Buenos Aires

On my way home from a great, but too short, trip to Buenos Aires. Spoke at a conference there. I had an afternoon off and was able to take a long walking tour, including taking the Avenida de Mayo. Where I took this picture of one view from the Plaza de Mayo, where there are many political demonstrations, including an on-going display by the veterans of the Malvinas War It shows some examples of the varied architecture of the city. See if you can tell what time it was when I took the photo.

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If you can see in high enough resolution, you will note that all 3 clocks have different times (and none of them were even close!)

Thanks to Gonzalo and a great group of friends and colleagues for organizing an excellent conference. See you all again soon.

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Probiotics; why not? Too cheap, too easy?

A nice new commentary piece in the Canadian Paediatric Journal (currently behind a paywall, should be free access in 6 months, if you want a copy I am sure that a judicious request could obtain one) asks exactly that question. Richard Taylor from Victoria BC writes that maybe probiotics are not high-tech enough, not ‘sexy’ enough, not expensive enough to attract our attention. But makes the strong case that it is time that we did, time that we advocate for our babies and not wait for the sometimes turgid processes of committees and official approval before doing what we know is right.

His center has been using probiotics with excellent results, we all should be following that lead.

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Dying Later

Several people have noted that the enormous gains in neonatal survival between the 60’s and the 90’s have levelled off. A new publication from our group (not me this time, but Amélie, Rosalie, and Annie, and no, all french-canadian women do not have names that end in -ie) has examined changes in timing of death among babies in our NICU. They show that although the overall mortality, when adjusted for gestation, is unchanged over this period, the average age of death has doubled, from about 11 days to about 21.

So we have got better at preventing early deaths from respiratory failure and metabolic disturbance, but the babies remain at high risk of dying from NEC, sepsis and progressive lung failure.

This may be worse for families, as the initial hope is dashed by serious complications, or it may be better, as parents know that we tried really hard to save their baby; but impacts on families of different pathways to death have not been well studied in the NICU.

I don’t know, but my ‘gut’ feeling is that this makes things harder for families, so we need to work ever harder at ways to reduce sepsis, reduce NEC, and protect the lungs, so the early ‘saves’ become long term survivors.

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Does massage help preterm infants?

I think the answer to the question posed in the title of the post is the usual answer: ‘it depends‘. In this case it depends on what you mean by massage, and what you mean by ‘help’. All massage is not the same, so exactly how it is done, how long for, and how frequently it is done, are bound to affect the results.

A systematic review published last year Wang, L., et al. (2013). “The Efficacy of Massage on Preterm Infants: A Meta-Analysis.” Am J Perinatol concluded that there seems to be an increase in weight gain in infants receiving regular massage, and some reduction in hospital stay (likely linked to the increased weight gain), but little evidence of other beneficial outcomes.

A new trial examined similar outcomes:  Abdallah B, Badr LK, Hawwari M. The efficacy of massage on short and long term outcomes in preterm infants. Infant Behavior and Development. 2013;36(4):662-9. that is; weight gain, hospital stay and development at 12 months corrected.

This study unfortunately used two sequential prospective cohorts rather than randomizing the infants, although the outcome assessments were said to be masked, I must say that is irrelevant. In fact, in general terms I would say that there really is no point trying to mask the intervention in a study design like this, you are just fooling yourself if you think it makes a difference. The Bayley scales of infant development were administered at 12 months of age, by one of the principal investigators, who must have known that this was a sequential group study, but is described as being blind to group assignment! The Bayley scores in the first group had a mean of 106, and in the second group were an amazing 120. Which is a spectacular result from 10 episodes of massage, each of which lasted 10 minutes.

On the other hand, we can maybe give the authors, in Beirut, a bit of slack (if I was a neonatologist in Beirut right now, I am not sure I would be trying to do clinical trials!). They listed 5 outcomes as important in the publication (and don’t choose a single primary outcome); including weight gain and developmental scores: they also examined pain scores after a heel-prick, which were lower in the massage group than the non-massage group.

Overall I think that the evidence that regular massage leads to increased weight gain is reasonably good, I presume that the mechanoreceptor stimulation probably leads to an increase in bone formation by a mechanism similar to the improved bone-mineralisation that occurs with weight bearing exercise, at least that is my guess.

Any effect on other outcomes remains unproven, despite this new, potentially biased study.

I also think it is a good way to get parents involved in the care of their infants, doing something which is pleasant for the parents and for their babies, which is harmless and may well have benefits.

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Spitzer’s rules

Alan Spitzer is a name well known to most neonatologists.  For several reasons: he has been a vital force in neonatology for many years, he is one of those good-natured, but intellectually rigorous physicians that neonatology has been blessed with. He also created many years ago a list of Spitzer’s rules of neonatology, that were recently challenged by a tongue-in-cheek study by my good friend Tony Ryan. To which he responded.

 After our recent article about etiquette in the NICU, Alan wrote to us about his own personal experiences on the receiving end of NICU care, the details of how it came about are his to tell if he wishes, but I asked him for permission to quote his additional rules of neonatal etiquette, which he granted.

So here, with gratitude to Alan, are some supplemental rules of etiquette for NICU docs.

1) Don’t disappear when I need you the most. Many physicians seem to become increasingly unavailable when the situation is complicated or unclear. That is when families need a physician to be most available to discuss changes in clinical condition, options for treatment, or likely prognosis. The worse the situation is, the more that you need to make yourself visible and present for a family in crisis.

 2) When parents appear with a wealth of material that they have located on the Internet, do not immediately dismiss it as rubbish. Some of it might be quite valuable and appropriate for the situation. More importantly, by briefly reviewing the information with the family, you validate them as your partners in the care of their infant and enhance your relationship.

3) If a parent is medically trained, do not assume that they need no detailed explanation of the infant’s situation. They may actually need more information from you than the usual family, since they may have an entirely different set of concerns that need to be addressed, generated from their prior medical experiences.

4) In times of difficult decisions, talking out loud to families and letting them see your thought processes are often helpful approaches. In complex situations, parents may wonder if you have evaluated all the possible options or truly understand what is going on with their infant. By letting them see how you are evaluating the situation in your own mind, you may greatly reassure them, since they will immediately perceive the broad scope of your thought processes. Nothing is more disconcerting to a family than wondering if their child’s doctor has overlooked something, nothing is more reassuring than to know that he or she has not only considered that issue, but many more possibilities.

5) Never, ever be curt, rude, or patronizing, no matter how demanding or confrontational a family may be. When a family persists with this kind of behavior, it is likely that you have not addressed their critical concerns and that is why they are so frantic. By directly asking them to tell you what is troubling them may reveal issues that will quickly allow you to put their minds at ease.

Thank you Alan for these insights!

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How should we feed preterm babies?

Two new interesting articles to address this important question.

Corvaglia, L., et al. (2014). “Cardiorespiratory Events with Bolus versus Continuous Enteral Feeding in Healthy Preterm Infants.” J Pediatr.
The authors evaluated the effects of bolus vs continuous tube feeding in 33 preterm babies on cardiorespiratory events, detected by polysomnographic monitoring. The infants received a bolus feed, followed by an infusion feed over 3 hours. Continuous tube feeding resulted in a significant increase of apneas and apneas-related hypoxic episodes compared with bolus feeding.

Nurses in my NICU often prolong the duration of feed infusion when they think the baby is not tolerating bolus feeds. Babies may end up with feeds over 2 hours out of 3, although they will not extend to continuous feeding without a medical order. many are convinced that longer feeding duration improves their baby’s tolerance, including having fewer apneas, I have never been sure, but for most babies, unless they are close to starting oral feeds, it is probably unimportant. This study by Corvaglia suggest the opposite, that prolonged feeds actually increase apneas.

In the next RCT, infants were randomized to either have gastric residuals measured routinely or not. In my career I have worked in NICUs where residuals were religiously measured and responded to, NICUs where they were measured but interpreted according to the day of the week, and one NICU where we had not measured a residual in 15 years. My impression was that the only difference in outcomes was that babies in NICU #3 achieved full feeds earlier, and had no increase in adverse outcomes. It is always nice to be proven right!

Torrazza, R. M., et al. (2014). “The value of routine evaluation of gastric residuals in very low birth weight infants.” J Perinatol. Perhaps ‘proven’ is a bit strong, this is a small RCT, just 30 very preterm babies per group, with a limited power as a result, but there is no evidence of adverse results in the group who had no measurement of residuals, and they got to full feeds sooner and stopped TPN and central venous access earlier than the controls.

I think that any NICU that wants to continue to use routine gastric residuals is now required to perform a bigger, adequately powered trial to prove that they are useful. Otherwise, everyone should stop.

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NO, not diaphragmatic Hernias!

Many of you will know that I am responsible for the inhaled NO systematic review in the Cochrane database.  One part of that review examines the data for iNO use in infants with diaphragmatic hernia. Unfortunately there were only about 80 babies with diaphragmatic hernias for whom we could find data. That is the data from the Ninos CDH trial, and the CDH stratum of Clark’s trial. Among this small number of babies there was no evident benefit of iNO, in fact a few more of the iNO treated babies ended up on ECMO than the controls, but given the small numbers that could just be chance.

A new publication (Campbell BT, Herbst KW, Briden KE, Neff S, Ruscher KA, Hagadorn JI. Inhaled Nitric Oxide Use in Neonates With Congenital Diaphragmatic Hernia. Pediatrics. 2014;134(2):e420-e6) reports iNO use among over 1700 babies with CDH. More than half of them received iNO at some point, and it was very variable between hospitals, ranging from 34% to 92% of their CDH babies receiving iNO.

The question now is, is that wrong? What is the right proportion? Should it be 0? My own practice is not to use iNO routinely in babies with CDH, given the data that we have, but that the data are so limited, that I would rather try iNO if a baby is approaching ECMO criteria. So rather than starting iNO fairly early in most babies with pulmonary hypertension, I start it prior to calling the ECMO team. I don’t know if that is right, and we probably treat more than 34% and less than 92% of our CDH babies with iNO.

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