Use of Intraosseous Access in Neonatal and Pediatric Retrieval-Neonatal and Pediatric Emergency Transfer Service, New South Wales.

OBJECTIVES: Pediatric patients who are critically unwell require rapid access to central vasculature for administration of life-saving medications and fluids. The intraosseous (IO) route is a well-described method of accessing the central circulation. There is a paucity of data surrounding the use of IO in neonatal and pediatric retrieval. The aim of this study was to review the frequency, complications, and efficacy of IO insertion in neonatal and pediatric patients in retrieval. METHODS: A retrospective review of cases referred to neonatal and pediatric emergency transfer service, New South Wales over the epoch 2006 to 2020. Medical records documenting IO use were audited for patient demographic data, diagnosis, treatment details, IO insertion and complication statistics, and mortality data. RESULTS: Intraosseous access was used in 467 patients (102 neonatal/365 pediatric). The most common indications were sepsis, respiratory distress, cardiac arrest, and encephalopathy. The main treatments were fluid bolus, antibiotics, maintenance fluids, and resuscitation drugs. Return of spontaneous circulation after resuscitation drugs occurred in 52.9%; perfusion improved with fluid bolus in 73.1%; blood pressure improved with inotropes in 63.2%; seizures terminated with anticonvulsants in 88.7%. Prostaglandin E1 was given to eight patients without effect. Intraosseous access-related injury occurred in 14.2% of pediatric and 10.8% of neonatal patients. Neonatal and pediatric mortality rates were 18.6% and 19.2%, respectively. CONCLUSIONS: Survival in retrieved neonatal and pediatric patients who required IO is higher than previously described in pediatric and adult cohorts. Early insertion of an IO facilitates early volume expansion, delivery of critical drugs, and allows time for retrieval teams to gain more definitive venous access. In this study, prostaglandin E1 delivered via a distal limb IO had no success in reopening the ductus arteriosus.

Characteristics and outcomes of respiratory distress among term infants born in a regional setting.

INTRODUCTION: Respiratory distress is the leading cause of admission to neonatal units and is a common indication for medical retrieval. Whilst approximately 25% of births in NSW occur in regional centres, there is a paucity of neonatal research in these settings. OBJECTIVE: To describe the characteristics and outcomes of term neonates admitted with respiratory distress to two regional special care nurseries (SCNs) and identify variables associated with the need for medical retrieval. DESIGN: We describe a cohort of 629 term infants admitted to the SCN in two regional hospitals, 2015-2019. We describe the admission characteristics, level of respiratory support, biochemical investigations, diagnosis and outcomes. FINDINGS: During the study period, 629 eligible term infants were admitted, retrieval occurred in 29 (4.6%). Those admitted were more often male (66.5%), with a mean gestational age of 39 + 1 weeks (±9 days) and birth weight of 3470 g (±500 g). Infants requiring medical retrieval had higher PaCO2 on blood gas analysis (59.8 mmHg vs. 53.3 mmHg, OR 1.03, p = 0.02). There was no association between maternal GBS status, meconium-stained liquor, gestational age, or raised inflammatory markers and medical retrieval. Transient tachypnoea of the newborn was the most common diagnosis of neonates admitted to SCN with respiratory distress. DISCUSSION: Among term infants admitted to a SCN for respiratory distress most were male, of a normal birthweight and born in good condition. Within our cohort there was no association between retrieval and maternal GBS colonisation, meconium-stained liquor or raised infectious biomarkers. Medical retrieval was infrequent and was associated with higher PaCO2 on initial blood gas analysis. CONCLUSION: We present a large cohort of term newborn infants managed for respiratory distress in a regional setting over a five-year period. Retrieval was infrequent, and outcomes for the cohort were excellent with no deaths during the study period.

How should the neonatal retrieval team respond to the neonate referred with bilious vomiting?

AIM: Bilious vomiting (BV) in the neonatal period may herald malrotation with life-threatening volvulus. In New South Wales, contrast fluoroscopy is not available in non-tertiary paediatric centres; therefore, transfer is required. An infant with BV referred to Newborn and Paediatric Emergency Transport Service is prioritised for urgent retrieval to a surgical centre for contrast fluoroscopy and paediatric surgical review. This study analysed how many neonates with BV needed retrieval to prevent bowel loss or to save one life and to identify predictors of malrotation and/or volvulus. METHODS: All neonatal referrals (<29 days) to Newborn and Paediatric Emergency Transport Service between 31 July 2014 and 31 July 2020 with BV or aspirates were examined. Data on time of onset of BV, time of call for retrieval, vital signs, lactate level and blood glucose at referral, time of arrival at the surgical centre and outcome were analysed. RESULTS: Of 391 neonates referred with BV, 113 (28.9%) had a surgical cause and 31 (7.9%) had a time-critical malrotation and/or volvulus. All 31 neonates were well at referral with normal vital signs including three neonates who subsequently died. Lactate levels at referral (1-7.5 mmol/L) were not predictive of outcome. The odds of a time-critical diagnosis increased with every day of age (odds ratio = 1.097), heart rate >140 (P = 0.04) and decreased for each kilogram of birthweight (odds ratio 0.475; confidence interval 0.294-0.768). CONCLUSIONS: Neonates with BV require urgent referral to paediatric surgery and contrast fluoroscopy. Thirteen urgent transfers are required to preserve the bowel integrity and life in one baby.

Infants With Congenital Heart Disease at Risk of Early Atherosclerotic Disease.

Background Aortic intima-media thickness (aIMT) measurement is an established indicator of preclinical atherosclerosis. We aimed to describe the aIMT in infants with congenital heart disease undergoing cardiac surgery over the first year of life and explore its association with cardiopulmonary bypass, growth velocity, and a diagnosis of left heart obstruction. Methods and Results A prospective cohort study measuring mean and maximum aIMT preoperatively, at 3 months, and 1 year of age in neonates with congenital heart disease undergoing cardiac surgery. Twenty-four infants with a median gestation of 39 weeks and a median birth weight of 3184 g were included. Sixteen (67%) infants had left outflow tract obstruction. Gestation correlated inversely with baseline mean aIMT (ß=-0.027, P=0.018) and positively with the percentage of increase in mean and maximum aIMT between baseline and 3 months (ß=17%, P=0.027 and ß=15%, P=0.023). The presence of left outflow obstruction was significantly associated with increasing mean and maximum aIMT between baseline and 1 year (mean aIMT change: ß=34%, P=0.017 and maximum aIMT change ß=43%, P=0.001). Both subgroups of left heart obstruction and non-left heart obstruction significantly changed over time (P=0.001 and P<0.001) but trends were not statistically different between both subgroups (P=0.21). Growth velocity and cardiopulmonary bypass were not associated with baseline or change in aIMT over the first year of life. Conclusions AIMT significantly increased over the first 3 months in our cohort of infants with repaired congenital heart disease. Increasing gestation was associated with decreasing aIMT at 3 months. Growth velocity and cardiopulmonary bypass were not associated with aIMT changes over the first year. Left heart obstruction was associated with a trend toward increased aIMT.

Duration of indomethacin treatment of the preterm patent ductus arteriosus as directed by echocardiography.

OBJECTIVE: To determine whether the duration of indomethacin administration could be shortened in infants with good early constrictive response of patent ductus arteriosus (PDA). STUDY DESIGN: Infants born at< 30 weeks' gestational age were assessed with echocardiography in the first 12 hours of life and treated with indomethacin (0.1 mg/kg) if the PDA was >2 mm in diameter. Randomization occurred before the second dose to either standard treatment (2 more doses of indomethacin at 0.1 mg/kg irrespective of echocardiographic findings) or to echocardiographically directed duration of indomethacin treatment (ECHO; further doses only if the PDA was>1.6 mm). Serial echocardiography was performed to day 28 of age. The primary outcome was failure of PDA closure. RESULTS: The infants were randomized to either the ECHO arm (n=34) or the standard treatment arm (n=40). No differences between the arms were seen in terms of failure of PDA closure, PDA reopening, need for further doses of indomethacin, or need for surgical ligation. More doses of indomethacin were given in the standard treatment arm (median, 3 doses [range, 1 to 12] vs 1 dose [range, 1 to 15]; P < .0001). CONCLUSION: Echocardiographically directed duration of indomethacin treatment is effective in achieving PDA closure and offers the potential for dose minimization.

Practical pain management in the neonate.

Neonatal care is advancing to levels where more neonates are now offered more invasive interventions, exposing them to more prolonged hospital care. Consequently, the provision of effective and consistent management of pain in these neonates has become a pressing challenge. Advances in neonatal care have not only increased the number of neonates, who are exposed to noxious stimuli, but, over recent decades, also altered the patterns of exposure. Both procedural and postoperative pain remain distinct in nature, prevalence and management, and need to be addressed separately. Recent advances in the management of neonatal pain have been facilitated by improved methods of pain assessment and an increased understanding of the developmental aspects of nociception. Over the past decade, there have been some advances in the available pharmacological armamentarium, modest clarification of the risks of both untreated pain and aggressive analgesic practice and a greater recognition of non-pharmacological analgesic techniques. However, even advanced health systems fail to consistently articulate pain management policy for neonates, institute regular pain assessments and bridge the gaps between research and clinical practice.

Congenital candidiasis presenting as septic shock without rash.

Congenital candidiasis is rare and often benign. This report describes the case of twins born at 32 weeks of gestation with different manifestations of congenital candidiasis. One twin was born well though neutropenic, and died from overwhelming sepsis with septic shock at 22 h. The other twin presented with a delayed onset of rash at 2 days, remained well and survived.

Congenital candidiasis presenting as septic shock without rash.

Congenital candidiasis is rare and often benign. We report the case of twins born at 32 weeks' gestation with different manifestations of congenital candidiasis. One twin was born well though neutropenic, and died from overwhelming sepsis with septic shock at 22 h. The other twin presented with a delayed onset of rash at 2 days, remained well and survived.

Drug treatment of neonatal seizures by neonatologists and paediatric neurologists.

OBJECTIVE: To survey anti-epileptic drug (AED) treatment of early-onset neonatal seizures by neonatologists and paediatric neurologists. METHODS: A self-administered questionnaire was posted to Australian and New Zealand neonatologists and paediatric neurologists. Participants were given the hypothetical case of a full-term infant with early-onset seizures following perinatal asphyxia and asked to nominate their preferred AED for treatment of three seizure episodes during the first 24 h. RESULTS: One hundred and seven (57%) of 187 individuals answered the questionnaire: neonatologists responded more often than neurologists (chi(2) (1,187) = 7.18, P = 0.007). Phenobarbitone was used by 95% of the respondents to treat the first episode of seizures and 75% of them used an appropriate loading dose (20 mg/kg). Phenobarbitone was used by 84 and 40% of the respondents to treat the second- and third-seizure episodes, respectively. Neonatologists used phenobarbitone, phenytoin and a benzodiazepine with equal frequency to treat a third episode of seizures, whereas neurologists rarely used a benzodiazepine. Neonatologists used significantly larger total doses of phenobarbitone than neurologists. Very few respondents used pyridoxine to treat recurrent seizures that were historically linked to perinatal asphyxia and hypoxic-ischaemic encephalopathy. Neonatologists were more likely than neurologists to discontinue AED within a few days of seizure cessation (chi(2) (1,106) = 11.60, P = 0.0006). CONCLUSIONS: Australian and New Zealand neonatologists and paediatric neurologists generally use phenobarbitone to treat neonatal seizures presumed to be owing to hypoxic-ischaemic encephalopathy, though they do not always use appropriate doses. Neonatologists use phenobarbitone, phenytoin or a benzodiazepine for second and third episodes of seizures, whereas neurologists tend not to use benzodiazepines. Neonatologists use larger total doses of phenobarbitone than neurologists in pursuit of seizure control. Neonatologists discontinue AED earlier than neurologists.