research out there; only 18 of 59 potentially relevant studies were included in this review the authors of this systematic review are not the "usual suspects" (guess whom!) - but a research group in China - the country quickly climbing the research ladder Link to the article in full-text: http://fn.bmj.com/content/99/2/F158.full

We also keep fortified breast milk (in the fridge) up to 24 hours.

We start Fe supplementation at 2-4 weeks of postnatal age, and when the baby is feed predominantly enterally. Our guidelines regardig blood transfusions and Fe: if the baby has recieved several transfusions we check S-Ferritin. If >350 mikrogram/L we follow S-Ferritin until it has decreased below 350 mikrogram/L and start supplementation then.

@mmerocru, the point by @Omer is that decreasing blood counts are commonly seen in septicemia and transfusions of blood products are often needed. I think the most important aspect here is to "follow the baby" and give what you consider needed as supportive care: to give platelets when the trombocytopenia becomes too bad or you see a steep/quick reduction, and to give erytrocyte transfusion when the Hb/EVF becomes too low (according to your local guidelines). We do not use platelet transfusions as a routine therapy. But, in severe septicemia we generally check blood counts 2-3 times/24h. We have no fixed lower threshold for platelet transfusions but generally want to levels above 15-20 if the baby is very sick. When it comes to erytrocyte transfusions we generally aim for EVF ≥ 40%.

We refer to the actual volume going in (iv or po), i.e. 160 ml/kg/d is the total volume given (iv or po) and not the estimated volume absorbed.

I hold these guidelines high, from Sydney, Australia, and authored by prof Nick Evans, leading expert on ductal shunting. http://www.sswahs.nsw.gov.au/rpa/neonatal%5Ccontent/pdf/guidelines/pda.pdf (here's the link to the guideline page of the RPA hospital in Sydney, good resource! http://www.sswahs.nsw.gov.au/RPA/neonatal/protocols.html)

We add fluid restriction (not always, but usually) as one "treatment modality" for infants BPD or PDA. But we do not go as far as to 110-130, but reduce less dramatic to 160 ml/kg/d. Even at that level we usually need to boost up the breastmilk-fortifications to maintain adequate nutrition.

Ok, that seems rather high with crp at that level. What antibiotics combination do you use? To me it seems that the infection is only partially treated.

How high is the CRP and how has it developed over the 10 days? Did you get a positive blood culture?

2014 Update in Neonatal Nephrology. March 28, 2014. New York, USA This is a CME/CE conference for neonatologists, pediatric nephrologists, pediatric urologists, fellows in training, and allied health professionals with an interest in neonatal nephrology. This conference will provide a forum for specialists in the field to interact and discuss new developments in our understanding and management of congenital anomalies of the kidney and urinary tract (CAKUT), comprehensive treatment of neonatal AKI and long‐term effects of low nephron number from prematurity. Date and venue Friday, March 28, 2014 7:30am ‐ 4pm Heart Conference Center, Vivian and Seymour Milstein Family Heart Center New York‐Presbyterian Hospital 173 Fort Washington Avenue, New York City 10032 2014 Update in Neonatal Nephrology_please post and share.pdf neonatal nephrology.pdf

If you need to show images of common and less common physical findings, the "Link to like" is the photo gallery compiled by MD Janelle Aby, at the Stanford School of medicine. Perfect for teaching of students and fresh fellows. I used it myself today when we discussed nose deviations of the newborn, and I could illustrate differences between a nose septal dislocation and the much more common septum deviation due to the fetus having the nose "stuck" in the uterine wall. The photo gallery is "semi-closed": you will be asked to submit your email address to view images, and then await the email with an URL that gives you a 24h access to the photos. Link to like: Photo gallery, Newborn nursery @ LPCH / Stanford

I think the major problem here is the infection itself. Jaundice is not uncommonly seen in septic babies. So my (general) advice is to give antibiotics as specific therapy and continue with supportive care for jaundice, and respiratory and hemodynamic stability. If the baby continues to be unwell, despite that the infection is under control - then you will need to investigate for causes of hyperbili.