Stefan Johansson

Before the end of the year, we have euros to spend... and our plan is to spend it on books that can be reviewed. The deal is, we buy you a book from Amazon, have it delivered directly to you, in exchange for a review in four weeks time. You may want to review books in neonatology, but you can also choose to review any books you feel we may want to read about (music, medicine, art, novels etc-etc) When you have finished your review, you will need post the review yourself in the review forum, here! (that's a piece of cake, but we will assist you if you need help) Please respond to this thread or email info@99nicu.org, if you want to review a book.

You're welcome! Nice to find someone in the Lounge (that's not often... )

Although I think religion can be supportive at these occasions, I believe that suffering and grief is a universal human feeling. I mean, for example, if African parents with 8 previous children loose a newborn baby, I am sure they share feelings with a couple in Sweden, losing a child that was a result of in-vitro fertilization. I belong to the state-church of Sweden (i.e. I am a protestant) but I must admit I hardly ever go to church as a practising christian. Maybe I cannot find religious support for myself due to myself being closer as an atheist or agnostic, but I find it hard to "understand" or reason about the death of a newborn infant. Nature is mysteriously cruel sometimes. Just in case someone would misunderstand my first post, what I have sometimes lacked in the NICU is not really a clinical protocol "Handling grief - chapter 1-9". But more that the working group should be more aware of grief and to "see" it, in ourselves and in others in the team. That we have an opportunity to put some words to it before leaving our shift.

My answer is... no (if the infant is not agitated)

Thanks for raising this important topic. Personally, I can be influenced a lot about death and misery in the NICU. And, I believe we could help each other in the NICU to manage these events in a more professional way. We are so keen to formalize and structure a lot of things/procedures, but this field is a white map for everyone to "do their best". I do not have any good solutions how we could cope in a better way, my point is that we may not just go away for a coffee break and then start working "business-as-usual". How I have solved this... my daily bike trip to/from work is my most important time for reflection (this may seem a bit strange, but it's true!). I process a lot of the days burden this way. Music and ordinary family life are also essential. I must rush now, will follow this discussion closely!

This thread may give you some info: http://www.99nicu.org/forum/showthread.php?t=6624

We have a "milk bank" of donated breast milk, where lactating mothers can donate breast milk. The honorarium for these donations is quite small but enough mothers do it for the good sake. I think most have past experience of neonatal care and want to contribute when they have other (well and term) children. As far as I know, donor milk can be used for several infants, but the batch id's are recorded. Parents need to give consent whether their infant can get donor milk. In our units we almost always use donor milk until the mother herself produce enough milk to feed her infant. All mothers are instructed to start pumping and typically are able to fully feed their infants after a week.

Yes, we almost always use two different additives, extra lipids and protein.

I would suggest that you browse OMIM http://www.ncbi.nlm.nih.gov/omim/ I made a quick search for with the keywords "white forelock" and "heterochromia" and got a few hits including various forms of Waardenburg syndrome. Are there any associated malformations?

Another aspect of dobutamine is that it has some beta2-agonist action, related to vasodilatation: http://www.ncbi.nlm.nih.gov/pubmed/9279221

Here's the link: http://www.hopkinscme.net/ofp/eneonatalreview/Newsletters/1108.html

This is not a book about neonatal medicine. But read it anyway! You will have a good time and feel enlighted about a fascinating world outside your neonatal unit. Where strong commercial interests and strange characters profit BIG MONEY from people aiming for a healthy life-style. Bad Science is written by the British doctor and writer Ben Goldacre. The book is based on his column in the Guardian, a leading newspapers in the UK. His mission is (what is seems) to bring basic principles of science to the general public, thereby uncovering the critical eye of people who are cheated to spend on miracle cures because of "studies have shown"-statements. As you know, most goods and services in the healthy-life-style industry are nothing but fraudulent rubbish. Ben Goldacre cleverly dismantles pseudo-science, such as Detox, Homeopathy, Pills solving complex social problems, etcera. Even when Ben Goldacre refers to hyped health prophets in the UK I haven't heard of, I find Bad Science truly amusing reading. His bottom-line: "If I had a T-shirt slogan for this whole book it would be I'll think you'll find it is a bit more complicated than that". Taking antioxidant pills (and the wide spread belief that these pills do good to you...) as an example, Goldacre goes through the four major errors in pseudo-science. Does data exist at all? The concepts of observation and intervention, are they mixed up? Is lab data being extrapolated far beyond reason? Are positive trials cherry-picked? A large bit of the book is about heavy irrationality, but Bad Science also deals with a more serious side of science. As you know, the quality of medical research varies quite a lot... For example, in the chapter "Is mainstream medicine evil?" Goldacre goes through ("for the doctors who bought the book to laugh at homeopaths") common statistical tricks that may boost scientific reporting of, for example, trials sponsored by pharmaceutical industry. These tricks include play with the baseline, ignore drop-outs, change outcome to fit your needs of a positive trial and after the study is completed, "torture the data and it will confess to anything", and "try every button on the computer". He also problematize the fact that media promote the public misunderstanding of science due its traditional way of communicating "good stories", and why "clever people believe stupid things". The only alternative to read Bad Science would to follow Goldacre's Guardian column and blog, both freely available here and here.

Regarding the fetal deaths; has H1N1 been identified in fetal tissue by PCR or culture?

Hi! I have meet people who advocate this practise and some who don't. I have not used this strategy myself. On the other hand, the units I have been working in have all had the tradition to perform very few urine cultures. In cases where the issue has been risen (like urinary tract malformations), whether there's really a cystitis/pyelonefritis, I have always made a bladder puncture to make sure the sample is not contaminated.

Nice material! I was so much into seeing the film that I missed that the movie is the illustration to the booklet presented! Click on the arrows underneath the booklet and you turn its pages. And, click on "Download PDF" to keep it.

I just wanted to say that I have no experience of the kind you request. My experience with older infants (ex-premies with BPD for instance) is that TcPCO2 works less well as the infant matures. But, maybe your equipment works better on older children. Have you asked the company representative for clinical data on the agreement between TcPO2 and PaCO2 (in blood)?

Dear Roy, despite the fact that I would advocate diagnostics of seizures first, I have commonly found that phenobarbital is started (10-20 mg/kg) on clinical grounds before CFM/EEG is available. So, if there´s no equipment to diagnose seizures, I would argue that symptomatic treatment of clinically evident irritability and seizures is appropriate. One can debate whether this phenobarbital and similar drugs really changes long-term outcome, but short-term it is usually well tolerated and may result in less irritability. I found these two papers, both from the same research group: http://www.ncbi.nlm.nih.gov/pubmed/16390805 http://www.ncbi.nlm.nih.gov/pubmed/15188805 They do not address your specific question, but give some light of the use of phenobarbital.

I have been wondering the same. According to the current guidelines I briefed, mothers with H1N1 needs to be isolated post-partum and the well infant does not need profylaxis unless the "situation is critical" (for the mother). Breast feeding is ok. Preterm infants with suspected H1N1-infection would need isolation in the NICU and be candidates for treatment with Tamiflu (2 mg/kg once daily over five days). But, I would like to express a word of caution about the guidelines I refer to. I would think it is hard to generalize guidelines about H1N1 since the virulence may differ between countries, and that different health authorities come to different conclusions, given the scarce amount of documentation for various strategies/dose regimes etc. I am sure many members would like to hear from other corners of the world, about other strategies. Please share how you tackle H1N1 in NICU settings. PS. Here's a link about a H1N1 case in a NICU in the US. http://cbs4.com/local/H1N1.Swine.Flu.2.1074463.html

Sorry about my short previous response. This is also how we do it!

Chloral hydrate (25-50 mg/kg)

I would not.

Very interesting question. I have often felt about "Do Not Resuscitate"-decisions in two different ways. Usually, one senses the situation correctly from the clinical scenario and "by gut-feeling". On the other hand, I have personally often felt that there's a lack of official policy on the decision-making process. I think one could decide upon a "work-flow"; how care and the infant's condition is assessed in the team; 2nd opinions from another consultant; parental involvement etc-etc. Some would argue that those steps are difficult to write down on a paper, but I would argue that it is a strength for a department to have these steps defined. We all need to consider certain aspects before we can consider treatment to be futile, so why not put this work-flow into words. A defined decision-making process would also be beneficial in contacts with parents, and give care a higher degree of transparency. "This is how we these decisions are formed". In the scenario you describe, I think one needs to consider the suffering of the individual infant. Although this is a hypothetical situation (and I know nothing about the legal aspects of the DNR form you have); if care seems futile and the infant is suffering this would be more important for me than not having the form counter-signed. For myself, I think papers are important, but the suffering of patients comes first. PS. A similar topic was discussed here: http://www.99nicu.org/forum/showthread.php?t=46

FFP = Fresh Frozen Plasma We generally administer 10 ml/kg of plasma and then re-check coagulation parameters, and repeat plasma if needed. Specific coagulation factors are not used unless very special circumstances.

I visited my first Hot Topic conference last year, it was great! Hope to go there this year too. I have started a "Social Group" for the Hot Topics: http://www.99nicu.org/forum/group.php?groupid=2

I can only agree on your clinical impression. One major problem with major bruising is the abnormal coagulation often detected, and I think there a reports supporting abnormal coagulation status with poor outcome. If I was not on holiday, I would search Pubmed