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AllThingsNeonatal

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Everything posted by AllThingsNeonatal

  1. Let me start off by giving thanks to John Minski for this article and in fact for many others that have been reviewed on this blog. John is a registered respiratory therapist in Winnipeg with a passion for respiratory care like no other. John frequently sends articles my way to think about for our unit and this one was quite sensational to me. As readers of this blog I thought you might find it pretty interesting as well. Why Would A Mask Cause Apnea To begin with this seems counterintuitive as don’t we use masks when babies are apneic to help them breathe? While this is true an
  2. In recent years we have moved away from measuring and reporting gastric residuals. Checking volumes and making decisions about whether to continue feeding or not just hasn’t been shown to make any difference to care. If anything it prolongs time to full feeds without any demonstrable benefits in reduction of NEC. This was shown in the last few years by Riskin et al in their paper The Impact of Routine Evaluation of Gastric Residual Volumes on the Time to Achieve Full Enteral Feeding in Preterm Infants. Nonetheless, I doubt there is a unit in the world that has not had the following situation h
  3. If you work in Neonatology you no doubt have listened to people talk in rounds or at other educational sessions about the importance of opening the lung. Many units in the past were what you might call “peepaphobic” but over time and with improvements in technology many centers are adopting an attitude that you use enough PEEP to open the lung. There are some caveats to this of course such as there being upper limits to what units are comfortable and not just relying on PEEP but adding in surfactant when necessary to improve pulmonary compliance. When we think about giving nitric oxide
  4. It seems so simple doesn’t it. Shouldn’t we just be able to feed milk whether it be from humans or cows and our preemies will just adapt? I have often written about human milk diets vs those with bovine but this week an intriguing article came my way that really gave me some pause to say hmmm. Human milk diets have been shown to reduce the risk of necrotizing enterocolitis (NEC) compared to use of formula. The use of bovine human milk fortifiers falls somewhere in the middle I suppose as the diet in that case is mostly human milk with some bovine sprinkled in so to speak. If NEC is something t
  5. It is certainly an interesting thought. I think the key though is minimizing trauma to the alveoli. Keeping on any positive pressure even if the volumes are set low I worry could lead to damage. Would need to be tested though as I believe you are suggesting in a trial
  6. Intubate-Surfactant- Extubate or INSURE has been around for awhile. The concept is to place an ETT while an infant is first on CPAP and then after pushing surfactant in quickly remove the ETT and put back on CPAP. This does not always go as planned though. If after surfactant the FiO2 remains above 30% many people would keep the ETT in place as they would surmise that the infant would fail if the tube was removed. They would probably be right. Sustained inflations have fallen out of favour ever since the SAIL trial results were published and written about here . Having said that, the c
  7. I recently had the honour of being asked to present grand rounds at the University of Manitoba. My former Department Head during the question period stumped me when he asked me what role angiotensin converting enzyme 2 receptor (ACE2) has in pediatric COVID19. Like all great teachers, after I floundered and had to confess that while I was aware there is a role in COVID19 I wasn’t sure of the answer, he sent me a paper on the subject. The reality is that a very small percentage of COVID19 illness is found in children. Some estimates have it at 2%. Why might that be? It’s what’s in the n
  8. Phenobarbital at least where I work has been first line treatment for seizure control for as long as I can recall. We dabbled with using phenytoin and fos-phenytoin in the past but the go to tried and true has been phenobarbital for some time. The use of this drug though has not been without trepidation. Animal studies have linked phenobarbital to increases rates of cerebral apoptosis. Additionally, in a retrospective comparison of outcomes between seizures controlled with phenobarbital vs Levetiracetam, the latter came out ahead in terms of better long term developmental outcomes. This study
  9. It’s Father’s Day so why not put out a post about a role for father’s in resuscitation. Given that we are talking about a parent being present for resuscitation after delivery and the mother will have just delivered, what follows is a discussion about having the other parent present at the ensuing resuscitation if needed. This will of course not always be a father as in female same sex parenting so what follows could apply to any situation in which there are two parents present and one has just delivered. Since I was a resident this question has been batted around. During a resuscitati
  10. It isn’t often I have had the pleasure of reviewing a paper from my own center (maybe because I have been reticient to critique my colleagues) but this paper I couldn’t resist. If my colleagues are reading this then I will provide a spoiler alert that I am not planning on trashing the paper. A few years ago my colleague Dr. Yasser El Sayed (who many of you will know from his work on targeted echocardiography and ultrasound and most recently on www.pocusneo.ca) began touting the benefits of vasopressin as an inotrope. I have to confess, my knowledge of the drug was mostly at that point as a mol
  11. We would do so but to be truthful we have had a very low burden of COVID illness in my province and so haven't had to deal with this issue of cleaning yet. If we had a ventilated infant with covid we would use an uncuffed tube but still put a viral filter on the inspiratory and expiratory limb of the ventilator. We would also put them in a negative pressure isolation room
  12. After several reports providing reassurance to breastfeeding mothers, two very recent reports are giving me reason to pause. The Canadian Pediatric Society has been recommending breastfeeding if a mother has COVID19 with precautions in place; Breastfeeding when mothers have suspected or proven COVID-19. It would be heresy to suggest that a mother not be permitted to breastfeed her infant but what follows are two reports that at the very least may need to enter the discussion when a COVID19 positive mother gives birth and is deciding about route of feeding. Toronto Case Report Th
  13. After developing a community of over 23000 people unfortunately I had to close my Facebook site due to concerns over a hack. Not to worry as I have created a new independent site to share information daily in Neonatology. I look forward to building an audience at this site and working to continue the dialogue I have come to enjoy with all the followers. I look forward to seeing you there! The New Site is at: https://www.facebook.com/allthingsneonatal2
  14. I doubt there is a unit in the world where at least once a day a discussion ensues about whether an infant is ready to wean or come off their CPAP. For many years we have made the decision based on a variety of markers. Some people would comment on the work of breathing, others on the FiO2 or what the oxygen saturations are at the moment as we round on the patient. Our unit has been pulling oxygen histograms off the patient monitor for years now to provide a more objective measurement to determine if an infant is ready or not. What is a histogram? It is a bar graph representation of the percen
  15. Good morning or evening everyone! As we move thorough these turbulent times everyone has questions about how this story will end. My experience with social media has been one that has been evolving for some time. Recently with so many questions about COVID19 I opted for setting up Facebook Live video sessions and although they aren't a visual question and answer session they do allow for people who are watching to make comments. One of my favourite sessions so far has been with Stefan from 99nicu as shown here! https://www.youtube.com/watch?v=AwNGxiYvgLg&list=PLHmYb5bfg4U3RuEO
  16. You might think this title is a joke but it is actually quite serious. Volatile organic carbons (VOCs) are what give stool it’s characteristic and often very malodorous scent. These same VOCs though could serve as biomarkers for preemies at risk of NEC. In fact previous research using an artificial nose has suggested as much. In 2015 de Meij TGJ et al published a study looking at VOCs entitled Early detection of necrotizing enterocolitis by fecal volatile organic compounds analysis. They used an electronic nose to try and detect changes in VOCs before the onset of NEC. This study which include
  17. I had the pleasure of being asked to speak to a Canadian audience of people working with newborns yesterday about the new CPS practice points for managing deliveries and newborns with suspected or proven COVID-19. Something fascinating happened over the course of the discussion and that was that we are a country divided. It didn’t help that the week prior to the CPS releasing their practice points the American Academy of Pediatrics released the following position: “Precautions for birth attendants: Staff attending a birth when the mother has COVID-19 should use gown and gloves, with ei
  18. This is another hot topic out there as centers around the world struggle to determine how best to manage the mother who has contracted COVID-19 in pregnancy. There are resources out there already such as the CDC which states the following. The World Health Organization also has this to say as of yesterday. The question though is where do these recommendations come from? How strong is the evidence? Let’s begin with another Coronavirus Do you remember SARS? This was another coronavirus. Wong SF et al published Pregnancy and perinatal outcomes of women w
  19. We are living in challenging times but, as a community caring for neonates and their families, we will get through this together. Canadians and others around the world are digesting a great deal of information in order to come up with a best approach to caring for mothers and infants with either suspected or confirmed COVID-19 infections. It is an imperfect science for sure as we have scarce information to go on but you may find it helpful to look at what centres are doing in terms of their approaches to delivery and care in the NICU. Please note that these are being posted in an attempt to
  20. This week on social media this seemed to be a hot topic. What should we do to protect ourselves as we start to see more mothers infected or at least suspected of having COVID-19 presenting in labour. Should we be assuming all of these infants are infected and if so should we all don personal protective equipment (PPE) including the N95 mask? Let’s see what we know so far. The Media The big concern with this began after a report of a 36 hour old newborn in China contracting the virus. This was published in Clinical Infectious Diseases in the paper A case report of n
  21. One of the most common conditions afflicting ex-preterm infants is chronic lung disease. Through advances in antenatal steroids, surfactant and modern ventilation we have done what we can to try and prevent this condition from occurring yet despite our best efforts CLD remains a common problem among those born at less than 1500g as is shown in the 2018 Canadian Neonatal Network data. Primary prevention is of course the ideal strategy to reduce disease but when you try and your best and an infant still has chronic lung disease what is one to do? For now we bide our time focusing on nutrit
  22. First off I should let you know that we do not do transpyloric feeding for our infants with BPD. Having said that I am aware of some units that do. I suspect the approach is a bit polarizing. A recent survey I posted to twitter revealed the following findings: I think the data from this small poll reveal that while there is a bias towards NG feeds, there is no universal approach (as with many things in NICU). Conceptually, units that are using transpyloric feeds would do so based on a belief that bypassing the stomach would lead to less reflux and risk of aspiration. The ques
  23. Inhaled nitric oxide has been around for some time now. I recall it being called at one point in medical school “endothelial relaxation factor” and then later on identified as nitric oxide. Many years later it finds itself in common usage in NICUs all over the world. Our experience though has been for treatment of pulmonary hypertension and for that it is pretty clear that for those afflicted by that condition it can be lifesaving. Over the years other uses have been looked at including prevention of BPD (turned out not to be the case). Rescue approaches therefore have found to be useful but o
  24. The Ortolani and Barlow manouvers are probably the two most requested parts of the physical exam that students ask to be shown. We line up several medical students who take turns applying the steps of abduction and then adduction, testing the stability of the hips. We routinely give oral sucrose, position in kangaroo care or breastfeed while performing other noxious stimuli such as heel lancing but at least in my centre give nothing for manipulating the hips in such a fashion. How can we determine if a newborn feels pain? In a recent paper entitled Neurophysiological and behavi
  25. Oral immune therapy (OIT) has really taken off at least in our units. The notion here is that provision of small amounts (0.2 mL intrabucally q2or 24 hours) can prime the immune system. Lymphoid tissue present in the oropharynx and intestine exposed to this liquid gold in theory will give the immune system a boost and increase levels of IgA. Such rises in IgA could help improve the mucosal defence barrier and therefore lessen the incidence of late onset sepsis. Rodriguez et al described this in their paper Oropharyngeal administration of colostrum to extremely low birth weight infants: theoret
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