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Objective: Considerable variation in the care of extremely low gestational age infants (ELGAN) contributes to the variation in incidence of bronchopulmonary dysplasia (BPD). We compared management and outcomes of two neonatal centres with different respiratory support strategies. Study design: Retrospective cohort study of infants <28 weeks gestational age treated at two units in Australia and the UK between 2015 and 2017. Result(s): Of 492 infants, the overall incidence of BPD for extremely preterm infants was 62.20% and was similar across both sites (64.84% at Monash vs. 60.65% at Oxford). Independent predictors for the development of BPD or mortality included the days on mechanical ventilation (MV, adjusted OR 1.13, 95% Cl 1.07-1.19) and use of inhaled nitric oxide (adjusted OR 13.42, 95% Cl 1.75-103.28). Conclusion(s): Primary choice of non-invasive respiratory support had no significant impact on BPD development. Duration of MV and using nitric oxide were independent predictors for death or BPD.Copyright © 2021, The Author(s), under exclusive licence to Springer Nature America, Inc.

Contains fulltext : 283147.pdf (Publisher’s version ) (Open Access), BACKGROUND: Infants with a congenital diaphragmatic hernia (CDH) and expected mild pulmonary hypoplasia have an estimated survival rate of 90%. Current guidelines for delivery room management do not consider the individual patient's disease severity, but an individualized approach with spontaneous breathing instead of routine mechanical ventilation could be beneficial for the mildest cases. We developed a resuscitation algorithm for this individualized approach serving two purposes: improving the success rate by structuring the approach and providing a guideline for other centers. METHODS: An initial algorithm was discussed with all local stakeholders. Afterwards, the resulting algorithm was refined using input from international experts. RESULTS: Eligible CDH infants: left-sided defect, observed to expected lung-to-head ratio ≥50%, gestational age at birth ≥37.0 weeks, and no major associated structural or genetic abnormalities. To facilitate fetal-to-neonatal transition, we propose to start stabilization with non-invasive respiratory support and to adjust this individually. CONCLUSIONS: Infants with mild CDH might benefit from an individualized approach for neonatal resuscitation. Herein, we present an algorithm that could serve as guidance for centers implementing this.

OBJECTIVE: Intraosseous access is recommended as a reasonable alternative for vascular access during newborn resuscitation if umbilical access is unavailable, but there are minimal reported data in newborns. We compared intraosseous with intravenous epinephrine administration during resuscitation of severely asphyxiated lambs at birth. METHOD(S): Near-term lambs (139 days' gestation) were instrumented antenatally for measurement of carotid and pulmonary blood flow and systemic blood pressure. Intrapartum asphyxia was induced by umbilical cord clamping until asystole. Resuscitation commenced with positive pressure ventilation followed by chest compressions and the lambs received either intraosseous or central intravenous epinephrine (10 mug/kg); epinephrine administration was repeated every 3min until return of spontaneous circulation (ROSC). The lambs were maintained for 30min after ROSC. Plasma epinephrine levels were measured before cord clamping, at end asphyxia, and at 3 and 15min post-ROSC. RESULT(S): ROSC was successful in 7 of 9 intraosseous epinephrine lambs and in 10 of 12 intravenous epinephrine lambs. The time and number of epinephrine doses required to achieve ROSC were similar between the groups, as were the achieved plasma epinephrine levels. Lambs in both groups displayed a similar marked overshoot in systemic blood pressure and carotid blood flow after ROSC. Blood gas parameters improved more quickly in the intraosseous lambs in the first 3min, but were otherwise similar over the 30min after ROSC. CONCLUSION(S): Intraosseous epinephrine administration results in similar outcomes to intravenous epinephrine during resuscitation of asphyxiated newborn lambs. These findings support the inclusion of intraosseous access as a route for epinephrine administration in current guidelines.Copyright © Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.

Perioperative applications of near-infrared spectroscopy (NIRS) to monitor regional tissue oxygenation and perfusion in cardiac and noncardiac surgery are of increasing interest in neonatal care. Complex neonatal surgery can impair adequate oxygen delivery and tissue oxygen consumption and increase the risk of neurodevelopmental delay. Coupled with conventional techniques, NIRS monitoring may enable targeted hemodynamic management of the circulation in both cardiac and noncardiac surgical procedures. In this narrative review, we discuss the application of perioperative NIRS in specific neonatal interventions, including surgical intervention for congenital heart defects, definitive closure of the patent ductus arteriosus, neurological and gastrointestinal disorders, and use of extracorporeal membrane oxygenation. We identified areas for future research within disease-specific indications and offer a roadmap to aid in developing evidence-based targeted diagnostic and management strategies in neonates. Impact: There is growing recognition that perioperative NIRS monitoring, used in conjunction with conventional monitoring, may provide critical hemodynamic information that either complements clinical impressions or delivers novel physiologic insight into the neonatal circulatory and perfusion pathways.Copyright © 2021, The Author(s), under exclusive licence to the International Pediatric Research Foundation, Inc.

BACKGROUND: Hypoxic-ischaemic encephalopathy (HIE) is an important cause of morbidity and mortality in neonates. When the gold standard MRI is not feasible, cerebral ultrasound (CUS) might offer an alternative. In this study, the association between a novel CUS scoring system and neurodevelopmental outcome in neonates with HIE was assessed. METHODS: (Near-)term infants with HIE and therapeutic hypothermia, a CUS on day 1 and day 3-7 after birth and available outcome data were retrospectively included in cohort I. CUS findings on day 1 and day 3-7 were related to adverse outcome in univariate and the CUS of day 3-7 also in multivariable logistic regression analyses. The resistance index, the sum of deep grey matter and of white matter involvement were included in multivariable logistic regression analyses. A comparable cohort from another hospital was used for validation (cohort II). RESULTS: Eighty-three infants were included in cohort I and 35 in cohort II. The final CUS scoring system contained the sum of white matter (OR = 2.6, 95% CI 1.5-4.7) and deep grey matter involvement (OR = 2.7, 95% CI 1.7-4.4). The CUS scoring system performed well in cohort I (AUC = 0.90) and II (AUC = 0.89). CONCLUSION: This validated CUS scoring system is associated with neurodevelopmental outcome in neonates with HIE.

Background: Spontaneous breathing is essential for successful non-invasive respiratory support delivered by a facemask at birth. As hypoxia is a potent inhibitor of spontaneous breathing, initiating respiratory support with a high fraction of inspired O2 may reduce the risk of hypoxia and increase respiratory effort at birth. Methods: Preterm rabbit kittens (29 days gestation, term ~32 days) were delivered and randomized to receive continuous positive airway pressure with either 21% (n = 12) or 100% O2 (n = 8) via a facemask. If apnea occurred, intermittent positive pressure ventilation (iPPV) was applied with either 21% or 100% O2 in kittens who started in 21% O2, and remained at 100% O2 for kittens who started the experiment in 100% O2. Respiratory rate (breaths per minute, bpm) and variability in inter-breath interval (%) were measured from esophageal pressure recordings and functional residual capacity (FRC) was measured from synchrotron phase-contrast X-ray images. Results: Initially, kittens receiving 21% O2 had a significantly lower respiratory rate and higher variability in inter-breath interval, indicating a less stable breathing pattern than kittens starting in 100% O2 [median (IQR) respiratory rate: 16 (4–28) vs. 38 (29–46) bpm, p = 0.001; variability in inter-breath interval: 33.3% (17.2–50.1%) vs. 27.5% (18.6–36.3%), p = 0.009]. Apnea that required iPPV, was more frequently observed in kittens in whom resuscitation was started with 21% compared to 100% O2 (11/12 vs. 1/8, p = 0.001). After recovering from apnea, respiratory rate was significantly lower and variability in inter-breath interval was significantly higher in kittens who received iPPV with 21% compared to 100% O2. FRC was not different between study groups at both timepoints. Conclusion: Initiating resuscitation with 100% O2 resulted in increased respiratory activity and stability, thereby reducing the risk of apnea and need for iPPV after birth. Further studies in human preterm infants are ma

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Background: Phenobarbitone (PB) is the first-line anti-convulsant for neonatal seizures. The use of peritoneal dialysis (PD) to enhance drug elimination in cases of neonatal PB overdose has not been reported. Objective(s): To report a case of neonatal severe PB toxicity and review the elimination of PB by PD. Method(s): Assessment of PD drug clearance. Result(s): A neonate with prolonged seizures was administered PB. Encephalopathy and myocardial failure developed, which were initially suspected to be secondary to hypoxia. At 42 h of age, the serum PB concentration was in the toxic range at 131 mg/L. Despite supportive care, the infant's condition deteriorated with escalating inotropes and the need for CPR. Enhanced PB elimination via multiple-dose activated charcoal and exchange transfusion were considered too risky. Hourly PD cycles via Tenckhoff catheter were commenced, based on reports suggesting that PD enhances PB clearance. The clinical state of the infant then improved. PD administration was continued for 60 h, recovering 20% of the estimated total PB body load. The infant survived and there were no PD complications. Conclusion(s): PD increased PB clearance in this neonate, correlating with clinical recovery. Where other techniques are not possible, PD may have a role to play in enhancing PB elimination.Copyright © 2017 S. Karger AG, Basel.

Item does not contain fulltext, There is a growing interest worldwide in using echocardiography in the neonatal unit to act as a complement to the clinical assessment of the hemodynamic status of premature and term infants. However, there is a wide variation in how this tool is implemented across many jurisdictions, the level of expertise, including the oversight of this practice. Over the last 5 years, three major expert consensus statements have been published to provide guidance to neonatologists performing echocardiography, with all recommending a structured training program and clinical governance system for quality assurance. Neonatal practice in Europe is very heterogeneous and the proximity of neonatal units to pediatric cardiology centers varies significantly. Currently, there is no overarching governance structure for training and accreditation in Europe. In this paper, we provide a brief description of the current training recommendations across several jurisdictions including Europe, North America, and Australia and describe the steps required to achieve a sustainable governance structure with the responsibility to provide accreditation to neonatologist performed echocardiography in Europe.

Background: Bi-nasal CPAP (bi-nCPAP) is more effective than mononasal CPAP (m-nCPAP) in preterm infants. Serious adverse events (SAEs) to bi-nCPAP include nasal erythema, skin erosions and necrosis. Proponents of m-nCPAP claim it causes less SAEs. We aimed to a) investigate if SAEs to CPAP differed between bi-nCPAP and m-nCPAP, b) if risk factors for SAEs could be identified, and c) if training staff on the use of bi-nCPAP decreased SAEs. Method(s): Observational study (2003-2009) performed in a tertiary neonatal intensive care unit which traditionally employed m-nCPAP and transitioned to bi-nCPAP. Regular staff training on application of bi-nCPAP was commenced alongside a new protocol mandating moving to m-nCPAP if SAEs on bi-nCPAP occurred. SAEs were prospectively documented in patient notes. Data were retrospectively analyzed (2003- 04; 2005-07; 2008-09). Result(s): 413 VLBWI, mean(SD) gestational age (GA) 28.6 weeks (26.7- 30.4), mean(SD) birth weight (BW) 990 g (780-1280) were studied. There was no significant difference in duration of either CPAP application. Compared to m-nCPAP, infants on bi-nCPAP had more nasal blanching and erythema (68.0% vs. 37.3%, p < 0.001), nasal erosion/ necrosis were more common with m-nCPAP (51.4% vs. 30%, p = 0.009). Risk factors: low GA, low BW and length of CPAP (p < 0.001). The median (IQR) SAEs/ patient decreased over time: 2003-2004 (n = 117): 6 (4-6), 2005-2007 (n = 186): 5 (4-6), 2008-2009 (n = 110): 4 (3-5), (p < 0.001). Trained staff showed greater awareness towards early recognition of SAEs. Conclusion(s): Both forms of nCPAP were associated with SAEs. Training resulted in timely recognition of SAEs and appropriate actions, potentially reducing the number of SAEs/patient.