Stefan Johansson

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.

We do not administer vitamin K on a routinely basis, BESIDES the first shot given intramusc to ALL newborn infants regardless of gestational age. (and we do give extra vitamin K in cases of cholestatic jaundice, but that's a somewhat different story)

@JACK - this is a great link! I was looking at this myself only a few days ago and planned to write up a blog post BTW - do you have "Links to like" - i.e. very useful web resources I can write about in the blog?

@wackdi - I was reading exactly this too just before lunch today! (and then titus came and we had lunch)