Hamed

@bimalc and @tarek Thank you both for your comments and sharing your experiences. I do understand your points and concerns. Our standard starting point for TFII is 50 ml/kg/d on day 0 for micro preemies, but we tailor the TFI for each case depending on mean arterial blood pressure, cardiac size on chest X-ray, ECHO heart findings, and urine output. Thus one preem may be receiving a TFI of 50 ml/kg/day on day 0 and another preem with the same GA and BW receiving a TFI of 80 ml/kg/d. Each case is different. In addition, our rate of increase is 10 ml/kg/d as a basic standard, but still, it could be higher depending on how the same factors mentioned above go In an NICU in Canada, the TFI was 60~80 ml/kg/d for micro preemies < 26 weeks GA, and 100 ml/kg/d for < 24 weeks GA, as a standard, and when these fluid volumes were not enough to maintain the BPs and there was poor peripheral perfusion indicated by high Lac and prolonged CRT, saline boluses were given and inotropes were considered. The daily rate of increase was as a standard 20 ml/kg, unless the prem was puffy or chest X-ray showed increased lung fluids, then daily increase in TFIs was decreased or skipped. I do not imply that one strategy is better than the other, however, tailoring the fluids and inotropes given per each preem`s condition for me sounds practical. We have a special session on tailoring IV fluids and inotropes for preterms next month in the 62nd annual conference of the Japanese society of neonatal health and development http://jsnhd62.umin.jp/en/abstract.html . This could be an important topic to be also discussed in next 99NICU meeting @Stefan Johansson

@Stefan Johansson Thanks a lot, no I wasn't aware of this recent Cochrane review. Thanks a lot. I will share it with my coworkers and colleagues.

Pain control in preterms. Umbilical cord milking. Management of seizures during cooling and rewarming. Targeted ECHO and Ultrasound for neonatologists. Decision making in case of ELGAN ( how to help parents decide their baby`s management pathway). Methods for breaking hard news to parents about their baby or in an antenatal consultation. Including families in NICU rounds and care of their infant. Latest updates on modes of ventilation. Effective with time and effort efficient policy for daily rounds (How to make it successful for the patients, their parents, and medical staff).

Hi Tarek, Your experience with this 600 g ELBW is not uncommon. It is important to mention the gestational age in your description of the case. It can help the reader give you a more practical answer. I am assuming this was a 24 ~ 25 weeker infant unless it was also an IUGR. To minimize IVH you have special concerns to cover: A- Before birth giving mom Antenatal steroids. B- Delivery: 1-With minimal handling as possible. 2- Cord milking and delay cord clamping C- After delivery: 1- Positioning the head and body in same line ie not tilting the head to one direction lt or rt which will kink the neck (Jugular) veins and cause congestion of the bain of that side. 3-Prophylactic indomethacin (indicated in Japan if BW less than 1000 g + GA below 28 wks/ and in some NICUs in Canada if GA is less than 26+0 wks whatever the body weight is). 4- Correcting acidosis. 5- Maintain a good circulatory volume and start low IV fluids with a TFI at 50 ml/kg/d on DOL 0 and increase fluids by 10 ml/kg/day, unless the circulatory volume is low then you have to balance it. 6- Minimal handling. First 3 days are the highest risk time for IVH development. As for your concerns about intubation especially when there is no experienced medical team member (physician or RT), that depends on your unit`s policy for staff coverage. However, I recommend you not to jump quickly to intubation, a lot of 23, 24 and 25 weekers manage to escape from being intubated using CPAP and NIPPV.

Hi Bimlac and thanks for asking, Midazolam infusion is one of the 2nd line AEDs in Japan, and the most commonly used one when the infant is intubated. I myself prefer Keppra over both Midazolam and fosphenytoin. Especially, during cooling. Midazolam causes hypotension and fosphenytoin has several side effects as well as, it's hard to reach and maintain a therapeutic level using fosphenytoin. In Japan Keppra is not yet accepted for use in children under 4 years of age unless the treating doctor submits a special request to use it. According to my practice, Keppra showed almost no side effects during using as a 2nd AED in infants with and without cooling. If the infant is not intubated, fosphenytoin takes place as the most commonly used 2nd AED.

I agree with treating recurrent electrical seizures, however, what frequency of seizures and how long is each seizure until we would tolerate until starting AED or adding a 2nd one that is a concern which needs to be clarified. So long that it is not yet clearly outlined, I would go with what Stefan mentioned using a trigger for AEDs use, increase or addition of another line if > 2 seizure episodes. However, yet it is not clear is the > 2 episodes time-related? i.e. > 2 episodes in 3~6 hrs or in 12 ~ 24 hrs.

Thanks very informative. What is your protocol for giving Caffeine in apnea of prematurity i.e. Preventive or therapeutic? If preventive when do you start giving it? Do you give Caffeine before extubation of prematures ? Even if no apnea is seen during intubation and mechanical ventilation? If apnea is still present beyond 34 weeks corrected GA will you keep giving caffeine? (after excluding GERD). Are you with giving a 2nd loading if apnea is still present despite being on caffeine (taken that caffeine serum level measurement is not available)? Are you weaning by maintaining the initial dose of caffeine and the infant is BW is growing and thus inducing a spontaneous weaning? Thank you.

@chandas Thanks a lot for sharing the article Keszler M, et al. Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema. J Pediatr 1991;119:85-93. It's a very conclusive article. The study used low PEEPs ( > 5 cm H2O), high resp. rates 60~100 BPM, low Tis 0.2 ~ 0.35 sec, and PIP guided by adequate chest wall movement and gas exchange. Lower pressures were targeted even at the cost of higher FIO2. It's clear, however, unfortunately, the authors didn't show how low did they go on the PEEPs and what was/were the indicator/s for how low they can go on PEEPs. Did they use PEEPs of 1 or 2 cm H2O and would that make any difference? We had a discussion in the NICU and it is hard to convince the team with PEEPs below 4 cm H2O. @mosarrat & @Stefan Johansson Thank you for your comments, really appreciated. I am attaching the article Keszler M, et al. Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema. J Pediatr 1991;119:85-93. I marked the site of CMV ventilatory settings. If you have an article which supports higher PEEPs in PIEs, I would really appreciate if you could share it with me, as both high PEEP and low PEEP were challenged in our unit`s discussion. Lower PEEP in CMV for PIE.pdf

According to my knowledge, if I have a case with PIE and I would like to use a conventional ventilator, I would use a low PEEP. Does anyone have an article which mentions that? In addition, can anyone let me know the settings they use on conventional ventilation for PIEs, using both with volume guaranteed and without? Thanks

We actually usually use HFNC as a step down from CPAP. However, sometimes we give it a try from the start after extubation in preterms who are doing well and have a good compliance " static compliance" on Resp. function test before extubation. Our starting flow is about 3~5 L/Kg. We weaning we go at a rate of 0.5 L q 12 hrs.

Hi Stefan, I am not sure if I understand your answer. Do you mean that you check the aEEG on daily basis i.e. every 12 or 24 hrs and see if seizures are increasing or decreasing to consider treating? According to my practice, once the aEEG shows a seizure or the baby shows a clinical seizure we start phenobarbital (PB). Later on during cooling, if the aEEG shows seizures in spite that the PB level in the blood is within the therapeutic range we add another (2nd) antiepileptic drug (AD) for example Midazolam. We continue to increase the 2nd AD if the seizure activity is still present until it stops or we reach the maximum dose of Midazolam. I mean by "seizure activity" here if even there is an aEEG seizure activity every six or 12 hrs. We actually don't wait to count them. Once there is a seizure we proceed further. In addition, when the baby receives PB we depend mainly on the aEEG because it causes uncoupling. Could you please make it clearer for me?

Is Recooling for Rebound Seizures After Rewarming in Neonatal Encephalopathy a common practice in your NICU? I could only find a case report to support this practice "Recooling for Rebound Seizures After Rewarming in Neonatal EncephalopathyPediatrics. 2012 Aug;130(2):e451-5". However, I know it is widely used in Canada and is stated in the CPS guideline posted in 2012 and reaffirmed in 2017.

We actually depend on aEEG finding to treat seizures. Especially, if the infant is already on PB considering the phenomenon of uncoupling.