Stefan Johansson

Hi Norbert, I sent your comment to BMJ - I hope to get some info from their office asap! If others experience the same problem to register, please post here!

We are planning to explore current health in 6-8 year old children born before 32 gestational weeks. Does anyone have experience from a validated questionnaire for parental assessment of their child's general health (including hearing, vision, gross/fine motor function)?

It would be interesting to hear about impressions from the Hot Topics meeting! (And BTW; did anyone notice our information leaflet?! )

Hmm, I will get in touch with our TPN group & the Pharmacy and see hear their opinion on why we don't cover the TPN.

We don't cover the TPN-bags at all. (Do manufacturers of TPN constituents have different recommendations, as to whether their products are light-sensitive?)

Dear all, we are considering to offer full text access to Archives of Disease in Childhood. We were offered by ADC to get access for a low cost per member, 25 euro, for online access to all contents at the ADC web site. The regular individual fee will be 163 euros for 2007, our discount would be about 85%! However, given the fact that we're rather soon approaching 1000 members, the cost for 99nicu would be 25,000 euros. In 2007, we expect to sell advertisment space for about 3,000 euros, which is basically needed for technical support, web hosting etc. How should we proceed? One approach would be to let individual users pay the rate of 25 euros somehow, either directly to ADC, or via 99nicu. Or should we search for a sponsor? Or should we just skip the idea of ADC as a member benefit? Please express your opinion!

Interesting case - given the fact that antibiotics were prescribed, were there any evidence of inflammation? I am thinking if some kind of inflammatory process / vasculitits could play a role here. Do you have a picture to add to your post above (we can help you to add it)?

The current (national) recommendations is to treat subclinical seizures if they are recurrent (as registr by CFM or EEG). We usually have infants with suspected seizures or post-asphyxia monitored with CFM, but check regular EEG's - daily until the infant is stable neurologically, and then less frequent until the EEG is normalized or has become stationary.

If you're particularly interested in the patent ductus arteriosus, you may be interested to visit the web site PDA.SE Besides a reference library, clinical protocols and a video clip library (work in progress...) there's also a section for parents, with a information leaflet for parents. The leaflet is available in Nordic languages and English, and translations in other european languages is on the way.

I see! That particular video clip is copyright-protected. Maybe we can make a (second) video for educational purposes with permissions from parents etc. Should we aim at collecting educational videos here at 99nicu?!

I don't have a video clip of the INSURE technique, but it is not complicated to explain. We use INSURE rather frequently for RDS-treatment/surfactant installation, in >27 week infants, with Xray-diagnosis of RDS, adequate nasal CPAP-pressure (which we consder 4-5 cm to be) and an a/A-ratio of <0.22. 1. Loading dose of teofyllin (5 mg/kg iv) 2. Slow injection of morphine before intubation (0.15-0.2 mg/kg iv) 3. Pentobarbital immediate before intubation (2-5 mg/kg iv). 4. Oral intubation. Don't push the tube to far down to avoid bronchial intubation. Check tube position clinically by listening for equal to the lungs. Fixate the tube by a single piece of tape, or hold the tube/infant's head with one hand. 5. Intratracheal administation of surfactant (100-200 mg/kg). 6. Naloxone iv (0.1 mg/kg). Wait and assist the infant's breathing until he/she breathe well and saturation >90% 7. Extubate and continue with nasal CPAP.

Are there any other symtoms or signs, from the respiratory tract, or any other organ system!?

Dear all, in our units most extremely preterm infants get umbil artery catheters (UACs), high position, and we tend to keep those for quite many days. In the most immature infants (23-24 weeks), sometimes up to 10-12 days, but usually we take it away at the end of the first week of life. We place peripheral radial artery catheters if those infants deterioate later (sepsis etc). Although we hardly see complications such as distal gangrene och symptomatic aortic thrombosis, I have a feeling that this practise of keeping UACs for many days is different from the routines in other units. What is your routines/protocols for UACs?

If you experience problems and have use MSN-messenger, please try to contact our online helpdesk: helpdesk.99nicu@hotmail.com or send an email to info@99nicu.org Please note that we are not online 24/7, but we reply messages and mails asap!

Some feedback: an incomplete and mild form of Pentalogy of Cantrell seems the main differential diagnosis. This infant has no serious internal malformations, such as cardiac malformation, diaphr hernia etc., and is doing fine. The pentalogy of Cantrell is a very rare disorder/syndrome characterized by a combination of severe defects of the middle of the chest including the sternum, diaphragm, heart, and abdominal wall. This defect can affect males or females and is apparent at birth or shortly after.

Dear Carlos, I have just read this commentary by Saugstad, it is highly recommended reading! Saugstad is one of the leading researchers on neonatal resuscitation and oxygen effects. According to Saugstad and co-authors, there are sufficient data to conclude that 100% oxygen at resuscitation should generally be avoided. I also interpret their views that oxygen administration should be rather low at initiation of resuscitation, but increased at 90 seconds if the infant has not improved. They put forward the Swedish strategy (which has been 40%) as an example. I think they have a point about the idea to reduce oxygen administration to the "lowest level needed as fast as possible". A blender is probably the best way to control oxygen administration. However, one may also consider alternative ways to achieve differentiated oxygen levels in simplier setups, such as * bag/mask with room air * bag/mask with oxygen connected but no reservior (approx 40%) * bag/mask with reservoir (100%).

Dear Rahmi Ors, CMV and preterm infants - that's a 1-million dollar question, I think! The rate of transmission (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11229670&query_hl=5&itool=pubmed_docsum) is high during neonatal care if the infant is given mothers breast milk. It is not always easy to disentangle what lab results and clinical signs are related to a positive CMV-test, for example in urine. I would not say that we have a clear practise about CMV in our unit, however, it there are multiple findings indicating CMV (other inflam/infect unlikely) including a CMV-positive CSF, we would probably favour treatment. Anyone who would like to comment in this question?

Dear Petri Mansfelt, I think that most of these problems could be prevented by careful nursing - our nurses are catious about of the risk of pressure induced necrosis and keep an extra eye on position and pressure of the nasal prong. For some sensitive infants we use a different prong. It is a not really a 'nasal prong', but rather a small triangular 'hood' which covers the nose. If this 'hood' is positioned well (with not too much leakage of air) I think it works just as good as the regular prongs.

We have a dedicated neonatal nurse in our unit, writing her thesis on enteral feeding. After this study, we now use continuous nasogastric feeding in our smallest infants.

Dear all, I have been asked to post the following clinical case born in a Swedish hospital: Term infant, normal pregnancy and delivery. The infant has a "ridge" of umbilical-like tissue, stretching from the umbilicus and to sternal tip. The ridge is freely movable from the deeper structure. No secretion. There are no external malformation apart from this ridge. The infant is well, breast-feeding normally, has passed meconium and urine, not vomiting etc. A plain abdominal x-ray has shown no pathologies. It seems that the infant has some kind of abdominal wall defekt, but what is the diagnosis? Has anyone seen something similar?

Check this out! http://www.adhb.govt.nz/newborn/TeachingResources/Ventilation/Ventilation.htm

Do you still have a "feeling" that this is primarely a pulmonary disorder? If so, have you considered performing a computer tomography of the lungs or a lung biopsy (histopathology)? Or do you have any indications that the breathing problems are secondary to dysfunction in a a different organ system; such as a neurological or neuromuscular disease?

Dear billyvega, do you mean how base deficit could be used as a predictive factor of encephalopathy? Could the two articles/abstracts below be of interest? ******* Threshold of metabolic acidosis associated with neonatal encephalopathy in the term newborn. Wayenberg JL. J Matern Fetal Neonatal Med. 2005 Dec;18(6):381-5. OBJECTIVE: To determine the threshold of metabolic acidosis associated with neonatal encephalopathy (NE) in the term newborn. METHODS: Term patients were included on the basis of abnormal hemodynamic, respiratory or neurological signs still persisting 30 min after birth. Base deficit (BD30) was measured in arterial blood between the 30th and the 45th min of life and correlated with the occurrence of NE during the first days of life using receiver operating characteristics (ROC) methodology. RESULTS: Moderate or severe NE occurred in 26% of patients whose BD30 was higher than 10 mmol/L and in 79% of patients whose BD30 was higher than 18 mmol/L. No infants developed moderate or severe NE when BD30 was less than 10 mmol/L. The apex of ROC curve related to moderate or severe NE corresponds to a BD30 of 14 mmol/L. At this threshold, the sensitivity of BD30 is 73.2% and the specificity 82%. CONCLUSION: The threshold of metabolic acidosis that provides the best combination of sensitivity and specificity in relation to the occurrence of moderate or severe NE was a BD30 higher than 14 mmol/L. Significant birth asphyxia should be considered if BD30 exceeds 10 mmol/L. Combination of early perinatal factors to identify near-term and term neonates for neuroprotection. Talati AJ, Yang W, Yolton K, Korones SB, Bada HS. J Perinatol. 2005 Apr;25(4):245-50. OBJECTIVE: To determine early predictors of abnormal outcome at > or =24 months' age in neonates at risk for hypoxic-ischemic brain injury. STUDY DESIGN: A prospective cohort study with developmental follow-up of > or =24 months. Infants were selected based on risk factors, and neurologic outcome was determined. Variables affecting the outcome were evaluated with univariate and multivariate methods, and a scoring system was devised to predict adverse outcome. RESULTS: A total of 41 infants born > or =35 weeks' gestational age with possibility of hypoxic-ischemic insult were enrolled. In all, 39 (95%) had known outcomes, of whom 17 (48%) had an abnormal neurologic outcome, including five deaths. The variables within the first hour of life correlating with the adverse outcome were 1- and 5-minute Apgar scores, intubation in the delivery room and cord/initial base-deficit > or =20 mmol/l. A scoring system was derived based on significant variables, and a score > or =5 had a 90% positive predictive value for abnormal outcome. Seizures, multiorgan failure and abnormal imaging studies were also significantly associated with abnormal outcome. CONCLUSIONS: The proposed scoring system, being highly predictive of outcome at 24 months' age, may be potentially useful in selecting subjects for preventive or therapeutic interventions to prevent or minimize neurologic morbidity due to hypoxic brain injury.

Dear all, consider the following scenario: a non-immune pregnant woman is incubated with morbilli around the time of birth. I'd be happy to hear about your experience/guidelines about maternal/congenital morbilli, especially your policies regarding immunoglobulin and immunization of the mother/child.

Dolphine liu have mailed the following x-ray pictures. 8th of June 11th of June 14th of June 22nd of June 26th of June