Randomised controlled trial.

Neonatal intensive care unit of a tertiary care hospital.

Neonates requiring continuous IV infusion for an expected duration of more than or equal to 72 hours.

Eligible cannulations were randomised to either "splint" or "no-splint" group. In the splint group, a cardboard splint was used to immobilise the joint at peripheral IV cannula site. No attempt was made to immobilise the limb in the no-splint group.

Functional duration of a peripheral IV cannula measured as interval from time of insertion to the development of predefined sign of removal (extravasation, blockage, inflammation).

A total of 69 peripheral IV cannulations in 54 neonates were randomised to either the splint (n = 33) or no-splint group (n = 36). Both groups were comparable in birth weight, gestation, site of cannulation and nature of fluids administered. Mean functional duration of cannula was lesser in the splint group compared to the no-splint group (h; 23.5 (SD15.9) vs 26.9 (SD15.5), mean difference: –3.3 h, 95% CI –11.02 to 4.3 h) although the difference was not statistically significant (p = 0.38). Extravasation at cannula site was found be the commonest indication for cannula removal in both the groups (84% vs 76.5%).

Joint immobilisation with splint at cannula site did not improve the functional duration of peripheral IV cannula.

A third-level neonatal intensive care unit.

Ten preterm babies (<32 weeks’ gestation) were randomised to receive 1 h FC-sIPPV followed by 1 h TC-sIPPV or the inverse shift, according to a computer-created randomisation table. Eligible babies had hyaline membrane disease and received 200 mg/kg surfactant at least 6 h before the study period. Respiratory mechanics, ventilatory and vital parameter data were registered real time.

FC-sIPPV resulted in lower-rate volume ratio, pressure x rate product, mean airway pressure and heart rate; tidal volume and oxygen saturation were higher (all p<0.001). Spontaneous inspiratory time was lower than usually set by the physician and it was directly correlated to birth weight (rho = 0.5, p = 0.001) and gestational age (rho = 0.32, p = 0.001). No differences were noticed in the mechanics and blood gas and vital parameters during the two study phases.

FC-sIPPV may safely result in a better patient ventilator synchrony. Inspiratory time usually set in neonatal critical care is higher than that decided by the baby during spontaneous effort. This should be considered when establishing time-cycled ventilation.

To study prospectively whether a single repeat dose of BM influences neurodevelopment and growth within 2 years.

Women with imminent delivery before 34.0 gestational weeks were eligible if they remained undelivered for >7 days after a single course of antenatal BM. After stratification, a single repeat dose of BM (12 mg) or placebo was given. The children underwent neurological and psychometric examinations and a speech evaluation at a corrected age of 2 years.

Prospective, blinded evaluation following the randomised multicentre trial.

259 (82%) surviving infants completed the 2-year follow-up, 120 in the BM group and 139 in the placebo group.

The rate of survival without severe neurodevelopmental impairment was similar in both groups (BM 98%, placebo 99%). The risk of cerebral palsy (BM 2%, placebo 1%), growth or re-hospitalisation rates (BM 60%, placebo 50%) did not differ between the groups.

A single repeat dose of antenatal BM tended not to influence physical growth or neurodevelopment at 2 years of age.

To examine the potential impact of the guidelines on survival rates, short-term complication rates and centre-to-centre outcome differences of extremely preterm infants (22–25 completed weeks).

Population-based, retrospective cohort study.

All nine level III neonatal intensive care units (NICU) and affiliated paediatric hospitals in Switzerland.

516 extremely preterm infants born alive between 1 January 2000 and 31 December 2004.

Delivery room and NICU mortality rates, survival to hospital discharge and incidence of short-term complications in survivors were assessed. To study the impact of the guidelines, two cohorts from two different time periods were compared (years 2000/2001, n = 220; years 2003/2004, n = 204) whereas patients born in the year of the publication (2002, n = 92) were excluded. For centre-to-centre comparisons, the entire population (n = 516) was analysed.

There was a significant increase in survival rates of extremely preterm infants from 31% to 40% (RR 1.24, 95% CI 1.02, 1.50) after the publication of the Swiss guidelines. This improvement was largely explained by significantly improved survival from 42% to 60% (p = 0.01) among infants born at 25 completed weeks because of decreased NICU mortality. Improved survival was not associated with statistically significant changes in the incidence of short-term complications. Despite national guidelines, considerable centre-to-centre outcome differences have persisted.

The publication of the Swiss guidelines was followed by significantly improved survival of extremely preterm infants but had no impact on centre-to-centre differences.

To determine postmenstrual age at hospital discharge for moderately preterm infants and its relation to perinatal risk factors and to organisation of care.

Population-based cohort including 2388 infants, born in 2004–2005 with a gestational age (GA) of 30–34 weeks and admitted to 21 NU reporting to the Swedish perinatal register. Main outcome: postmenstrual age (PMA) at hospital discharge to home.

Mean PMA at hospital discharge was 36.9 (1.7) weeks. High (>=35 years) maternal age, multiple birth, small for gestational age, respiratory distress syndrome, infection, hypoglycaemia and hyperbilirubinaemia were significantly associated with higher PMA at discharge, but could only explain 13% of the variation in PMA at discharge. Mean PMA at discharge differed by up to 2 weeks between hospitals. Infants treated at NUs without fixed discharge criteria had 4.7 days lower PMA at discharge and infants receiving domiciliary care had 9.8 days lower PMA at discharge. Breastfed infants also had lower PMA at discharge (mean 2.7 days lower) than those not breast fed, partly explained by lower morbidity in the breastfed infants.

Perinatal risk factors have small overall impact on length of hospital stay in moderately preterm infants. Organisation of care is probably an important factor. The number of bed-days differs significantly between centres, which may have effects on quality of care and health economy.

This is a retrospective survey of all live born, singleton neonates with a birth weight of >=4000 g, delivered at the Albert Einstein Medical Center, Philadelphia during a 3-year period (2003 through 2005). 305 infants of the 7158 delivered during this period met entry criteria. Data were analysed using ² and Fisher’s exact test. Logistic regression analysis was also performed.

Compared to IDMs, non-IDMs were born later (40 vs 38 weeks) and were more likely to be delivered vaginally (70% vs 34%). Half of the non-IDMs (49.6%) had at least one morbidity compared with 73.2% of the IDMs. Non-IDMs had a higher incidence of birth injury than IDMs (8% vs 2.4%). Logistic regression showed an increased risk of poor outcome with weight >=4500 g and vaginal delivery.

All macrosomic infants represent a high-risk group, regardless of maternal diabetes status.

Retrospective review of all NIC admissions from 1996 to 2001 throughout a geographically defined region. Area deprivation indices were grouped into quintiles from least (1) to most (5) deprived. Admissions were classified by predefined hierarchical criteria.

The rate of admissions was 31.4 per 1000 births. There was a J-shaped relation with socioeconomic group (28.1 NIC admissions per 1000 in quintile 1, 34.0 in quintile 5 and below 28 in the other quintiles). The most deprived areas had a rate 19% above the regional average. The relation with socioeconomic group differed significantly according to primary reason for admission. The rates of admissions with significant prematurity (34% of all admissions) and IUGR as primary reason were highest in quintile 5 (18% and 41% above the regional average, respectively). This contrasted with the rate of admission for multiple birth which was highest in quintile 1 (45% above average). These differences provided the main explanation for the J-shaped overall curve.

Measures to alleviate deprivation and to improve the preterm birth and IUGR rates in deprived groups would have the greatest potential to reduce inequality in need for NIC admission. Efforts to achieve targets for reduction in infant mortality need to take account of the different effects of socioeconomic inequalities for different conditions and groups of infants.

Prospective, multi-centre surveillance study from 1993 to 2006 of invasive fungal infection, defined as positive blood or cerebrospinal fluid culture, in babies <1500 g birth weight in neonatal units in Australia and New Zealand.

There were 118 episodes of invasive fungal infection in 14 778 babies <1500 g, an incidence of 0.80% (95% confidence interval (CI) 0.66 to 0.94%). All infections were due to Candida species, mostly C. albicans (74, 62.7%) and C. parapsilosis (39, 33.1%). The mortality was 16.5%. The incidence was 0.54% (0.38 to 0.70%) for babies <1500 g in units using selective or universal oral nystatin prophylaxis and 1.23% (0.84 to 1.62%) in units using no prophylaxis (p<0.001). The incidence of infection in babies <1000 g was 1.78% (106/5948) (95% CI 1.44 to 2.12%). The incidence was 1.23% (0.92 to 1.54%) for babies <1000 g in units using nystatin prophylaxis and 2.67% (1.97 to 3.37%) in units using no prophylaxis (p<0.001).

The incidence of neonatal fungal infection was low in Australia and New Zealand, even without antifungal prophylaxis. Antifungal prophylaxis with oral nystatin was associated with a significantly lower incidence of fungal infection compared with no prophylaxis.

To describe type, doses and reasons for administering medications as part of end-of-life decisions in the Dutch neonatal intensive care units.

We reviewed the medical files of 340 newborn deaths with a preceding end-of-life decision over a 12-month period to describe the use of analgesics, sedatives and/or neuromuscular blockers. The neonatologists of 147 of the 150 newborns with a preceding end-of-life decision based on the infant’s poor prognosis were interviewed to obtain additional details about the use of medication.

Analgesics and sedatives were administered to 224 of 340 newborns before the end-of-life decision and to 292 newborns after the decision. The medication was increased in 94 of 289 newborns whose death was imminent and in 110 of 150 newborns with a poor prognosis. Reasons for the increase were treatment of pain and suffering, and in 4% of cases hastening of death. Reasons were undocumented in 55% of deaths. Neuromuscular blockers were administered in 16% of patients because they already received these agents or to stop or prevent gasping.

Analgesics and sedatives are generally increased after the end-of-life decision to treat pain and suffering and rarely to hasten death. Neuromuscular blockers were administered in 16% of deaths. Medical files provide insufficient documentation of considerations leading to the increase of medication, which hinders (external) review.

Prospective observational study, as part of a quality improvement initiative.

Two level 3 neonatal intensive care units in Ottawa, Canada

60 infants, median 27 weeks gestation, 1023 g at birth were included.

Infants received atropine, fentanyl +/– succinylcholine prior to the intubation. Succinylcholine was given for all infants >=34 weeks and at the discretion of the physician for those <34 weeks.

The primary outcome was the number of attempts. Secondary outcomes were number of attempts and intubation conditions in infants who received and those who did not receive succinylcholine and safety.

The median number of attempts was 2. 91.7% had excellent or good conditions. The median number of attempts for infants who received succinylcholine was lower (1 vs 2) than those who did not. No serious adverse events were noted. 2 cases of difficult bag and mask ventilation after administration of fentanyl were noted.

Atropine, fentanyl and succinylcholine before non-urgent intubations in newborns has led to a low number of attempts and good intubation conditions with no adverse events.

We performed a systematic literature review and summarised the data on the value of subependymal pseudocysts or choroid plexus cysts for the diagnosis of chromosomal anomalies or congenital infections. Sensitivity, specificity, predictive values and likelihood ratios were calculated for single, multiple, unilateral and bilateral cysts.

305 patients with cystic lesions were retrieved. Bilateral cysts, irrespective of their number, had a sensitivity of 88% and negative predictive value of 94% for a congenital infection or genetic disorder. Unilateral single cysts had a specificity of 92% for normal microbiological and genetic results. Bilateral multiple subependymal pseudocysts or choroid plexus cysts had a positive likelihood ratio of 9.1 for a chromosomal anomaly or congenital infection. Unilateral cysts had a negative likelihood ratio of 0.2 for a congenital infection or chromosomal anomaly. There was a chance of 1 in 4–5 for a congenital infection or chromosomal anomaly if bilateral multiple subependymal pseudocysts or choroid plexus cysts were found.

Bilateral multiple subependymal pseudocysts or choroid plexus cysts suggest an underlying disease. Further investigations should be undertaken even if the patient is otherwise normal. Parents of well newborns with a single cyst should be reassured.

The triglyceride, - and β-carotene, lutein and lycopene concentrations of 30 samples of mature HM of mothers who delivered a term infant and 10 samples of infant formula were measured after refrigeration, freezing, microwave heating and tube feeding with and without exposure to normal light and phototherapy, imitating the clinical feeding routine in the NICU.

After tube feeding triglyceride, lutein and β-carotene concentrations decreased with 33%, 35% and 26% respectively. The decrease in triglycerides in HM accounts for 16% of the total caloric intake of neonates. Triglyceride and carotenoid concentrations in HM remained stable after refrigeration, freezing or low temperature microwave heating, except for lutein which decreased after refrigeration and freezing. In infant formula no differences were found.

Mature human milk can be stored safely in a freezer and heated in a microwave oven without loss of fat or carotenoids. The clinically important loss of fat during tube feeding is probably the most important contributing factor to the decrease in lutein and β-carotene in tube feeding, with only a small role for peroxidation during light-exposure.

The care of infants with biliary atresia (BA) in England and Wales is centralised to only three centres. All infants (treated from January 1999 to December 2006) were identified from a prospective national database; demographic details were ascertained from medical records and compared between two groups based on presumed aetiology (isolated biliary atresia (IBA) and developmental biliary atresia (DBA) (for example, syndromic infants, biliary atresia splenic malformation, cystic biliary atresia)).

There were 302 (133 male (44%)) infants with BA that could be divided into IBA (n = 219, 73%) and DBA (n = 76, 25%). The overall incidence was 0.58/10 000 (1 in 17 049) live births with marked regional differences along a north-west/south-east axis varying from 0.38 (north-west England) to 0.78 (south-east England)/10 000 live births (OR 2.05 (95% CI 1.26–3.41); p = 0.002). The commonest month of birth was September with December being the least common, although there was no evidence for significant seasonal variation (p = 0.2). Infants with DBA were more likely to be female (p<0.001), of white background (p = 0.01), first-born (p = 0.04) and to be formula-fed (p = 0.07). Infants of south Asian origin came to surgery at an older age (59 (IQ 45–75) versus 52 (IQ 42–65) days; p = 0.03).

There is a remarkable variation of incidence of biliary atresia within England and Wales, some of which may have been caused by factors related to a different aetiological and racial background.

Infants with a ZZ or SZ phenotype born in The Netherlands between January 1991 and December 2006 were identified from the databases of the five Dutch diagnostic centres for alpha-1-antitrypsin phenotyping and/or genotyping. We determined the risk of VKD bleeding upon diagnosis of A1AD in breastfed and formula fed infants and searched for correlations between serum levels of conjugated bilirubin and the risk of bleeding.

A total of 40 infants with A1AD were studied. VKD bleeding was noted in 15/20 (75%) of breastfed infants, compared with 0/20 of formula fed infants with A1AD. The relative risk for VKD bleeding in breastfed versus formula fed infants was at least 15.8 (95% CI 2.3 to 108). Conjugated bilirubin levels at diagnosis did not correlate with the risk of VKD bleeding.

The risk of VKD bleeding in breastfed infants with A1AD was high and did not correlate with serum level of conjugated bilirubin at diagnosis. A similar absolute risk was previously reported in breastfed infants with biliary atresia under the same prophylactic regimen. This confirms that—without adequate prophylaxis—the risk of VKD bleeding is uniformly high in exclusively breastfed infants with cholestatic jaundice, irrespective of underlying aetiology.

5 Neopuffs were set to a PIP of 20, PEEP of 5 and P_max of 30 cm H₂O at a gas flow of 5 l/min. PIP, PEEP and P_max were recorded at flow rates of 10, 15 l/min and maximum flow. Maximum achievable pressures at 10 l/min gas flow, with a 50% air leak, were measured.

At gas flow of 15 l/min, mean PEEP increased to 20 (95% CI 20 to 21), PIP to 28 (95% CI 28 to 29) and the P_max to 40 cm H₂O (95% CI 38 to 42). At maximum flow (85 l/min) a PEEP of 71 (95% CI 51 to 91) and PIP of 92 cm H₂O (95% CI 69 to 115) were generated. At 10 l/min flow, with an air leak of 50%, the maximum PEEP and PIP were 21 (95% CI 19 to 23) and 69 cm H₂O (95% CI 66 to 71).

The maximum pressure relief valve is overridden by increasing the rate of gas flow and potentially harmful PIP and PEEP can be generated. Even in the presence of a 50% gas leak, more than adequate pressures can be provided at 10 l/min gas flow. We recommend the limitation of gas flow to a rate of 10 l/min as an added safety mechanism for this device.

In this prospective observational study, we enrolled all asphyxiated neonates transferred by the Veneto Region Neonatal Transport Service in the period 1 January 2006 to 31 March 2007. Asphyxia was defined as a pH<=7.00 and/or a base deficit of >=16 mmol per litre. Neonatal and maternal blood samples were obtained for cTnI determination.

We enrolled 19 asphyxiated neonates (median gestational age: 39 weeks, interquartile range 34–40; birth weight 3100 g, 1950–3340). Their cTnI concentrations were significantly higher in comparison with their mothers: 0.24 µg/l (0.13–0.50) vs 0.04 µg/l (0.04–0.04); p<0.01.

Increased cTnI concentrations detected in asphyxiated neonates are of neonatal origin and are not derived from the mother. In asphyxiated neonates, there may be predisposing factors that could cause earlier switching from skeletal TnI to cTnI in the myocardium.