Neonatal early-onset sepsis calculator safety in an Australian tertiary perinatal centre.

AIM: To determine if any cases of culture-positive neonatal early-onset sepsis (EOS) would be missed using the neonatal EOS calculator, when compared with current guidelines and practices. METHODS: Retrospective audit of all neonates born at ≥35 weeks and admitted to Royal Brisbane and Women's Hospital with EOS from January 2014 to December 2020. A missed case was defined as antibiotic therapy not being recommended within 24 h of birth. Management recommendations according to the neonatal EOS calculator were compared with current guidelines and current practices. RESULTS: There were significantly more missed cases using the neonatal EOS calculator compared to the current guideline and current management groups. Using the neonatal EOS calculator, 11 neonates (35%, 95% confidence interval 19.2-54.6%) would not have received antibiotics by 24 h of age. In comparison, only one neonate (3%, 95% confidence interval 0.1-16.7%) would not have received antibiotics by 24 h of age using the current guidelines. In terms of the current practice in the cohort of patients, two neonates (6%) did not receive antibiotics by 24 h of age. CONCLUSIONS: The significantly higher rate of missed cases using the neonatal EOS calculator compared with current guidelines and practice supports the concerns many neonatologists have regarding safety of the neonatal EOS calculator.

Bacterial colonisation of the endotracheal tube in ventilated very preterm neonates: A retrospective cohort study.

AIM: To determine the rate, type and timing of bacterial endotracheal tube (ETT) colonisation in neonates born <32 weeks gestational age (GA); and if bacterial colonisation is associated with chronic lung disease (CLD), septicaemia, length-of-stay or mortality. METHODS: All intubated newborns born <32 weeks GA were included. Endotracheal aspirates were routinely obtained three times-per-week. Cohort was divided into three colonisation groups: no growth, normal respiratory flora only, significant bacteria. Logistic regression was performed to identify if ETT bacterial colonisation was associated with CLD, septicaemia or mortality. A general linear model was fitted for length-of-stay. RESULTS: ETT aspirates were sent from 1054 infants: no growth n = 319, only normal respiratory flora n = 357, and significant bacteria n = 378. ETTs became colonised in 70%, most in the first week of life (82%). Most grew normal respiratory flora (642 infants). In those with significant bacteria, 40% grew Gram-negative species; Klebsiella in 34%. Staphylococcus aureus grew in 104 patients. Adjusted odds ratios for CLD (43% of cohort) compared with no growth were, for normal respiratory flora, 0.58 (95% confidence interval (CI) 0.34-0.99) and, for significant bacteria, 0.48 (95% CI 0.24-0.93). With no overall association between colonisation group and CLD in the adjusted model P = 0.07. The odds of septicaemia (10% of cohort) were 4.50 (95% CI 1.98-10.23, P < 0.001) times greater for significant bacteria compared with no growth. No significant associated was found with mortality or length-of-stay. CONCLUSIONS: Bacterial colonisation of ETTs is common. It is associated with more septicaemia. There was no significant association with CLD, longer admission or mortality.

Methods for securing endotracheal tubes in newborn infants.

BACKGROUND: Securing the endotracheal tube is a common procedure in the neonatal intensive care unit. Adequate fixation of the tube is essential to ensure effective ventilation of the infant whilst minimising potential complications secondary to the intervention. Methods used to secure the endotracheal tube often vary between units and sometimes even between healthcare providers in the same nursery. OBJECTIVES: To compare the different methods of securing the endotracheal tube in the ventilated neonate and their effects on the risk of accidental extubation and other potential complications that can result from an unstable endotracheal tube. SEARCH METHODS: A literature search of MEDLINE (from 1966 to June 2013), CINAHL (from 1982 to June 2013) and CENTRAL in The Cochrane Library was conducted to identify relevant trials to be analysed. SELECTION CRITERIA: All randomised and quasi-randomised controlled trials of infants who were intubated for mechanical ventilation in a neonatal intensive care nursery where methods of stabilising the endotracheal tube were being compared. DATA COLLECTION AND ANALYSIS: Data were collected from individual studies to determine the methods being compared, the methodology of the trial, and whether there were areas of bias that could significantly affect the results of the studies. In particular, studies were assessed for blinding of randomisation and allocation, blinding of the intervention, completeness of follow up, blinding of outcome assessments and selective reporting. MAIN RESULTS: Five randomised controlled trials were identified and included for review. Accidental extubation was the most common outcome measured (five studies). None of the studies reported on the need for re-intubation or the rate of tube malposition, however one study did report on endotracheal tube slippage. A variety of other adverse effects were reported including mortality, incidence of perioral skin trauma and tube re-taping. All five studies were of poor methodological quality, small size, contained significant risks of bias and compared methods of securing the endotracheal tube that were too dissimilar for the data to be collated or included in a meta-analysis. We have not reported these further. AUTHORS' CONCLUSIONS: This review highlighted the need for further well designed and completed studies to be conducted for this common neonatal procedure. Evidence is lacking to determine the most effective and safe method to stabilise the endotracheal tube in the ventilated neonate.

Leak around endotracheal tubes in ventilated newborns: an observational study.

AIM: The study aims to determine the incidence and magnitude of leak around endotracheal tubes (ETTs) in ventilated babies in our unit, and to identify any relationship between weight, gestation, head position or ETT tip position, and the amount of leak. METHODS: Ventilated infants in the neonatal unit of the Royal Brisbane and Women's Hospital were observed. Data were collected on ETT size, ventilator settings, body position, head position and amount of leak. Also recorded were weight, post-menstrual age and radiological position of the ETT tip. RESULTS: Two hundred ninety-six sets of data were collected from 60 infants. At the time of recruitment, infants had a median (interquartile range) post-menstrual age of 32(+3) (28(+4) -36(+3)) years. Minimal leak (defined as <10% measured leak) and a small leak (10-25% leak) were observed on 162 occasions (55%) and 77 occasions (26%), respectively. A large leak of more than 25% was observed on 57 (19%) occasions. The odds of having a large leak with the head turned to the right, or midline, was greater than with the head turned to the left (odds ratio = 2.0; 95% confidence interval: 1.0 to 4.1 and 6.8; 1.4 to 31.5, respectively). Infants lying prone were more likely than those lying supine to have a leak >25% (odds ratio = 2.1; 95% confidence interval: 1.1 to 3.8). There was no association between leak and distance from carina, or weight. CONCLUSIONS: Few babies in our unit had a large leak around the ETT, and many had minimal leak. A leak was less likely when a baby's head was turned to the left. Further study is required to clarify the reasons for this. Weight and post-menstrual age were not associated with the extent of leak.

Relationship between blood culture collection method and proportion of contaminated cultures in neonates.

AIM: This study aims to document methods of blood culture collection used in our neonatal unit and to determine whether or not the proportion of contaminated cultures varied according to method of collection. Two specific comparisons of interest were the proportion of contaminated cultures in samples collected via (i) preferred versus non-preferred methods, and (ii) peripheral cannulae at the time of insertion versus separate arterial or venous puncture. METHODS: Data were collected on every blood culture taken in the Grantley Stable Neonatal Unit of the Royal Brisbane and Women's Hospital over a 12-month period. The method used to collect blood for culture was recorded, and the proportion of contaminated cultures taken by each method was calculated. RESULTS: Blood was collected via peripheral cannulae at the time of insertion in 63.1% of cultures, umbilical catheters at the time of insertion in 18.1%, peripheral arterial or venous puncture in 7.7%, and indwelling lines in 2.1%, and the method was unknown in 9.0%. The proportion of contaminated blood cultures was 11.5% with collection via peripheral vascular puncture, 11.1% via indwelling lines, 2.1% via peripheral cannulae at the time of insertion and 1.1% via umbilical catheters at the time of insertion. There was no significant difference in the proportion of contaminated cultures taken via preferred and non-preferred methods. The proportion of contaminated cultures taken via peripheral cannulae at the time of insertion was significantly less than when samples were taken via a separate arterial or venous puncture. CONCLUSIONS: In our unit, blood cultures are frequently collected via peripheral cannulae at the time of insertion. Blood cultures taken in this manner are less likely to be contaminated than cultures collected via separate vascular puncture.

Prophylactic antibiotics to reduce morbidity and mortality in newborn infants with intercostal catheters.

BACKGROUND: Intercostal catheters are commonly used for the drainage of intrathoracic collections in newborn infants, including pneumothorax and pleural effusions. Placement of an intercostal drain is a potential risk factor for nosocomial infection due to breach of the cutaneous barrier. Therefore, neonates who require intercostal drainage, especially those in high risk groups for nosocomial infection, may benefit from antibiotic prophylaxis. However, injudicious antibiotic use carries the risk of promoting the emergence of resistant strains of micro-organisms or of altering the pattern of pathogens causing infection. OBJECTIVES: To determine the effect of prophylactic antibiotics compared to selective use of antibiotics on mortality and morbidity (especially septicaemia) in neonates undergoing placement of an intercostal catheter. SEARCH METHODS: The standard search strategy of the Cochrane Neonatal Review Group was used to search the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 5), MEDLINE (1948 to June 2011) and CINAHL (1982 to June 2011). SELECTION CRITERIA: Randomised controlled trials or some types of non-randomised (that is, quasi-randomised) controlled trials of adequate quality in which either individual newborn infants or clusters of infants were randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: We used the standard methods of the Cochrane Neonatal Review Group. MAIN RESULTS: We did not find any randomised controlled trials that met the eligibility criteria. AUTHORS' CONCLUSIONS: There are no data from randomised trials to either support or refute the use of antibiotic prophylaxis for intercostal catheter insertion in neonates. Any randomised controlled trials of antibiotic prophylaxis would need to account for the fact that neonates who require insertion of an intercostal catheter may already be receiving antibiotics for other indications.

Strategies for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants.

BACKGROUND: While indications for the use of nasal continuous positive airway pressure (NCPAP) and its associated risks and benefits are extensively investigated, the best strategy for the withdrawal of NCPAP remains unknown. In a survey of Australian and New Zealand Neonatologists, 56% stated that their approach to NCPAP weaning was "ad hoc" (Jardine 2008). At what point an infant is considered stable enough to attempt to start withdrawing their NCPAP is not clearly established. The criteria for a failed attempt at NCPAP withdrawal is also not clear. OBJECTIVES: To determine the risks and benefits of different strategies used for the withdrawal of NCPAP in preterm infants. SEARCH STRATEGY: Searches were made of the Cochrane Neonatal Review Group Specialised Register, MEDLINE from 1966 to June 2010, CINAHL from 1982 to June 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2). Previous reviews (including cross references) were also searched. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials in which either individual newborn infants or clusters of infants (such as separate neonatal units) were randomised to different NCPAP withdrawal strategies (from the first time they come off NCPAP and any subsequent weaning and/or withdrawal attempt). DATA COLLECTION AND ANALYSIS: We used standard methods of The Cochrane Collaboration and its Neonatal Review Group. MAIN RESULTS: We identified four potentially eligible studies. Three studies are included in this review. One study showed a significant decrease in the duration of oxygen therapy and a significantly decreased length of stay for babies randomised to a weaning strategy where NCPAP is simply stopped when infants met predefined stability criteria. AUTHORS' CONCLUSIONS: Infants who have their NCPAP pressure weaned to a predefined level and then stop NCPAP completely have less total time on NCPAP and shorter durations of oxygen therapy and hospital stay compared with those that have NCPAP removed for a predetermined number of hours each day. Future trials of withdrawing NCPAP should compare proposed strategies with weaning NCPAP pressure to a predefined level and then stopping NCPAP completely. Clear criteria need to be established for the definition of stability prior to attempting to withdraw NCPAP.

Neonatal blood cultures: effect of delayed entry into the blood culture machine and bacterial concentration on the time to positive growth in a simulated model.

AIMS: To determine if: time from blood culture inoculation to positive growth (total time to positive) and time from blood culture machine entry to positive growth (machine time to positive) is altered by delayed entry into the automated blood culture machine, and if the total time to positive differs by the concentration of organisms inoculated into blood culture bottles. METHODS: Staphylococcus epidermidis, Escherichia coli and group B beta-haemolytic streptococci were chosen as clinically significant representative organisms. Two concentrations (> or =10 colony-forming units per millilitre and <1 colony-forming units per millilitre) were inoculated into PEDS BacT/Alert blood culture bottles and randomly allocated to one of three delayed automated blood culture machine entry times (30 min/8.5 h/15.5 h). RESULTS: For all organisms at all concentrations, except the Staphylococcus epidermidis, the machine time to positive was significantly decreased by delayed entry. For all organisms at all concentrations, the mean total time to positive significantly increased with increasing delayed entry into the blood culture machine. Higher concentrations of group B beta-haemolytic streptococci and Escherichia coli grew significantly faster than lower concentrations. CONCLUSION: Bacterial growth in inoculated bottles, stored at room temperature, continues although at a slower rate than in those blood culture bottles immediately entered into the machine. If a blood culture specimen has been stored at room temperature for greater than 15.5 h, the currently allowed safety margin of 36 h (before declaring a result negative) may be insufficient.

Prenatal and postnatal presentation of severe achondroplasia with developmental delay and acanthosis nigricans (SADDAN) due to the FGFR3 Lys650Met mutation.

We present prenatal and postnatal features of a patient with severe achondroplasia with developmental delay and acanthosis nigricans (SADDAN). Mutation analysis confirmed the clinical diagnosis by detecting the FGFR3 Lys650Met mutation. This case, one of only six with molecular analysis reported in the literature, confirms the severe morbidity and adds to the reports with early mortality associated with SADDAN. Clinical-radiological characteristics of all reported cases of SADDAN are reviewed and discussed.

Establishing normal values of central venous pressure in very low birth weight infants.

The objective of this paper is to establish a reference range of central venous pressure (CVP) values during the first 4 days of life in very low birth weight (VLBW) infants. A prospective observational study with continuous monitoring of CVP in VLBW newborns who had an umbilical venous catheter (UVC) positioned in or near the right atrium is conducted. All UVCs were inserted as part of normal care of the infants. The mean CVP (mCVP) was monitored for 72 h from recruitment, or until the UVC was removed. The mean mCVP was calculated for each infant. The median of the mean mCVPs was then calculated. Data were analysed in 17 infants. The median gestational age was 27 weeks and median birth weight was 940 g. Sixteen were mechanically ventilated and of these, six also received continuous positive airway pressure (CPAP) during the study period. One infant received no respiratory support. One infant died during the study period. The lowest mean mCVP was 2.8 mmHg and the highest was 13.9 mmHg. The median mean mCVP was 4.9 mmHg (interquartile range 4.4-6.1). The normal range of CVP in VLBW infants during the first 4 days of life is wider than previously suggested.

A randomised controlled trial of blended learning to improve the newborn examination skills of medical students.

OBJECTIVE: To evaluate the hypotheses that a blended learning approach would improve the newborn examination skills of medical students and yield a higher level of satisfaction with learning newborn examination. METHOD: Undergraduate medical students at a tertiary teaching hospital were individually randomised to receive either a standard neonatology teaching programme (control group), or additional online access to the PENSKE Baby Check Learning Module (blended learning group). The primary outcome was performance of newborn examination on standardised assessment by blinded investigators. The secondary outcomes were performance of all 'essential' items of the examination, and participant satisfaction. RESULTS: The recruitment rate was 88% (71/81). The blended learning group achieved a significantly higher mean score than the control group (p=0.02) for newborn examination. There was no difference for performance of essential items, or satisfaction with learning newborn examination. The blended learning group rated the module highly for effective use of learning time and ability to meet specific learning needs. CONCLUSIONS: A blended learning approach resulted in a higher level of performance of newborn examination on standardised assessment. This is consistent with published literature on blended learning and has implications for all neonatal clinicians including junior doctors, midwifes and nurse practitioners.

Aspiration of parenteral nutrition -- a previously unreported complication of central venous access in an infant: a case report.

INTRODUCTION: The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal. CASE PRESENTATION: A female infant with a complicated gastroschisis developed signs of short bowel syndrome post surgery. She was treated with a combination of parenteral nutrition and enteral feeds. A central venous line was inserted through a scalp vein. The tip was noted to be in a vessel at the level of the mandible. She subsequently became unwell with large milky pharyngeal aspirates and episodes of bradycardia. Chest radiography revealed aspiration. The central venous line was removed because of presumed extravasation. This is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant. CONCLUSION: This complication may have been prevented by recognising that the tip of the catheter was not correctly placed. When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.