Brain 3T magnetic resonance imaging in neonates: features and incidental findings from a research cohort enriched for preterm birth.

BACKGROUND AND OBJECTIVES: The survival rate and patterns of brain injury after very preterm birth are evolving with changes in clinical practices. Additionally, incidental findings can present legal, ethical and practical considerations. Here, we report MRI features and incidental findings from a large, contemporary research cohort of very preterm infants and term controls. METHODS: 288 infants had 3T MRI at term-equivalent age: 187 infants born <32 weeks without major parenchymal lesions, and 101 term-born controls. T1-weighted, T2-weighted and susceptibility-weighted imaging were used to classify white and grey matter injury according to a structured system, and incidental findings described. RESULTS: Preterm infants: 34 (18%) had white matter injury and 4 (2%) had grey matter injury. 51 (27%) infants had evidence of intracranial haemorrhage and 34 (18%) had punctate white matter lesions (PWMLs). Incidental findings were detected in 12 (6%) preterm infants. Term infants: no term infants had white or grey matter injury. Incidental findings were detected in 35 (35%); these included intracranial haemorrhage in 22 (22%), periventricular pseudocysts in 5 (5%) and PWMLs in 4 (4%) infants. From the whole cohort, 10 (3%) infants required referral to specialist services. CONCLUSIONS: One-fifth of very preterm infants without major parenchymal lesions have white or grey matter abnormalities at term-equivalent age. Incidental findings are seen in 6% of preterm and 35% of term infants. Overall, 3% of infants undergoing MRI for research require follow-up due to incidental findings. These data should help inform consent procedures for research and assist service planning for centres using 3T neonatal brain MRI for clinical purposes.

Doctor-Parent Disagreement for Preterm Infants Born in the Grey Zone: Do Ethical Frameworks Help?

OBJECTIVE: To examine i) how ethical frameworks can be used in concrete cases of parent-doctors' disagreements for extremely preterm infants born in the grey zone to guide such difficult decision-making; and ii) what challenges stakeholders may encounter in using these frameworks. DESIGN: We did a case analysis of a concrete case of parent-doctor disagreement in the grey zone using two ethical frameworks: the best interest standard and the zone of parental discretion. RESULTS: Both ethical frameworks entailed similar advantages and challenges. They have the potential 1) to facilitate decision-making because they follow a structured method; 2) to clarify the situation because all relevant ethical issues are explored; and 3) to facilitate reaching an agreement because all parties can explain their views. We identified three main challenges. First, how to objectively evaluate the risk of severe disability. Second, parents' interests should be considered but it is not clear to what extent. Third, this is a value-laden situation and different people have different values, meaning that the frameworks are at least partially subjective. CONCLUSIONS: These challenges do not mean that the ethical frameworks are faulty; rather, they reflect the complexity and the sensitivity of cases in the grey zone.

Assessment of the Impact of Technical Incidents in Critical Situations Using High-Fidelity Simulation Techniques in Pediatric Intensive Care.

Introduction In certain fields such as anesthesia and critical care, technical incidents are rare events; however, when they occur, they disrupt workflow, optimal patient care, and survival, with human factors often implicated. In pediatric resuscitation, the impact of these incidents on patient care has not yet been thoroughly explored through simulation. Consequently, we investigated how healthcare teams integrate technical incidents in critical situations and whether this interferes with the adequate management of patients. Materials & methods In a single-blind randomized study utilizing high-fidelity simulation, we incorporated a pediatric scenario involving hypoxemia in an intubated and ventilated infant where the endotracheal tube (ETT) was obstructed. A technical incident (disconnected oxygen supply) was either present (TI+) or absent (TI-) in the scenario. We compared reaction times for "removal of the obstructed ETT" between the two groups (TI+ and TI-). Additionally, we recorded and analyzed reaction times for "bag ventilation" and "repair of the technical incident" in the TI+ group. To assess the scenario's credibility, we conducted an analysis comparing the medians of evaluation forms that were anonymously completed by participants at the end of the sessions. Results In total, 10 simulation sessions were conducted, five TI+ and five TI-. The time required for removal of the obstructed ETT in the presence of a technical incident was significantly prolonged compared to controls (Mann-Whitney test, p=0.03). Furthermore, bag ventilation precedes tube removal in the TI+ group, a contrast to the TI- group, which quickly removes the obstructed ETT before stabilizing the patient with bag-mask ventilation. Conclusion Technical incidents in simulated pediatric scenario adversely affect urgent care in ventilated children. Developing and validating a procedural response to these situations through further simulation is imperative.

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study.

OBJECTIVE: To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL). DESIGN: Prospective single-centre observational study. SETTING: Quaternary neonatal intensive care unit. PATIENTS: Infants requiring NTI at the Children's Hospital of Philadelphia. INTERVENTIONS: VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location. MAIN OUTCOME MEASURE: VL NTI attempt success. RESULTS: A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009). CONCLUSION: We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.

Association between video laryngoscopy characteristics and successful neonatal tracheal intubation: a prospective study.

OBJECTIVE: To identify associations between procedural characteristics and success of neonatal tracheal intubation (NTI) using video laryngoscopy (VL). DESIGN: Prospective single-centre observational study. SETTING: Quaternary neonatal intensive care unit. PATIENTS: Infants requiring NTI at the Children's Hospital of Philadelphia. INTERVENTIONS: VL NTI recordings were evaluated to assess 11 observable procedural characteristics hypothesised to be associated with VL NTI success. These characteristics included measures of procedural time and performance, glottic exposure and position, and laryngoscope blade tip location. MAIN OUTCOME MEASURE: VL NTI attempt success. RESULTS: A total of 109 patients underwent 109 intubation encounters with 164 intubation attempts. The first attempt success rate was 65%, and the overall encounter success rate was 100%. Successful VL NTI attempts were associated with shorter procedural duration (36 s vs 60 s, p<0.001) and improved Cormack-Lehane grade (63% grade I vs 49% grade II, p<0.001) compared with unsuccessful NTIs. Other factors more common in successful NTI attempts than unsuccessful attempts were laryngoscope blade placement to lift the epiglottis (45% vs 29%, p=0.002), fewer tracheal tube manoeuvres (3 vs 8, p<0.001) and a left-sided or non-visualised tongue location (76% vs 56%, p=0.009). CONCLUSION: We identified procedural characteristics visible on the VL screen that are associated with NTI procedural success. Study results may improve how VL is used to teach and perform neonatal intubation.

Webcam technology on neonatal wards-examining the objective and subjective workload of nurses: a combined observational and survey study.

BACKGROUND: This study was conducted to estimate the additional objective and perceived workload of nurses resulting from the use of webcams. The successful implementation of webcam technology into routine care requires an analysis to prevent adverse events of increased nursing workload. METHODS: The study took place on three neonatal wards in two University Hospitals in Germany. In the first Hospital, the study was conducted from February to July 2021; in the second one it was conducted between June and November 2021. Data were collected using a combined approach of a standardised diary questionnaire study and passive observations. The participants were accompanied in their daily work and their activities were recorded 65 nurses participated. RESULTS: 2,031 h were observed in 1,630 observation blocks. In 14.74% of the observation blocks webcam activities were detected. The extent to which the nurses had webcam-related additional workloads was rated as no additional workload in 82.16% of the daily questionnaires (n = 1,026). CONCLUSION: The observed low workload due to the webcams is in line with the nurses' perception. The observational data revealed, on a number of different analysis levels, that a limited additional workload was generated. There was no decrease in activity performance observed and no clear indication for interruptions due to the webcam-related activities for the nurses. However, it is important to raise awareness about the individual workload levels for the successful implementation. Additional education programs can be provided for nurses. TRIAL REGISTRATION: The Neo-CamCare study is registered at the German Clinical Trials Register. DRKS-ID: DRKS00017755 .

Lyophilization as an alternative for conservation of equine plasma as a source of immunoglobulin G for neonatal foals.

Providing plasma with immunoglobulins is essential for the health of foals with failure of passive transfer of immunity. The use of lyophilized plasma (LP) offers a simple and affordable option in terms of transportation and storage. This study aimed to measure the concentrations of immunoglobulin G (IgG), total protein (TP), and total solids (TS) in fresh equine plasma before and after lyophilization. Plasma was collected from six healthy male horses. The samples underwent freeze-drying and were reconstituted in deionized water to their original volume. The concentrations of IgG in both fresh and reconstituted LP were determined by simple radial immunodiffusion and TS and TP concentrations measured using refractometry. Results indicated that the IgG concentration in fresh plasma (8.9 ± 3.2 g/L) was not different from LP (7.1 ± 2.2 g/L; P > 0.05). The TP concentration in fresh plasma was 6.6 ± 0.5 g/dL, which decreased to 5.7 ± 0.2 g/dL after lyophilization (P < 0.05). The TS of fresh plasma were 7.5 ± 0.8 %, and also lower in LP 6.3 ± 0.5 % (P < 0.05). The findings revealed that the lyophilization process preserves IgG concentration with small losses in TS and TP upon reconstitution. The research supports the potential of lyophilized equine plasma as a promising treatment option, with future efforts focused on optimizing the product, validating its efficacy and stability through clinical trials, and developing practical packaging solutions for use in the equine industry.

Outcome of creating clustering nursing care and healing environment on premature infants' behavioural outcomes.

We conducted a quasi-experimental study in two neonatal intensive care units (NICUs) from January to July 2021, focusing on the effects of clustering nursing care and creating a healing environment on premature infants' behavioural outcomes. The study included 106 infants, with 53 in both the study and control groups. Significant improvements were observed in organisation state/sleep and responsiveness/interaction domains in the study group, along with shorter hospital stays and greater weight gain on discharge. These findings highlight the positive impact of targeted interventions on premature infants' developmental outcomes, emphasising the need for comprehensive care strategies in NICU settings.

Breastfeeding challenges among adolescent mothers: a phenomenological study at the Korle Bu Teaching Hospital in Ghana.

BACKGROUND: The natural and best approach to give newborns the nutrients they need for healthy growth and development is through breast feeding. Breastfeeding rates fall more sharply with time for mothers under the age of 20 years. AIM: This study sought to explore the challenges experienced by adolescent mothers who visit the department of obstetrics and gynaecology of Korle Bu Teaching Hospital in Ghana. METHOD: This study employed a qualitative phenomenology design and collected data from adolescent mothers. Data were gathered with the aid of a semistructured in-depth interview guide from 13 breastfeeding adolescent mothers. Data for the study were analysed using content analysis. The study was conducted at the obstetrics and gynaecology department of Korle Bu Teaching Hospital, Ghana. FINDINGS: Two major themes were generated from the study to be the challenges that confront adolescent breastfeeding mothers, and they are maternal factors of breastfeeding barriers and societal factors of breastfeeding barriers. Subcategories were generated for both themes during the process. CONCLUSION AND RECOMMENDATION: Training of pregnant adolescents during antenatal care visits on how to manage the inability to lactate, breastfeeding stress, painful and sore nipple, engorged breast, stigma from society will lessen their burden. Furthermore, training close family members and friends on how to be kind and support adolescent mothers during breast feeding is important. In-service training should be organised for health workers to enhance their knowledge and practice of approaching and guiding adolescent mothers on effective breast feeding and the provision of cubicles in public places where adolescent mothers can comfortably breastfeed.

Optimising paediatric bedside teaching for medical students.

Bedside teaching is a common teaching modality in undergraduate and postgraduate curricula and involves students being supervised in a clinical interaction at a patient's bedside by a more senior clinician. Following the clinical encounter, the students and teacher discuss the case and students' consultation skills. This is of particular value in teaching paediatrics to medical students, for whom paediatrics is an unfamiliar environment, and the approach to consultation is very different to usual adult practice. Junior doctors are often tasked with teaching medical students, either in structured bedside teaching sessions during formal teaching roles, or in ad hoc sessions with students shadowing on clinical placements. As paediatrics may be unfamiliar to the junior doctors themselves, offering teaching to medical students may cause some anxiety in their own ability and knowledge. This article provides doctors in paediatrics with an insight into the evidence base underlying paediatric bedside teaching, including model structures for bedside teaching and debriefing after the session, with the aims of improving their confidence in undertaking these sessions and improving their learners' and their own yield of learning.

Efficacy of refrigerated gel packs for therapeutic hypothermia in neonatal retrieval: a retrospective cohort study.

OBJECTIVE: To determine the efficacy of refrigerated gel packs in achieving and maintaining target temperature in neonates receiving therapeutic hypothermia (TH) for hypoxic ischaemic encephalopathy during neonatal retrieval. DESIGN: Retrospective cohort study. SETTING: Paediatric Infant Perinatal Emergency Retrieval, Victoria, Australia. PATIENTS: 200 neonates treated with TH during retrieval between 1 January 2015 and 31 December 2020. INTERVENTIONS: Active cooling with refrigerated gel packs or passive cooling. MAIN OUTCOME MEASURES: The primary outcomes were the proportion of neonates who achieved therapeutic cooling rectal temperature (33-34°C) within 6 hours of birth and maintained target temperature range once TH was achieved. Secondary outcomes included need for respiratory support, inotropes, anticonvulsant therapy, sedation and survival at 7 days of life. RESULTS: 200 neonates received TH. Median gestational age was 39 weeks and median birth weight 3300 g. 120 (60%) were actively cooled with refrigerated gel packs and the remainder passively cooled. 121 neonates (61%) reached target temperature within 6 hours and 14 (7%) after 6 hours of birth. Of those who achieved target temperature, 38% were maintained in therapeutic cooling range for the remainder of the retrieval. CONCLUSIONS: Achieving and maintaining TH during neonatal retrieval with gel packs is challenging. Target temperature was not maintained in most neonates in this study. These findings support existing evidence favouring the use of servo-controlled cooling devices to optimise TH in the retrieval setting.

Implications of right aortic arch prenatal diagnosis: the multicentric nationwide ARCADE cohort.

OBJECTIVES: This study aims to describe the various presentations of the prenatally diagnosed isolated right aortic arch (RAA), that is, without associated congenital heart defect and to evaluate the impact of prenatal diagnosis of isolated RAA in terms of postnatal outcome. METHOD: In this multicentric retrospective study, from 2010 to 2019, all live births with a prenatal ultrasound diagnosis of isolated RAA were included, with a 1-year postnatal follow-up. The concordance between the different diagnostic steps (prenatal ultrasound, postnatal ultrasound and postnatal CT scan) was evaluated using Gwet's AC1 coefficient. RESULTS: A total of 309 cases of prenatally diagnosed RAA were analysed, most of which had a left ductus arteriosus (83%). The concordance between prenatal and postnatal ultrasound diagnosis was excellent regarding the RAA type (AC1=0.97, 95% CI=(0.94 to 0.99)). The rare discrepancies mainly involved non-diagnosed or misdiagnosed double aortic arch (2%). CT scan was performed in 108 neonates (35%) and the concordance between prenatal ultrasound and postnatal CT scan was good regarding the RAA diagnosis (AC1=0.80, 95% CI=(0.69 to 0.90)) but poor regarding the distribution of brachiocephalic vessels (AC1=0.21, 95% CI=(0.06 to 0.36)). An associated genetic anomaly was sought for in half of the cases and identified in 4% of the cohort. During the first year of life, 50 (18%) infants presented with vascular ring symptoms and 24 (8%) underwent aortic arch surgery. CONCLUSION: This multicentric nationwide cohort of 309 prenatally diagnosed isolated RAA demonstrated the reliability of prenatal screening, highlighted the rare cases of discrepancies between prenatal and postnatal diagnosis and underlined the value of CT scan to improve the postnatal follow-up. TRIAL REGISTRATION NUMBER: NCT04029064.

Predictors of successful neonatal intubation in inexperienced operators: a secondary, non-randomised analysis of the SHINE trial.

OBJECTIVE: Neonatal endotracheal intubation is a lifesaving but technically difficult procedure, particularly for inexperienced operators. This secondary analysis in a subgroup of inexperienced operators of the Stabilization with nasal High flow during Intubation of NEonates randomised trial aimed to identify the factors associated with successful intubation on the first attempt without physiological stability of the infant. METHODS: In this secondary analysis, demographic factors were compared between infants intubated by inexperienced operators and those intubated by experienced operators. Following this, for inexperienced operators only, predictors of successful intubation without physiological instability were analysed. RESULTS: A total of 251 intubations in 202 infants were included in the primary intention-to-treat analysis of the main trial. Inexperienced operators were more likely to perform intubations in larger and more mature infants in the neonatal intensive care unit where premedications were used. When intubations were performed by inexperienced operators, the use of nasal high flow therapy (nHF) and a higher starting fraction of inspired oxygen were associated with a higher rate of safe, successful intubation on the first attempt. There was a weaker association between premedication use and first attempt success. CONCLUSIONS: In inexperienced operators, this secondary, non-randomised analysis suggests that the use of nHF and premedications, and matching the operator to the infant and setting, may be important to optimise neonatal intubation success. TRIAL REGISTRATION NUMBER: ACTRN12618001498280.

Infection in preterm infants receiving topical emollient oil massage: a systematic review and meta-analysis of randomised control trials.

BACKGROUND: Preterm infants are highly susceptible to infections, which significantly contribute to morbidity and mortality. This systematic review and meta-analysis investigated the effectiveness of topical emollient oil application in preventing infections among preterm infants. METHODS: A comprehensive search was conducted across multiple electronic databases (PubMed, Cochrane, Scopus, Clinical trials, Epistemonikos, HINARI and Global Index Medicus) and other sources. A total of 2185 articles were identified and screened for eligibility. The quality of included studies was assessed using the Cochrane Risk of Bias Tool for randomised controlled trials. Data analysis was performed using StataCrop MP V.17 software. Heterogeneity among the studies was evaluated using the I2 and Cochrane Q test statistics. Sensitivity and subgroup analyses were conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist guided the presentation of the results. RESULTS: Of 2185 retrieved articles from initial searches, 11 met eligibility criteria and were included in the final analysis. A random effects meta-analysis revealed that infants who received massages with emollient oils had a 21% reduced risk of infection (risk ratio=0.79, 95% CI 0.64 to 0.97, I2=0.00%). Subgroup analyses indicated that preterm babies who received topical emollient oil massages with coconut oil, administered twice a day for more than 2 weeks, had a lower likelihood of acquiring an infection compared with their non-massaged counterparts. CONCLUSION: It is quite evident from this analysis that topical emollient oil application in preterm neonates is most likely effective in preventing infection. However, further studies, particularly from the African continent, are warranted to support universal recommendations.

Cumulative sucrose exposure for repeated procedural pain in preterm neonates and neurodevelopment at 18 months of corrected age: a prospective observational longitudinal study.

INTRODUCTION: Oral sucrose is repeatedly administered to neonates in the neonatal intensive care unit (NICU) to treat pain from commonly performed procedures; however, there is limited evidence on its long-term cumulative effect on neurodevelopment. We examined the association between total sucrose volumes administered to preterm neonates for pain mitigation in the NICU and their neurodevelopment at 18 months of corrected age (CA). METHODS: A prospective longitudinal single-arm observational study that enrolled hospitalised preterm neonates <32 weeks of gestational age at birth and <10 days of life was conducted in four level III NICUs in Canada. Neonates received 0.1 mL of 24% sucrose 2 min prior to all commonly performed painful procedures during their NICU stay. Neurodevelopment was assessed at 18 months of CA using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Multiple neonatal and maternal factors known to affect development were adjusted for in the generalised linear model analysis. RESULTS: 172 preterm neonates were enrolled and 118 were included in the analysis at 18 months of CA. The total mean sucrose volume administered/neonate/NICU stay was 5.96 (±5.6) mL, and the mean Bayley-III composite scores were: cognitive 91 (±17), language 86 (±18) and motor 88 (±18). There was no association between Bayley-III scores and the total sucrose volume: cognitive (p=0.57), language (p=0.42) and motor (p=0.70). CONCLUSION: Cumulative sucrose exposure for repeated procedural pain in preterm neonates was neither associated with a delay in neurodevelopment nor neuroprotective effects at 18 months of CA. If sucrose is used, we suggest the minimally effective dose combined with other non-pharmacological interventions with demonstrated effectiveness such as skin-to-skin contact, non-nutritive sucking, facilitated tucking and swaddling. TRIAL REGISTRATION NUMBER: NCT02725814.