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Found 6 results

  1. until
    It is an online course which lasts 3 months, starting in July, 2019. 28 topics avilable 24/24 and 7/7. 22 mexican professors and 8 international ones.
  2. Hypoglycemia has to be one of the most common conditions that we screen for or treat in the NICU and moreover in newborn care in general. The Canadian Pediatric Society identifies small for gestational age infants (weight <10th percentile), large for gestational age (LGA; weight > 90th percentile) infants, infants of diabetic mothers (IDMs) and preterm infants as being high risk for hypoglycemia. It is advised then to screen such babies in the absence of symptoms for hypoglycemia 2 hours after birth after a feed has been provided (whether by breast or bottle). I am sure though if you ask just about any practitioner out there, they will tell you a story about a baby with “no risk factors” who had hypoglycemia. These one-off cases have the effect though of making us want to test everyone for fear that we will miss one. If that is the case though should we be recommending that all babies get at least one check? The Canadian Pediatric Surveillance Program (CPSP) The CPSP is a branch of the Canadian Pediatric Society that “provides an innovative means to undertake active paediatric surveillance and increase awareness of childhood disorders that are high in disability, morbidity, mortality and economic cost to society, despite their low frequency. I submit my surveys each month as i hope other Canadian Pediatricians do and help to determine the impact of these rare conditions in our Canadian population. Like with any survey we rely on people taking the time to submit but there is always the risk that what is being sent in under represents the true burden of illness as some cases may not be identified. Having said that, it is the best we have! Turning our attention to hypoglycemia in low risk newborns From April 2014 to March 2016 the CPSP searched for these types of patients and just published the results of their findings in Hypoglycemia in unmonitored full-term newborns—a surveillance study by Flavin MP et al. What I like about the study is that they have been able to look at a group of babies that fall outside those identified as being at risk in the CPS statement Screening guidelines for newborns at risk for low blood glucose. They were looking for severe hypoglycemia by using a threshold of < 2.0 mmol/L (36 mg/dl) and all infants must have received IV dextrose. In the end after excluding ineligible cases they had 93 babies who met criteria. Based on the Canadian birth rate this translates to an incidence of 1 in every 8378 births. These babies were all supposed to be low risk but there were in fact clues that while not strictly identified as risks in the CPS statement could have increased the likelihood of a low blood glucose. Twenty three percent of mothers had maternal hypertension and another 23% were obese while 47% had excessive weight gain during pregnancy. Furthermore, 8% of mothers were treated with a beta blocker (most likely labetalol I would think) during pregnancy which is a risk factor for hypoglycemia although not specifically cited in the current CPS statement. A concerning finding as well was the likelihood of severe symptoms in this group on presentation. Twenty percent presented with major clinical signs (seizure, apnea or cyanosis). Median glucose levels at presentation were much lower than those without major signs (median = 0.8 mmol/L, interquartile range [IQR] = 0.5 versus 1.6 mmol/L, IQR = 0.7; P < 0.001). Lastly, providers were asked about neurodevelopmental concerns at discharge approximately 20% were thought to have issues. Are these patients really low risk though? Twenty five percent of the patients submitted had a birth weight less than the 10%ile for GA. These patients as per the CPS guideline recommendations are actually considered at risk and should have been screened. The second issue to address has to do with the way we diagnose diabetes in pregnancy. All women are provided with the oral glucose tolerance test around 28 weeks of pregnancy. No test is perfect but it is the best we have. Women who have excessive weight gain in pregnancy (almost 50% of the cohort) are at higher risk of developing diabetes or some degree of insulin resistance as are those who are classified as obese. I have long suspected and think it may be the case here that some babies who do not meet the criteria for screening as their mothers do not have a diagnosis of GDM actually are at risk due to some degree of insulin resistance or perhaps their mothers develop GDM later. The evidence for this are the occasional LGA babies who are born to mothers without a GDM diagnosis but who clearly have been exposed to high insulin levels as they behave like such affected infants with poor feeding and low sugars in the newborn period. The authors here comment on those that were SGA but how many in this cohort were LGA? The effect of hypertension can also not be minimized which was present in about a quarter of patients. These babies while not being officially SGA may have experienced a deceleration in weight gain in the last few weeks but remained above the 10%ile. These infants would not have the glycogen stores to transition successfully but would not be targeted as being at risk by the current definitions. Should we be screening everyone then? If we acknowledge that about 25% were IUGR in this study (<10%ile) and should have been screened, the expected rate would be 1:1170 births alone. In Manitoba with our 17000 births a year we would capture about two extra babies a year which translates into a low of pokes for a lot of healthy babies. Given the further information that 1:5 babies who are identified may have neurodevelopmental concerns it would take about 2-3 years of testing to prevent one concern. That pick up rate for me is far too low to subject so many babies to testing. What this study though does highlight is the need to view risk factors a little less strictly. Babies who are almost meeting the criteria for being LGA or those whose mother’s have taken lebetalol should have a low threshold for screening. Should hypertension on medications, excessive maternal weight gain or obesity in the mother be considered a risk? What I didn’t see in the end of this study were patients who truly were AGA, being born to healthy non overweight mothers presenting as high risk. Maybe what is really needed based on this study is to re-evaluate what we consider at risk. In the meantime, maybe we should be testing a few extra babies who fall into these “lesser” risk categories. Better yet a study isolating such patients and looking at the frequency of hypoglycemia in these patients is warranted to get a better idea of whether they are indeed risks.
  3. The story is typical. A family notices a small red spot in the weeks following delivery which enlarges over the next month. They present to their family doctor or Pediatrician who identifies the most common skin lesion in childhood; a hemangioma affecting about 3-10% of all children depending on the population observed. As a resident I was given the following advice regarding hemangiomas; "As long as the hemangioma is not of cosmetic concern, sight threatening, multiple in number or causing anemia or thrombocytopenia watchful waiting is recommended." Furthermore I recall the following general advice that while they tend to enlarge over the first year of life, 40% are gone by 4 years, 60% by 6 years and 90% by 9 years. After my training I started a practice passing along the same advice to the infants I now cared for. Then something happened similar to the serendipitous discovery of penicillin. In 2008, Leaute-Labreze et al published a case report in which they described a child being treated for a facial hemangioma with corticosteroids. Unfortunately the hemangioma did not respond to treatment but rather led to a cardiomyopathy requiring treatment with propranolol. Curiously the hemangioma demonstrated significant regression on propranolol. The results of this case report prompted further treatments with propranolol in an unblinded fashion. Since this time propranolol and more recently topical Timolol (sample size 41) have been studied both in observational and small randomized controlled trials. Propranolol while effective has potential side effects such as hypotension, bradycardia and bronchospasm which has limited it's widespread application except for those patients with either large, sight threatening or multiple hemangiomas. Topical timolol in the RCT above was demonstrated to be safe and when given locally, free of such side effects making it a seemingly ideal treatment for smaller hemangiomas that may have some cosmetic concerns later in life as they regress. That being said, the time of onset for regression was noted to be after 12-16 weeks of therapy and the target they aimed for was a reduction of >5% which is certainly modest. While only a small improvement it was seen 60% of the time in the treatment group and 11% in the placebo arm. From personal experience I have used topical Timolol with patients in the NICU with varying success but in some cases the results were quite impressive. Looking at the RCT by Chan, timolol was only applied to those hemangiomas that were small and deemed unsuitable for treatment with propranolol. This leaves us with the question; what does one use if anything for larger hemangiomas which traditionally don't fit into the category of needing treatment vs patient observation. Secondly, is it wise to systematically treat all larger hemangiomas with propranolol as outpatients, given the potential severity of the side effects, some of which may be life threatening. This past week in the New England Journal of Medicine we have come full circle as Leaute-Labreze et all have published a large prospective RCT http://bit.ly/1ACqn2Cto determine the optimal dose and duration of propranolol for treatment of hemangiomas requiring systemic treatment. The number of patients enrolled in this study was 456 which makes it the largest study to date in this field. This study sought to determine whether 1 mg/kg/day vs 3 mg/kg/day divided twice a day for 3 or 6 months would provide the best resolution without unacceptable side effects. Eligible patients were between 1-5 months of age with a proliferating hemangioma and were treated for either 3 or 6 months depending on which arm of the study they were on. The results of this trial were striking and found that the best balance of benefit and risk was with 3 mg/kg/day for 6 months and is shown below graphically compared to placebo. This difference translates into a number need to treat to cause regression = 1.7 or rounded up 2. For every two patients that you treat with propranolol you will cause one hemangioma to regress. Try finding a therapeutic benefit like that in another trial! But what about safety? Side effects were rare compared to placebo but not negligible. The most common side effect was diarrhea and with respect to life threatening adverse effects the only one really noted was bradycardia but in a patient with enterocolitis. My take on this treatment is that it appears to have great impact with little downside! How do we apply these results though to "real life" situations. We now have as I see it a "one-two punch". Hemangiomas that are deemed to require no systemic treatment can be treated with a safe topical drop that has been used for years for glaucoma patients. Patients with larger more significant hemangiomas may be treated with a highly efficacious treatment that may have very few side effects. The downside of systemic therapy at least in Winnipeg is that treatment with propranolol generally requires a hospital admission at the start of treatment to monitor for side effects that would be considered life threatening. With an incidence of 5% of children it would be impractical to admit 600 children a year for such treatment based on an estimated 12000 births in the region a year. I do believe the time is upon us for change though. As I see it, gone are the days where we tell parents that we will see what develops when their child has a small hemangioma. If you have a willing parent who is concerned about the hemangioma and it is < 1.5 cm in size I believe topical Timolol should be offered to the family for a period of 6 months treatment. Anything larger than that would merit treatment with propranolol. Nine years is potentially a very long time to wait for a lesion to regress and potentially leave a scar or telangiectasia behind. If we can do something about it now with such a high rate of success and minimal risk to the patient, why wait? My advice to you if you either have a child with a hemangioma or know someone else with one is to have them ask their doctor whether Timolol or Propranolol would be right for them. Given these findings I know my practice will change.
  4. Hi, we had a (more academically) discussion about APGAR scoring. I would like to hear your opinion about scoring breathing effort: A fullterm infant breathing spontaneously but needing CPAP via a T-piece device. Would you score it as APGAR 1 or 2? Would the need of extra oxygen affect your decision? Greetings Dirk
  5. European Neonatal Ethics Conference 1st and 2nd May 2014 Venue: Chilworth Manor Hotel Southampton United Kingdom Simulation Neonatal Ethics & Difficult Situations Workshops 1st May 2014 The first day challenges participants to address challenging issues, ethical dilemmas, and difficult clinical circumstances in a safe simulated environment. Simulations cover decision making regarding difficult ethical scenarios, limits of viability, neonatal death, and serious medical errors. Workshop 1 Neonatal Ethics 15 places Workshop 2 Difficult Situations 15 places Conference 2nd May 2014 The second day allows neonatal staff from different European centers to interact and share with each other practices governing Rights of the newborn Withdrawal of intensive care Extremes of viability Issues of Faith, Pain Conflict within the team about decisions When/How to approach your ethics committee Providing Expert opinions The first day of the conference is limited to 30 delegates in two workshops. Participants from all over Europe are welcome For more information visit the website www.wonepedu.com Contact: Dr Alok Sharma Consultant Neonatologist Lead Wessex Oxford Neonatal Education Programme Lead Neonatal Education Simulation Training (NEST) Princess Anne Hospital University Hospital Southampton SO16 5YA Tel: 07725868090 Email: aloksharma@nhs.net Web: www.wonepedu.com European_Sim_Flyer.doc
  6. Please let me know what this rash is? A full term baby born vaginally. No complications during pregancy. Mom GBS positive, inadequate treatment. She had borderline low platelets (cause not known). Baby was pale, hypoperfused at birth needing fluid bolus. Admitted for "rule out sepsis". A rash (see attached) noted at birth. Itchy. Blanching with pressure. Papulo-erythematous over face, trunk. None noted on palms, soles, diaper area. Some part of rash appeared scaly after 24 hours. Any ideas what this rash is? Baby's CBC was normal with normal platelet count.
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