Postmaturity is a syndrome of failing placental function cf post-term, simply a statement of dates.
Snuffly but patent nostrils = neonatal rhinitis. ?syphilis. Saline not steroids (nasal drops are potent).
A difference of 20 mm Hg in BP between arm and leg is seen in 8% of normal babies.
In healthy term newborns, hyperbilirubinaemia (>250 micro mol/l) can be safely ruled out by eye if jaundice does not reach the abdomen or the extremities (Kramer zones 1 and 2).
Does the routine neonatal check achieve anything? It misses about a half of all cases of congenital heart disease; if there's a murmur, there is a roughly 50% chance of it being significant. Arch Dis Child 80(1):F43-5, 1999. PMID 10325811. Of the murmurs referred for 6 week clinic, about a third will present symptomatically before their clinic date arrives. Archives Dis Child 80(1):F49-53, 1999 PMID 10325813. So it isn't great, and parents must remain vigilant about new symptoms. There's evidence too that nurses or midwives but be just as good at doing it.
Routine sats monitoring to detect congenital cardiac disease? Failed to detect any of 12 cases in 1 study when done at discharge Pediatr Cardiol. 2008 Mar, PMID 17932712. In another, all neonates with a critical congenital heart defect were detected clinically. 5% of readings were below 96% at 4 hours. 3 turned out to have cardiac disease but this was picked up clinically. 768 had repeat at discharge, of which all but 1 were normal (the one that remained abnormal had a normal echo!) 1 case of Fallots had normal sats and was detected clinically. These results do not support a recommendation for routine pulse oximetry screening in seemingly healthy neonates. Pediatrics. 2008 Oct [PMID: 18762486]. Echo would be more sensitive, but a lot more expensive, especially as more cases detected antenatally now; and has a 5% false positive rate.
Aberdeen study shows second neonatal check is of no benefit BMJ 1999; 318: 627-632
Bleeding nipples in infants is almost always due to ductal ectasia and resolves spontaneously over 6 months or so.
Lymphopenia is damn common! But should prompt consideration of other SCID features.Scott Hacket letter to Archives
No evidence to support albumin infusions for preterms with hypoalbuminaemia (Cochrane review).
A chest drain under suction is theoretically more likely to lead to a fistula, so use a flutter valve instead if possible.
A measure of lung disease in terms of level of oxygenation achieved for a given ventilation strategy. =Mean airway pressure/pO2 x100 (where MAP is in mmHg and pO2 is in kPa; to convert cmH20 to mmHg multiply by 7.5).
Flow driver has expiratory limb to increase reserve of oxygen. Pressure of 8cm gives highest EEV and TV but optimal? You could even argue for 10 cm for worsening RDS! Mouth closure gives higher pharyngeal pressure.
IFDAS study sadly showed no benefit in CLD from early cpap in v preterm, even with prophyl curosurf... At least there was no increase in airleak cf oxygen or ventilation. ?role for added NIPPV.
A potent but short acting vasodilator, so when given into the ventilator circuit acts selectively on pulmonary hypertension. Most effective for meconium aspiration syndrome (prevents need for ECMO), dubious for pulmonary hypoplasia eg congenital diaphragmmatic hernia (presumably because limited reversibility in underlying condition.
Typically started when OI is greater than 20. Begin at 10ppm, increase to 20ppm if necessary.
Side effect is methaemoglobinaemia. MetHb should be kept under 2% else indicates a problem with the delivery mechanism.
Wean slowly, especially at low concentrations eg under 5ppm as rebound hypertension can occur.
To diagnose PDA, measure consistent width of colour jet: >0.2 cm significant.
(Evans, j ped)
Blood pressure is notoriously unreliable. Colour, capillary refill, toe-core gap not much better. Superior vena cava (SVC) flow assesses blood flow echocardiographically from the upper body, and may provide a reliable assessment of systemic blood flow. Dublin study, found low flow state in 1st 24hrs of VLBW associated with early death or G2 IVH (50%, cf 6.7%). No correlation between SVC flow and right ventricular output, ACA velocity or blood pressure measurements!
Routine use of non-sterile gloves plus alcohol rub reduced late onset sepsis by a factor of 2.8 (factor of 7 for fungal, and significantly less NEC too) in Hong Kong. Less days in oxygen too... (Arch Fet 2004)
Candida - Nystatin PO TID effective (Sims, Am J Perinat 1988). Single-center studies have shown that prophylactic fluconazole reduces the rates of invasive candidiasis and/or colonization of extremely-low-birth-weight infants.
CNS rate of late onset sepsis very stable, although diversity of flora varies. Hence prevention of CNS may encourage pseudomonas, E coli
Crossover study showed increased antibiotic resistance in units using 3rd generation cephalosporins as first line. Lancet 2000, P de Man
Topical emollients improved neonatal skin condition, but in some studies were associated with an increased risk of nosocomial bacterial sepsis. Daily massage with sunflower seed oil (n=159) 41% less likely to develop nosocomial infections than controls (adjusted incidence rate ratio [IRR] 0.59, 95% CI 0.37-0.96). Aquaphor did not significantly reduce the risk of infection (RCT of 33/40 or less babies, Bangladesh).Lancet. 2005 Mar 16;365(9464):1039-45. . But the gut is much more likely to be the source of any infection - see Immunity.
Physical demarcation of a cot space is helpful in preventing nosocomial infection.
Quality improvement projects to improve adherence to appropriate hand hygiene and best practices for central venous catheter insertion and maintenance can reduce rates of nosocomial sepsis.
Current Opinion in Pediatrics. 18(2):101-6, 2006 Apr. pmid 16601486
The mean day 1 prem blood volume correlates positively with heart rate (higher HR was associated with higher BV!!!). and negative base excess (more acidotic babies tended to have higher BV!!!). There was no significant correlation between core-toe gap, mean arterial pressure, or packed cell volume. Even base excess with HR together only predict 29% of the variability in BV. QMH, Arch Fet 2004
Using a Hb threshold for transfusion of 7g/dl in ICU has no negative consequences cf using threshold of 9.5. NEJM 2007.
May be your only chance of a culture if meningitis (37% have negative blood cultures), plus allows you to rationalize antibiotics. In RDS, only 1 in 1500 LPs positive, so a selective strategy seems sensible. In late onset sepsis, meningitis is unusual so only for very sick or for a suspected pathogen (eg on skin) that is likely to cause meningitis.
The first lumbar puncture in meningitis: CSF WBC counts of >0 cells per mm3 had sensitivity at 97% (so not quite zero). CSF WBC counts of >21 cells had specificity of 81% (so lots of false positives). In neonates with both positive blood and CSF cultures, the organisms isolated were discordant in 3.5%, and usually require different antimicrobial therapy! Pediatrics. 2006 Apr;117(4):1094-100 PMID 16585303.
Trying to correct the CSF white cell count for the number or red cells does not help! You lose sensitivity and gain very little specificity PIDJ Nov 08).
Trying to diagnose meningitis on the basis of CSF parameters in the absence of a positive culture is really unreliable (poor ROC curves, 0.63-0.8) in the preterm. American Journal of Perinatology. 25(7):421-6, 2008 PMID: 18726835 The strategy of deferring lumbar puncture after starting antibiotics appears to have no place in the preterm neonate.
Choice fluclox and gent for late onset unless high MRSA rate, in which case use Vancomycin. Gentamicin effective against most CNS! Broad spectrum=not thinking! LP is perhaps more important if using fluclox and gent as first line.
Lancet 355, Mar 18, 2000: use of cefotaxime led to increased resistant bacilli but reversible. Cefotaxime is poor against listeria and enterococcus (ampicillin better).
Gentamicin has been associated with hypocalcaemia in OD regimes (enhances excretion, also Na and Mg).
Vancomycin Coag neg staph does not cause fulminant sepsis, has low mortality, and note that use of vanc leads to higher gram neg rates. 1997 Parkkud? Fluclox and gent protocol showed that 83% of coag neg staph infections turned up positive in first 24 hours allowing rapid change in treatment. If not improved but cultures negative, ampicillin should be added. There was no increase in mortality; change in morbidity was less certain.
Stopping antibiotics early after negative cultures did not lead to increased rated of sepsis (Arch Dis Child 62, 727, 1987). Not very good reasons usually for continuing, eg sick baby (lots of other reasons for appearing sick), high CRP (not specific - stop testing!), ?false negative blood culture (very rare). In early onset infection, good evidence that it is safe to stop antibiotics after 24 hours if cultures negative!
2 blood cultures are the best way to determine real infection vs contaminant. IL6 is most sensitive marker. Benj, Peds 2001: Outcome of catheter infection worse if not removed within 24 hours, particularly with staph aureus and non enteric gram negatives. But cf Karlowicz Paed Inf Dis J 2002: 79% of Coag neg staph infection successfully treated without removal if unwell for less than 2 days. If fungal, then catheter must be removed.
CRP is useful at the end of a course of treatment to decide on whether treatment is complete.
Deep ear swab is most sensitive way of screening for bugs, at least in early onset infection.
IL-8 study - Term and preterm infants who were less than 72 hours of age and had clinical signs or obstetric risk factors suggesting neonatal bacterial infection but stable enough to wait for results of diagnostic tests were enrolled into the study. In the IL-8 group, fewer infants received antibiotic therapy than in the standard group (36.1% [237 of 656] vs 49.6% [315 of 635]). About 15% in each group were missed and became infected. Pediatrics. 2004 Jul;114(1):1-8
Procalcitonin - At a cut off value of 0.5 ng/ml, the sensitivity of Procalcitonin was 97%, whereas that of CRP was 73% in predicting late-onset sepsis in VLBW. J Perinatol. 2005 Apr 14
Heart rate abnormalities appear to be an independent predictor Pediatrics. 2005 Apr;115(4):937-41.
Ureaplasma probably important in abnormal CSF with negative cultures. If persistent, treat with clarithro 15 mg/kg BD or doxy. Clindamycin effective vs Mycoplasma hominis.
Ibuprofen prophylaxis in preterm infants reduced the need for PDA surgical ligation from six (9%) to zero (p=0.03), and possibly decreased the rate of severe intraventricular haemorrhage from 15 (23%) to seven (11%) (p=0.10). However, survival was not improved (47 [71%] placebo vs 47 [72%] treatment, p=1.00), because of high frequency of adverse respiratory, renal, and digestive events. (Lancet. 2004 Nov 27;364(9449):1939-44.)
Postnatal steroids are usually prescribed as:
Breastfeeding provides superior analgesia for heel lance compared with oral sucrose in term neonates.PMID: 18762508
Clingfilm prevents heat loss in first hour after birth of preterm RCT (J Pediatr. 2004 Dec;145(6):750-3.)
Pleasant odour in incubator reduces apnoeas/bradycardias within a day (not randomized). Pediatrics. 2005 Jan;115(1):83-8.
Delayed cord clamping of 30-60 seconds was popular in the 80s, and has been suggested as effective vs NEC, BPD and IVH. Recent Cochrane suggests prevents IVH and blood transfusion, others that it reduced late onset sepsis (!) pmid 17890882. Delayed cord clamping 60-90 secs plus oxytocin improves cerebral oxygenation during first 24 hrs in preterm babies. Peds 2007;119:55-9 Difficult studies to do, no reduction in severe IVH seen. Certainly no evidence of any harms. Milking the cord works in ELBW babies, even reduces days ventilated pmid 17234653.
Screen babies born <=31/40 or under 1500g, but not until corrected age 31/40 AND 4/52 old (allow vitreous to clear). Fortnightly in first instance.
See Outcome.
Running heparin (0.5 U/kg per hour) through peripherally inserted central venous catheters increases chance of elective catheter removal (for completed therapy), reduces rate of occlusion (6% vs 31%). No adverse events were noted. Pediatrics. 2007;119:e284-91.
High vs Low UAC for NEC is uncertain. However, high UAC tip placement results in a lower incidence of aortic thrombosis, fewer ischaemic complications and a longer duration of catheter use.
DTP in steroid treated babies has good immunogenicity and no extra doses are needed.
Arch Fet 2004; 89
Cerebral function activity monitoring. Like an EEG but only 2 probes. Normal CFAM pattern is:
You need low impedance to get good recordings - if too high eg over 20 kOhm then the machine will usually alarm. If the impedance changes at the same time as changes occur on the trace, this is likely to be artefact related to the leads.
Mild changes are loss of sleep/wake cycling, increased variability, and a drop in lower margin. More severe changes are loss of variability and a drop in upper margin. A seizure usually shows as a rise in lower & often upper margins, with overall narrowing of the trace, and repeated spikes lasting over 10 seconds. Rising baseline without spikes is probably artefact.
Burst suppression is where baseline is below 5 with flatline, upper intermixed with bursts over 10 for 1-3s (prolonged burst suppression is associated with a high probability of severe brain injury). Unilateral injury may show as discrepancy between channels. ECG artefact is low voltage so check vertical sensitivity.
Arch 2005;90:F201
Don't do it in the delivery room! Wait until they've reached the postnatal ward. Best to come from someone they are familiar with rather than a stranger. Tell both parents or have support person present too. Parents may appreciate doctor passing the news on to the rest of the family.
Don't delay - parents are often aware that staff are being wary of them, holding something back. Emphasize the health of the child. Point out features on child with child present (otherwise parent may imagine disfigurements!). "This makes me think your child may have Downs syndrome. The only way to know for sure is to do a blood test. This should take no more than 48 hours."
Try to stay neutral and listen. Many families will see the diagnosis as an unmitigated tragedy; this is understandable. Attitudes will also be affected by previous experience and expectations. Doctors tend to give overwhelming information on medical complications without balancing it with what affected individuals and their families might have to say. For instance, mental retardation is variable and can be very mild. They can usually participate in education, sports, employment.
Mention feeding problems and cardiac disease (50%). Beware congenital leukaemias and other haematological problems. Other complications are probably best put aside unless they are suspected. Parent support groups may be the best way of leading parents through their initial emotions. Return to see the family after some time. Ensure information/contacts are available at the time of discharge.
Several RCTs indicate that there are no adverse outcomes of early discharge, including no differences in weight gain, short-term complications and hospital readmissions, if the infants are discharged when the following criteria are met:
Car seat challenge? See Respiratory.
In stable pre-terms over 1500g, kangaroo care is as safe as conventional care. May reduce infections and improve exclusive breastfeeding rates and weight gain. Under 1500g, not clear because many of these infants were excluded from studies. In resource-poor settings kangaroo care may be effective even in clinically unstable LBW infants including those with birth weights <1500g.
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