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Found 13 results

  1. Neonatal Hemodynamics: From Developmental Physiology to Comprehensive Monitoring https://www.frontiersin.org/articles/10.3389/fped.2018.00087/full?
  2. Caffeine seems to be good for preterm infants. We know that it reduces the frequency of apnea in the this population and moreover facilitates weaning off the ventilator in a shorter time frame than if one never received it at all. The earlier you give it also seems to make a difference as shown in the Cochrane review on prophylactic caffeine. When given in such a fashion the chances of successful extubation increase. Less time on the ventilator not surprisingly leads to less chronic lung disease which is also a good thing. I have written about caffeine more than once though so why is this post different? The question now seems to be how much caffeine is enough to get the best outcomes for our infants. Last month I wrote about the fact that as the half life of caffeine in the growing preterm infant shortens, our strategy in the NICU might be to change the dosing of caffeine as the patient ages. Some time ago though I wrote about the use of higher doses of caffeine and in the study analyzed warned that there had been a finding of increased cerebellar hemorrhage in the group randomized to receive the higher dosing. I don’t know about where you work but we are starting to see a trend towards using higher caffeine base dosing above 5 mg/kg/d. Essentially, we are at times “titrating to effect” with dosing being as high as 8-10 mg/kg/d of caffeine base. Does it work to improve meaningful outcomes? This month Vliegenthart R et al published a systematic review of all RCTs that compared a high vs low dosing strategy for caffeine in infants under 32 weeks at birth; High versus standard dose caffeine for apnoea: a systematic review. All told there were 6 studies that met the criteria for inclusion. Low dosing (all in caffeine base) was considered to be 5- 15 mg/kg with a maintenance dose of 2.5 mg/kg to 5 mg/kg. High dosing was a load of 5 mg/kg to 40 mg/kg with a maintenance of 2.5 mg/kg to 15 mg/kg. The variability in the dosing (some of which I would not consider high at all) makes the quality of the included studies questionable so a word of warning that the results may not truly be “high” vs “low” but rather “inconsistently high” vs. “inconsistently low”. The results though may show some interesting findings that I think provide some reassurance that higher dosing can allow us to sleep at night. On the positive front, while there was no benefit to BPD and mortality at 36 weeks PMA they did find if they looked only at those babies who were treated with caffeine greater than 14 days there was a statistically significant difference in both reduction of BPD and decreased risk of BPD and mortality. This makes quite a bit of sense if you think about it for a moment. If we know that caffeine improves the chances of successful extubation and we also know it reduces apnea, then who might be on caffeine for less than 2 weeks? The most stable of babies I would expect! These babies were all < 32 weeks at birth. What the review suggests is that those babies who needed caffeine for longer durations benefit the most from the higher dose. I think I can buy that. On the adverse event side, I suppose it shouldn’t surprise many that the risk of tachycardia was statistically increased with an RR of 3.4. Anyone who has explored higher dosing would certainly buy that as a side effect that we probably didn’t need an RCT to prove to us. Never mind that, have you ever taken your own pulse after a couple strong coffees in the morning? What did it not show? It’s what the study didn’t show that is almost equally interesting. The cerebellar hemorrhages seen in the study I previously wrote about were not seen at all in the other studies. There could be a lesson in there about taking too much stock in secondary outcomes in small studies… Also of note, looking at longer term outcome measures there appears to be no evidence of harm when the patients are all pooled together. The total number of patients in all of these studies was 620 which for a neonatal systematic review is not bad. A larger RCT may be needed to conclusively tell us what to do with a high and low dosing strategy that we can all agree on. What do we do though in the here and now? More specifically, if you are on call tomorrow and a baby is on 5 mg/kg/d of caffeine already, will you intubate them if they are having copious apneic events or give them a higher dose of caffeine when CPAP or NIPPV that they are already on isn’t cutting it? That is where the truth about how you feel about the evidence really comes out. These decisions are never easy but unfortunately you sometimes have to make a decision and the perfect study hasn’t been done yet. I am not sure where you sit on this but I think this study while certainly flawed gives me some comfort that nothing is truly standing out especially given the fact that some of the “high dose” studies were truly high. Will see what happens with my next patient!
  3. This is a title that I hope caught your eye. In the nearly twenty years I have been in the field of Pediatrics the topic of parking being a barrier to parental visitation has come up again and again. A few years ago the concern about the cost of parking was so great that I was asked if I could find a pool of donors to purchase parking passes to offset the burden to the family. The theory of course is based on the idea that if parking were free in the NICU parents would visit more. If parents visit more they will be more involved in the care of their baby, more likely to breastfeed and with both of these situations in play the infant should be discharged earlier than other infants whose parents don’t visit. Try as I might it was a tough sell for donors who tend to prefer buying something more tangible that may bear their name or at least something they can look at and say “I bought that”. This is quite tough when it comes to a parking stall and as such I am still looking for that elusive donor. Having said that, is there any basis to believe that free parking is the solution that will deliver us from minimal visitation by some parents? A Study May Help Answer The Question Northrup TF et al published an article that was sent my way and to be honest I couldn’t wait to read it. A free parking trial to increase visitation and improve extremely low birth weight infant outcomes. This is like the holy grail of studies. A study that gets right to the point and attempts to answer the exact question I and others have been asking for some time. The study took place in Houston, Texas and was set up as an RCT in which families were randomized into two groups. Inclusion criteria were birth weight ⩽1000 g, age 7 to 14 days and deemed likely to survive. Seventy two patients were enrolled in the free parking group while 66 were placed in the usual care. Interestingly the power calculation determined that they would need 140 to show a difference so while 138 is close it wasn’t enough to truly show a difference but let’s see what they found. The Results Free parking made absolutely no difference for the whole group. Specifically there was no difference in the primary outcome of length of stay or hours spent per visit. Some interesting information though that may not be that surprising was found to be of importance in the table below. It may not seem like a surprise but the patients who were more affluent and those who had less children tended to visit more. The latter makes a lot of sense as what are many people to do when they have one or more other children to care for at home especially in the face of little support? Would free parking make one iota of difference if the barrier has nothing to do with the out of pocket cost? The conclusion was that the strategy didn’t work that well but as you may have picked up I think the study was flawed. By applying the strategy to all they were perhaps affected by choosing the wrong inclusion criteria. Taken to an extreme, would a 50 million dollar Powerball winner care one bit about parking vouchers? It wouldn’t make any difference to whether they were going to come or not. Similarly a single mother with 5 other kids who lives below the poverty line and has little support is not going to come more frequently whether they have a voucher or not. What if the study were redone? I see a need to redo this study again but with different parameters. What if you randomized people with a car or access to one who lived below a certain income level and had a committed support person who could assure that team that they could care for any other children the family had when called upon? Or one could look at families with no other children and see if offering free parking led to more frequent visitation and then from there higher rates of Kangaroo Care and breastfeeding. I for one haven’t given up on the idea and while I was truly excited to be sent this article and sadly initially dismayed on first read, I am hopeful that this story has not seen it’s end. It is intuitive to me that for some parents parking is a barrier to visiting. Finding the right population to prove this though is the key to providing the evidence to arm our teams with evidence to gain support from hospital administrations. Without it we truly face an uphill battle to get this type of support for families. Stay tuned…
  4. AllThingsNeonatal

    Autopilot Non-Invasive Ventilation

    I had a chance recently to drive a Tesla Model S with autopilot. Taking the car out on a fairly deserted road near my home I flicked the lever twice to activate the autopilot feature and put my hands behind my head while the vehicle took me where I wanted to go. As I cruised down the road with the wheel automatically turning with the curves in the road and the car speeding up or slowing down based on traffic and speed limit notices I couldn’t help but think of how such technology could be applied to medicine. How far away could the self driving ventilator or CPAP device be from development? I have written about automatic saturation adjustments in a previous post but this referred to those patients on mechanical ventilation. Automatic adjustments of FiO2. Ready for prime time? Why is this goal so important to attain? The reasoning lies in the current design trends in modern NICUs. We are in the middle of a large movement towards single patient room NICUs which have many benefits such as privacy which may lead to enhanced breastfeeding rates and increased parental visitation. The downside, having spoken to people in centres where such designs are already in place is the challenge nursing faces when given multiple assignments of babies on O2. If you have to go from room to room and a baby is known to be labile in their O2 saturations it is human nature to turn the O2 up a little more than you otherwise would to give yourself a “cushion” while you are out of the room. I really don’t fault people in this circumstance but it does pose the question as to whether in a few years we will see a rise in oxygen related tissue injury such as CLD or ROP from such practice. In the previous post I wrote about babies who are ventilated but these infants will often be one to one nursed so the tendency to overshoot the O2 requirements may be less than the baby on non- invasive ventilation. A System For Controlling O2 Automatically For Infants on Non-Invasive Ventilation This month in Archives Dr. Dargaville and colleagues in Australia provide two papers, the first demonstrating the validation of the mathematical algorithm that they developed to control O2 and the second a clinical report outlining how well the system actually performed on patients. The theoretical paper Development and preclinical testing of an adaptive algorithm for automated control of inspired oxygen in the preterm infant. is a challenge to comprehend although validates the approach in the end while the clinical paper at least for me was easier to digest Clinical evaluation of a novel adaptive algorithm for automated control of oxygen therapy in preterm infants on non-invasive respiratory support. The study was really a proof of concept with 20 preterm infants (mean GA 27.5 weeks, 8 days of age on average) included who each underwent two hours of manual control by nursing to keep saturations between 90-94% and then 4 hours of automated control (sats 91 – 95%) then back to manual for two hours. The slightly shifted ranges were required due to the way in which midpoint saturations are calculated. The essential setup was a computer equipped with an algorithm to make adjustments in FiO2 using an output to a motor that would adjust the O2 blender and then feedback from an O2 saturation monitor back to the computer. The system was equipped with an override to allow nursing to adjust in the event of poor signal or lack of response to the automatic adjustment. The results though demonstrate that the system works and moreover does a very good job! The average percentage of time that the saturations were in the target range were significantly better with automated control (81% automated, 56% manual). As well as depicted in the following figure the amount of time spent in both hypoxic and hyperoxic ranges was considerable with manual control but non-existent on either tail with automated control (defined as < 85% or > 98% where black bars are manual control and white automatic). From the figure you can see that the amount of time the patients are in target range are much higher with automatic control but is this simply because in addition to automatic control, nurses are “grabbing the wheel” and augmenting the system here? Not at all. “During manual control epochs, FiO2 adjustments of at least 1% were made 2.3 (1.3–3.4) times/hour by bedside staff. During automated control, the minimum alteration to FiO2 of 0.5% was being actuated by the servomotor frequently (9.9 alterations/min overall), and changes to measured FiO2 of at least 1% occurred at a frequency of 64 (49–98) /hour. When in automated control, a total of 18 manual adjustments were made in all 20 recordings (0.24 adjustments/hour), a reduction by 90% from the rate of manual adjustments observed during manual control (2.3/hour).” From the above quote from the paper it is clear that automated control works to keep the saturation goal through roughly 7 X the number of adjustments than nursing makes per hour. It is hard to keep up with that pace when you have multiple assignments but that is what you need I suppose! The use of the auto setting here reduced the amount of nursing interventions to adjust FiO2 by 90% and yields tighter control of O2 saturations. Dare to Dream Self driving oxygen administration is coming and this proof of concept needs to be developed and soon into a commercial solution. The risk of O2 damage to developing tissues is too great not to bring this technology forward to the masses. As we prepare to move into a new institution I sincerely hope that this solution arrives in time but regardless I know our nurses and RRTs will do their best as they always do until such a device comes along. When it does imagine all of the time that could be devoted to other areas of care once you were able to move away from the non-invasive device!
  5. AllThingsNeonatal

    Hold Their Hand

    Each day the number of people following these sites grows and at the time of this post, the largest following on Facebook has over 8200 people who receive the feed on a daily basis. That is nothing short of remarkable and I hope that each of you gets something out of my writings and postings. I recognise that each post may not “light it up” in your mind but if you get at least a few “a ha” moments along the way then I am very happy that you have found these sites! What This Is Not! As I begin hinting at money, many of you may be thinking “here we go”, he is finally asking for some payment for this site! To be clear I have no interest in personal financial gain from this hobby I have developed, but rather find my joy in sharing ideas, getting your feedback and helping to generate interest overall in topics pertaining to Neonatology. I have no intention of ever asking for such payment but that doesn’t mean that I might not want to help someone else. For those of you who make philanthropy a part of your lives you will know the joy that comes from helping others. Being able to help others need not take tremendous dollars per donor when you have many people banding together to help a cause. This is the power that I am hoping to harness through this initiative and make a difference in care to our babies in hospital. For the past year and a half, I have put my fingers to the keyboard to hopefully share my knowledge and expertise with you about an industry I am so passionate about. My Philanthropic Side When I am not busy finding content for the sites or being a Neonatologist, I am quite dedicated to philanthropy. One thing people may not realise about our province/country is that the government helps out the best they can financially but with the heavy demands of our province, they can’t meet all the needs. That’s why I’m proud of my partnership with the Children’s Hospital Foundation of Manitoba. The Foundation’s donors have helped bridge the gap so our hospital doesn’t go without the specialised items they need. From ultrasounds, starting a breast milk depot, specialised pediatric equipment and funding a position to support Quality Improvement in our unit to a soon to be announced Family Support coordinator position and so much more. But now, I turn to you to help us make the next difference in our unit. The other day as the Facebook page hit 8,000 followers a thought struck me. What if I asked everyone on the page to just give $1 towards the purchase of a piece of equipment for babies in our units? Hold Their Hand In the Neonatal Intensive Care Unit (NICU), they are watched closely to make sure they are getting the right balance of fluids and nutrition. Incubators or special warmers help babies maintain their body temperature. This reduces the energy the babies have to use to stay warm and allow them to use that energy elsewhere. Premature babies need to receive good nutrition so they grow at a rate close to that of babies still inside the womb. Babies born under 38 weeks have different nutritional needs than babies born at full term (after 38 weeks). They often have problems feeding from a bottle or a breast. This is because they are not yet mature enough to coordinate sucking, breathing, and swallowing. Many NICUs will give donor milk from a milk bank to high-risk babies who cannot get enough milk from their own mother. But because the baby must be kept at a certain temperature to stay warm, so does their milk. Thanks to the generous support of donors to the Children’s Hospital Foundation of Manitoba, 12 milk warmers have been purchased. However, we need 24 more warmers to keep up with demand. Each one costs $2,000 and will make a huge impact. An impact to help our babies get the nutrition they need at the temperature they require to survive and thrive. So let’s hold their hand and let’s do it together! Has this journey of learning been worth at least $1 to you? If it has, then please help make a difference by giving at least $1. Giving more will only increase the power of this campaign! If you aren’t able to donate $1 or more, I ask that you share this post and challenge your friends to help make a difference to the over 1,000 patients we see a year. Click the link below to donate and make your difference today. chfm.convio.net/help-hold-their-hand
  6. Francesco Cardona

    Clinics in Perinatology

    Review Journal on perinatal topics
  7. Now that I have caught your attention it is only fair that I explain what I mean by such an absurd title. If you work with preterm infants, you have dealt with apnea of prematurity. If you have, then you also have had to manage such infants who seemingly are resistant to everything other than being ventilated. We have all seen them. Due to increasing events someone gives a load of methylxanthine and then starts maintenance. After a couple days a miniload is given and the dose increased with the cycle repeating itself until nCPAP or some other non-invasive modality is started. Finally, after admitting defeat due to persistent episodes of apnea and/or bradycardia, the patient is intubated. This, in the absence of some other cause for apnea such as sepsis or seizures is the methylxanthine resistant preterm infant. Seemingly no amount of treatment will amount to a reduction in events and then there is only so much that CPAP can do to help. What Next? Other strategies have been attempted to deal with such infants but sadly none have really stood the test of time. Breathing carbon dioxide might make sense as we humans tend to breathe quickly to excrete rising CO2 but in neonates while such a response occurs it does not last and is inferior to methylxanthine therapy. Doxapram was used in the past and continues to be used in Europe but concerns over impacts on neurodevelopment have been a barrier in North America for some time. Stimulating infants through a variety of methods has been tried but the downside to using for example a vibrating mattress is that sleep could be interfered with and there are no doubt impacts to the preterm infant of having weeks of disturbed sleep states on developmental outcomes. What if we could make our preterm infants walk? This of course isn’t physically practical but two researchers have explored this question by using vibration at proprioceptors in the hand and foot. Such stimulation may simulate limb movement and trick the brain into thinking that the infant is walking or running. Why would we do this?. It has been known for 40 years that movement of limbs as in walking triggers a respiratory stimulatory effect by increasing breathing. This has been shown in adults but not in infants but this possibility is the basis of a study carried out in California entitled Neuromodulation of Limb Propriceptive Afferents Decreases Apnea of Prematurity and Accompanying Intermittent Hypoxia and Bradycardia. This was a small pilot study enrolling 19 patients of which 15 had analyzable data. The design was that of alternating individual preterm infants born between 23 – 35 weeks to receive either vibratory stimulation or nothing and measuring the number and extent of apnea and bradycardia over these four periods. In essence this was a proof of concept study. The stimulation is likened to that felt when a cell phone vibrates as this was the size of device used to generate the sensation. The authors note that during the periods of stimulation the nurses noted no signs of any infant waking or seeming to be disturbed by the sensation. The results were quite interesting especially when noting that 80% of the infants were on caffeine during the time of the study so these were mostly babies already receiving some degree of stimulation Should we run out and buy these? The stimulation does appear to work but with any small study we need to be careful in saying with confidence that this would work in a much larger sample. Could there have been some other factor affecting the results? Absolutely but the results nonetheless do raise an eyebrow. One thing missing from the study that I hope would be done in a larger sample next time is an EEG. The authors are speculating that by placing the vibration over the hand and foot the brain is perceiving the signal as limb movement but it would have been nice to see the motor areas of the brain “lighting up” during such stimulation. As we don’t have that I am left wondering if the vibration was simply a form of mild noxious stimulus that led to these results. Of course in the end maybe it doesn’t matter if the results show improvement but an EEG could also inform us about the quality of sleep rather than relying on nursing report of how they thought the baby tolerated the stimulus. I know our nursing colleagues are phenomenal but can they really discern between quiet and active sleep cycles? Maybe some but I would guess most not. There will also be the naysayers out there that will question safety. While we may not perceive a gentle vibration as being harmful, with such a small number of patients can we say that with certainty? I am on the side of believing it is probably insignificant but then again I tend to see the world through rose coloured glasses. Regardless of the filter through which you view this world of ours I have to say I am quite excited to see where this goes. Now we just have to figure out how to manage the “real estate” of our infant’s skin as we keep adding more and more probes that need a hand or a foot for placement!
  8. AllThingsNeonatal

    A New Years Wish. Are We Up to It?

    I have been at this writing thing for almost a year and as I was approaching the end of 2015 my thoughts turned to asking myself what I have learned. There have been so many posts, in fact so many between the blog and Facebook posts that I have truly lost count. Having said that the posts have generally fallen into two dominant categories; those promoting a therapy or diagnostic tool and those suggesting that we should avoid certain practices. If I had to have one wish though it would be that we could improve upon our diagnostic accuracy when it comes to treating suspected infections in the newborn. As health care providers we have an extremely loud inner voice trying to tell us to minimize risk when it comes to missing a true bacterial infection. On the other hand so much evidence has come forth in the last few years demonstrating that prolonging antibiotics beyond 48 hours is not just unwise in the absence of true infection but can be dangerous. Increased rates of necrotizing enterocolitis is just one such example but other concerns due to interfering with the newborn microbiome have arisen in more recent years. What follows are some general thoughts on septic workups that may help you (and myself in my own practice) as we move ahead into the New Year and may we cause less harm if we consider these. The Role of Paired Blood Cultures Although not published by our centre yet, we adopted this strategy for late onset sepsis a couple years back and have seen a significant reduction in work-ups deemed as true infections since adoption. While the temptation to do only one blood culture is strong as we have a desire to minimize skin breaks consider how many more there will be if you do one culture and get a CONS organism back. There will be several IV starts, perhaps a central line, repeat cultures etc. If you had done two at the start and one was positive and the other negative you could avoid the whole mess as it was a contaminant from the start. On my list of do no harms I think this may have the greatest benefit. The Chest X-Ray Can Be Your Friend While I am not a fan of routine chest x-rays I do believe that if you are prepared to diagnose an opacification on a chest x-ray as being due to a pneumonia (VAP or in those non-ventilated) that you need to follow this up with a repeat x-ray 24 - 48 hours later. If the opacity is gone it was atelectasis as a true pneumonia will not clear that easily. Well worth the radiation exposure I say. If You Are Going To Do a Work-up Make It A Complete One We hear often in rounds the morning after a septic work-up that the baby was too sick to have an LP and that we can just check the CSF if the blood is positive. There are two significant problems to this approach. The first which is a significant concern is that in a recent study of patients with GBS meningitis, 20% of those who had GBS in the CSF had a negative blood culture. Think about that one clearly... relying on a positive culture to decide to continue antibiotics may lead to partially treated GBS meningitis when you discontinue the antibiotics prematurely. Not a good thing. The second issue is that infants with true meningitis can have relatively low CSF WBC counts and may drift lower with treatment. Garges et al in a review of 95 neonates with true meninigits found that CSF WBC counts >21 cells per mm3 had a sensitivity of 79% and specificity at 81%. This means that in those with true meningitis 19% of the time the WBC counts would be below 21 leading to the false impression that the CSF was "fine". If antibiotics were effective it could well be by 48 hours that the negative CSF culture you find would incorrectly lead you to stop antibiotics. Message: Do the CSF sampling at the time of the septic work-up whenever possible. If We Aren't Prepared To Do a Supra Pubic Aspirate Should We Not Collect Urine At All? This provocative question was asked by a colleague last week and is based on the results of a study which was the topic of the following post: Bladder Catherterizations for UTI: Causing more harm than good? The gist of it is that it would appear that in many cases the results of a catheter obtained urine cannot be trusted. If that is the case then are we ultimately treating infections that don't actually exist when the only positive culture is from a urine. I believe using point of care ultrasound to obtain specimens from a SPA will be the way to go but in the meantime how do we address the question of whether a UTI is present or not? May need to rely on markers of inflammation such as a CRP or procalcitonin but that is not 100% sensitive or specific either but may be the best we have at the moment to determine how to interpret such situations. Lastly, Slow Down And Practice Good Hand Hygiene So much of what I said above is important when determining if an infection is present or not. The importance of preventing infection cannot be understated. Audits of hand hygiene practice more often than not demonstrate that physicians are a group with some of the lowest rates of compliance. Why is that? As a physician I think it has nothing to do with ignorance about how to properly perform the procedure but rather a tendency to rush from patient to patient in order to get all the things done that one needs to do well on service or call. If we all just slow down a little we may eventually have less need to run from patient to patient as the rate of infections may drop and with it demand for our time. If slowing down is something that you too think is a good idea you may want to have a look at the book In Praise of Slowness by Carl Honore (TED Talk by Carl Below) which may offer some guidance how to do something that is more easily said than done. Here is hoping for a little slower pace in the new year. We could reap some fairly large benefits! https://www.ted.com/talks/carl_honore_praises_slowness?language=en
  9. As anyone who has been reading this blog knows, I have an affinity for anything that is non-invasive and improves the care of newborns. Add to this my interest in Neonatal Abstinence (which has been the focus of other pieces such as Long term cognitive deficits in infants exposed to in-utero opioids and polysubstance use. In a rare finding, girls may have worse outcomes.) and a recent report of laser acupuncture for adjuvant treatment of neonatal abstinence syndrome would have to pique my interest. In 2014 a case report entitled Laser acupuncture as an adjuvant therapy for a neonate with neonatal abstinence syndrome (NAS) due to maternal substitution therapy: additional value of acupuncture. was published by Raith. I recall seeing this paper prior to starting this blog and Facebook page and made a mental note to check it out someday. That someday is upon me now that an RCT has been published on the subject which will be looked at below. What is laser acupuncture? Before we get into critiquing such a study it is worth explaining what laser acupuncture is. From the website acupuncture today I found the following background: "In 1991, a study was done in Novosibirsk, Russia that applied directly to the study of acupuncture. Researchers shined light on various parts of the body and found that light traveled under the skin to other acupuncture points, but it didn't travel to places that were not on acupuncture meridians. It appears that the body contains a sort of fiber optic network—where light enters an acupuncture point, travels through the meridian and can be detected at other places along the meridian with a sensitive photon detector. This is a fascinating study showing how light is actually received, used and transmitted throughout the body." The RCT in question above is another paper by Raith W et al Laser Acupuncture for Neonatal Abstinence Syndrome: A Randomized Controlled Trial. This study compared patients receiving treatment for NAS with morphine and phenobarbital and compared 14 in each group on a blinded fashion to laser acupuncture or nothing in addition to the standard regimen. They avoided the need for a placebo in that the intervention was done by the health care provider and then a separate person calculated a pain score who was blind to whether the laser had been provided or not. By blinding the people scoring they hoped to address the criticism that would be present had the study been unblinded. The acupuncture was performed daily at five ear and four body points bilaterally with the primary outcome being duration of oral opiate use. The authors found a reduction in days of opiate treatment but being a small study it would be considered a pilot at best. The results were 28 days (22 to 33) vs 39 days (32 to 48), respectively, P =.019 and the authors make a comment that phenobarb levels were similar between the groups as well but with overall shorter lengths of stay of 35 days (25 to 47) vs 50 days (36 to 56), respectively, P = .048. There are several issues with the study though and they are as follows. Yes, the light therapy was provided behind a closed door but how do we know that the providers truly kept it a secret during the whole stay of the patient? What medications were the mothers taking and at what doses and for what duration? Was the exposure between groups really the same? Also there was no standard means of weaning that I can see so how do we know by chance that the difference is simply who was on at the time with respect to physician deciding on aggressiveness of weaning. Another issue is that women on replacement medications such as methadone or suboxone were excluded as were women with polysubstance abuse. How close to our patient population really were these patients? Lastly, nearly significant was a preponderance of males in the conventional group and we all know how males generally do compared to females in most studies. Nonetheless it is a exciting study to imagine an effect from and that is what the authors I think were banking on. What about laser acupuncture for treatment of pain? One other study comparing sucrose to laser acupuncture for prevention of pain with heel lances. In this study of 42 infants randomized to the intervention or sucrose the authors concluded that sucrose was superior to acupuncture for managing pain from heel lancing. This study did not have a third arm in which no treatment was given (likely due to it being unethical) so what we can't say for sure is whether laser is better than nothing. Personally I find a bit of a leap to believe that shining a light through the skin would have an effect on pain perception by anyone. I can certainly understand the concept of putting a needle into tissue or applying pressure no different from the effect of rubbing ones temples when they have a headache (works for me at least). The Chemistry major in me though has trouble with the effect of photons passing through tissue even if directed at acupuncture points. Having said that the only positive thing I can say is that a quick search for such instruments shows them to be commercially available and as cheap as $50 or so. I have no doubt there are people who will read this RCT and be impressed with its additional purported impact on NAS and thankfully if they do decide to pursue this intervention they will not have spent a fortune on it. Money in health care should be directed to what works to help patients and the skeptic in me just isn't buying this even if it appeals to my curiosity with non-invasive strategies.
  10. Port said neonatology society will launch its Fifth neonatology conference, at the 23rd -24th of October 2014, Al Fayrouz resort, Port said. Sessions will start at 5.30 pm Thursday 23rd & Friday the 24th at 10 am & 5.30 pm. There will be a preconference NRP doctors' workshop at the 22nd 23rd of October, another workshop about neonatal echocardiography will be held at Friday 24th . Attending the conference sessions is free but for accommodation at Al Fayrouz resort, a sponsoring company is needed. Registration is needed to attend conference sessions by sending personal data (name, address, workplace, mobile & email), by an email to portsaidnicus@gmail.com. Our organizer: Spark travel, Telefax: +20(2) 240 33 427 / Mob: 01007557666 Address: 8Dr. Mohamed Hamam St, Nasr City, Cairo-
  11. According to the current report by WHO still death rate for babies are high due to improper resuscitation. There are lot of reasons like lacking of proper knowledge or inexperience which leads to the cause. So have look on these best e-books which are recommended by worldwide pediatricians which one can get information during practice also. Pediatric eBooks
  12. can anyone tell me about their experience with dragger evita 2 dura with neoflow ventilator for preterm and term neonate, its pro & cons .
  13. dr_osama_hussein

    Portsaid NICU first Conference

    Our first conference is to be held in Portsaid Egypt, at the 21 st - 23 rd of October 2010, it's a conjoint effort from Portsaid NICU workers to help raise the quality of life for our neonates. The title will be Perinatal medicine, so obstetricians will participate also in this conference in our charming city of Portsaid on Suez Canal, hope you share this acitivity with us M Osama Hussein El Nasr NICU Portsaid