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Abstract Background Surveys from the USA, Australia and Spain have shown significant inter-institutional variation in delivery room (DR) management of very low birth weight infants (VLBWI, < 1500 g) at birth, despite regularly updated international guidelines. Objective To investigate protocols for DR management of VLBWI in Germany, Austria and Switzerland and to compare these with the 2005 ILCOR guidelines. Methods DR management protocols were surveyed in a prospective, questionnaire-based survey in 2008. Results were compared between countries and between academic and non-academic units. Protocols were compared to the 2005 ILCOR guidelines. Results In total, 190/249 units (76%) replied. Protocols for DR management existed in 94% of units. Statistically significant differences between countries were found regarding provision of 24 hr in house neonatal service; presence of a designated resuscitation area; devices for respiratory support; use of pressure-controlled manual ventilation devices; volume control by respirator; and dosage of Surfactant. There were no statistically significant differences regarding application and monitoring of supplementary oxygen, or targeted saturation levels, or for the use of sustained inflations. Comparison of academic and non-academic hospitals showed no significant differences, apart from the targeted saturation levels (SpO2) at 10 min. of life. Comparison with ILCOR guidelines showed good adherence to the 2005 recommendations. Summary Delivery room management in German, Austrian and Swiss neonatal units was commonly based on written protocols. Only minor differences were found regarding the DR setup, devices used and the targeted ranges for SpO2 and FiO2. DR management was in good accordance with 2005 ILCOR guidelines, some units already incorporated evidence beyond the ILCOR statement into their routine practice.

Abstract Background In ventilated newborns the use of multiple breath washout (MBW) techniques for measuring both lung volume and ventilation inhomogeneity (VI) is hampered by the comparatively high dead space fraction. We studied how changes in ventilator settings affected VI indices in this particular population. Methods Using a computer simulation of a uniformly ventilated volume the interaction between VI indices (lung clearance index (LCI), moment ratios (M1/M0, M2/M0, AMDN1, AMDN2) of the washout curve) and tidal volume (VT), dead space (VD) and functional residual capacity (FRC) were calculated. The theoretical results were compared with measurements in 15 ventilated piglets (age Results The computer simulation showed that the sensitivity of most VI indices to changes in VD/VT and VT/FRC increase, in particular for VD/VT > 0.5. In piglets, the raised PIP caused a significant increase of VT from 15.4 ± 9.5 to 21.9 ± 14.7 (p = 0.003) and of the FRC from 31.6 ± 14.7 mL to 35.0 ± 15.9 mL (p = 0.006), whereas LCI (9.15 ± 0.75 to 8.55 ± 0.74, p = 0.019) and the moment ratios M1/M0, M2/M0 (p < 0.02) decreased significantly. No significant changes were seen in AMDN1 and AMDN2. The within-subject variability of the VI indices (coefficient of variation in brackets) was distinctly higher (LCI (9.8%), M1/M0 (6.6%), M2/M0 (14.6%), AMDN1 (9.1%), AMDN2 (16.3%)) compared to FRC measurements (5.6%). Computer simulations showed that significant changes in VI indices were exclusively caused by changes in VT and FRC and not by an improvement of the homogeneity of alveolar ventilation. Conclusion In small ventilated lungs with a high dead space fraction, indices of VI may be misinterpreted if the changes in ventilator settings are not considered. Computer simulations can help to prevent this misinterpretation.

Aim It takes several minutes for infants to become pink after birth. Preductal oxygen saturation (SpO2) measurements are used to guide the delivery of supplemental oxygen to newly born infants, but pulse oximetry is not available in many parts of the world. We explored whether the pinkness of an infant's tongue provided a useful indication that supplemental oxygen was required. Methods This was a prospective observational study of infants delivered by Caesarean section. Simultaneous recording of SpO2 and visual assessment of whether the tongue was pink or not was made at 1-7 and 10 min after birth. Results The 38 midwives and seven paediatric trainees carried out 271 paired assessments on 68 infants with a mean ( SD) birthweight of 3214 (545) grams and gestational age of 38 (2) weeks. When the infant did not have a pink tongue, this predicted SpO2 of <70% with a sensitivity of 26% and a specificity of 96%. Conclusion Tongue colour was a specific but insensitive sign that indicated when SpO2 was <70%. When the tongue is pink, it is likely that an infant has an SpO2 of more than 70% and does not require supplemental oxygen. [ABSTRACT FROM AUTHOR]

Objective Early continuous positive airway pressure (CPAP) may reduce lung injury in preterm infants. Patients and methods Spontaneously breathing preterm infants were randomised immediately after birth to nasal CPAP or intubation, surfactant treatment and mechanical ventilation. Pulmonary function tests approximately 8 weeks post-term determined tidal breathing parameters, respiratory mechanics and functional residual capacity (FRC). Results Seventeen infants received CPAP and 22 mechanical ventilation. Infants with early CPAP had less mechanical ventilation (4 vs 7.5 days; p=0.004) and less total respiratory support (30 vs 47 days; p=0.017). Post-term the CPAP group had lower respiratory rate (41 vs 48/min; p=0.007), lower minute ventilation (223 vs 265 ml/min/kg; p=0.009), better respiratory compliance (0.99 vs 0.82 ml/cm H(2)O/kg; p=0.008) and improved elastic work of breathing (p=0.004). No differences in FRC were found. Conclusions Early CPAP is feasible, shortens the duration of respiratory support and results in improved lung mechanics and decreased work of breathing. [ABSTRACT FROM AUTHOR]

The European Society for Paediatric Research (ESPR) first developed recommendations for a Neonatology specific European training curriculum in 1998, with updates in 2007 and 2021. The aim of these recommendations was to define a common, European standard of training for national educational programmes for Neonatologists. Following the Union of European Medical Specialists' (UEMS) framework of European Training Requirements (ETR), and similar to the American Board of Pediatrics (ABP) recommendations, graduates of training programmes conforming to the ETR will be eligible throughout Europe for recognition of equality of training, and with that should be enabled to freedom-of-movement. This concept also accounts for neonatal specialists. We therefore present the pan-European work on the ETR Neonatology in its third iteration (ETR III), summarising the basic requirements for contemporary training programmes, trainers, and training centres in neonatology. We highlight the European School of Neonatology (ESN) as a comprehensive online educational platform which provides the theoretical and practical background to satisfy the ETR-III. Lastly, we introduce the European Board of Neonatal & Child Health Research (EBNCHR) as a committee dedicated to gaining acceptance for the concept of harmonising education and training in Neonatology and recognising Neonatology as a Paediatric subspecialty in every European Union member state. IMPACT: Neonatology currently is not uniformly recognised as a Paediatric subspecialty throughout the 27 European countries. Hence, training in Neonatology formerly followed no commonly agreed standard throughout the European Union (EU). To ensure a minimum standard of care, an agreed minimum standard of training is required. The European Society for Paediatric Research (ESPR) has led on generating an EU-accredited, pan-European Syllabus for Neonatal training in Europe, the European Training Requirements (ETR) in Neonatology (2021). This article presents the ETR Neonatology from commissioning to accreditation and discusses means of how high-grade post-graduate education, aligned with the ETR can be achieved by practitioners., Competing Interests: Competing interests: The authors declare no competing interests. Consent for publication: All co-authors have given their consent to the final publication., (© 2025. The Author(s).)

Background: High quality data is important to understanding epidemiology and supporting improvement efforts in perinatal brain injury. It is not clear which data items relevant to brain injury are captured across UK sources of routinely collected data, nor what needs to be done to ensure that those sources are fit for purpose in improving care., Methods: We reviewed data dictionaries of four main UK perinatal data sources and consulted a multi-professional group (N = 27) with expertise in neonatal/maternity care, statistics, and clinical negligence., Results: None of the data sources we reviewed currently captures, on its own, the range of items relevant to brain injury. Data items lack common definitions and ongoing linkage across the different sources. Our consultation identified the need for standardising the definition of avoidable perinatal brain injury, resolving inconsistencies in capturing data, improving linkage of data across existing data sources, and co-designing a strategy for meaningful use of data., Conclusions: Limited standardisation and linkage across UK data sources are key problems in using data to guide improvement efforts aimed at reducing risk of avoidable perinatal brain injury. A programme involving co-design with healthcare professionals and families to improve capture and use of data is now needed., Impact: Limited standardisation and linkage across UK data sources currently challenge the use of data as the basis of efforts to reduce risk of avoidable perinatal brain injury. A harmonisation programme involving consultation and co-design with healthcare professionals, families, and other specialists is needed to enable better capture and use of data in this key area. There is need to standardise the definition of avoidable perinatal brain injury, resolve inconsistencies in capturing data, improve linkage of data collected across existing data sources, and co-design a strategy for meaningful use of data., Competing Interests: Competing interests: The authors declare no competing interests. Ethics approval and consent to participate: Patient consent was not required, as they were not involved in the conduct of this study. The UK’s Health Research Authority decision tool ( http://www.hra-decisiontools.org.uk/research/ ) showed that ethics approval was not required for the multi-professional consultation, as it was classified as a quality improvement activity, in which all of the participants were invited to join the authorship group and to be acknowledged in the project’s outputs. Participants were provided with information about the consultation, had the possibility to ask questions and withdraw their involvement at any time, and gave their written consent to take part and agree to recording of this quality improvement activity (including giving permission to publish anonymised quotes and synthesis of their expressed views)., (© 2025. The Author(s).)

Competing Interests: Competing interests: The authors declare no competing interests.

Objective: Despite lack of evidence supporting efficacy, prophylactic fresh frozen plasma and Octaplas transfusions may be administered to very preterm infants to reduce bleeding risk. International variation in plasma transfusion practices in neonatal intensive care units (NICUs) is poorly understood, therefore, we aimed to describe neonatal plasma transfusion practice in Europe., Design: Prospective observational study., Setting: 64 NICUs in 22 European countries, with a 6-week study period per centre between September 2022 and August 2023., Patients: Preterm infants born below 32 weeks of gestational age., Interventions: Admission to the NICU., Main Outcome Measures: Plasma transfusion prevalence, cumulative incidence, indications, transfusion volumes and infusion rates and adverse effects., Results: A total of 92 of 1143 infants included (8.0%) received plasma during the study period, collectively receiving 177 transfusions. Overall prevalence was 0.3 plasma transfusion days per 100 admission days, and rates varied substantially across Europe. By day 28 of life, 13.5% (95% CI 10.0% to 16.9%) of infants received at least one plasma transfusion, accounted for competing risks of death or discharge. Transfusions were given for a broad range of indications, including active bleeding (29.4%), abnormal coagulation screen results (23.7%) and volume replacement/hypotension (21.5%). Transfusion volumes and infusion rates varied significantly; the most common volume was 15 mL/kg (range: 5-30 mL/kg) and the most common duration was 2 hours (range: 30 min to 6 hours)., Conclusions: We found wide variation in plasma transfusion practices in Europe, highlighting the need for evidence to inform neonatologists in daily practice and guidelines, in particular for non-bleeding indications., Trial Registration Number: ISRCTN17267090., Competing Interests: Competing interests: SGu disclosed receiving grants from Sanquin Blood Supply Foundation (PPOC21-08/L2588, RES/00264), the European Blood Alliance (EBA Grant Agreement 2021-02) and the European Society for Paediatric Research (ESPR Post-Doc Research Grant 2020). CH and TM disclosed receiving compensation from Sanquin Blood Supply Foundation. JM disclosed receiving compensation from Sanquin Blood Supply Foundation, research grants from Cooperatio and Personmed, and consulting fees from Danone, Nestlé, Baxter and Chiesi. SG disclosed receiving lecture fees from Entegrion, outside this study., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Objectives: To survey practices of iron and recombinant human erythropoietin (rhEpo) administration to infants born preterm across Europe., Study Design: Over a 3-month period, we conducted an online survey in 597 neonatal intensive care units (NICUs) of 18 European countries treating infants born with a gestational age of <32 weeks., Results: We included 343 NICUs (response rate 56.3%) in the survey. Almost all NICUs (97.7%) routinely supplement enteral iron, and 74.3% of respondents to all infants born <32 weeks of gestation. We found that 65.3% of NICUs routinely evaluate erythropoiesis and iron parameters beyond day 28 after birth. Most NICUs initiate iron supplementation at postnatal age of 2 weeks and stop after 6 months (34.3%) or 12 months (34.3%). Routine use of rhEpo was reported in 22.2% of NICUs, and in individual cases in 6.9%. RhEpo was mostly administered subcutaneously (70.1%) and most frequently at a dose of 250 U/kg 3 times a week (44.3%), but the dose varied greatly between centers., Conclusions: This survey highlights wide heterogeneity in evaluating erythropoietic activity and iron deficiency in infants born preterm. Variation in iron supplementation during infancy likely reflects an inadequate evidence base. Current evidence on the efficacy and safety profile of rhEpo is only poorly translated into clinical practice. This survey demonstrates a need for standards to optimize patient blood management in anemia of prematurity., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether management guidelines for infants born extremely preterm are representative for those infants <25 weeks of gestation., Study Design: Three guidelines were reviewed: the 2022 European Consensus Guidelines on the Management of Respiratory Distress Syndrome, the 2017 American Academy of Pediatrics Guidelines for Perinatal Care, and the 2020/2021 International Liaison Committee on Resuscitation guidelines. All referenced studies for overlapping recommendations were reviewed. Data extracted included the total number and proportion of infants <25 weeks of gestation in the original articles referred in the guidelines. Where the exact number of infants <25 weeks of gestation was unobtainable, this was conservatively estimated by statistical deduction., Results: Eight recommendations were included in 2 or more guidelines: (1) antenatal corticosteroids, (2) antenatal magnesium sulfate, (3) delayed cord clamping, (4) thermoregulation at birth, (5) initial oxygen concentration at birth, (6) continuous positive airway pressure, (7) surfactant, and (8) parenteral nutrition. In total, 519 studies (n = 409 986) informed these 8 recommendations, of which 335 (64.5%) were randomized controlled trials (n = 78 325). Across all studies, an estimated 59 360 (14.5%) infants were <25 weeks of gestation. Within randomized controlled trials alone, an estimated 5873 (7.5%) infants were <25 weeks of gestation. A total of 196 (37.8%) studies did not include any infants <25 weeks of gestation., Conclusions: Infants born <25 weeks of gestation are not well-represented in the evidence used to develop major clinical guidelines for infants born extremely preterm. Future studies should provide evidence for this population as a distinct cohort., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests The authors have no conflicts of interest to declare except that they are working with an international group of clinicians and methodologists to plan and conduct a trial of intact cord resuscitation for preterm infants in the UK, Europe, and Australasia. They have received no relevant grant funding but are supported by their employing organizations.

Infants requiring admission to the neonatal intensive care unit (NICU) are particularly vulnerable to developing brain injury. The severity of the underlying clinical conditions and the complexity of care call for continuous, cot-side, non-invasive monitoring tools. Near-infrared spectroscopy (NIRS) measures the regional tissue oxygen saturation of hemoglobin (rStO 2 ) and provides continuous information on the net-result of several factors. Cerebral rStO 2 correlates with echocardiography-derived measures of blood flow. Cerebral fractional tissue oxygen extraction provides information on the balance between oxygen supply and demand and can be continuously derived from the combined use of cerebral rStO 2 and arterial oxygen saturation. Information on cerebral blood flow autoregulatory capacity can be obtained from combining cerebral rStO 2 and invasive blood pressure monitoring by appropriate software. Cerebral rStO 2 provides real-time, end-organ information on perfusion-oxygenation, and when interpreted in the clinical context based on pathophysiological principles may be used as a help to guide interventions in the NICU. In this review we will discuss how to optimize NIRS monitoring for application in the NICU, with a particular focus on the preterm infant. IMPACT: Near-infrared spectroscopy (NIRS) provides cot-side, real-time information on blood and oxygen supply to the brain. Therefore, it is a valuable tool to better understand the pathophysiology underlaying disease processes. Current evidence suggests that NIRS-guided treatment in extremely preterm infants during transitional circulation does not improve clinical outcomes. Specific training is needed to maximize potential performance. Pathophysiological interpretation of cerebral NIRS data in the given clinical context may help in decision-making. Appropriate use of this monitoring technique, interpreted concurrently with other routine parameters, is a potential clinical tool to guide interventions in the NICU setting., Competing Interests: Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.)

Objective: Regarding the use of lung ultrasound (LU) in neonatal intensive care units (NICUs) across Europe, to assess how widely it is used, for what indications and how its implementation might be improved., Design and Intervention: International online survey., Results: Replies were received from 560 NICUs in 24 countries between January and May 2023. LU uptake varied considerably (20%-98% of NICUs) between countries. In 428 units (76%), LU was used for clinical indications, while 34 units (6%) only used it for research purposes. One-third of units had <2 years of experience, and only 71 units (13%) had >5 years of experience. LU was mainly performed by neonatologists. LU was most frequently used to diagnose respiratory diseases (68%), to evaluate an infant experiencing acute clinical deterioration (53%) and to guide surfactant treatment (39%). The main pathologies diagnosed by LU were pleural effusion, pneumothorax, transient tachypnoea of the newborn and respiratory distress syndrome. The main barriers for implementation were lack of experience with technical aspects and/or image interpretation. Most units indicated that specific courses and an international guideline on neonatal LU could promote uptake of this technique., Conclusions: Although LU has been adopted in neonatal care in most European countries, the uptake is highly variable. The main indications are diagnosis of lung disease, evaluation of acute clinical deterioration and guidance of surfactant. Implementation may be improved by developing courses and publishing an international guideline., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Platelet transfusions are given to preterm infants with severe thrombocytopenia aiming to prevent haemorrhage. The PlaNeT2/MATISSE trial revealed higher rates of mortality and/or major bleeding in preterm infants receiving prophylactic platelet transfusions at a platelet count threshold of 50 × 10 9 /L compared to 25 × 10 9 /L. The extent to which this evidence has been incorporated into clinical practice is unknown, thus we aimed to describe current neonatal platelet transfusion practices in Europe., Methods: We performed a prospective observational study in 64 neonatal intensive care units across 22 European countries between September 2022 and August 2023. Outcome measures included observed transfusion prevalence rates (per country and overall, pooled using a random effects Poisson model), expected rates based on patient-mix (per country, estimated using logistic regression), cumulative incidence of receiving a transfusion by day 28 (with death and discharge considered as competing events), transfusion indications, volumes and infusion rates, platelet count triggers and increment, and adverse effects., Findings: We included 1143 preterm infants, of whom 71 (6.2%, [71/1143]) collectively received 217 transfusions. Overall observed prevalence rate was 0.3 platelet transfusion days per 100 admission days. By day 28, 8.3% (95% CI: 5.5-11.1) of infants received a transfusion. Most transfusions were indicated for threshold (74.2%, [161/217]). Pre-transfusion platelet counts were above 25 × 10 9 /L in 33.1% [53/160] of these transfusions. There was significant variability in volume and duration., Interpretation: The restrictive threshold of 25 × 10 9 /L is being integrated into clinical practice. Research is needed to explore existing variation and generate evidence for various aspects including optimal volumes and infusion rates., Funding: Sanquin, EBA, and ESPR., Competing Interests: CH and TM have received compensation from Sanquin Blood Supply Foundation. JM has received compensation from Sanquin Blood Supply Foundation, research grants from Cooperatio and Personmed, and consulting fees from Danone, Nestlé, Baxter, and Chiesi. All other authors declare no competing interests., (© 2024 The Authors.)

Neonatology is a pediatric sub-discipline focused on providing care for newborn infants, including healthy newborns, those born prematurely, and those who present with illnesses or malformations requiring medical care. The European Training Requirements (ETR) in Neonatology provide a framework for standardized quality and recognition of equality of training throughout Europe. The latest ETR version was approved by the Union of European Medical Specialists (UEMS) in April 2021. Here, we present the curriculum of the European School of Neonatology Master of Advanced Studies (ESN MAS), which is based on the ETR in Neonatology and aims to provide a model for effective and standardized training and education in neonatal medicine. We review the history and theory that form the foundation of contemporary medical education and training, provide a literature review on best practices for medical training, pediatric training, and neonatology training specifically, including educational frameworks and evidence-based systems of evaluation. The ESN MAS Curriculum is then evaluated in light of these best practices to define its role in meeting the need for a standardized empirically supported neonatology training curriculum for physicians, and in the future for nurses, to improve the quality of neonatal care for all infants. IMPACT STATEMENT: A review of the neonatology training literature was conducted, which concluded that there is a need for standardized neonatology training across international contexts to keep pace with growth in the field and rapidly advancing technology. This article presents the European School of Neonatology Master of Advanced Studies in Neonatology, which is intended to provide a standardized training curriculum for pediatricians and nurses seeking sub-specialization in neonatology. The curriculum is evaluated in light of best practices in medical education, neonatology training, and adult learning theory., (© 2024. The Author(s).)