Neurodevelopmental outcomes of extremely preterm infants with bronchopulmonary dysplasia (BPD) - A retrospective cohort study.

OBJECTIVE: To investigate the neurodevelopmental outcomes for preterm infants born < 29 weeks gestation with/without bronchopulmonary dysplasia (BPD). STUDY DESIGN: Preterm infants < 29 weeks' gestation born 2007-2018 in New South Wales and the Australian Capital Territory, Australia, were included. Infants who died < 36 weeks' postmenstrual age and those with major congenital anomalies were excluded. Subjects were assessed at 18-42 months corrected age using the Bayley Scales of Infant Development, 3rd edition. RESULTS: 1436 infants without BPD (non-BPD) and 1189 infants with BPD were followed. The BPD group, 69 % infants were discharged without respiratory support (BPD1), 29 % on oxygen (BPD2) and 2 % on pressure support/tracheostomy (BPD3). Moderate neurodevelopmental impairment (NDI) was evident in 5.7 % of non-BPD infants, 11 % BPD1, 15 % BPD2, 15 % BPD3 infants. Severe NDI was seen in 1.7 % non-BPD infants, 3.4 % BPD1, 7.3 % BPD2, 35 % BPD3 infants. After adjusting for confounders, infants with BPD2 (OR 2.24, 99.9 % CI 1.25 to 5.77) or BPD3 (OR 5.99, 99.9 % CI 1.27 to 46.77) were more likely to have moderate-severe NDI compared to non-BPD infants. CONCLUSION: The majority of infants with BPD were discharged home without respiratory support and had better neurocognitive outcomes in early childhood compared to those that required home-based oxygen or respiratory support.

Provision of bubble continuous positive airway pressure for the stabilisation of extremely and very preterm infants after birth: A single-centre experience.

AIM: To describe the effect of resuscitation with bubble CPAP (bCPAP) versus T-piece device at birth on early clinical parameters and hospital outcomes in infants born <32 weeks gestation. METHODS: This is a single-centre pre- and post-implementation study comparing outcomes in two epochs. In epoch 1 (1 July 2013-31 December 2014), infants were managed with non-humidified gas using Neopuff® T-piece devices to support breathing after birth. In epoch 2 (1 March 2020-31 December 2021), routine application of bCPAP with humidified gas was introduced at birth. RESULTS: Three hundred fifty-seven patients were included (176 epoch 1, 181 epoch 2). The mean gestational age was 28 ± 2 weeks. The demographics of the two epochs were comparable. There were significant improvements in outcomes of infants in epoch 2 with less infants intubated at delivery (16% vs. 4%, P ≤ 0.001), improved 5 min Apgar (7 vs. 8, P ≤ 0.001), reduced need for ventilation (21% vs. 8.8%, P ≤ 0.001), duration of ventilation in the first 72 h (9.6 vs. 4.6 h) and mortality (10.8% vs. 1.7%, P ≤ 0.001). There was, increased incidence of chronic lung disease (30% vs. 55%, P = 0.02) but no increase in infants discharged on oxygen (3.8% vs. 5%, P = 0.25). Similar findings were observed in a subgroup of infants born <25 weeks' gestation with no increase in the incidence of CLD. CONCLUSION: Introducing application of bCPAP from the first breaths in infants <32 weeks' gestation was associated with better short-term outcomes and mortality, albeit with increased incidence of CLD. The subgroup of infants born <25 weeks' gestation showed similar change in outcomes, with no increase in CLD.

Accuracy of bilirubin on the Siemens RAPIDPoint 500 blood gas analyser: A data mining study.

AIM: Blood gas analysers which can measure bilirubin in whole blood are commonly available in neonatal intensive care units; however, the accuracy of these measurements is not well established. We sought to determine accuracy of whole blood bilirubin on the Siemens RAPIDPoint 500 blood gas analyser with reference to formal laboratory total serum bilirubin on the Ortho Vitros 5600. METHODS: A method comparison of the bilirubin results from the blood gas analysers compared with the chemistry analysers was performed by data mining of results obtained as part of routine patient care. Results were included if patients underwent bilirubin testing by blood gas analyser and formal TSB, with both samples being collected within 20 min. Retrospective laboratory data was collected over a 28-month period, 1 January 2019 to 1 May 2021. RESULTS: 449 eligible sample pairs were included. A Bland-Altman plot was generated to identify systematic differences between the methods. A mean bias of -11 µmol/L was observed with 95% limits from -60 µmol/L to 38 µmol/L. Some blood gas bilirubin results were up to 70 µmol/L lower than formal TSB measurements around the clinically significant concentration range of 200 to 300 µmol/L. CONCLUSION: Clinicians need to be aware of potential differences between the results from their blood gas analysers compared to formal TSB results. Sole reliance on blood gas bilirubin results which underestimate TSB may lead to under-recognition of neonatal jaundice that meets treatment thresholds. Formal measurement of TSB should be sought to inform decisions regarding treatment of neonatal jaundice.

Implementation of the 'PicNic' handover huddle: A quality improvement project to improve the transition of infants between paediatric and neonatal intensive care units.

AIMS: Thorough handover and effective communication are crucial to the transfer of clinical information between different intensive care units. Following a sentinel patient safety event, an improvement project was initiated to reduce patient safety risks associated with the transfer of complex patients between the neonatal and paediatric intensive care. METHODS: A handover tool was implemented over a 4-month period, guiding handover through means of a handover huddle. The tool ensured a full ISBAR (Introduction, Situation, Background, Assessment, Response) handover, with a specified attendance register. It acknowledged specific safety points inclusive of outstanding investigations, procedural history and medication transcription. Post implementation, huddle checklist sheets were audited for compliance and a staff satisfaction survey was conducted. RESULTS: Thirty-nine handovers took place during this trial period, of which 69% were captured in the huddle process. Senior medical and nursing staff attendance was greater than 95% throughout the process, and 100% of huddles attended to a full ISBAR handover. Sixty staff satisfaction survey responses were received, 90% of which identified the process to improve the safety of patient handover. Responses also identified safety issues such as discontinuity of medication transcription between the units, and inappropriate patient transfers occurring outside of working hours. Qualitative feedback highlighted how the tool improved interdepartmental educational and collaboration opportunities. CONCLUSIONS: The 'PicNic' huddle effectively facilitated a standardised handover between paediatric and neonatal intensive care. It also recognised the importance of interdepartmental collaboration and education surrounding culturally different clinical practices. Further improvement cycles continue to progress the tool and initiate a digital format for ongoing use.

Neurodevelopmental outcomes in neonatal extracorporeal membrane oxygenation survivors: An institutional perspective.

AIM: To describe the neurodevelopmental outcomes following extracorporeal membrane oxygenation (ECMO) in early infancy. METHODS: Thirty-seven patients who had survived following ECMO support from 2008 to 2018 had their neurodevelopmental outcomes assessed and analysed using the Bayley Scales of Infant and Toddler Development. Developmental outcome was defined as impairment in any of the developmental domains of motor function, cognition and language with mild impairment being 1-2 standard deviations below the test mean, moderate being 2-3 standard deviations below and severe being greater than 3 standard deviations below. RESULTS: Of these 37 patients, the median age at admission to Paediatric Intensive Care Unit was 0.4 months (interquartile range 2.8 months) with all of the study patients having an underlying diagnosis of congenital cardiac disease and 37/40 (92.5%) ECMO runs occurring in the immediate post-operative period. Of the 29 patients who had had follow-up at 12 months of age or older, 3 (10.3%) had severe impairment, 4 (13.8%) had moderate impairment, 12 (41.3%) had mild impairment and 10 (34.5%) had no impairment. Gross motor function was most significantly impacted in 18/29 (62.1%) patients, of which 7/18 (38.9%) had severe impairment. This was followed by impairment of receptive language in 8/29 (27.6%) patients and expressive language in 6/29 (20.1%) patients. CONCLUSIONS: One in four infants undergoing ECMO treatment in early infancy has moderate to severe neurodevelopmental impairment. Gross motor and language are the most affected developmental domains.

Delayed versus Immediate Cord Clamping in Preterm Infants.

BACKGROUND: The preferred timing of umbilical-cord clamping in preterm infants is unclear. METHODS: We randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births. RESULTS: Of 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were available for 1497 infants (95.6%). There was no significant difference in the incidence of the primary outcome between infants assigned to delayed clamping (37.0%) and those assigned to immediate clamping (37.2%) (relative risk, 1.00; 95% confidence interval, 0.88 to 1.13; P=0.96). The mortality was 6.4% in the delayed-clamping group and 9.0% in the immediate-clamping group (P=0.03 in unadjusted analyses; P=0.39 after post hoc adjustment for multiple secondary outcomes). There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities. CONCLUSIONS: Among preterm infants, delayed cord clamping did not result in a lower incidence of the combined outcome of death or major morbidity at 36 weeks of gestation than immediate cord clamping. (Funded by the Australian National Health and Medical Research Council [NHMRC] and the NHMRC Clinical Trials Centre; APTS Australian and New Zealand Clinical Trials Registry number, ACTRN12610000633088 .).

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.

PURPOSE OF REVIEW: Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS: Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

Ophthalmic findings in neonates receiving sildenafil.

AIM: To determine the risk of ocular complications of sildenafil therapy in neonates. METHODS: Retrospective case review of neonates with persistent pulmonary hypertension of the newborn who received sildenafil therapy between 2010 and 2015 in a single, tertiary surgical neonatal intensive care unit in Australia. Ophthalmic examination findings in the neonatal intensive care unit and follow-up were examined. RESULTS: Twenty-seven neonates with persistent pulmonary hypertension of the newborn received sildenafil. The median gestational age (GA) was 38 weeks (range 24-41 weeks), and median birthweight was 2690 g (range 454-4270 g). Ophthalmic review was undertaken in 23 neonates, and 16 neonates were term or near-term infants (GA 31-40 weeks). All of them had a normal initial ophthalmic examination; one child was later diagnosed with hypermetropia and another with infantile esotropia. Amongst the seven premature infants (GA 24-30 weeks), three had retinopathy of prematurity (ROP) diagnosed at the first ophthalmic review and the other four had normal initial examinations. Two patients later developed ROP, one of whom was also diagnosed with congenital motor nystagmus. All five patients diagnosed with ROP were extremely preterm (<28 weeks) with low birthweight (454-635 g). CONCLUSIONS: There were no short-term complications attributable to sildenafil therapy identified in term or near-term neonates (GA ≥31 weeks). This cohort of neonates does not typically undergo ophthalmic review as part of the ROP screening protocol in our institution. Routine ophthalmic review of neonates on sildenafil therapy, who are not at risk of ROP, is therefore unlikely to be warranted. Further research is required to clarify the relationship between sildenafil and ROP.

Associations of measures of systemic blood flow used in a randomized trial of delayed cord clamping in preterm infants.

OBJECTIVE: To determine associations of low superior vena cava (SVC) flow (≤55 ml/kg/min) and low right ventricular output (RVO) (≤150 ml/kg/min) in preterm infants. DESIGN/METHODS: An observational study in infants <30 weeks gestation randomized to receive immediate (<10 s) or delayed cord clamping (DCC) (≥60 s). RESULTS: The study enrolled 265 infants with a mean (SD) gestation 28 (2) weeks. Eighty-six (33%) infants had low SVC flow and 81 (31%) infants had low RVO. In multivariate analysis, low SVC flow was associated with gestation; low RVO was associated with DCC, gender and 5-minute Apgar; whereas mean RVO was negatively associated with both FiO2 and mean airway pressure (MAP) at 9 h and 24 h. Low SVC flow was associated with ductus arteriosus (DA) treatment. Infants with low RVO had higher mortality on univariate analysis, but this was not significant after adjusting for gestation. CONCLUSIONS: SVC flow was associated with gestation, whilst RVO was associated with placental transfusion, gender, condition at birth, and early respiratory adaptation. Compared to infants with normal values, more infants with low SVC flow were treated for DA, but infants with low RVO had no significant difference in mortality or morbidity.

Correction: Associations of measures of systemic blood flow used in a randomized trial of delayed cord clamping in preterm infants.

A correction to this paper has been published and can be accessed via a link at the top of the paper.

Unilateral vocal cord paralysis after surgical closure of a patent ductus arteriosus in extremely preterm infants.

AIM: Left vocal cord paralysis (LVCP) is variably reported post ligation of patent ductus arteriosus (PDA). Our objective was to determine the incidence of LVCP and identify predictive factors and associated morbidities in preterm infants post PDA ligation. METHODS: This is a retrospective cohort study of infants less than 29 weeks gestational age from 2006 to 2014 who underwent PDA ligation. Infants with laryngeal symptoms underwent flexible fibreoptic nasopharyngolaryngoscopy to evaluate vocal cord function. We compared short- and long-term morbidities among infants with and without symptomatic LVCP. RESULTS: A total of 35 infants underwent PDA ligation in the study period, of which 11 infants (31%) developed symptomatic LVCP. Dysphonia was the presenting symptom in all neonates with LVCP and stridor was present in 46% (5/11) of them. The median (interquartile range) gestation (25 weeks (24-27) vs. 25 weeks (23-28)), birthweight (810 g (550-1180) vs. 825 g (550-1220)) and age at surgery (19 days (9-27) vs. 20 (5-69)) were similar in infants with and without LVCP, respectively. Infants with LVCP took significantly longer to reach suck feeds (128 vs. 90 days, P = <0.001), stayed longer in hospital (119 vs. 95 days, P = 0.01) and were more likely to go home on oxygen (73 vs. 27%; P = 0.024). Neurodevelopmental outcomes were similar in the two groups. CONCLUSIONS: LVCP was noted in 31% of infants post PDA ligation and was associated with prolonged hospital stay, a longer time to reach suck feeds and a need for home oxygen. No predictive factors for development of LVCP were identified.

Effect of Delayed Cord Clamping on Systemic Blood Flow: A Randomized Controlled Trial.

OBJECTIVE: To determine whether delayed cord clamping improves systemic blood flow compared with immediate cord clamping in very preterm infants in the first 24 hours. STUDY DESIGN: Women delivering at <30 weeks' gestation at 5 tertiary centers were randomized to receive immediate cord clamping (<10 seconds) or delayed cord clamping (≥60 seconds). Echocardiography and cardiorespiratory data were collected at 3, 9, and 24 hours after birth. The primary outcome was mean lowest superior vena cava (SVC) flow. RESULTS: Of 266 infants enrolled, 133 were randomized to immediate cord clamping and 133 to delayed cord clamping. The 2 groups were similar at baseline, including mean gestation (immediate cord clamping 28 weeks vs delayed cord clamping 28 weeks) and birth weight (immediate cord clamping 1003 g vs delayed cord clamping 1044 g). There was no significant difference between groups in the primary outcome of mean lowest SVC flow (immediate cord clamping 71.4 mL/kg/min [SD 28.1] vs delayed cord clamping 70.2 mL/kg/min [SD 26.9]; P = .7). For secondary outcomes, hemoglobin increased by 0.9 g/dL at 6 hours in the group with delayed cord clamping (95% CI 3.9, 14.4; P = .0005, adjusted for baseline). The group with delayed cord clamping had lower right ventricular output (-21.9 mL/kg/min, 95% CI -39.0, -4.7; P = .01). Rates of treated hypotension, ductus arteriosus size and shunt direction, and treatment of the ductus arteriosus were similar. CONCLUSIONS: Delayed cord clamping had no effect on systemic blood flow measured as mean lowest SVC flow in the first 24 hours in infants <30 weeks' gestation. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry: ACTRN12610000633088.

Potentially avoidable neonatal retrievals in New South Wales: a retrospective analysis.

OBJECTIVE: To identify areas for improvement in outcomes in retrieved newborns by reviewing newborn retrieval activity and evaluating potentially avoidable retrievals from each referring hospital stratified by the level of service delivery over the study period. DESIGN: A retrospective analysis of newborn retrievals from 1 January 2006 to 31 December 2009. SETTING: Newborn and Paediatric Emergency Transport Service (NETS). PARTICIPANTS: Newborns less than 72 hours old retrieved by NETS in the study period. Each retrieval was classified as potentially avoidable, unavoidable or unclassified, based on predefined criteria. MAIN OUTCOME MEASURES: Newborn retrieval rates (per 10,000 live births) and potentially avoidable retrievals for each referring hospital level and overall. RESULTS: There were 2494 newborn retrievals over the study period, with an annual mean of 623 total and 30 potentially avoidable retrievals. There was a reduction in the potentially avoidable retrieval rate (per 10,000 live births) over the study period (from 3.9 in 2006 and 4.2 in 2007 to 2.2 in 2008 and 2.3 in 2009) despite an increase in the total retrieval rate over the same time. Discretionary caesarean, defined as elective (pre-labour) caesarean section without documented fetal or maternal indications before 39 completed weeks of gestation, accounted for two-thirds of the potentially avoidable retrievals. CONCLUSIONS: Potentially avoidable retrievals were a small but significant proportion and are becoming less frequent. Discretionary caesarean is the most common cause of potentially avoidable retrieval. Strict implementation of the elective caesarean section policy directive has the potential to reduce morbidity and the costs related to retrieval.

Improved survival at the cost of more chronic lung disease? Current management and outcomes in extremely preterm infants born in New South Wales and the Australian Capital Territory: 2010-2020.

BACKGROUND: Since 2010, most tertiary care hospitals in Australia have changed how they care for extremely premature infants. However, in-hospital and longer-term outcome data have suggested unchanged or even worse health outcomes in later epochs, especially respiratory outcomes. This study examined the trend in outcomes since these changes were introduced, particularly the prevalence of chronic neonatal lung disease (CLD). METHODS: This is a retrospective cross-sectional analysis of data from the Neonatal Intensive Care Units' (NICUS) database of all perinatal intensive care units in New South Wales and the Australian Capital Territory, including infants born at ≥ 24 and ≤ 28 weeks of gestational age in tertiary perinatal units between January 1, 2010, and December 31, 2020. Temporal trends and changes in primary outcome were examined by linear and adjusted multivariable logistic regression models. RESULTS: This study included 3258 infants. We saw significant changes in antenatal magnesium sulfate (75% increase), delayed cord clamping (66% increase), delivery room intubations (30% decrease), any time (20% decrease), duration on mechanical ventilation (100-hour decrease), and hours on noninvasive ventilation (200-hour increase). Mortality decreased from 17% to 6%. The incidence of CLD increased significantly even when adjusted for confounders (15% increase). Any time and mean hours spent on mechanical ventilation significantly increased the odds of CLD. This study could not find a significant association of any of the protective antenatal treatments on CLD. CONCLUSIONS: The last decade saw a significant improvement in survival and survival to discharge without major morbidity. There was increased use of magnesium sulfate, delayed cord clamping, and less invasive respiratory management of extremely preterm infants. The avoidance of mechanical ventilation may impact the incidence of CLD.

Vein of Galen Aneurysmal Malformation: A Case Report.

Vein of Galen aneurysmal malformation is a relatively rare disease in which failure of the median prosencephalic vein of Markowski to involute early in gestation leads to a grossly dilated deep cerebral vein with multiple arterial feeders, causing a large arteriovenous shunt which leads to high-output cardiac failure. We describe a case of a term neonate who presented to a tertiary neonatal centre on day one of life with history, symptoms, and signs consistent with perinatal asphyxia; however, in the context of worsening multi-organ dysfunction and cardiomegaly, the infant was found to have a severe vein of Galen aneurysmal dilatation leading to high-output cardiac failure. The patient was transferred to a tertiary paediatric hospital and underwent a total of four coiling procedures to embolise the multiple feeder arteries supplying the aneurysmal malformation. This case highlights the difficulties in diagnosing this relatively uncommon condition, particularly in the context of a possible perinatal insult.

Developmental care education in Australian surgical neonatal intensive care units: A cross-sectional study of nurses' perceptions.

Background: Nurse perceptions of developmental care practices have been researched globally for almost 30 years. Yet, there is a lack of research exploring this subject in the specialised setting of the surgical neonatal intensive care unit (sNICU). This research explores the effect of developmental care education programs on sNICU nurses' perceptions of developmental care. Objective: To determine perceptions and attitudes towards developmental care in a specialty neonatal setting. Design: Cross-sectional study. Settings: Two surgical neonatal intensive care units in Australia. Participants: Registered nurses permanently employed at the study sites between May 2021 to April 2022. Methods: A modified electronic survey explored sNICU nurse perceptions of developmental care organised around three themes: effects of developmental care on parents and infants, application of developmental care, and unit practices. Associations between site, nurse characteristics, developmental care education and nurses' perceptions were explored using logistic regression [odds ratios (OR) and 95 % confidence intervals (CI)]. Results: Of 295 sNICU nurses, 117 (40 %) participated in the survey. Seventy-five percent of respondents had attended a formal developmental care education program. High levels of agreement (>90 %) were reported regarding the benefits of developmental care for parents and infants. Exposure to developmental care education influenced perceptions of its application. Nurses without formal developmental care education were more likely to agree that it was consistently applied [OR:3.3, 95%CI:1.3-8.6], developmental care skills are valued [OR:2.7, 95%CI:1.1-6.8], and that their nursing peers offered support in its application ([OR:2.5, 95%CI:1.1-6.2]. Conclusions: The results from our research suggest sNICU nurses have a high level of awareness of developmental care and its positive impacts. Despite differences between the surveyed units' developmental care education programs, the value of developmental care in reducing stress for infants and supporting families was collectively recognised. Future research in this setting should focus on evaluating the application of developmental care in this setting.

Neonatologist-performed point-of-care abdominal ultrasound: What have we learned so far?

This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound.

Individualized vancomycin dosing in infants: prospective evaluation of an online dose calculator.

BACKGROUND: Empiric vancomycin dosing regimens fail to achieve recommended target trough concentrations of 10-20 mg/L in the majority of infants. This study assessed the performance of a model-based dosing calculator (Vanc App) in achieving target vancomycin concentrations at first steady-state level. METHODS: This was a multicenter prospective study in four tertiary pediatric hospitals over an 18-month period. Infants aged 0-90 days with suspected Gram-positive sepsis requiring empiric vancomycin treatment were included if they did not meet any of the exclusion criteria: post-menstrual age (PMA) <25 weeks, weight <500 g, glycopeptide allergy, receiving extracorporeal membrane oxygenation, vancomycin use within the previous 72 h, and renal impairment. The Vanc App used a published population pharmacokinetic model to generate a dose based on the infant's PMA, weight, creatinine, and target vancomycin concentration. RESULTS: A total of 40 infants were included; 40% were female, median (range) weight was 2505 (700-4460) g and median (range) PMA was 37.4 (25.7-49.0) weeks. The median (range) vancomycin dose was 45 (24-79) mg/kg/day. All infants had trough vancomycin concentrations measured at steady-state (24-<48 hours) and 30 (75%) infants achieved target concentrations. Five infants had supratherapeutic (median 25, range 21-38 mg/L) and five had subtherapeutic (median 6, range <5-9 mg/L) concentrations. An area under the concentration-time curve (AUC0-24) of 400-650 mg/L.h was achieved in 33 (83%) infants. There were no infusion-related reactions or nephrotoxicity. CONCLUSION: Individualized intermittent vancomycin dosing using a model-based online calculator resulted in 75% and 83% of infants achieving target trough and AUC0-24, respectively, at first steady-state level. There were no vancomycin-related nephrotoxicity or infusion-related reactions.