Parental Perspectives on a Trial Using Waived Informed Consent at Birth

Objectives

To determine parental perspectives in a trial with waived consent.

Study Design

Biological parents of non-vigorous term infants randomized using a waiver of consent for a delivery room intervention completed an anonymous survey after discharge.

Results

121 survey responses were collected. Most responding parents reported that this form of consent was acceptable (92%) and that they would feel comfortable having another child participate in a similar study (96%). The majority (> 90%) also reported that the information provided after randomization was clear to understand future data collection procedures. Four percent had a negative opinion on the study's effect on their child's health.

Conclusions

The majority of responding parents reported both acceptability of this study design in the neonatal period and that the study had a positive effect on their child's health. Future work should investigate additional ways to involve parents and elicit feedback on varied methods of pediatric consent.

High continuous positive airway pressures versus non-invasive positive pressure ventilation in preterm neonates: protocol for a multicentre pilot randomised controlled trial

INTRODUCTION

Low pressure nasal continuous positive airway pressure (nCPAP) has long been the mainstay of non-invasive respiratory support for preterm neonates, at a constant distending pressure of 5-8 cmH2O. When traditional nCPAP pressures are insufficient, other modes including nasal intermittent positive pressure ventilation (NIPPV) are used. In recent years, high nCPAP pressures (≥9 cmH2O) have also emerged as an alternative. However, the comparative benefits and risks of these modalities remain unknown.

METHODS AND ANALYSIS

In this multicentre pilot randomised controlled trial, infants <29 weeks' gestational age (GA) who either: (A) fail treatment with traditional nCPAP or (B) being extubated from invasive mechanical ventilation with mean airway pressure ≥10 cmH2O, will be randomised to receive either high nCPAP (positive end-expiratory pressure 9-15 cmH2O) or NIPPV (target mean Paw 9-15 cmH2O). Primary outcome is feasibility of the conduct of a larger, definitive trial as assessed by rates of recruitment and protocol violations. The main secondary outcome is failure of assigned treatment within 7 days postrandomisation. Multiple other clinical outcomes including bronchopulmonary dysplasia will be ascertained. All randomised participants will be analysed using intention to treat. Baseline and demographic variables as well as outcomes will be summarised and compared using univariate analyses, and a p<0.05 will be considered significant.

ETHICS AND DISSEMINATION

The trial has been approved by the respective research ethics boards at each institution (McMaster Children's Hospital: Hamilton integrated REB approval #2113; Royal Alexandra Hospital: Health Research Ethics Board approval ID Pro00090244; Westmead Hospital: Human Research Ethics Committee approval ID 2022/ETH01343). Written, informed consent will be obtained from all parents/guardians prior to study enrolment. The findings of this pilot study will be disseminated via presentations at national and international conferences and via publication in a peer-reviewed journal. Social media platforms including Twitter will also be used to generate awareness.

TRIAL REGISTRATION NUMBER

NCT03512158.

50 Poractant alfa versus bovine lipid extract surfactant for respiratory distress syndrome in preterm infants: A prospective comparative effectiveness cohort study

Primary Subject area

Neonatal-Perinatal Medicine

Background

There is a paucity of comparative effectiveness data for bovine lipid extract surfactant (BLES) and poractant alfa (Curosurf).

Objectives

To compare duration of respiratory support and short-term outcomes in very preterm infants treated with bovine lipid extract surfactant and poractant alfa.

Design/Methods

We performed a prospective, multicentre, comparative effectiveness study. Thirteen Canadian level III neonatal intensive care units (NICUs) provided bovine lipid extract surfactant to infants born &lt;32 weeks’ gestational age (GA) for a set period of time in the year 2019 (3 to 9 months), then changed to poractant alfa for the remainder of the year. The primary outcome was total duration of respiratory support (invasive and non-invasive). We utilized the Canadian Neonatal Network database for all study data.

Results

A total of 968 eligible infants (530 infants &lt; 28 weeks’ GA and 438 infants 280-316weeks’ GA) were included, of which 494 received bovine lipid extract surfactant and 474 received poractant alfa. In unadjusted analysis, no difference was observed in total duration of any respiratory support (median 38 vs. 40.5 days). After adjusting for baseline characteristics and accounting for cluster effects, infants treated with poractant alfa spent a median of 4.16 fewer days on respiratory support (95% CI 0.05, 8.28 days). This reduction was observed in the subgroup of infants 280-316 weeks’ GA, but not in those &lt; 28 weeks’ GA, and was explained by their shorter time on non-invasive respiratory support. No differences were observed in the need to re-dose surfactant, hospital mortality, bronchopulmonary dysplasia, or length of stay in NICU.

Conclusion

Administration of poractant alfa was associated with shorter median duration of respiratory support compared to bovine lipid extract surfactant in preterm neonates &lt; 32 weeks’ GA.

Family presence during resuscitation in paediatric and neonatal cardiac arrest: A systematic review

CONTEXT

Parent/family presence at pediatric resuscitations has been slow to become consistent practice in hospital settings and has not been universally implemented. A systematic review of the literature on family presence during pediatric and neonatal resuscitation has not been previously conducted.

OBJECTIVE

To conduct a systematic review of the published evidence related to family presence during pediatric and neonatal resuscitation.

DATA SOURCES

Six major bibliographic databases was undertaken with defined search terms and including literature up to June 14, 2020.

STUDY SELECTION

3200 titles were retrieved in the initial search; 36 ultimately included for review.

DATA EXTRACTION

Data was double extracted independently by two reviewers and confirmed with the review team. All eligible studies were either survey or interview-based and as such we turned to narrative systematic review methodology.

RESULTS

The authors identified two key sets of findings: first, parents/family members want to be offered the option to be present for their child's resuscitation. Secondly, health care provider attitudes varied widely (ranging from 15% to >85%), however, support for family presence increased with previous experience and level of seniority.

LIMITATIONS

English language only; lack of randomized control trials; quality of the publications.

CONCLUSIONS

Parents wish to be offered the opportunity to be present but opinions and perspectives on the family presence vary greatly among health care providers. This topic urgently needs high quality, comparative research to measure the actual impact of family presence on patient, family and staff outcomes.

PROSPERO REGISTRATION NUMBER

CRD42020140363.

Chest Compression Quality in a Newborn Manikin: A Randomized Crossover Trial (August 2016)

The objective of this paper was to examine the changes in applied force and rate of chest compression (CC) during 5 min of CC with a target CC rate of 90/min (CC90) or 120/min (CC120) with and without metronome guidance during simulated neonatal cardiopulmonary resuscitation (CPR). We performed a randomized controlled manikin trial. Fourteen neonatal resuscitation program providers performed CC90 and CC120 with or without a metronome in a randomized order. Peak and residual leaning force and CC rate each minute of CPR were analyzed with Friedman’s analysis of variance (ANOVA) (within interventions) and two-way repeated measures ANOVA (between interventions). There was a large variability in force application, with no difference between groups. Peak and residual leaning forces in CC90 and CC120 did not change with time with or without a metronome. The CC rate increased with time in all groups except CC90 without a metronome. In conclusion, neither the target CC rate nor using a metronome influenced the peak and residual leaning forces during simulated neonatal CPR.

ASSESSMENT OF HEART RATE USING AUSCULTATION AND ELECTROCARDIOGRAPHY DURING NEONATAL RESUSCITATION IN A PORCINE MODEL OF ASPHYXIA

BACKGROUND

Recent neonatal resuscitation guidelines have suggested the potential benefit of introducing Electrocardiography (ECG) to monitor neonatal heart rate (HR) as standard of care for newborns receiving respiratory support in the delivery room due to advantages over auscultation.

OBJECTIVES

To assess effectiveness of HR detection using either ECG or auscultation.

DESIGN/METHODS

We reviewed recordings from our piglet neonatal resuscitations to compare an ECG with auscultation for assessing the detection of HR at cardiac arrest. Term newborn piglets (n=41) were anesthetized, intubated, instrumented, and exposed to 40-min normocapnic hypoxia followed by asphyxia, which was achieved by clamping the endotracheal tube until asystole. Asystole was confirmed by using Electrocardiography and auscultation.

RESULTS

The median (±IQR) duration of asphyxia was 318 (200–560)sec. In 41 piglets both auscultation and ECG HR were assessed. In 11 (27%) cases both auscultation and ECG correctly identified a bradycardic HR (mean (SD) 32(14)/min) at the beginning of chest compression. In 11 (27%) cases both auscultation and ECG correctly identified absent of any HR. However, in 19 (46%) cases auscultation did not detect a HR while ECG did detect a HR. Overall, the Positive Predictive Value was 37%, Negative Predictive Value was 100%, Sensitivity was 100%, and Specificity was 37% for the ECG to display accurate HR during asphyxia in newborn piglets.

CONCLUSION

Our data illustrates the need for caution in the routine use of ECG monitoring for all neonatal who might need advanced resuscitation in the deliver room.

Assessment of heart rate changes during positive pressure ventilation in asphyxia induced bradycardia porcine model of neonatal resuscitation

BACKGROUND

The Neonatal Resuscitation Program (NRP) states that if positive pressure ventilation (PPV) was started because a baby had a low heart rate (HR), the baby’s HR should begin to increase within the first 15sec of PPV. However, this recommendation has not been examined in either an animal models nor in the delivery room.

OBJECTIVES

To assess changes in HR in piglets with asphyxia induced bradycardia.

DESIGN/METHODS

Term newborn piglets (n=30) were anesthetized, intubated, instrumented, and exposed to 40min normocapnic hypoxia followed by asphyxia. Asphyxia was achieved by clamping the endotracheal tube until the piglet had bradycardia (defined as HR 25% of baseline); at that time CPR was initiated. As per NRP protocol PPV was immediately started for 30sec followed by chest compression. HR was continuously recorded using an ECG during the whole duration of the experiment. Changes in HR during PPV were assessed and divided into four epochs (0-10sec, 5-15sec, 10-20sec and 20-30sec, respectively) after start of PPV.

RESULTS

The median (IQR) duration of asphyxia was similar between the groups with 189 (128–291)sec, 126 (70–197)sec, 118 (66–250)sec for 3:1C:V, SI+90 and SI+120 respectively (p=0.37; oneway ANOVA with Bonferroni). At time of start of PPV the mean (SD) HR was 35 (13)/min. An increase in HR >100/min was observed in 6/30 (5%) at 30 seconds of PPV. None achieved changes in HR at the epochs 0-10sec, 5-15sec, or 10-20sec. After 15sec of PPV 13/30 (43%) had a decrease in HR and 11/ 30 (36%) had no change in HR.

CONCLUSION

Adequate PPV does not increase HR in piglets with asphyxia induced bradycardia. This is contrary to the current NRP, which recommends that after 15 sec of PPV HR should be assessed.

USING CHEST COMPRESSIONS WITH ASYNCHRONOUS VENTILATION AT VARIOUS CHEST COMPRESSION RATES (90, 100, 120/MIN) – A RANDOMIZED CONTROLLED ANIMAL TRIAL

BACKGROUND

The current Pediatric Advanced Life Support guidelines recommends that newborns who require cardiopulmonary resuscitation (CPR) in settings (e.g., prehospital, Emergency department, or paediatric intensive care unit, etc.) should receive continuous chest compressions with asynchronous ventilations (CCaV) if an advanced airway is in place. However, this has never been examined in a newborn model of neonatal asphyxia.

OBJECTIVES

To determine if CCaV at rates of 90/min or 120/min compared to current standard of 100/min will reduce the time to return of spontaneous circulation (ROSC) in a porcine model of neonatal resuscitation.

DESIGN/METHODS

Term newborn piglets were anesthetized, intubated, instrumented, and exposed to 40-min normocapnic hypoxia followed by asphyxia, which was achieved by clamping the endotracheal tube until asystole. Piglets were randomized into 3 CCaV groups: chest compression (CC) at a rate of 90/min (CCaV 90,n=7), of 100/min (CCaV 100,n=7), of 120/min (CCaV 120,n=7), or sham-operated group. A two-step randomization process with sequentially numbered, sealed brown envelope was used to reduce selection bias. After surgical instrumentation and stabilization an envelope containing the allocation “sham” or “intervention” was opened (step one). The sham-operated group had the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia. Only piglets randomized to “intervention” underwent hypoxia and asphyxia. Once the criteria for CPR were met, a second envelope containing the group allocations was opened (step two). Cardiac function, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.

RESULTS

The mean (±SD) duration of asphyxia was similar between the groups with 260 (±133)sec, 336 (±217)sec, and 231 (±174)sec for CCav 90, CCaV 100, and CCaV 120, respectively (p=1.000; oneway ANOVA with Bonferroni post-test). The mean (SD) time to ROSC was also similar between groups 342 (±345)sec, 312 (±316)sec, and 309 (±287)sec for CCav 90, CCaV 100, and CCaV 120, respectively (p=1.000; oneway ANOVA with Bonferroni post-test). Overall, 5/7 in the CCaV 90, 5/7 in CCaV 100, and 5/7 in the CCaV 120 survived.

CONCLUSION

There was no significant difference in time to ROSC for either chest compression technique during cardiopulmonary resuscitation in a porcine model of neonatal asphyxia.

USING DIFFERENT CHEST COMPRESSIONS AND VENTILATION RATIOS (2:1, 3:1, 4:1) DURING NEONATAL ASPHYXIA IN A PORCINE MODEL OF NEONATAL RESUSCITATION – A RANDOMIZED CONTROLLED ANIMAL TRIAL

BACKGROUND

The rationale for a compression to ventilation ratio of 3:1 in neonates with primary hypoxic, hypercapnic cardiac arrest is to emphasize the importance of ventilation; however, there are no published studies testing this approach against alternative methods.

OBJECTIVES

To evaluate if using a 2:1 C:V ratio or a 4:1 C:V ratio will improve ROSC compared to using a 3:1 C:V ratio.

DESIGN/METHODS

Term newborn piglets were anesthetized, intubated, instrumented, and exposed to 40-min normocapnic hypoxia followed by asphyxia. Asphyxia was achieved by clamping the endotracheal tube until the piglet had asystole; at that time CPR was initiated. Piglets were then randomized into 3 groups: 2:1 C:V ratio (n=8), 3:1 ratio (n=8), 4:1 C:V ratio (n=8), or a sham operated group. A two-step randomization was used to reduce selection bias. After surgical instrumentation and stabilization, a sequentially numbered, sealed brown envelope containing the allocation “sham” or “intervention” was opened (step one). The sham-operated group had the same surgical protocol, stabilization, and equivalent experimental periods without hypoxia and asphyxia. Only piglets randomized to “intervention” underwent hypoxia and asphyxia. Once the criteria for CPR were met, a second envelope containing the allocations “2:1”,“3:1”,or “4:1”, was opened (step two). Cardiac function, carotid blood flow, cerebral oxygenation, and respiratory parameters were continuously recorded throughout the experiment.

RESULTS

The median (IQR) duration of asphyxia was similar between the groups with 318 (194–576)sec, 255 (226–334)sec, 233 (169–395)sec for 2:1, 3:1, 4:1 C:V, respectively (p=0.68; oneway ANOVA with Bonferroni). The median (IQR) time to ROSC was also similar between groups 127 (82–210)sec, 96 (88–126)sec, 119 (83–256)sec for 2:1, 3:1, 4:1 C:V, respectively (p=0.67; oneway ANOVA with Bonferroni). Overall, 8/8 in the 2:1 C:V ratio group, 7/8 in the 3:1 C:V ratio group, and 7/8 in the 4:1 C:V ratio group survived.

CONCLUSION

There was no significant difference in time to ROSC for either chest compression technique during cardiopulmonary resuscitation in a porcine model of neonatal asphyxia.

GROWTH MINDSET MODERATES THE IMPACT OF NEONATAL RESUSCITATION SKILL MAINTENANCE ON PERFORMANCE IN A SIMULATION TRAINING VIDEO GAME

BACKGROUND

The Joint Commission on Accreditation of Healthcare Organizations (2004) reporting on preventing infant death and injury during delivery identified human errors during neonatal resuscitation as responsible for more than two thirds of perinatal mortality and morbidity. One of the main causes of human error in neonatal resuscitation stems from a lack of practical learning experiences highlighted by the neonatal training paradox of high-acuity, low-occurrence (HALO) situations that arise infrequently. simulation-based medical education (SBME) is resource and cost intensive, and not offered frequently enough for development of competency and for supporting knowledge retention. Therefore, other methods of training to improve knowledge retention and decision-making are needed. We therefore developed a complementary tool to the physical SBME to improve knowledge retention during neonatal resuscitation in the delivery room. Specifically, we developed a game-based neonatal resuscitation training simulator called RETAIN.

OBJECTIVES

We hypothesized that HCP playing the video game will have an improved mindset and therefore an improved neonatal resuscitation performance.

DESIGN/METHODS

HCPs trained in NRP, including registered nurses, respiratory therapists, neonatal nurse practitioners, neonatal consultants, and neonatal fellows were recruited from the Royal Alexandra Hospital, a tertiary NICU. Each participant was asked to complete a pre-game questionnaire to obtain demographics (e.g. last Neonatal Resuscitation Course (NRP)-course, years of experience) and assess their neonatal resuscitation knowledge by completing a Resuscitation scenario. Afterwards each participant played the RETAIN simulator, which started with a tutorial before the actual three rounds and there was a countdown for each of the rounds to simulate the stress of a real-world scenario. After completion of the game each participant also completed a Post-game questionnaire to assess the player’s mindset (e.g. How much do you agree with the following statements? You can always change how good you are at your job or You can get better at your job with practice) using a Likert scale (1=Strongly Disagree to 5=Strongly agree).

RESULTS

We recruited 50 (45 females, 4 males, and 1 not reported) HCP who were all NRP-trained and had completed a NRP refresher course within the last 24 months. Participants needed a mean (SD) 8.47 (8.66) minutes to complete the game. On average, participants reported high levels of growth mindset (with scores ranging from seven to ten), took their latest NRP course more than eight months prior to the current study, and scored 93% in the game (32 was a perfect score). Interestingly, participants who took the NRP course more recently made more mistakes in the simulation game. There was a significant interaction of Last NRP Course and Growth Mindset in predicting Number of Tries (b =.09, S.E.=.04, beta=.32, t=2.25, p=.03), as well as a main effect for Last NRP Course (b= -.08, S.E.=.04, beta=-.30, t=-2.04, p<.05). Thus, participants who took an NRP course recently (i.e., within eight months), before the current study, completed the game in significantly fewer tries when they endorsed more rather than less of a growth mindset. However, participants who endorsed more of a growth mindset performed similarly on the game regardless of when they took the NRP course.

CONCLUSION

The study examined the relation between HCP task performance and time elapsed since their latest NRP course and found that growth mindset moderates this relation. Specifically, HCP who took the NRP course within the past eight months, those who endorsed a higher growth mindset made fewer mistakes in a simulation game. Some implications include growth mindset interventions and increased opportunities to practice skills in simulation sessions to help HCP achieve better performance after taking a refresher NRP course.

DURATION OF SUSTAINED INFLATION DURING SUSTAINED INFLATION AND CHEST COMPRESSION IN A PORCINE MODEL OF ASPHYXIA

BACKGROUND

Current resuscitation guidelines recommend 3:1 C:V ratio, however the most effective C:V ratio in newborns remains controversial. We recently demonstrate that combining chest compressions (CC) with a sustained inflation (SI) (=CC+SI) significantly improves return of spontaneous circulation (ROSC) in asphyxiated newborn piglets compared to 3:1 C:V resuscitation. However, the optimal length of SI during CC+SI is unknown.

OBJECTIVES

To examine if a 60sec SI compared to a 20sec SI or 3:1 C:V will reduce will reduces ROSC during resuscitation in asphyxiated newborn piglets.

DESIGN/METHODS

Cardiac arrest with achieved was induced in newborn piglets and then randomized to receive either “3:1 C:V ratio, SI+CC-20sec” or “SS+CC-60sec”. Piglets randomized to “SI+CC+20sec” or “SI+CC+60sec” received 90/min CC during a SI of 20sec or 60sec. Piglets randomized to 3:1 C:V received 90/min CC and 30 inflations/min. The default settings for airway pressures were peak inflation pressure of 30 cm H2O and a positive end expiratory pressure of 6 cm H2O. The primary outcome was duration of CC to achieve ROSC.

RESULTS

Eight piglets were randomized to each group; the mean (SD) age and weight was similar between groups.

Median (IQR) ROSC was significantly shorter in the SI+CC-20sec and SI+CC-60sec group with 96 (68–168) sec and 78 (60–91) sec compared to the 3:1 C:V group with 235 (182–347)sec (p=0.002). 5/8 in the SI+CC-60sec group, 7/8 in the SI+CC-20sec and 8/8 in the 3:1 C:V group received epinephrine (p=0.82).

CONCLUSION

Lengths of SI during CC+SI does not affect ROSC, however CC+SI compared to 3:1 C:V does improve ROSC in newborn piglets.

The Effects of High Frequency Oscillatory Ventilation (HFOV) with Volume Guarantee (VG) on Left Ventricular Function, Systemic and Regional Oxygenation, and Ventilation When Compared to HFOV and Conventional Mechanical Ventilation (CMV) in A Newborn Piglet Model of Respiratory Distress Syndrome (RDS)

BACKGROUND: RDS due to surfactant deficiency is commonly seen in preterm infants. These infants often require ventilatory support such as CMV and HFOV. HFOV with VG (HFOV+VG) is an alternative mode that delivers a set tidal volume. There is limited data on either HFOV mode regarding the effects on left ventricular (LV) function, systemic and regional oxygenation, and ventilation.

OBJECTIVES: We primarily compared the effects of CMV with VG, HFOV, and HFOV+VG on cardiac index (CI). Secondary parameters included heart rate (HR), mean arterial pressure (MAP), LV ejection fraction (EF), stroke volume (SV), dP/dt max, LV end-systolic volume and pressure (ESV, ESP), end-diastolic volume and pressure (EDV, EDP), and measures of oxygenation and ventilation. Oxygenation parameters included cerebral and renal near-infrared spectroscopy (NIRS), partial pressure of arterial oxygen (PaO2), and carotid artery flow index (CAFI). Ventilation parameters included partial pressure of arterial carbon dioxide (PaCO2) and minute ventilation (MV).

DESIGN/METHODS: Piglets (1.4-2.4 kg; 1-3 days old) were acutely anesthetized and instrumented with the placement of a right femoral arterial catheter for blood gas analysis, NIRS probes (Invos®), Transonic® flow probe on right common carotid artery, and Millar® catheter in the LV. Warm saline lung lavage was performed to achieve an AaDO2 of 300-450 mmHg to simulate moderate to severe RDS. Piglets were then block-randomized to CMV, HFOV or HFOV+VG for 4 hours using a Fabian HFO ventilator (Acutronic Medical Systems AG, Switzerland)(n=8 per group). Sham-operated piglets without RDS were monitored for the same duration under CMV (n=6). Two-way repeated measures ANOVA was used to analyze the data between modes or time points.

RESULTS: Piglets developed moderately severe RDS with comparable AaDO2 and Paw along with stable hemodynamic parameters. Both HFOV and HFOV+VG groups had similar PaCO2 whereas the CMV group had elevated PaCO2 when compared to that of the Sham (p&lt;0.01). Switching to HFOV resulted in a higher MV than its baseline. HFOV+VG but not HFOV or CMV groups had lower regional oxygenation and CAFI than its respective normoxic baseline (all p&lt;0.01). HFOV and HFOV+VG had higher CI, EF, and SV than CMV at 4 hours of recovery (p&lt;0.05) with similar HR, MAP, dP/dt max, ESV, ESP, EDV and EDP.

CONCLUSION: In our piglet model of RDS, HFOV shows benefits to LV function and ventilation when compared to CMV. HFOV+VG does not show benefits compared to HFOV.

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Multi-modal approach to prophylaxis of necrotizing enterocolitis: clinical report and review of literature

For the first time a multimodal approach to NEC prophylaxis is reported, consisting of early trophic feeding with human breast milk, and enteral administration of an antibiotic, an antifungal agent, and probiotics. A retrospective analysis of local protocol of NEC prophylaxis is presented. Included were all VLBWI admitted to the NICU, including transfers within the first 28 days of life. These infants were divided into two groups, an "inborn group" (infants admitted within the first 24 h of life) and an "outborn group" (infants admitted after the onset of their second day of life). Prophylaxis of NEC according to protocol was started at the day of admission, and was continued until discharge. Between 1998 and 2004, 405 VLBWI were admitted, including all transfers within the first 28 days of life. A total of 334 (82%) infants were admitted within the first 24 h of life (inborn group), and 71 (18%) were admitted after 24 h of life (outborn group). Five infants developed clinical features of necrotizing enterocolitis. The inborn group showed a NEC incidence of 0.7% (two infants), whereas the outborn group showed a NEC incidence of 4.5% (three infants), respectively. This difference was significant (P=0.049, Fisher's exact test). A surgical treatment with bowel resection was performed in two infants (both from the outborn group). The present study used a combination of different strategies, all having shown to have some beneficial effect, but not having brought a clinical breakthrough in single administration studies. Combinated were the beneficial effects of human breast milk feeding, oral antiobiotics, oral antifungal agents, and the administration of probiotics. In a homogenous group of preterm infants, using this protocol of multimodal NEC prophylaxis, there was a very low incidence of NEC, when started within the first 24 h of life.