hehady

Merry Xmass and Happy New Year

Femoral fractures after CS are ususally iatrogenic due to difficuty in extracting the baby. Otherwise multiple fracture can be seen in diseases like oseogenesis imperfecta

As far as I know there is no evidence that keeping babies NPO during blood transfusion will reduce the incidence of NEC. Are you intersted in doing a RCT? do you have some lab animal data or observational studies?

Please refer to the following articles: 1- Chessex P, Harrison A, Khashu M, Lavoie JC. In preterm neonates, is the risk of developing bronchopulmonary dysplasia influenced by the failure to protect total parenteral nutrition from exposure to ambient light? J Pediatr. 2007 Aug;151(2):213-4. 2: Khashu M, Harrison A, Lalari V, Gow A, Lavoie JC, Chessex P. Photoprotection of parenteral nutrition enhances advancement of minimal enteral nutrition in preterm infants. Semin Perinatol. 2006 Jun;30(3):139-45. 3: Lavoie JC, Rouleau T, Gagnon C, Chessex P. Photoprotection prevents TPN-induced lung procollagen mRNA in newborn guinea pigs. Free Radic Biol Med. 2002 Aug 15;33(4):512-20. 4: Chessex P, Laborie S, Lavoie JC, Rouleau T. Photoprotection of solutions of parenteral nutrition decreases the infused load as well as the urinary excretion of peroxides in premature infants. Semin Perinatol. 2001 Apr;25(2):55-9. Review. 5: Laborie S, Lavoie JC, Chessex P. Increased urinary peroxides in newborn infants receiving parenteral nutrition exposed to light. J Pediatr. 2000 May;136(5):628-32. 6: Baird LL. Protecting TPN and lipid infusions from light: reducing hydroperoxides in NICU patients. Neonatal Netw. 2001 Mar;20(2):17-22. Review. 7: Lavoie JC, Belanger S, Spalinger M, Chessex P. Admixture of a multivitamin preparation to parenteral nutrition: the major contributor to in vitro generation of peroxides. Pediatrics. 1997 Mar;99(3):E6.

After the great success of the first course last May and owing to increasing pressure from our colleagues who could not attend it, we are glad to offer you a new opportunity to join the 2nd course. The course will cover all topics related to neonatal ventilation starting from basic pulmonary physiology, basics and modes of ventilation, CPAP, High frequency ventilation, care of the ventilated baby, pulmonary graphics, CXR and ABG interpretations, surfactant therapy, complications of mechanical ventilation. We will also offer interactive case scenarios, hands on practice sessions on CPAP, CMV, HFOV, chest tube and PICC line insertion. There will be daily clinical rounds with discussion on topics related to mechanical ventilation. The course faculty will be our staff in Mansoura University Children's Hospital. If you do work in a teritary neonatal care unit that provides care for neonates with respiratory problem, this course will be a great chance for you to upgrade your practice. If you are intersted please contact me at my e-mail or contact our NICU's secretary

Dear Stefan. It is a great idea. We should share our educational resources. How can we submit photos?

Happy birthday. Stefan and Alexander deserve a special thanks for their efforts

Dear Egyptian Memebrs: We are arranging a neonatal ventilation course from 28-5-2007 to 1-6-2007, the course will be held in the auditorium of Mansoura University Children's Hospital, Course faculty will include Neonatology Staff memebrs from our NICU as well as a distinguished speaker from USA (surprise will be announced later), the course will cover major aspects of ventilation; topics like pulmonary physiology, basics of mechanical ventilation, modes of ventilation, CPAP, HFV, surfactant therapy, weaning of mechanical ventilation, complications of ventilation, oxygen therapy, interpretation of ABG and CXR. Hands on practice sessions with training on ventilators like Draeger 8000 + conventional and HFV, Benett, Bearcup ventilators; Bubble CPAP, Flow-driver CPAP, interactive case scenarios on mechanical ventilatoion using simulators etc. I think it will be a major event with a lot of topics to cover for those intersted in ventilation. there will be a limited number of seats. Please reserve early. The course fees will be very cheap with opportunities for young residents and fellows for reduced fees. Those intrseted can contact our secretary or contact me personally on my e-mail

Please check senstivities to Tazobactam, ciprofloxacin

In our institution the decision of discontinuation of life support will be after a joint meeting with the parents and the consultants of the unit. We do respect parents opinion to continue life support, but many parents agree to withdraw life support in situations like ventilator dependent-severe HIE, grade 4 IVH and PVL, untreatable inborn errors of metabolism

Breast feeding is the best for initial feedings (evidence based). Oral glucose increases feeding intolerance and aspiration (personal experience)

There is only one study from UK. Not yet published, but presented in PAS 2006 Meeting and ESPR 2006 Meeting

Dear Alexander I meant both conditions

When would you consider giving Na Bicarbonate for your neonates? What is the dosage? and how fast would you give it?

I'd like to share with you you experinces in respiratory morbidities in late preterm (near term ) infants? Need for CPAP? Need for surfactant? Need for Mechanical ventilation? In your opinion what is the best timing for an elective CS?

Point one: Neither hypertension nor diabetes are contraindications to antenatal steroids PArt two: Repeated courses please look at the NIH Consensus Statement Volume 17, Number 2 August 17–18, 2000 *The collective international data continue to support unequivocally the use and efficacy of a single course of antenatal corticosteroids using the dosage and interval of administration specified in the 1994 Consensus Development Conference report. • The current benefit and risk data are insufficient to support routine use of repeat or rescue courses of antenatal corticosteroids in clinical practice. • Clinical trials are in progress to assess potential benefits and risks of various regimens of repeat courses. Until data establish a favorable benefitto- risk ratio, repeat courses of antenatal corticosteroids, including rescue therapy, should be reserved for patients enrolled in clinical trials.

Hypothermia may be the only hope for asphyxiated infants. The evidence from 2 large RCTs supports the use of selective head cooling and total body hypothermia, However the evidence is not that clear and it is premature to recommend brain cooling until results of more trials like the TOBY trial are published and a metanalysis completed. 1- CooLCAP trial ( Gluckman PD, Wyatt JS, Azzopardi D, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet 2005;365:663-70). 234 term infants with moderate to severe neonatal encephalopathy and abnormal amplitude integrated electroencephalography (aEEG) were randomly assigned to either head cooling for 72 h, within 6 h of birth, with rectal temperature maintained at 34–35°C (n=116), or conventional care (n=118). Primary outcome was death or severe disability at 18 months. Analysis was by intention to treat. We examined in two predefined subgroup analyses the effect of hypothermia in babies with the most severe aEEG changes before randomisation—ie, severe loss of background amplitude, and seizures—and those with less severe changes. Findings In 16 babies, follow-up data were not available. Thus in 218 infants (93%), 73/110 (66%) allocated conventional care and 59/108 (55%) assigned head cooling died or had severe disability at 18 months (odds ratio 0·61; 95% CI 0·34–1·09, p=0·1). After adjustment for the severity of aEEG changes with a logistic regression model, the odds ratio for hypothermia treatment was 0·57 (0·32–1·01, p=0·05). No difference was noted in the frequency of clinically important complications. Predefined subgroup analysis suggested that head cooling had no effect in infants with the most severe aEEG changes (n=46, 1·8; 0·49–6·4, p=0·51), but was beneficial in infants with less severe aEEG changes (n= 172, 0·42; 0·22–0·80, p=0·009). Interpretation These data suggest that although induced head cooling is not protective in a mixed population of infants with neonatal encephalopathy, it could safely improve survival without severe neurodevelopmental disability in infants with less severe aEEG changes. 2- NICDH Whole Body Hypothermia Trail (Shankaran S, Laptook AR, Ehrenkranz RA, et al. Whole-body hypothermia for neonates with hypoxic–ischemic encephalopathy.N Engl J Med 2005;353:1574-84. Of 239 eligible infants, 102 were assigned to the hypothermia group and 106 to the control group. Adverse events were similar in the two groups during the 72 hours of cooling. Primary outcome data were available for 205 infants. Death or moderate or severe disability occurred in 45 of 102 infants (44 percent) in the hypothermia group and 64 of 103 infants (62 percent) in the control group (risk ratio, 0.72; 95 percent confidence interval, 0.54 to 0.95; P=0.01). Twenty-four infants (24 percent) in the hypothermia group and 38 (37 percent) in the control group died (risk ratio, 0.68; 95 percent confidence interval, 0.44 to 1.05; P=0.08). There was no increase in major disability among survivors; the rate of cerebral palsy was 15 of 77 (19 percent) in the hypothermia group as compared with 19 of 64 (30 percent) in the control group (risk ratio, 0.68; 95 percent confidence interval, 0.38 to 1.22; P=0.20). Conclusions Whole-body hypothermia reduces the risk of death or disability in infants with moderate or severe hypoxic–ischemic encephalopathy. In developing countries economic methods for cooling like ice bags, electric fan may be used, however, the problem will be the availability of aEEG machines which are expensive, yet, very crucial for the selection of infants in hypothermia trials. We had difficulty in enrolling infants in multicenter trials because of that. Any suggestions for some research group that can provide us with aEEG and we can paricipate in a RCT that looks at economic methods of head cooling that can be applied in developing countires (where the problem of asphyxia is more common and number of babies who can benifit is larger)

Abnormalities in early aEEG (within 3 hours of birth) can be a useful adjunt to blood gas abnormalities (sepcifically a base deficit > 10 mEq/L) in umbilical or early arterial blood sample and clinical evidence (Apgar score at 5 minutes < 5; delayed first brith, antenatal evidence (Abnormalities in FHR tracing).

We still use Amp. and Gent. for early onset sepsis

Our experience with Babylog 8000+ is not bad. Yet it is not as powerful as sensormedics and SLE 5000 in the HFV mode

These are excellent books. Yet, I believe you can access nice papers, lectures and webcasts from experts on these sites (for free): http://www.emedicine.com http://www.freemedicaljournals.com/ http://www.nicuniversity.org/newsviews.asp http://www.gfmer.ch/400_Publications_En.htm http://www.or-live.com/ http://www.pae.cuhk.edu.hk/IPOKRaTES%20Handouts/Title%20Page.htm

It is true Jes. That was your practice in Rigshospitalet, when I worked in your unit in the late 90s for 2 years. It is surprising that you experience resistant infections in your units (very low nosocomial sepsis rate). In developnig countries like Egypt we had greater problem with nosocomial sepsis, Klebseilla pneumonia is the commonest organism and about 66% of strains are ESBL producers according to a recent study we have just finnished. It is my practice to give meropenem + vancomycin whenever we encounter nosocmial sepsis pending results of C&S. This practice is exe=cellent according to our practice (Experience rather than evidence-based), we are actually in a situation where most neonatologist will not accept a RCT comparing this practice with other antibiotics. I woudl also add that the wide use of cefotaxime and other cephalosporines in our unit in the 80s and 90s was probably one factor for the development of ESBL gram negative strains. We do not expeience resistance to these antibiotic combination till now as 100% of our gram negative strains we sensitive to meropenem. I do not know what will happen in the future with the deveolpemnt of more resistant bugs.

Dear Stefan Lipids and multivitamines are particularliy involved in peroxides production on exposure to light. Using special bags or covering TPN solutions with alminum foil may be a good practice.

A number of researchers have demonstarted that covering TPN solutions would decrease peroxide load. We have just finnished a RCT in our institution and we had similar reults. We are updating our guidelines and we are searching for other institutions guidelines

Do you routinely cover TPN solution? How?