Association between glycemia and outcomes of neonates with hypoxic-ischemic encephalopathy: a systematic review and meta-analysis.

OBJECTIVES: The research aimed to provide the most recent and comprehensive analysis and evidence update comparing outcomes in neonatal encephalopathy (NE) based on different glycemia levels. PATIENTS AND METHODS: A comprehensive search of Cochrane, PubMed, Embase, Web of Science, CNKI, and Wanfang databases was conducted until September 2023. The purpose was to identify research that examined the effects of hyperglycemia, hypoglycemia, and normoglycemia on NE outcomes. The hyperglycemic, normoglycemic and hypoglycemic group were compared. Outcomes measured were mortality, abnormal MRI, hearing or visual unfavorable outcomes, neurodevelopmental delay, cerebral palsy, and all unfavorable outcomes. RESULTS: Thirteen literatures comprising 2,427 participants (1,233 with normoglycemia, 835 with hyperglycemia, and 359 with hypoglycemia) were considered. Pooled analysis showed more overall adverse outcomes, higher mortality and worse hearing or visual outcomes in the hyperglycemic and hypoglycemic group compared to the normoglycemic group. There was no notable distinction found in abnormal MRI and cerebral palsy among all groups. The hypoglycemic group exhibited greater neurodevelopmental delay than normoglycemia. CONCLUSIONS: Maintaining normal blood glucose levels in neonates with NE can help reduce the risk of adverse consequences such as hearing and visual impairment.

Bacterial profiles and their antibiotic susceptibility patterns in neonatal sepsis at the University of Gondar Comprehensive Specialized Hospital, Ethiopia.

Background: Neonatal sepsis is a major cause of morbidity and mortality worldwide. Understanding the bacterial profiles and antibiotic susceptibility patterns causing neonatal sepsis is crucial for guiding appropriate treatment, improving patient outcomes, and combating the emergence of antibiotic resistance. Despite its importance, data regarding neonatal sepsis in the study area is limited. Therefore, this study aimed to characterize the bacterial pathogens and identify associated factors among neonates with suspected sepsis at the University of Gondar Comprehensive Specialized Hospital, Ethiopia. Methods: A cross-sectional study was conducted by reviewing laboratory records of neonates admitted for suspected sepsis from January 2019 to December 2021. Data were checked for completeness and encoded in a spreadsheet program. Then, data were exported to STATA version 17 for analysis. Descriptive statistics such as frequency and percentage were computed. The association between neonatal sepsis and potential risk factors was assessed using Pearson's chi-square test. A p-value of < 0.05, was considered statistically significant. Results: A total of 1,236 neonates were included. Of these, 96.2% (1,190/1,236) had a fever before admission. The prevalence of culture-confirmed sepsis was 25.4% (314/1,236). Bacterial pathogens accounted for 23% (284/1,236) of these isolates, with Gram-negative bacteria being more prevalent at 75.3% (214/284) than Gram-positive bacteria at 24.7% (70/284). The most frequently isolated bacterial pathogens were K. pneumoniae 38.7% (110/284) and S. aureus 13% (37/284). The isolates demonstrated a high resistance level to commonly used antibiotics, with 61.6% exhibiting multidrug resistance. K. pneumoniae showed the highest rate of multidrug resistance (90.9%). Neonatal sepsis was associated with several factors, including fever before and after admission, hypothermia, increased respiration, suspected pneumonia, and suspected meningitis. Conclusion: This study identified a high prevalence of culture-confirmed sepsis in neonates at UoGCSH, with Gram-negative bacteria, especially K. pneumoniae, dominating the isolated pathogens. The isolated bacteria exhibited alarming resistance to commonly used antibiotics, with a high proportion demonstrating multidrug resistance. Implementing effective antibiotic stewardship programs is crucial to optimize antibiotic use, reduce unnecessary prescriptions, and curb the spread of resistant strains.

A rare case report of hemolysis in a newborn: hereditary elliptocytosis.

Introduction: Hereditary Elliptocytosis (HE) comprises clinically and genetically heterogeneous red cell membranopathies resulting from defects in the horizontal linkage between red blood cell (RBC) membrane and cytoskeletal proteins, which affect mechanical stability and deformability, thereby reducing RBC lifespan. The principal defect in HE is due to dysfunction or deficiency of RBC cytoskeletal proteins. Case description: This study reported a case of severe hemolysis occurring within one day after birth in a term newborn. High-throughput sequencing was used to characterize the pathogenic gene variation in this child and to study the correlation between the identified variation and its corresponding phenotypic characteristics. Conclusion: HE is caused by monoallelic mutations, which justify the phenotypic heterogeneity observed in patients. Furthermore, molecular analysis using high-throughput sequencing enables diagnosis in disorders with highly variable heterogeneity. HE can also present with severe hemolysis during the neonatal period.

Maternal Herpes Zoster Infection Preceding Neonatal Langerhans Cell Histiocytosis: Coincidence or Association?

Langerhans cell histiocytosis (LCH) is a rare proliferative disorder involving bone marrow-derived antigen-presenting cells. It can present across a wide age range, from infancy to adulthood, with neonatal cases being particularly uncommon but often associated with a favorable prognosis. The factors contributing to the development of LCH remain poorly understood, though possible influences include genetic predispositions, immune dysregulation, and prenatal environmental exposures. We report a case of a female newborn diagnosed with LCH, whose mother had a history of varicella-zoster infection during pregnancy, suggesting a potential prenatal influence.

Serological diagnosis of Toxocara canis in mothers and their neonate referred to selected teaching hospitals, Tehran, Iran, 2020.

Toxocariasis is a common zoonotic parasitic disease, primarily caused by the larvae of Toxocara canis or T. cati. Humans become infected through accidental ingestion of infective eggs in soil contaminated with feces of infected animals, or by consuming undercooked meat from paratenic hosts harboring Toxocara larvae. This cross-sectional study aimed to evaluate the seroprevalence of Toxocara spp. in 250 mothers and their 250 neonates referred to selected teaching hospitals affiliated with Shahid Beheshti University of Medical Sciences, Tehran, Iran in 2020. Data were recorded using a specialized questionnaire, and serum and peripheral blood smears (for eosinophil count) were collected. Serum samples were tested using the ELISA serological test for IgG antibodies against Toxocara spp. The collected data were analyzed using IBM SPSS Statistics software version 21.0. A chi-square test was performed, and a P value less than 0.05 was considered statistically significant. Among the 500 participants, 24 cases (4.8%) tested positive for anti-Toxocara canis IgG antibodies. Seropositive cases included 6 mothers only (25%), 6 neonates only (25%), and 12 cases both mother and their neonate (50%). Statistical analysis showed a significant relationship between the presence of anti-Toxocara antibodies and hospital type and nationality (P value < 0.05). However, no significant relationship was found between the presence of antibodies and other demographic variables such as age, sex, eosinophilia, and history of contact with animals in mothers and their neonates (P value > 0.05). This study indicates a substantial rate Toxocara infection in mothers and neonates, necessitating appropriate preventive measures by the relevant authorities.

Anastomotic Leak and its Implications: A Multicenter Analysis of "Type C" Esophageal Atresia / Tracheo-esophageal fistula (EA/TEF).

PURPOSE: Repair of type C esophageal atresia with tracheo-esophageal fistula (EA/TEF) may be complicated by esophageal anastomotic leak. Risk factors associated with leak and the impact of leak on inpatient outcomes remains uncertain. Our objectives are to estimate the associations between clinical factors and esophageal anastomotic leak and quantify the association of leak with length of stay (LOS) in infants who underwent repair of type C EA/TEF. METHODS: Using the Children's Hospitals Neonatal Database (CHND), we identified infants with type C EA/TEF from 2021 to 2023. The main outcomes were anastomotic leak and LOS. Multivariable associations between patient and clinical factors and these outcomes were quantified using logistic regression (leak) and Cox proportional hazards modelling (LOS). RESULTS: Among 365 infants at 36 centers, anastomotic leak occurred in 55 (15.1 %) infants, and thoracoscopic approach, lower birthweight, small for gestational age less than 10th percentile, male sex, staged repair, ventricular septal defect, and center were independently associated with leak (area under receiver operating curve = 0.853). Also, LOS was increased in infants with leak compared to those without [hazard ratio (HR): 0.655, 95 % CI = 0.431-0.996, p = 0.044], independent of birth weight, surgical approach, male sex, or VSD. The adjusted LOS demonstrated a 11-fold inter-center variation (p = 0.034). CONCLUSIONS: Several clinical and operative factors are associated with esophageal anastomotic leak in infants after type C EA/TEF repair. Leak significantly prolongs LOS. The magnitude of inter-center variability in LOS also suggests that identifying best practices could aid in improving patient care in this patient population. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: III.

Struggling to Understand the NEC Spectrum-Could the Integration of Metabolomics, Clinical-Laboratory Data, and Other Emerging Technologies Help Diagnosis?

Necrotizing enterocolitis (NEC) is the most prevalent and potentially fatal intestinal injury mainly affecting premature infants, with significant long-term consequences for those who survive. This review explores the scale of the problem, highlighting advancements in epidemiology, the understanding of pathophysiology, and improvements in the prediction and diagnosis of this complex, multifactorial, and multifaced disease. Additionally, we focus on the potential role of metabolomics in distinguishing NEC from other conditions, which could allow for an earlier and more accurate classification of intestinal injuries in infants. By integrating metabolomic data with other diagnostic approaches, it is hoped to enhance our ability to predict outcomes and tailor treatments, ultimately improving care for affected infants.

The mother-child interface: A neurobiological metamorphosis.

From the start of pregnancy, mother and child induce reciprocal neurobiological changes in the brain that will prove critical for neurodevelopment and survival of both. Molecular communication between mother and fetus is constantly active and persists even after the fetus starts to synthesize its hormones in late gestation. Intriguingly, some mother and fetus exchange cells remain in the other's brain and body with long-lasting effects and memories that do not follow the laws of classical genetics but involve complex epigenetic mechanisms. After childbirth, mother and child go through a transitional phase, a sort of limbo in which both will have a peculiar functioning profile, which is adaptive for contingencies but also renders them vulnerable. The interplay between these two "limbo" states allows for an easier transition to the subsequent phases of development. In this review, we will trace mother's and child's path from pregnancy to the months following birth and, in particular, unravel i) the key features of pregnancy and brain development and the reciprocal influences; ii) how a transitory pattern of functioning characterize mother and child, moving them toward more flexible and evolved forms; and iii) how mother and fetus act during childbirth to promote neuroprotection, pain reduction, and neurophysiological changes. Therefore, this review covers a wide range of topics, integrating neuroanatomical, neurological, biochemical, neurophysiological, and psychological studies in a meaningful way, trying to integrate them in a holistic view of the mother-child interface that is usually neglected.

Transient clitoromegaly in an extremely preterm twin infant with popliteal pterygium.

Clitoromegaly can be congenital or acquired, and it is usually associated with exposure to androgen excess. Pathophysiological mechanisms responsible for transient clitoromegaly in premature female infants have not been fully elucidated. Herein, we present the case of an extremely premature female twin infant, with an extensive web of skin on the back of the left leg, hypoplastic left labia majora, and normal clitoris appearance at birth. At the age of 48 days, clitoral enlargement was observed. Significantly elevated levels of gonadotropins, testosterone, and dehydroepiandrosterone sulphate (DHEAS) were recorded. 17-hydroxyprogesterone (17OHP) was unremarkable, and anti-Müllerian hormone (AMH) was low, in accordance with normal female karyotype. Ovaries were not visualised ultrasonographically. During the following weeks, gradual normalisation of gonadotropin, testosterone, and DHEAS levels was accompanied by regression of clitoromegaly. As described in this case, transient clitoral enlargement may appear in extremely premature female infants due to transitory elevated androgens of ovarian and adrenal origin.

Procurement and Preservation of Neonatal Porcine Cardiac Tissue.

The porcine and human heart are remarkably similar in cardiac physiology and biochemistry. Translational research involving the porcine biomedical model is becoming increasingly applicable for the study of human cardiac function in health and disease. Presently, few protocols exist for collecting experimentally viable cardiac tissue from large animal models, particularly during neonatal maturation. To address this deficiency, we have developed a technique to procure and preserve ventricular tissue from neonatal piglets at day 3 (n=4) and day 30 (n=6) post-partum. Piglets were subjected to a strict sedation, anesthesia, and analgesia regimen. During surgery, cardiopulmonary indices of electrocardiogram, heart rate, systolic and diastolic blood pressure, respiration rate, peripheral O2 saturation, and end-tidal CO2 were monitored continuously to ensure normal cardiac function. Prior to cardiectomy, each heart was perfused with an intravenous administration of heparin (10 ml/kg) and ice-cold Custodiol HTK cardioplegia solution (10 ml/kg). After cardiac explantation, myocardial samples (dimensions: 1 x 1 x 1 cm) were dissected from the left and right ventricles and snap-frozen in liquid nitrogen. Analysis via SDS-PAGE and densitometry demonstrated that myofibrillar proteins are stable and undegraded. Western Blots showed full expression of protein. These results suggest that the detailed cardiac tissue procurement technique preserves the experimental viability of the cardiac tissue and prevents the degradation of myofibrillar proteins.

Implantable loop recorder via subscapular approach in 2.7 kg neonate.

Implantable loop records allow continuous heart rhythm monitoring with the ability to be stored and viewed remotely. The limited use in the pediatric population stems from the unknown indications of use and feasibility of implantation. We describe the case of a 2.7kg female with Long QT3. A loop recorder helped identify breakthrough tachycardia and helped her transition to the next stage of care. Placement was at the left subscapular region with no complications. Implantable loop recorder placement is achievable in a 2.7 kg patient at corrected gestational age 38 weeks for LQT3 syndrome monitoring and management.

[Box: see text].

A pilot randomized controlled trial comparing noradrenaline and adrenaline as a first-line vasopressor for fluid-refractory septic shock in neonates.

Background and study design: Limited data exists on noradrenaline therapy in neonatal septic shock. We compared the efficacy of noradrenaline with adrenaline in neonatal septic shock. This single center, open label, pilot randomized controlled trial included neonates with clinical evidence of sepsis and shock. Study outcomes: Primary outcomes were: 1) resolution of shock one hour after treatment, and 2) mortality during hospital stay. Secondary outcomes included: need for additional vasopressors; hemodynamic stability without further administration of vasopressors for ≥2 h; changes in blood pressure and heart rate after 1 h of vasopressor treatment; and morbidities during the hospital stay. Results: Of 65 eligible neonates, 42 were randomized (21 each in adrenaline and noradrenaline treatment arms) between August 2020 and January 2022, at level III neonatal intensive care unit (NICU) of Bharati Vidyapeeth Deemed University Medical College and Hospital (BVDUMCH). The mean (SD) gestational age and mean (SD) birth weight were 36.1(4.2) weeks and 1.8 (0.2) kilograms birth weight for noradrenaline and 36.9 (4.1) weeks and 1.7 (0.7) kilograms for adrenaline. Shock resolved within 1 h of vasopressor therapy in 76.2% neonates in the noradrenaline arm and 61.9% in adrenaline arm (p value-0.53). Mortality during hospital stay was 28.6% (6/21) in noradrenaline group and 33.3% (7/21) in adrenaline group (p value- 0.58). Additional vasopressors were required in 23.8% neonates of the noradrenaline group compared to 38.1% neonates in adrenaline arm (p value-0.53). Median (SD) duration of intensive care stay was 6 (SD) days in the noradrenaline group and 10 (SD) days in the adrenaline group (p value-0.045). Conclusion: Among neonates with septic shock, the efficacy of noradrenaline was comparable to adrenaline in resolving septic shock after one hour of infusion and on the mortality during hospital stay. Clinical Trial Registration: https://ctri.nic.in/Clinicaltrials/pmaindet2.php?EncHid=NDI2NTc=&Enc=&userName=noradrenaline, Clinical Trials Registry - India with identifier CTRI/2020/08/027185 (17/08/2020).

Effect of different CPAP levels on ultrasound-assessed lung aeration and gas exchange in neonates.

BACKGROUND: Respiratory distress syndrome (RDS) and transient tachypnoea (TTN) are the two commonest neonatal respiratory disorders. The optimal continuous positive airway pressure (CPAP) to treat them is unknown. We aim to clarify the effect of different CPAP levels on lung aeration and gas exchange in patients with RDS and TTN. METHODS: Prospective, observational, pragmatic, physiological cohort study. CPAP was sequentially increased from 4 to 6 and 8 cmH2O and backwards, with interposed wash-out periods. Lung aeration was assessed with a validated neonatal lung ultrasound score. Gas exchange was non-invasively evaluated with transcutaneous monitoring. Ultrasound score and PtcO2/FiO2 ratio were the co-primary outcomes. PtcCO2 and other oxygenation metrics were the secondary outcomes. RESULTS: 30 neonates with RDS and 30 with TTN were studied. Each CPAP increment significantly (overall always p < 0.001) improved both lung aeration and oxygenation, but the increase from 6 to 8 cmH2O achieved a small absolute benefit. In RDS patients, the absolute improvements were small and the diagnosis of TTN was significantly associated with greater improvement of lung aeration (ß= -1.4 (95%CI: -2.4; -0.3), p = 0.01) and oxygenation (ß = 39.6 (95%CI: 4.1; 75.1), p = 0.029). Aeration improved in 16 (53.3%) and 27 (90%) patients in the RDS and TTN groups, respectively (p = 0.034). Lung aeration showed significant hysteresis in TTN patients. Secondary outcomes gave similar results. CONCLUSIONS: Increasing CPAP from 4 to 8 cmH2O improves ultrasound-assessed lung aeration and oxygenation in RDS and TTN. The absolute improvements are small when CPAP is beyond 6 cmH2O or for RDS patients.

Consequences of NICU Intubations: Incidence, Identifications, and Interventions.

OBJECTIVE: Prolonged intubation often leads to laryngeal injuries such as subglottic stenosis (SGS), especially in neonates with prematurity and congenital defects key for tissue healing. Recognizing at risk patients in the neonatal intensive care unit (NICU) is not well studied. The study's goals were to determine intubation risk factors, characterize laryngeal injuries, and calculate the incidence of intervention. STUDY DESIGN: Retrospective case review. SETTING: Quaternary pediatric referral center. METHODS: This retrospective study included all intubated patients in the NICU from April 1, 2020 to 2023. Electronic records were reviewed for demographics and intubation details. Patients were categorized to into intubation only or intervention groups, including direct laryngoscopy and bronchoscopy (DLB) and tracheostomy history. RESULTS: A total of 441 patients were identified with 94 (21%) neonates undergoing DLB. Characteristics impacting intervention included older gestational age, genetic syndromes, and congenital heart disease. Significant risk factors were older age at first intubation, recurrent intubation events, longer intubation duration, and larger endotracheal tube (ETT) diameter, but not birth weight or intubation attempts. Otolaryngology was more likely to intubate the intervention cohort. SGS overall incidence was 2.95% with balloon dilation in 6.4%. Two-thirds of neonates with DLB ultimately required tracheostomy, in which all variables remained significant risk factors except for gestational age. CONCLUSION: Older age at first intubation, more intubation events, longer intubation duration, and larger ETT increased risk for future DLB and tracheostomy but not birth weight or number of intubation attempts. Most NICU patients selected for DLB ultimately required further procedures.

Successful therapy of a newborn with Stenotrophomonas maltophilia nosocomial pneumonia with cefiderocol.

Cefiderocol is a new siderophore-beta-lactam antibiotic used for the treatment of severe multidrug-resistant infections like sepsis, hospital-acquired and ventilator-associated pneumonia in adults, but there are only single reports on its use in the neonatal population. We describe the successful cefiderocol treatment of a newborn with pneumogenic sepsis due to Stenotrophomonas maltophilia.

Psychometric properties of the Turkish version of the developmental care scale for neonates with congenital heart disease.

OBJECTIVE: Developmental care for newborns with congenital heart disease (CHD) improves cardiac and respiratory patterns. According to the American Heart Association, developmental care in newborns with CHD is important for improving neurodevelopmental outcomes. This study aimed to evaluate the validity and reliability of the Turkish version of the Developmental Care Scale for Neonates with Congenital Heart Disease. METHODS: This was a methodological, descriptive study conducted with 169 nurses from a tertiary-level NICU. The Demographical Information Form and the Developmental Care Scale for Neonates with Congenital Heart Disease were used to collect the data. The scales' language and content validity, construct validity, and internal consistency were also assessed. RESULTS: The scale consists of 31 items and four subscales. Factor loadings ranged from 0.44 to 0.82 and explained 65% of the total variance. Fit indices indicate that the model is acceptable. Cronbach's α was 0.95 for the entire instrument, 0.91 for developing the external environment subscale, 0.94 for assessing family well-being, 0.86 for the caregiver activities toward the neonate, and 0.82 for the basic need subscale. Item-total correlations ranged between 0.34 and 0.75, according to the item analysis results. CONCLUSIONS: The Turkish version of the Developmental Care Scale for Neonates with Congenital Heart Disease is valid and reliable. The use of this scale could improve the performance of neonatal intensive care nurses in providing developmental care to newborns with CHD as well as the quality of care.

Schwannosis in the brain of a neonatal calf.

Schwannosis is a rare, non-neoplastic, perivascular proliferation of aberrant Schwann cells within the CNS with simultaneous partial myelination of axons. A single report exists in veterinary medicine of schwannosis in the spinal cord of 3 foals and 1 calf. Here we describe a case of schwannosis in the brain of a 1-d-old Holstein-Friesian calf, submitted for autopsy due to arthrogryposis and premature death, with no other gross abnormalities observed. Histologically, the brain had multifocal, mainly perivascular, spindle-cell proliferations within the white matter of the medulla oblongata and focally within the gray matter of the midbrain. These cells immunolabeled with periaxin, myelin protein zero, SOX10, S100, and equivocally for vimentin, indicating Schwann cell origin. No changes were identified within other organs. Ancillary tests did not support an infectious etiology. Schwannosis should be considered as a differential diagnosis when investigating cases of arthrogryposis in calves with negative ancillary tests for infectious conditions.

Prospective Evaluation of Extubation Failure in Neonates and Infants After Cardiac Surgery.

Background: Extubation failure and its associated complications are not uncommon after pediatric cardiac surgery, especially in neonates and young infants. We aimed to identify the frequency, etiologies, and clinical characteristics associated with extubation failure after cardiac surgery in neonates and young infants. Methods: We conducted a single center prospective observational study of patients ≤180 days undergoing cardiac surgery between June 2022 and May 2023 with at least one extubation attempt. Patients who failed extubation, defined as reintubation within 72 h of first extubation attempt, were compared with patients extubated successfully using χ2, Fisher exact, or Wilcoxon rank-sum tests as appropriate. Results: We prospectively enrolled 132 patients who met inclusion criteria, of which 11 (8.3%) failed extubation. Median time to reintubation was 25.5 h (range 0.4-55.8). Extubation failures occurring within 12 h (n = 4) were attributed to upper airway obstruction or apnea, whereas extubation failures occurring between 12 and 72 h (n = 7) were more likely to be due to intrinsic lung disease or cardiac dysfunction. Underlying genetic anomalies, greater weight relative to baseline at extubation, or receiving positive end expiratory pressure (PEEP) > 5 cmH2O at extubation were significantly associated with extubation failure. Conclusions: In this study of neonates and young infants recovering from cardiac surgery, etiologies of early versus later extubation failure involved different pathophysiology. We also identified weight relative to baseline and PEEP at extubation as possible modifiable targets for future investigations of extubation failure in this patient population.

Evaluation of lung homogeneity in neonates and small infants during general anaesthesia using electrical impedance tomography: a prospective observational study.

Background: Prolonged mechanical ventilation can create heterogeneous ventilation patterns, which increase the risk of lung injury in infants. However, little is understood about the risk of brief exposure to mechanical ventilation during anaesthesia. The aim of this prospective observational study was to describe the regional pattern of lung ventilation during general anaesthesia in healthy neonates and infants, using electrical impedance tomography. Methods: Twenty infants (age 3 days to 12 months), without known lung disease and receiving general anaesthesia with endotracheal intubation for supine positioned surgery, were included in the study. Anaesthesia and ventilation management was at the discretion of the treating clinician. Standardised lung imaging using electrical impedance tomography was made at six time points during anaesthesia from induction to post-extubation. At each time point, the gravity-dependent and right-left lung centre of ventilation was calculated. Results: Tidal ventilation favoured the dorsal lung regions at induction, with a median (inter-quartile range) centre of ventilation (CoV) of 58.2 (53.9-59.3)%. After intubation, there was a redistribution of ventilation to the ventral lung, with the greatest change occurring early in surgery: CoV of 53.8 (52.3-55.2)%. After extubation, CoV returned to pre-intubation values: 56.5 (54.7-58)%. Across all time points, the pattern of ventilation favoured the right lung. Conclusions: General anaesthesia creates heterogenous patterns of ventilation similar to those reported during prolonged mechanical ventilation. This potentially poses a risk for lung injury that may not be recognised clinically. These results suggest the need to better understand the impact of general anaesthesia on the developing lung. Clinical trial registration: Australian New Zealand Clinical Trials Registry (ACTRN 12616000818437, 22 June 2016).