Newborns at risk of Covid-19 - lessons from the last year

After more than 1 year of the SARS-CoV-2 pandemic, a great deal of knowledge on how this virus affects pregnant women, the fetus and the newborn has accumulated. The gap between different guidelines how to handle newborn infants during this pandemic has been minimized, and the American Academy of Pediatrics (AAP)'s recommendations are now more in accordance with those of the World Health Organization (WHO). In this article we summarize present knowledge regarding transmission from mother to the fetus/newborn. Although both vertical and horizontal transmission are rare, SARS-CoV-2 positivity is associated with an increased risk of premature delivery and higher neonatal mortality and morbidity. Mode of delivery and cord clamping routines should not be affected by the mother's SARS-CoV-2 status. Skin to skin contact, rooming in and breastfeeding are recommended with necessary hygiene precautions. Antibodies of infected or vaccinated women seem to cross both the placenta and into breast milk and likely provide protection for the newborn.

Fathers' experiences of feeding their extremely preterm infants in family-centred neonatal intensive care: a qualitative study

BACKGROUND

Extremely preterm infants need advanced intensive care for survival and are usually not discharged before they reach the time of expected birth. In a family-centred neonatal intensive care unit both parents are involved at all levels of care including the feeding process. However, studies focusing on fathers in this situation are scarce. The purpose of this study was to explore the experiences of feeding extremely preterm infants in a neonatal intensive care unit from fathers' perspectives.

METHODS

The study adopts a qualitative inductive method, reported according to the COREQ checklist. Seven fathers of extremely preterm infants (gestational age 24-27 weeks) in neonatal intensive care in Sweden were interviewed by telephone after discharge in 2013-2014. The interviews were analysed using a qualitative content analysis and confirmed by triangulation in 2021.

RESULTS

Six sub-categories and two generic categories formed the main category: "a team striving towards the same goal". The fathers were equally involved and engaged members of the feeding team all hours of the day. The fathers shared responsibility and practical duties with the mothers, and they provided as much support to the mothers as they could. However, the fathers found it difficult to support and encourage the mothers to breastfeed and express breastmilk when the breastmilk production was low. The fathers experienced a loss when breastfeeding was not successful.

CONCLUSIONS

The findings indicate that fathers want to be involved with infant care, including night-time feeds, and long and demanding feeding processes. Fathers and staff need to collaborate to provide the best support to mothers during the feeding process. This study may inspire hospital staff to acknowledge and support fathers to become more involved in the oral feeding process when an infant is born extremely preterm.

Unequal care: Racial/ethnic disparities in neonatal intensive care delivery

Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.

An integrative review of maternal distress during neonatal intensive care hospitalization

To synthesize literature addressing maternal distress and associated variables in response to infant hospitalization in the NICU. CINAHL, Medline, PubMed, PsychINFO, and Scopus were searched for studies addressing maternal distress during NICU hospitalization published between January 2009 and August 2019. The initial literature search yielded 862 articles. Articles were included for analysis if (a) they were peer-reviewed, (b) maternal distress was defined or measured, and (c) maternal distress occurred in the NICU. Ultimately, 33 articles were included for analysis. Distress symptoms were not consistently measured across the literature by one specific instrument. However, despite the variety of instruments, distress was prevalent in this population. Individual elements of maternal distress in the NICU include depression, anxiety, trauma, and post-traumatic stress symptoms. These elements often occur together and tend to follow a specific trajectory during hospitalization. This body of literature was inconsistent regarding the timing of distress measurement as well as the relationship between relevant associated variables (e.g., marital status or infant illness severity) and maternal distress. Additionally, researchers often excluded mothers of non-preterm infants and infants with congenital anomalies from investigation. Researchers and clinicians should carefully consider timing and instrumentation in their interpretations of maternal distress measurement during a NICU hospitalization. Future work should focus on developing a comprehensive, valid, and reliable screening tool for clinicians and researchers to use to identify maternal distress in the NICU. Additionally, future research should address gaps in the populations included in studies.

The financial burden on families of infants requiring neonatal intensive care

While the high costs of neonatal intensive care have been a topic of increasing study, the financial impact on families have been less frequently reported or summarized. We conducted a systematic review of the literature using Pubmed/Medline and EMBASE (1990-2020) for studies reporting estimates of out-of-pocket costs or qualitative estimates of financial burden on families during a neonatal intensive care unit stay or after discharge. 44 studies met inclusion criteria, with 25 studies providing cost estimates. Cost estimates primarily focused on direct non-medical out-of-pocket costs or loss of productivity, and there was a paucity of cost estimates for insurance cost-sharing. Available estimates suggest these costs are significant to families, cause significant stress, and may impact care received by patients. More high-quality studies estimating the entirety of out-of-pocket costs are needed, and particular attention should be paid to how these costs directly impact the care of our high-risk population.

Concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills and the Bayley Scales of Infant and Toddler Development, Third Edition

AIM

To determine the concurrent validity of the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA-FS), a criterion-specified questionnaire that assesses a child's adaptive skills in everyday contexts, and the Bayley Infant and Toddler Scales of Development, Third Edition (Bayley-III).

METHOD

In a prospective cohort study, 431 WIDEA-FS and Bayley-III assessments were completed among 341 children, aged 10 to 36 months corrected age (158 females, 183 males; median [interquartile range] gestational age at birth 32wks [29-38]), monitored in a high-risk neonatal intensive care unit follow-up clinic.

RESULTS

WIDEA-FS scores were significantly associated with Bayley-III scores in all domains. Lower scores on the WIDEA-FS were significantly associated with an increased risk of adverse developmental performance on all Bayley-III scales. The association was strongest for motor and language Bayley-III scores when tested at <30 months of age, and for cognitive Bayley-III scores when tested at ≥30 months of age.

INTERPRETATION

The WIDEA-FS has concurrent validity with the Bayley-III and may be a useful tool in high-risk follow-up settings.

WHAT THIS PAPER ADDS

WIDEA-FS mobility, communication, and social cognition domains are concurrently valid in infants at high-risk for neurodevelopmental disability. Bayley-III motor, language, and cognitive composite scores are concurrently valid in the same group. The WIDEA-FS mobility and communication domains may be most clinically useful in children <30 months.

Neonates as intrinsically worthy recipients of pain management in neonatal intensive care

One barrier to optimal pain management in the neonatal intensive care unit (NICU) is how the healthcare community perceives, and therefore manages, neonatal pain. In this paper, we emphasise that healthcare professionals not only have a professional obligation to care for neonates in the NICU, but that these patients are intrinsically worthy of care. We discuss the conditions that make neonates worthy recipients of pain management by highlighting how neonates are (1) vulnerable to pain and harm, and (2) completely dependent on others for pain management. We argue for a relational account of ethical decision-making in the NICU by demonstrating how an increase in vulnerability and dependence may be experienced by the healthcare community and the neonate's family. Finally, an ethical framework for decisions around neonatal pain management is proposed, focussing on surrogate decision-making and the importance of compassionate action through both a reflective and an affective empathy. As empathy can be highly motivating against pain, we propose that, in addition to educational programs that raise awareness and knowledge of neonatal pain and pain management, healthcare professionals must cultivate empathy in a collective manner, where all members of the NICU team, including parents, are compassionate decision-makers.

Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care).

DATA SOURCES

PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020.

STUDY ELIGIBILITY CRITERIA

Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori.

STUDY APPRAISAL AND SYNTHESIS METHODS

Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I² statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model.

RESULTS

Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I²=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I²=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I²=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported.

CONCLUSION

The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.

[Comparative assessment of off-label and unlicensed drug prescription in neonatal intensive care: FDA versus Brazilian guidelines]

INTRODUCTION

Regulatory agencies are responsible for defining the use of off-label (OL) and unlicensed (UL) drug prescription in neonatal intensive care. However, these regulatory criteria may differ between agencies in different countries. The aim of this study was to establish the frequency of OL and UL drug prescription in a sample of patients in a neonatal intensive care unit applying the criteria of the Food and Drug Administration (FDA) of the United States and the Agência Nacional de Vigilância Sanitária (ANVISA) of Brazil, analysing the differences observed in the results based on the applied criteria.

METHODS

Prospective cohort study in neonates admitted for more than 24hours to the neonatal intensive care unit (NICU) of a teaching maternity hospital between August 2017 and July 2018. We obtained information concerning the drugs included in the analysis of OL and UL prescriptions from the DrugDex-Micromedex® and official information on pharmaceutical products in Brazil. We used the kappa correlation coefficient to assess the agreement between the FDA and ANVISA criteria. We defined disagreement as a kappa value of less than 0.200.

RESULTS

We evaluated 220 neonates admitted to the NICU and 17,421 items prescribed during the study period. We did not find a difference in the proportion of neonates in which at least 1 drug was prescribed under OL conditions applying the FDA versus the ANVISA criteria (96.4% vs. 98.6%). We found differences between the FDA and ANVISA in the OL classification based on the authorised age of use and indications for prescription, mainly in systemic antimicrobials and cardiovascular drugs. When we compared the prescribing information provided by the FDA and the ANVISA, we found that the criteria of the ANVISA were less specific.

CONCLUSIONS

OL and UL drug prescription are frequent in neonatal intensive care applying the criteria of either agency, although the FDA has established more detailed criteria in terms of the ages and indications for which prescription is authorised.

Caring for Critically Ill Children With Suspected or Proven Coronavirus Disease 2019 Infection: Recommendations by the Scientific Sections' Collaborative of the European Society of Pediatric and Neonatal Intensive Care

OBJECTIVES

In children, coronavirus disease 2019 is usually mild but can develop severe hypoxemic failure or a severe multisystem inflammatory syndrome, the latter considered to be a postinfectious syndrome, with cardiac involvement alone or together with a toxic shock like-presentation. Given the novelty of severe acute respiratory syndrome coronavirus 2, the causative agent of the recent coronavirus disease 2019 pandemic, little is known about the pathophysiology and phenotypic expressions of this new infectious disease nor the optimal treatment approach.

STUDY SELECTION

From inception to July 10, 2020, repeated PubMed and open Web searches have been done by the scientific section collaborative group members of the European Society of Pediatric and Neonatal Intensive Care.

DATA EXTRACTION

There is little in the way of clinical research in children affected by coronavirus disease 2019, apart from descriptive data and epidemiology.

DATA SYNTHESIS

Even though basic treatment and organ support considerations seem not to differ much from other critical illness, such as pediatric septic shock and multiple organ failure, seen in PICUs, some specific issues must be considered when caring for children with severe coronavirus disease 2019 disease.

CONCLUSIONS

In this clinical guidance article, we review the current clinical knowledge of coronavirus disease 2019 disease in critically ill children and discuss some specific treatment concepts based mainly on expert opinion based on limited experience and the lack of any completed controlled trials in children at this time.

Death after Birth Asphyxia in the Cooling Era

In asphyxiated newborn infants treated with hypothermia, 31 of 50 (62%) deaths occurred in unstable infants electively extubated before completing hypothermia treatment. Later deaths occurred after consultation with palliative care (13/19) or clinical ethics (6/19) services, suggesting these decisions were challenging and required support, particularly if nutrition and hydration were withdrawn (n = 4).

The effect of early oral stimulation with breast milk on the feeding behavior of infants after congenital cardiac surgery

OBJECTIVE

To investigate the effect of early oral stimulation with breast milk on the feeding behavior of infants after congenital cardiac surgery.

METHODS

Infants with congenital heart disease were randomly divided into the breast milk oral stimulation group (n = 23), physiological saline oral stimulation group (n = 23) and control group (n = 23). Debra Beckman's oral exercise program was used with breast milk and physiological saline in the breast milk oral stimulation group and the physiological saline oral stimulation group, respectively. The time oral feeding and total oral nutrition were started, the length of intensive care unit (ICU) stay and hospital stay, weight and the complications at discharge were recorded for each group and statistically analyzed.

RESULTS

The time oral feeding and total oral nutrition were started and the length of ICU stay and hospital stay were significantly less in the breast milk oral stimulation group and physiological saline oral stimulation group than in the control group (P < 0.05). There were no significant differences in other indicators between the breast milk oral stimulation group and the physiological saline oral stimulation group, except for the time total oral nutrition began (P < 0.05). However, there were no significant differences in weight or complications at discharge among the three groups (P > 0.05).

CONCLUSION

Early oral stimulation exercises with breast milk can help infant patients quickly recover total oral nutrition and reduce the length of ICU and hospital stay after cardiac surgery.

A machine-learning algorithm for neonatal seizure recognition: a multicentre, randomised, controlled trial

BACKGROUND

Despite the availability of continuous conventional electroencephalography (cEEG), accurate diagnosis of neonatal seizures is challenging in clinical practice. Algorithms for decision support in the recognition of neonatal seizures could improve detection. We aimed to assess the diagnostic accuracy of an automated seizure detection algorithm called Algorithm for Neonatal Seizure Recognition (ANSeR).

METHODS

This multicentre, randomised, two-arm, parallel, controlled trial was done in eight neonatal centres across Ireland, the Netherlands, Sweden, and the UK. Neonates with a corrected gestational age between 36 and 44 weeks with, or at significant risk of, seizures requiring EEG monitoring, received cEEG plus ANSeR linked to the EEG monitor displaying a seizure probability trend in real time (algorithm group) or cEEG monitoring alone (non-algorithm group). The primary outcome was diagnostic accuracy (sensitivity, specificity, and false detection rate) of health-care professionals to identify neonates with electrographic seizures and seizure hours with and without the support of the ANSeR algorithm. Neonates with data on the outcome of interest were included in the analysis. This study is registered with ClinicalTrials.gov, NCT02431780.

FINDINGS

Between Feb 13, 2015, and Feb 7, 2017, 132 neonates were randomly assigned to the algorithm group and 132 to the non-algorithm group. Six neonates were excluded (four from the algorithm group and two from the non-algorithm group). Electrographic seizures were present in 32 (25·0%) of 128 neonates in the algorithm group and 38 (29·2%) of 130 neonates in the non-algorithm group. For recognition of neonates with electrographic seizures, sensitivity was 81·3% (95% CI 66·7-93·3) in the algorithm group and 89·5% (78·4-97·5) in the non-algorithm group; specificity was 84·4% (95% CI 76·9-91·0) in the algorithm group and 89·1% (82·5-94·7) in the non-algorithm group; and the false detection rate was 36·6% (95% CI 22·7-52·1) in the algorithm group and 22·7% (11·6-35·9) in the non-algorithm group. We identified 659 h in which seizures occurred (seizure hours): 268 h in the algorithm versus 391 h in the non-algorithm group. The percentage of seizure hours correctly identified was higher in the algorithm group than in the non-algorithm group (177 [66·0%; 95% CI 53·8-77·3] of 268 h vs 177 [45·3%; 34·5-58·3] of 391 h; difference 20·8% [3·6-37·1]). No significant differences were seen in the percentage of neonates with seizures given at least one inappropriate antiseizure medication (37·5% [95% CI 25·0 to 56·3] vs 31·6% [21·1 to 47·4]; difference 5·9% [-14·0 to 26·3]).

INTERPRETATION

ANSeR, a machine-learning algorithm, is safe and able to accurately detect neonatal seizures. Although the algorithm did not enhance identification of individual neonates with seizures beyond conventional EEG, recognition of seizure hours was improved with use of ANSeR. The benefit might be greater in less experienced centres, but further study is required.

FUNDING

Wellcome Trust, Science Foundation Ireland, and Nihon Kohden.

Former NICU Families Describe Gaps in Family-Centered Care

Care and outcomes of infants admitted to neonatal intensive care vary and differences in family-centered care may contribute. The objective of this study was to understand families' experiences of neonatal care within a framework of family-centered care. We conducted focus groups and interviews with 18 family members whose infants were cared for in California neonatal intensive care units (NICUs) using a grounded theory approach and centering the accounts of families of color and/or of low socioeconomic status. Families identified the following challenges that indicated a gap in mutual trust and power sharing: conflict with or lack of knowledge about social work; staff judgment of, or unwillingness to address barriers to family presence at bedside; need for nurse continuity and meaningful relationship with nurses and inconsistent access to translation services. These unmet needs for partnership in care or support were particularly experienced by parents of color or of low socioeconomic status.

Body composition and neuromotor development in the year after NICU discharge in premature infants

BACKGROUND

Hypothesis: neuromotor development correlates to body composition over the first year of life in prematurely born infants and can be influenced by enhancing motor activity.

METHODS

Forty-six female and 53 male infants [27 ± 1.8 (sd) weeks] randomized to comparison or exercise group (caregiver provided 15-20 min daily of developmentally appropriate motor activities) completed the year-long study. Body composition [lean body and fat mass (LBM, FM)], growth/inflammation predictive biomarkers, and Alberta Infant Motor Scale (AIMS) were assessed.

RESULTS

AIMS at 1 year correlated with LBM (r = 0.32, p < 0.001) in the whole cohort. However, there was no effect of the intervention. LBM increased by ~3685 g (p < 0.001)); insulin-like growth factor-1 (IGF-1) was correlated with LBM (r = 0.36, p = 0.002). IL-1RA (an inflammatory biomarker) decreased (-75%, p < 0.0125). LBM and bone mineral density were significantly lower and IGF-1 higher in the females at 1 year.

CONCLUSIONS

We found an association between neuromotor development and LBM suggesting that motor activity may influence LBM. Our particular intervention was ineffective. Whether activities provided largely by caregivers to enhance motor activity in prematurely born infants can affect the interrelated (1) balance of growth and inflammation mediators, (2) neuromotor development, (3) sexual dimorphism, and/or (4) body composition early in life remains unknown.

Plasma ammonia concentrations in extremely low birthweight infants in the first week after birth: secondary analysis from the ProVIDe randomized clinical trial

BACKGROUND

Little is known about normative ammonia concentrations in extremely low birthweight (ELBW) babies and whether these vary with birth characteristics. We aimed to determine ammonia concentrations in ELBW babies in the first week after birth and relationships with neonatal characteristics and protein intake.

METHODS

Arterial blood samples for the measurement of plasma ammonia concentration were collected within 7 days of birth from ProVIDe trial participants in six New Zealand neonatal intensive care units.

RESULTS

Three hundred and twenty-two babies were included. Median (range) gestational age was 25.7 (22.7-31.6) weeks. Median (interquartile range (IQR)) ammonia concentration was 102 (80-131) µg/dL. There were no statistically significant associations between ammonia concentrations and birthweight or sex. Ammonia concentrations were weakly correlated with mean total (Spearman's rs = 0.11, P = 0.047) and intravenous (rs = 0.13, P = 0.02) protein intake from birth, gestational age at birth (rs = -0.13, P = 0.02) and postnatal age (rs = -0.13, P = 0.02).

CONCLUSIONS

Plasma ammonia concentrations in ELBW babies are similar to those of larger and more mature babies and only weakly correlated with protein intake. Currently, recommended thresholds for investigation of hyperammonaemia are appropriate for ELBW babies. Protein intake should not be limited by concerns about potential hyperammonaemia.

Initiating end-of-life decisions with parents of infants receiving neonatal intensive care

OBJECTIVE

To investigate whether parent-initiated or doctor-initiated decisions about limiting life-sustaining treatment (LST) in neonatal care has consequences for how possible courses of action are presented.

METHOD

Formal conversations (n = 27) between doctors and parents of critically ill babies from two level 3 neonatal intensive care units were audio or video recorded. Sequences of talk where decisions about limiting LST were presented were analysed using Conversation Analysis and coded using a Conversation Analytic informed coding framework. Relationships between codes were analysed using Fisher's exact test.

RESULTS

When parents initiated the decision point, doctors subsequently tended to refer to or list available options. When doctors initiated, they tended to use 'recommendations' or 'single-option' choice (conditional) formats (p=0.017) that did not include multiple treatment options. Parent initiations overwhelmingly concerned withdrawal, as opposed to withholding of LST (p=0.030).

CONCLUSION

Aligning parents to the trajectory of the news about their baby's poor condition may influence how the doctor subsequently presents the decision to limit LST, and thereby the extent to which parents are invited to participate in shared decision-making.

PRACTICE IMPLICATIONS

Explicitly proposing treatment options may provide parents with opportunities to be involved in decisions for their critically ill babies, thereby fostering shared decision-making.

The Congenital Heart Disease Brain: Prenatal Considerations for Perioperative Neurocritical Care

Altered brain development has been highlighted as an important contributor to adverse neurodevelopmental outcomes in children with congenital heart disease. Abnormalities begin prenatally and include micro- and macrostructural disturbances that lead to an altered trajectory of brain growth throughout gestation. Recent progress in fetal imaging has improved understanding of the neurobiological mechanisms and risk factors for impaired fetal brain development. The impact of the prenatal environment on postnatal neurological care has also gained increased focus. This review summarizes current data on the timing and pattern of altered prenatal brain development in congenital heart disease, the potential mechanisms of these abnormalities, and the association with perioperative neurological complications.

Video-call based newborn triage system for local birth centres can be established without major instalment costs using commercially available smartphones

Neonates often develop transition problems after low-risk birth, precise assessment of which is difficult at primary birth centres. The aim of this study was to assess whether a video triage system can be established without a specially designed communication system between local birth centres and a tertiary neonatal intensive care unit in a region with a population of 700,000. 761 neonates who were referred to a tertiary neonatal intensive care unit were examined. During period 1 (April 2011-August 2015), only a voice call was available for consultations, whereas, during period 2 (September 2015-December 2017), a video call was additionally available. The respiratory condition was assessed based on an established visual assessment tool. A video consultation system was established by connecting personal smartphones at local birth centres with a host computer at a tertiary neonatal intensive care centre. During period 2, video-based triage was performed for 42.4% of 236 consultations at 30 birth centres. Sensitivity and specificity for predicting newborns with critical respiratory dysfunction changed from 0.758 to 0.898 and 0.684 to 0.661, respectively. A video consultation system for ill neonates was established without major instalment costs. Our strategy might improve the transportation system in both high- and low-resource settings.

The natural history of congenital hypothyroidism with delayed TSH elevation in neonatal intensive care newborns

OBJECTIVE

To assess the clinical and neurological outcomes in newborns with primary congenital hypothyroidism presented with delayed TSH elevation (dTSH), and to define parameters that may predict the evolution of transient vs. permanent hypothyroidism in these newborns.

DESIGN AND PATIENTS

An observational study was performed of a cohort of 113 children with a history of dTSH.

MEASUREMENTS

Birth parameters, thyroid screening results, thyroid gland imaging, levothyroxine dose and neurological outcome were compared between newborns with spontaneous recovery and children with a final diagnosis of either transient or permanent hypothyroidism.

RESULTS

Of the children with a history of dTSH, 93% demonstrated recovery, either spontaneously or following levothyroxine treatment (transient hypothyroidism). Newborns with spontaneous recovery demonstrated milder thyroid dysfunction at the newborn screening compared to those who started levothyroxine treatment. Levothyroxine dose was lower in children with transient vs. permanent hypothyroidism only during the first 6 months of life; otherwise, these groups were similar in birth parameters, thyroid screening results and gland images. Seventeen out of 61 children (28%) that underwent neurological assessment demonstrated a developmental delay. Duration of treatment was highly variable in children with transient hypothyroidism.

CONCLUSIONS

Thyroid dysfunction is transient in most cases of dTSH. No reliable parameters can predict a priori transient vs. permanent hypothyroidism.

Supporting the use of sildenafil infusions in paediatric and neonatal intensive care - A compatibility study

OBJECTIVE

Intravenous (IV) sildenafil, a phosphodiesterase type 5 inhibitor, is increasingly being used for the treatment of pulmonary hypertension (PH) in the paediatric population. Sildenafil (Revatio®) is approved for the treatment of pH in adults where it is administered as a bolus injection. However, in paediatrics it is used off-label and administered by continuous IV infusion. In the critically unwell child, limited IV access necessitates the administration of multiple IV infusions through a single IV lumen. The absence of compatibility data between sildenafil and other IV medications commonly used in this context necessitates the use of a dedicated IV line for sildenafil. The overall aim of this study was to establish the physical and chemical compatibility of sildenafil with commonly administered infusions in the paediatric and neonatal intensive care setting.

DESIGN

This study evaluated the chemical and physical compatibility of binary and multiple combinations (n = 42) of sildenafil with adrenaline, noradrenaline, milrinone, vasopressin and heparin. These were tested using three diluents (NaCl 0.9%w/v, Glucose 5%w/v, and Glucose 10%w/v) and two environmental conditions (room temperature and 37 °C) frequently encountered in paediatric or neonatal intensive care units. Prior to drug combination analysis, HPLC methods were developed and optimised to allow for the quantification of drugs in accordance with current pharmaceutical guidance. Binary and multiple drug mixtures of sildenafil were examined for physical and chemical compatibility to establish compatibility.

MEASUREMENTS AND MAIN RESULTS

Of the drug combinations not containing heparin, all were deemed compatible with the exception of the five drug mix of Sildenafil 800 μg/mL, Milrinone 200 μg/mL, Vasopressin 0.4Units/mL, Noradrenaline 60 μg/mL, Adrenaline 60 μg/mL at 37 °C, in 10%w/v glucose. All binary or multi drug combinations containing heparin were deemed incompatible.

CONCLUSIONS

This research provides support and information to clinicians looking to co-administer sildenafil with other IV medicines thus removing the requirement to subject their patients to multiple intravenous cannula insertion points where IV access is restricted.

ARTICLE TWEET

New evidence to support administration of sildenafil infusions in #PedsICU and #nicu- collaboration between @RCSIPharBioMol@FionaSOBrien1 and @OLCHCrumlin @RCSI_Irl @MoninneHowlett #CHI.