We surveyed tertiary neonatal units in the UK from October 2010 to January 2011 for the drugs used for comfort/palliative care...]]> 2012-05-11T02:01:20-07:00 info:doi/10.1136/fetalneonatal-2012-301883 hwp:master-id:fetalneonatal;fetalneonatal-2012-301883 BMJ Publishing Group 2012-05-11 Letter http://fn.bmj.com/cgi/content/short/fetalneonatal-2012-301672v1?rss=1 Pneumatocoele, a rare complication of cavitary pulmonary tuberculosis (TB), had not been reported previously in neonates. We report here a premature infant of 28 weeks gestation weighing 1150 g who had pneumatocoele following pulmonary TB infection. He was diagnosed to have TB pneumonia at 2 weeks of age (figure 1A) when acid fast bacilli were isolated from his tracheal aspirate. Tracheal aspirate culture and polymerase chain reaction for Mycobacterium were also positive. He made a speedy recovery following treatment with isoniazid, rifampicin and pyrazinamide. Two weeks after treatment, a large pneumatocoele developed in the right lung (figure 1B). Resolution of the lesion occurred 6 months later (figure 1C). Throughout this period, he remained well and continued to gain weight. After completing 1 year of TB treatment, his growth and development was appropriate for his age.

Matsaniotis et al reported five children of age between 3 months and...]]> 2012-05-11T02:01:20-07:00 info:doi/10.1136/fetalneonatal-2012-301672 hwp:master-id:fetalneonatal;fetalneonatal-2012-301672 BMJ Publishing Group 2012-05-11 Images in neonatal medicine http://fn.bmj.com/cgi/content/short/fetalneonatal-2012-301695v1?rss=1 A 30-week preterm baby born by emergency caesarean section because of placenta praevia and antepartum haemorrhage was ventilated from birth and had repeated reintubations. By day 7 ventilation became difficult and on day 12 was transferred to a tertiary centre for escalation of ventilatory support. The transfer diagnosis was sepsis and pulmonary hypertension. Review of the chest x-rays (figures 1 and 2) shows pneumomediastinum not seen on previous x-ray, likely iatrogenic perforation of the trachea or bronchi. During echocardiogram showing marked compression of the left atrium she became bradycardic, desaturated and resuscitation was started. Discussions with cardiologists, cardiothoracic surgeons and anaesthetists decided risk of tracheal surgery too high and the patient too small to cannulate for extracorporeal support. Parents understood futility of the situation and intensive therapy was stopped. Postmortem examination reported perforation of the right main bronchus.

Tracheal perforation is a known but rare and severe...]]> 2012-05-06T02:02:35-07:00 info:doi/10.1136/fetalneonatal-2012-301695 hwp:master-id:fetalneonatal;fetalneonatal-2012-301695 BMJ Publishing Group 2012-05-06 Images in neonatal medicine http://fn.bmj.com/cgi/content/short/fetalneonatal-2011-301373v1?rss=1 Background

Neonatal sepsis due to intestinal bacterial translocation is a major cause of morbidity and mortality. Understanding microbial colonisation of the gut in prematurity may predict risk of sepsis to guide future strategies to manipulate the microbiome.

Prospective longitudinal study of premature infants. Stool samples were obtained weekly. DNA was extracted and the V6 hypervariable region of 16S rRNA was amplified followed by high throughput pyrosequencing, comparing subjects with and without sepsis.

Six neonates were 24–27 weeks gestation at birth and had 18 samples analysed. Two subjects had no sepsis during the study period, two developed late-onset culture-positive sepsis and two had culture-negative systemic inflammation. 324 350 sequences were obtained. The meconium was not sterile and had predominance of Lactobacillus, Staphylococcus and Enterobacteriales. Overall, infants who developed sepsis began life with low microbial diversity, and acquired a predominance of Staphylococcus, while healthy infants had more diversity and predominance of Clostridium, Klebsiella and Veillonella.

In very low birth weight infants, the authors found that meconium is not sterile and is less diverse from birth in infants who will develop late-onset sepsis. Empiric, prolonged antibiotics profoundly decrease microbial diversity and promote a microbiota that is associated not only with neonatal sepsis, but the predominant pathogen previously identified in the microbiome. Our data suggest that there may be a ‘healthy microbiome’ present in extremely premature neonates that may ameliorate risk of sepsis. More research is needed to determine whether altered antibiotics, probiotics or other novel therapies can re-establish a healthy microbiome in neonates.

The obstetric and neonatal outcome data for 23 such pregnancies, diagnosed at a single referral Fetal Medicine Centre, were retrospectively obtained.

The overall intrauterine fetal death rate was 61%, with a progressive decline in live fetuses up to 39 weeks gestation. For fetuses diagnosed before 20 weeks gestation, there was a trend towards a higher intrauterine fetal death rate (88%), in comparison to those diagnosed after this period (44%) (p=0.06). For live births, the preterm delivery rate was 44%. All infants born alive died within 48 h of birth.

These data provide reliable information for parental counselling pertaining to risk of intrauterine death when trisomy 18 is diagnosed prenatally. These findings suggest that long-term survival implications for trisomy 18 are different when it is diagnosed prenatally.

Using data previously collected during the SBT, the following respiratory variables were analysed: inspiratory time (T_I), expiratory time (T_E), T_I/total breath time, tidal volume (V_T) and mean inspiratory flow (V_T/T_I). RV was quantified using time-domain analysis for each respiratory variable and expressed as a variability index (VI). The sensitivity, specificity, positive and negative predictive values (PPV and NPV) of the SBT, each VI and combined SBT+VI were calculated. Extubation failure was defined as need of re-intubation within 72 h.

A total of 44 infants were included. Successfully (n=36) and unsuccessfully (n=8) extubated infants had similar baseline characteristics and number of breaths analysed. VI for V_T/T_I was significantly decreased in the failure group. The combination of the SBT and VI of either T_I or V_T were the most accurate predictors of successful extubation with a sensitivity of 100% and specificity of 75% and a PPV and NPV for extubation success of 95% and 100%, respectively.

A significant decrease in V_T/T_I variability occurred in infants requiring re-intubation. The combination of a SBT failure and decreased variability in T_I or V_T was highly predictive of failure. This combination is promising but requires prospective evaluation in a larger population.

Secondary analyses of database.

The Canadian Neonatal Network database (2003–2009).

Neonates with HCAI defined as blood/cerebrospinal fluid positive with pathogenic organism in a symptomatic infant after 2 days of age.

The incidence rate for HCAI per 1000 days with a 95% CI, for the 4 warmest months (June–September) was compared with the remaining 8 months, to calculate the incidence rate ratio (IRR).

Of 75 629 total infants, 4305 (5.7%) had HCAI (3367 had 1 and 938 had >1 episodes). Infants who had HCAI were of lower gestation, birth weight and Apgar score; but had higher severity of illness scores and clinical chorioamnionitis. There was a borderline increase in all HCAI (IRR 1.05, 95% CI 1.00 to 1.11) and a significant increase in Gram-negative HCAI (IRR 1.20, 95% CI 1.04 to 1.39) during the summer months. Overall, there was a 20% reduction in HCAI from 4.45/1000 days in January 2003 to 3.54/1000 days in December 2009 (mean difference 0.91/1000 days (95% CI 0.89 to 0.92).

Gram-negative infections were significantly increased during the summer months of the year compared with the rest of the year among neonates. Overall, there was a significant temporal reduction in HCAI rates over the study period.

We studied a group of 150 patients who were randomised in two groups after parental consent was obtained, to receive either a daily feeding supplementation with a multispecies probiotic (Lactobacillus acidophilus, Lactobacillus rhamnosus, Lactobacillus casei, Lactobacillus plantarum, Bifidobacteruim infantis, Streptococcus thermophillus) 1 g per day plus their regular feedings or to receive their regular feedings with nothing added (control group), over the period of January 2007 through June 2010. Clinicians in care of the infants were blinded to the group assignment.

The primary outcome was the development of NEC. Both groups were comparable, with no differences during hospitalisation, including the type of nutrition received. Blood cultures obtained from cases that developed sepsis did not reveal lactobacillus or Bifidobacteria growth. No differences were detected in terms of NEC risk reduction (RR: 0.54, 95% CI 0.21 to 1.39) although we did observe a clear trend in the reduction of NEC frequency in the studied cases: 6 (8%) versus 12 (16%) in the control group. When the combined risk of NEC or death was calculated as a post hoc analysis, we found a significantly lower risk (RR: 0.39, 95% CI 0.17 to 0.87) for the study group.

Probiotics may offer potential benefits for premature infants and are a promising strategy in the reduction of the risk of NEC in preterm newborns.

Retrospective audit.

Single tertiary neonatal intensive care unit at The Royal Women's Hospital in Australia.

Fifty-eight term newborn infants with moderate-to-severe hypoxic-ischaemic encephalopathy. Forty infants were treated with whole-body hypothermia between February 2001 and May 2010, 16 of whom were enrolled in the Infant Cooling Evaluation (ICE) trial, and 18 control infants randomised to normothermia in the ICE trial.

Comparison of simultaneous axillary and rectal temperatures measured between 0 and 84 h post randomisation or induction of cooling.

During the initiation of hypothermia (0–<6 h) axillary and rectal temperatures were similar (mean difference rectal-axillary =0.07°C), but with large variability (95% limits of agreement –1.18 to 1.33°C). There was larger variability in measurements between 6 and <72 h in the hypothermic infants (total SD 0.44) than in the normothermic group (total SD 0.24, p<0.001). In the hypothermic infants, the mean difference between the measurements during the rewarming phase (72–<84 h) was –0.19°C (95% limits of agreement –0.95 to 0.57°C).

As there is wide variability in the difference between axillary and rectal temperatures at all stages of whole-body cooling, our data do not support the use of axillary temperature as a surrogate for core rectal temperature during therapeutic hypothermia.

280 babies born <31 weeks of gestation and SGA were entered into the trial. Outcome was determined at 2 years to determine neurodevelopmental and general health outcomes, including economic costs.

The authors found no significant differences in health outcomes or health and social care costs between the trial groups. In the GM-CSF arm, 87 of 134 (65%) babies survived to 2 years without severe disability compared with 87 of 131 (66%) controls (RR: 1·0, 95% CI 0·8 to 1·2). Marginally, more children receiving GM-CSF were reported to have cough (RR 1·7, 95% CI 1·1 to 2·6) and had signs of chronic respiratory disease (Harrison's sulcus; RR 2·0, 95% CI 1·0 to 3·9) though this was not reflected in bronchodilator use or need for hospitalisation for respiratory disease. Overall, the rate of neurologic abnormality (7%–9%) was similar but mean overall developmental scores were lower than expected for gestational age.

The administration of GM-CSF to very preterm SGA babies is not associated with improved or more adverse outcomes at 2 years of age. The apparent excess of developmental impairment in the entire PROGRAMS cohort, without corresponding increase in neurological abnormality, may represent diffuse brain injury attributable to intrauterine growth restriction.

To describe the defecation pattern of healthy infants in The Netherlands.

From a research population of 1175 healthy Dutch infants, 600 infants without any complaints were selected. The parents recorded details of feeding and defecation at the age of 1, 2 and 3 months using a standardised questionnaire and bowel diary.

In breastfed infants, average daily defecation frequency decreased significantly during the first 3 months (from 3.65 to 1.88 times per day), whereas no significant changes were observed in infants fed standard formula or mixed feeding. At every age both the average and the range of defecation frequency of breastfed infants were higher than those of infants receiving formula feeding. Breastfed infants had softer faeces than formula-fed infants and the colour more often was yellow. At the age of 3 months, 50% of stools of formula-fed infants were green coloured. There was no significant difference in quantity between the three types of feeding, but there existed a negative correlation between defecation frequency and quantity.

This study gives insight into the defecation patterns of the largest cohort of healthy infants published so far. In the first 3 months of life, breastfed infants have more frequent, softer and more yellow-coloured stools than standard formula-fed infants. Green-coloured stools in standard formula-fed infants should be considered normal.

Population-based retrospective study.

Former ‘Trent’ health region.

Babies born between 1 January 1991 and 31 December 2010 at 22⁺⁰ to 25⁺⁶ weeks gestational age.

Survival and use of respiratory support.

Data of all babies born between 1 January 1991 and 31 December 2010 with a gestational age of 22⁺⁰ to 25⁺⁶ weeks and admitted to a neonatal unit were extracted from The Neonatal Survey. Use of respiratory support in terms of ventilation and continuous positive airway pressure (CPAP) for this group of babies was calculated as a proportion of the total used by the whole neonatal intensive care population within the defined study area.

The proportion of babies surviving to discharge increased significantly over time in those born at 24 and 25 weeks (p<0.01) but failed to achieve statistical significance for those at 23 weeks (p=0.08). No babies born at 22 weeks survived. The babies born at 22–25 weeks accounted for 26.3% of all ventilation and 21.5% of CPAP given.

Our work concurs with the current UK guidelines. There could be advantages in focusing the care of babies born at 23 weeks to a small number of intensive care units to allow specialist expertise to develop in all aspects of the management of these babies. However, focusing care will not necessarily improve survival or reduce morbidity.

Randomised trial

Tertiary neonatal unit

Thirty-six infants, median gestational age 29 (range 24 to 39) weeks

Weaning by either ACV or PSV.

At baseline, 24 hours after entering the study and immediately prior to extubation, the work of breathing (PTPdi), thoracoabdominal asynchrony (TAA) and respiratory muscle strength (Pimax) were assessed and weaning duration recorded.

There were no significant differences in the median PTPdi, TAA and Pimax results at any time point. The inflation times during ACV and PSV were similar. The median duration of weaning was 34 (range 7–100) hours in the ACV group and 27 (range 10–169) hours in the PSV group (p=0.88).

No significant differences were found between weaning by PSV and ACV when similar inflation times were used.

Cohort study.

Four Italian teaching hospitals – Padua, Brescia, L'Aquila and Udine.

Deliveries were classified as vaginal, elective caesarean (primary and repeat) or emergency caesarean. A total of 2296 (24.7%) infants born by caesarean section (CS), 816 of which (35.5%) classified as primary elective CS and 796 (34.7%) as repeat elective CS, were studied. Moreover, 30.2% of the elective CS deliveries took place before 39 weeks.

Feeding modalities at discharge: formula, complementary and breastfeeding.

At discharge, 6.9% of the vaginal delivery mothers, 8.3% of the emergency CS mothers, 18.6% of the elective CS mothers, 23.3% of the primary CS mothers and 13.9% of the repeat CS mothers were using infant formula exclusively. Multivariate analysis (OR; 95% CI) identified primary elective delivery (3.74; 3.0 to 4.60), lower gestational age (1.16; 1.10 to 1.23), and place L'Aquila versus Udine (1.42; 1.01 to 2.09) and of Brescia versus Udine hospitals (6.16; 4.53 to 8.37) as independent predictors of formula feeding at discharge.

These findings provide new information about the risks of breastfeeding failure connected to elective CS delivery, particularly if primary and scheduled before 39 weeks of gestation.

Prospective study with a preintervention and postintervention measurement using direct observation.

NICU in a tertiary hospital in the Netherlands.

A multifaceted educational intervention including teaching and self-study.

The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts.

The incidence of errors decreased from 49% (43–54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25–36%). Preintervention, 0.3% (0–2%) medications contained severe errors, 26% (21–31%) moderate and 23% (18–28%) minor errors; postintervention, none 0% (0–2%) was severe, 23% (18–28%) moderate and 8% (5–12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29–0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)).

The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.

Compare 3:1, 5:1 and 15: 2 CV ratios using the two-thumb technique in relationship to depth of compressions, decay of compression depth over time, compression rates and breaths delivered.

Thirty-two subjects, physicians and neonatal nurses, participated with compressions performed on a manikin. Evaluations included 2 min of compressions using 3:1, 5:1 and 15:2 CV ratios.

Compression depth was comparable between groups. By paired analysis per subject, the depth was only greater for 3:1 versus 15:2 (ie, 0.91±2.2 mm) (p=0.01) and greater for women than men. Comparing the initial and second minute of compressions, no decay in compression depth for 3:1 ratio was noted, however significant decay was observed for 5:1 and 15:2 ratios (p<0.05). The compression rates were least and ventilations breaths were highest for 3:1 as opposed to the other ratios (p<0.05).

Providers using a 3:1 versus 15:2 achieve a greater depth of compressions over 2 min with a greater difference noted in women. More consistent compression depth over time was achieved with 3:1 as opposed to the other ratios. Thus, the 3:1 ratio is appropriate for newly born infants requiring resuscitation.

Each full-term infant with PAIS was matched to three healthy controls for gestational age, date of birth and hospital of birth. Antenatal and perinatal risk factors were studied using univariate and multivariate conditional logistic regression analysis.

Fifty-two infants were diagnosed with PAIS. Significant risk factors in the univariate analysis (p<0.05) were nulliparity (64% vs 47%), maternal fever (>38°C) during delivery (10% vs 1%), fetal heart rate decelerations (63% vs 16%), meconium-stained amniotic fluid (44% vs 17%), emergency caesarean section (35 vs 2%), Apgar score (1 min) ≤3 (29% vs 1%), Apgar score (5 min) <7 (25% vs 1%), umbilical artery pH <7.10 (56% vs 10%), hypoglycaemia <2.0 mmol/l (29% vs 3%) and early-onset sepsis/meningitis (14% vs 2%). In the multivariate analysis, maternal fever (OR 10.2; 95% CI 1.3 to 78.5), Apgar score (5 min) <7 (OR 18.1; 95% CI 3.4 to 96.8), hypoglycaemia <2.0 mmol/l (OR 13.0; 95% CI 3.2 to 52.6) and early-onset sepsis/meningitis (OR 5.8; 95% CI 1.1 to 31.9) were significantly associated with PAIS.

Maternal fever during delivery and early-onset sepsis/meningitis were found to be involved with PAIS as was previously noted. Apgar score (5 min) <7 and hypoglycaemia were found to be important risk factors in term PAIS.

A retrospective chart review and parental survey.

Tertiary level Neonatal Intensive Care Unit (NICU).

Infants who had WANH after withdrawal of other life-sustaining treatment, and their parents.

Parental perspectives on the care and process were obtained through a survey administered 1 to 4 years after the death of their infant.

Fifteen cases (5.5% of all mortality and 0.5% of all admissions) of WANH were identified, and 10 parents participated in the survey. The median (range) gestational age was 40 weeks (31–42) and birth weight was 3409 g (2000–4640). The reason for WANH was predicted poor outcome due to severe neurological injury/disease. The median (range) time between WANH and death was 16 days (2–37). All parents reported favourable perceptions of preparation, support, communication and care. Seven parents reported concerns regarding pain experienced by their infant. Parents reported the ability to spend quality time, creating tangible memories and the virtues and professional qualities of the caregivers to be helpful, but identified that consistency and continuity of care could be improved.

Within the spectrum of palliative care in neonates, WANH can be a tenable, justifiable and humane practice in the NICU.

Using the Canadian Neonatal Network database of admissions to neonatal intensive care units from 2003 to 2008, cases with NEC were matched with controls by gestational age (GA) at birth. Exposure to transfusion within 2 days of NEC (for cases) or 2 days before the median age of NEC diagnosis among cases of the same GA (for controls) was determined. After controlling for confounders, the differences in characteristics and neonatal outcomes of transfusion-associated NEC (TANEC) and NEC not associated with transfusion (non-TANEC) were compared.

NEC cases (n=927) were matched with 2781 controls. Transfusion in previous 2 days was significantly higher in NEC cases than in controls (15.5 vs 7.7%; adjusted OR (AOR) 2. 44; 95% CI 1.87 to 3.18). TANEC cases versus non-TANEC cases had a lower mean GA (25.8 vs 29.3 weeks), a lower mean birthweight (885 vs 1373 grams), and a higher proportion of infants with SNAPII score >20 (52.1 vs 22.9%). After adjustment for confounders, no significant differences in mortality (AOR 1.28, 95% CI 0.82 to 2.01), severe retinopathy (AOR 1.15, 95% CI 0.71 to 1.87), or severe neurological injury (AOR 0.83, 95% CI 0.43 to 1.60) were identified.

Exposure to transfusion in previous 2 days was an independent risk factor for NEC. After controlling for confounders, no significant differences in mortality and morbidities were observed between infants who had transfusion-associated NEC and those with NEC not associated with transfusion.

This prospective study was approved by the institutional review board and the infants' parents gave their consent. Postmortem MRI was performed in 16 infants (1 month to 1 year of age) at 1.5 T within 48 h of their sudden death. Virtual organ volumes were estimated using the Myrian software. Real volumes were recorded at autopsy by water displacement. The agreement between virtual and real volumes was quantified following the Bland and Altman's method.

There was a good agreement between virtual and real volumes for brain (mean difference: –0.03% (–13.6 to +7.1)), liver (+8.3% (–9.6 to +26.2)) and lungs (+5.5% (–26.6 to +37.6)). For kidneys, spleen and thymus, the MRI/autopsy volume ratio was close to 1 (kidney: 0.87±0.1; spleen: 0.99±0.17; thymus: 0.94±0.25), but with a less good agreement. For heart, the MRI/real volume ratio was 1.29±0.76, possibly due to the presence of residual blood within the heart. The virtual volumes of adrenal glands were significantly underestimated (p=0.04), possibly due to their very small size during the first year of life. The percentage of interobserver and intraobserver variation was lower or equal to 10%, but for thymus (15.9% and 12.6%, respectively) and adrenal glands (69% and 25.9%).

Virtual volumetry may provide significant information concerning the macroscopic features of the main organs and help pathologists in sampling organs that are more likely to yield histological findings.

Nationwide, population-based nested case-control study. All infants with a verified first-time diagnosis of AIS, VTE or both in Denmark through the years 1994–2006 were included, and 10 population controls were selected for each case.

Case-infants presented with AIS (n=71) or VTE (n=38). AIS in infancy was associated with primiparity (adjusted OR 5.9 CI 95% 3.0 to 11.6)), delivery by an emergency caesarean section (adjusted OR 1.9 (CI 95% 1.0 to 3.3)), and post-term birth (adjusted OR 2.2 (CI 95% 1.1 to 4.8)). Male sex was associated with an increased risk of AIS among neonates (crude OR 1.8 (CI 95% 1.0 to 3.4)) but not among later born (crude OR 0.6 (CI 95% 0.2 to 1.4)). Risk factors for VTE in infancy included preterm birth (adjusted OR 5.5 (CI 95% 1.8 to 16.9)), low Apgar score (adjusted OR 9.2 (CI 95% 1.9 to 45.2)), and multiple births (adjusted OR 7.1 (CI 95% 1.1 to 48.1)). Previous maternal thromboembolism and pregnancy-related disorders were not associated with the risk of thromboembolism in the children.

Several apparently independent infant, obstetrical and maternal characteristics were associated with thromboembolism in early life.

SVC flow was assessed in 15 neonates with VGAM. SVC flow results, Bicêtre scores (clinical assessment), echocardiographic assessment and clinical outcomes are presented.

SVC flows (166–581 ml/kg/min) were significantly elevated at presentation (p<0.001; normal range 55–111 ml/kg/min). Endovascular intervention was undertaken in 12 cases, with nine survivors. SVC flows decreased sequentially with each embolisation, with a median SVC flow at discharge of 124 ml/kg/min (IQR 79–155 ml/kg/min). All cases with SVC flow >400 ml/kg/min (n=5) had an adverse outcome (death or profound neurological damage). Cases with SVC flow <400 ml/kg (n=10) required embolisation before discharge at a median age of 6 days. There were no survivors with Bicêtre scores <8 (n=2) but the predictive value of early Bicêtre score was poor.

SVC flow measurements provide insight into the haemodynamic challenges of VGAM and provide additional useful prognostic information.

A descriptive, retrospective design using tape-recorded semistructured interviews with fathers present during the resuscitation of their baby at delivery. Fathers described what happened, their interactions with healthcare professionals, their feelings at the time and afterwards.

Participants were recruited from a large teaching hospital in the UK.

A purposive sample of 20 fathers whose baby required resuscitation at delivery.

Participant responses were analysed using thematic analysis. Four broad themes were identified: ‘preparation’, ‘knowing what happened’, ‘his response’ and ‘impact on him’. Fathers had no difficulty recalling their emotions during the resuscitation. These feelings remained vivid and were mostly negative. Most fathers wanted to go to their baby during the resuscitation but did not do so. They felt they should stay with their partner, did not want to impede the resuscitation or felt they were not ‘allowed’ to go to their baby. The fathers' position in the room and the extent to which they were focusing on their partner had an impact on their recollection of what happened. Fathers had no opportunity to discuss the resuscitation with healthcare professionals afterwards. Several fathers felt they had not yet recovered from the experience and a few had symptoms synonymous with post-traumatic stress disorder.

This is the first study to specifically explore fathers' experiences of newborn resuscitation. The findings should inform healthcare education, policy development and the provision of support to fathers.

The authors analysed the Nationwide Inpatient Sample, 1993 to 2008. Singleton births diagnosed with FMH were identified by International Classification of Diseases (ICD-9) code 762.3. Descriptive, univariate and multivariable regression analyses were performed to determine the national annual incidence of FMH over time as well as demographics and clinical characteristics of neonates with FMH.

FMH was identified in 12 116 singleton births. Newborns with FMH required high intensity of care: 26.3% received mechanical ventilation, 22.4% received blood product transfusion and 27.8% underwent central line placement. Preterm birth (OR 3.7), placental abruption (OR 9.8) and umbilical cord anomaly (OR 11.4) were risk factors for FMH. Higher patient income was associated with increased likelihood of FMH diagnosis (OR 1.2), and Whites were more likely to be diagnosed than ethnic minorities (OR 1.9). There was reduced frequency of diagnosis in the Southern USA (OR 0.8 vs the Northeastern USA).

Diagnosis of FMH is associated with significant morbidity as well as regional, socioeconomic and racial disparity. Further study is needed to distinguish between diagnostic coding bias and true epidemiology of the disease. This is the first report of socioeconomic and racial/ethnic disparities in FMH, which may represent disparities in detection that require national attention.

To compare the frequency, distribution and severity of hypoxic–ischaemic lesions on brain MRI between SHC or WBC.

In a single centre retrospective study, 83 infants consecutively cooled using either SHC (n=34) or WBC (n=49) underwent brain MRI. MRI images were evaluated by a neuroradiologist, who was masked to clinical parameters and outcomes, using a basal ganglia/watershed (BG/W) scoring system. Higher scores (on a scale of 0 to 4) were given for more extensive injury. The score has been reported to be predictive of neuromotor and cognitive outcome at 12 months.

The two groups were similar for severity of depression as assessed by a history of an intrapartum sentinel event, Apgar scores, initial blood pH and base deficit and early neurological examination. However, abnormal MRI was more frequent in the SHC group (SHC 25 of 34, 74% vs WBC 22 of 49, 45%; p=0.0132, OR 3.4, 95% CI 1.3 to 8.8). Infants from the SHC group also had more severe hypoxic–ischaemic lesions (median BG/W score: SHC 2 vs WBC 0, p=0.0014).

Hypoxic–ischaemic lesions on brain MRI following therapeutic cooling were more frequent and more severe with SHC compared with WBC.

To determine whether injection of air via feeding tube before taking radiographs improves radiological assessment of its position.

In the study group (n=153), air was injected via gastric feeding tube before taking a radiograph. The tube position on radiographs was compared with a blinded control group (n=381) with no injection of air.

The definition of exact gastric tube position was possible in 95% of the study group compared with 78% in the control group (p<0.001).

Injection of air before taking a radiograph significantly improves the definition of exact gastric feeding tube position in neonates.

Cases of SIA delivered during January 1990 to December 2006 notified to 20 EUROCAT registers formed the population-based case series. Prevalence over time was estimated using multilevel Poisson regression, and heterogeneity between registers was evaluated from the random component of the intercept.

In total 1133 SIA cases were reported among 5126, 164 registered births. Of 1044 singleton cases, 215 (20.6%) cases were associated with a chromosomal anomaly. Of 829 singleton SIA cases with normal karyotype, 221 (26.7%) were associated with other structural anomalies. Considering cases with normal karyotype, the total prevalence per 10 000 births was 1.6 (95% CI 1.5 to 1.7) for SIA, 0.9 (95% CI 0.8 to 1.0) for duodenal atresia and 0.7 (95% CI 0.7 to 0.8) for jejunoileal atresia (JIA). There was no significant trend in SIA, duodenal atresia or JIA prevalence over time (RR=1.0, 95% credible interval (CrI): 1.0 to 1.0 for each), but SIA and duodenal atresia prevalence varied by geographical location (p=0.03 and p=0.04, respectively). There was weak evidence of an increased risk of SIA in mothers aged less than 20 years compared with mothers aged 20 to 29 years (RR=1.3, 95% CrI: 1.0 to 1.8).

This study found no evidence of a temporal trend in the prevalence of SIA, duodenal atresia or JIA, although SIA and duodenal atresia prevalence varied significantly between registers.

Case-control study embedded in an epidemiological survey over a 2-year period.

Throughout 2009, every paediatric department in Germany was asked to report cases of unexplained SID or S-ALTE in term infants with a 10-min Apgar score ≥8 to the Surveillance Unit for Rare Pediatric Conditions. Throughout 2010, the inclusion criteria were extended to infants ≥35 week gestational age and those where an explanation for the deterioration had been found. For each unexplained case, hospitals were asked to fill in a questionnaire for 3 (near-)term controls with good postnatal adaptation at the age (in minutes) when the event had occurred in the case under study.

Of the 85 cases reported, 34 fulfilled the entry criteria; of these, two were near-term newborns and, in three cases, a cause had been identified for the event. For the 31 cases with unknown cause for the event (13 males; mean (SD) gestational age 38.9 (1.7) week), the authors gathered 93 controls (51 male infants; 38.9 (1.4) week). As significant risk factors for S-ALTE and SID, the authors could identify primipara (OR 6.22; 95% CI 2.11 to 18.32) and potentially asphyxiating position (OR 6.45; 95% CI 1.22 to 34.10).

Close observation of newborns seems necessary, particularly in primipara; a potentially asphyxiating position should be avoided.

A retrospective cohort study comparing the incidence of IVH in very premature infants with thrombocytopaenia (platelet count <150x10⁹/l) admitted between 2007 and 2008 to two neonatal intensive care unit in The Netherlands. The restrictive platelet-transfusion unit (N=353 infants <32 weeks gestation) transfused only in case of active haemorrhage and a platelet count <50x10⁹/l. The liberal-transfusion unit (N=326 infants <32 weeks gestation) transfused according to predefined platelet count thresholds. Primary outcome was the incidence and severity of IVH in infants with thrombocytopaenia in both units.

The number of infants with thrombocytopaenia that received a platelet transfusion was significantly lower in the restrictive-transfusion unit compared with the liberal-transfusion unit, 15% (21/145) versus 31% (41/141), (p<0.001). The incidence of IVH in infants with thrombocytopaenia in the restrictive-transfusion and liberal-transfusion units was 30% (44/145) and 29% (41/141), respectively (p=0.81). The incidence of severe IVH (grade 3 or 4) in the restrictive-transfusion and liberal-transfusion units was 8% (12/145) and 11% (16/141), respectively (p=0.38).

In the restrictive-transfusion unit, the rate of platelet transfusions was significantly lower, but the incidence and severity of IVH was similar to the liberal-transfusion unit.

Prospective observational study.

Peripheral-muscle NIRS was performed in the first week of life. Tissue-oxygenation index (TOI), mixed venous oxygenation (SvO₂), fractional oxygen extraction (FOE), haemoglobin flow (Hbflow), oxygen delivery (DO₂) and oxygen consumption (VO₂) were assessed. Blood samples were taken within 3 h of the NIRS measurements.

Cardiocirculatory stable term and preterm neonates with infection-related and infection-unrelated CRP elevations >10 mg/l were compared with neonates without CRP elevation. The two groups were matched for gestational and postnatal age.

33 neonates with CRP elevation (gestational age 37.7±2.9 weeks) were compared with 33 controls (gestational age 37.3±2.9 weeks). In neonates with CRP elevation, TOI (68.9±6.6%), SvO₂ (66.9±7.3%) DO₂ (39.2±16.1 µmol/100ml/min) and VO₂ (10.9±3.4 µmol/100ml/min) were significantly lower compared with controls (TOI 72.9±3.8%, SvO₂ 70.2±4.7%, DO₂ 48.8±18.4 µmol/100ml/min, VO₂ 12.3±3.8 µmol/100ml/min). There was no significant difference in any other NIRS or routine haemodynamic parameter between the two groups.

Inflammatory processes with CRP elevation cause impaired peripheral oxygenation and perfusion in neonates even when routine haemodynamic variables are still normal. NIRS might offer a new non-invasive tool for the early recognition and diagnosis of infectious and non-infectious inflammatory processes.

Administrative health records of live infants born between January 1, 1997, and December 31, 2000 with 3 years follow-up data (N=35733) were linked. First, diagnoses of morbidities were compared between late-preterm and term infants using Cox's proportional hazards models. Healthcare costs expressed as mean total costs and cost ratios, accrued following initial hospital discharge after birth, were also examined.

The three most common reasons for hospitalisation in late-preterm and term infants were acute bronchitis, otitis media and pneumonia. The most frequent reasons for physician visits included acute upper respiratory infections, otitis media and bronchiolitis. The highest HR were detected for chronic bronchitis 1.64 (1.13–2.39), hearing loss 1.56 (1.14–2.15) and bacterial diseases 1.28 (1.09–1.49). The mean total cost for late-preterm infants during the first 2 years of life was $2568 CAD compared with $1285 CAD for term infants, cost ratio =1.99 (95% CI 1.90 to 2.09). In the third year of life, the cost ratio reduced to 1.46 (95% CI 1.39 to 1.54).

Late-preterm infants are at higher risk of specific morbidities compared with term infants. Their mean total costs fall from almost double that of term infants during the first 2 years of life, to just 46% greater in the third year of life.

In this prospective observational study, left ventricular output (LVO) was simultaneously measured by EV (LVO_ev) using Aesculon and by echocardiography (LVO_echo) in healthy term neonates during the first 2 postnatal days. To determine the agreement between the two methods, we calculated the bias (mean difference) and precision (1.96xSD of the difference). As LVO_echo has its own limitations, the authors also calculated the ‘true precision’ of EV adjusted for echocardiography as the reference method.

The authors performed 115 paired measurements in 20 neonates. LVO_ev and LVO_echo were similar (534±105 vs 538±105 ml/min, p=0.7). The bias and precision of EV were –4 and 234 ml/min, respectively. The authors found the true precision of EV to be similar to the precision of echocardiography (31.6% vs 30%, respectively). There was no difference in bias and precision between the measurements obtained in patients with or without a haemodynamically significant patent ductus arteriosus.

EV is as accurate in measuring LVO as echocardiography and the variation in the agreement between EV and echocardiography among the individual subjects reflects the limitations of both techniques.

Retrospective observational study.

Neonates >37 weeks gestation born between 2003 and 2010 in two hospitals.

Off-line analysis of prolonged continuous multichannel video-EEG recordings was performed independently by two experienced encephalographers. Comparison between the recorded electrographic seizure burden in non-cooled and cooled neonates was assessed. Data were treated as non-parametric and expressed as medians with interquartile ranges (IQR).

One hundred and seven neonates with HIE underwent prolonged continuous multichannel EEG monitoring. Thirty-seven neonates had electrographic seizures, of whom 31 had EEG recordings that were suitable for the analysis (16 non-cooled and 15 cooled). Compared with non-cooled neonates, multichannel EEG monitoring commenced at an earlier postnatal age in cooled neonates (6 (3–9) vs 15 (5–20) h)and continued for longer (88 (75–101) vs 55 (41–60) h). Despite this increased opportunity to capture seizures in cooled neonates, the recorded electrographic seizure burden in the cooled group was significantly lower than in the non-cooled group (60 (39–224) vs 203 (141–406) min). Further exploratory analysis showed that the recorded electrographic seizure burden was only significantly reduced in cooled neonates with moderate HIE (49 (26–89) vs 162 (97–262) min).

A decreased seizure burden was seen in neonates with moderate HIE who received cooling. This finding may explain some of the therapeutic benefits of cooling seen in term neonates with moderate HIE.

Outcomes were assessed using a parental questionnaire, including the Health Utilities Index (HUI-3) to assess functional impairment, and specific medical and behavioural outcomes. Educational outcomes for children in England were explored using national standardised tests. Multiple logistic regression was used to explore independent associates of NEC within the cohort.

The authors obtained data for 119 (77%) of 157 children following proven or suspected NEC and compared their outcomes with those of the remaining 6496 children. NEC was associated with an increase in risk of neonatal death (OR 14.6 (95% CI 10.4 to 20.6)).

At 7 years, NEC conferred an increased risk of all grades of impairment. Adjusting for confounders, risks persisted for any HUI-3 defined functional impairment (adjusted OR 1.55 (1.05, 2.29)), particularly mild impairment (adjusted OR 1.61 (1.03, 2.53)) both in all NEC children and in those with proven NEC, which appeared to be independent. No behavioural or educational associations were confirmed. Following NEC, children were more likely to suffer bowel problems than non-NEC children (adjusted OR 3.96 (2.06, 7.61)).

The ORACLE Children Study provided opportunity for the largest evaluation of school age outcome following neonatal NEC and demonstrates significant long-term consequences of both gut function (presence of stoma, admission for bowel problems and continuing medical care for gut-related problems) and motor, sensory and cognitive outcomes as measured using HUI-3.

A population-based, longitudinal study.

The national child mortality surveillance network.

Population of the 79 surveillance counties.

IMR, leading causes of infant death and the RR of IMR.

The IMR in coastal, inland and remote regions declined by 72.4%, 62.9% and 58.2%, respectively, from 1996 to 2008. Compared with the coastal region, the RR of IMR were 1.7 (95% CI 1.6 to 1.9), 1.9 (95% CI 1.7 to 2.0) and 1.8 (95% CI 1.6 to 2.0) for inland region and 2.6 (95% CI 2.4 to 2.7), 3.2 (95% CI 3.0 to 3.5) and 3.1 (95% CI 2.7 to 3.4) for the remote region during 1996–2000, 2001–2005 and 2006–2008, respectively. The regional disparities existed for both male and female IMRs. The postneonatal mortality showed the highest regional disparities. Pneumonia, birth asphyxia, prematurity/low birth weight, injuries and diarrhoea were the main contributors to the regional disparities. There were significantly more infants who did not seek healthcare services before death in the remote region relative to the inland and coastal regions.

The results indicated persistent existence of regional disparities in IMR in rural China. It is worth noting that regional disparities in IMR increased in the remote and coastal regions during 2001–2005 in rural China. These disparities remained unchanged during 2006–2008. The results indicate that strategies to reduce mortality caused by pneumonia, birth asphyxia and diarrhoea are keys to reducing IMR.

This prospective, observational study was performed from April 2007 until June 2009 among 315 infants born <32 weeks of gestation. Postnatal CMV infection was diagnosed by CMV PCR on urine collected at term-equivalent age. In CMV-positive infants, congenital infection was excluded. The authors compared the clinical and demographic data, feeding pattern and cUS results of infected and non-infected patients. Logistic regression analysis was performed.

In 39 of 315 infants, the diagnosis of postnatal CMV infection has been made. The majority of CMV-infected infants (33/39.85%) did not develop any symptoms of CMV infection. The most important, independent risk factors of postnatal CMV infection were non-native Dutch maternal origin (OR 9.6 (95% CI 4.3 to 21.5)) and breast milk (OR 13.2 (95% CI 1.7 to 104.5)). The risk of infection significantly increased in infants with lower gestational age (GA) (OR 0.7 (95% CI 0.5 to 0.9)). Lenticulostriate vasculopathy (LSV) was significantly more often present in infants with CMV infection (OR 4.1 (95% CI 1.9 to 8.8)).

Postnatal CMV infection is an asymptomatic infection among preterm infants. Infants with lower GA are at greatest risk of postnatal CMV infection, especially when fed with fresh breast milk from their non-native Dutch mother. LSV not present at birth but confirmed at term-equivalent age can suggest a postnatal CMV infection.

To examine the trend of survival rates of borderline viable infants over a 10-year-period and to further explore CTC differences.

Population-based, retrospective cohort study.

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

6532 preterm infants with a gestational age (GA) <32 weeks born alive between 1 January 2000 and 31 December 2009.

Trends of GA-specific delivery room and NICU mortality rates and survival rates to hospital discharge were assessed. For CTC comparisons, centre-specific risk-adjusted ORs for survival were calculated in three GA groups: A: 23 0/7 to 25 6/7 weeks (n=976), B: 26 0/7 to 28 6/7 weeks (n=1943) and C: 29 0/7 to 31 6/7 weeks (n=3399).

Survival rates of infants with a GA of 25 completed weeks which had improved from 42% in 2000/2001 to 60% in 2003/2004 remained unchanged at 63% over the next 5 years (2005–2009). Statistically significant CTC differences have persisted and are not restricted to borderline viable infants.

In Switzerland, survival rates of infants born at the limit of viability have remained unchanged over the second half of the current decade. Risk-adjusted CTC outcome variability cannot be explained by differences in baseline demographics or centre case loads.

Sodium, in paired retrospective samples, measured by the main laboratory and neonatal unit blood-gas (POCT) analysers were compared.

Hypoalbuminaemia (<30 g/l) was present in 1400/2420 paired results. Sodium was higher when measured by laboratory analyser, the difference increased with decreasing albumin; sodium (laboratory – POCT)=7.6 (±1.1)–0.22 (±0.04)xalbumin. A difference >3 mmol/l was present in 31% and consequently underestimated (9.4%) hyponatraemia and overestimated (3.8%) hypernatraemia.

Hypoalbuminaemia is common in sick neonates and monitoring electrolytes using POCT and laboratory analysers frequently yield significantly different results with consequent misclassification. In these patients, measurement of electrolytes by direct ISE (blood-gas analyser) may be more accurate.

Prospective crossover study.

Sixteen infants, median gestational age of 38 (range 34–41) weeks, birth weight of 3.1 (range 1.5–4.1) kg and postnatal age of 5 (range 2–17) days were studied. The infants were receiving time-cycled, pressure-limited ventilation in a continuous mandatory or in a triggered mode.

The infants were studied first without VT (baseline) and then at VT levels of 4, 5 and 6 ml/kg delivered in a random order. After each VT level, the infants were returned to baseline.

The WOB was assessed by measuring the transdiaphragmatic pressure-time product (PTPdi).

One infant became apnoeic at VT of 6 ml/kg. At a VT level of 4 ml/kg, four infants were making such vigorous respiratory efforts that no inflations were delivered. The median PTPdi was higher at a VT level of 4 ml/kg than at 5 ml/kg (p<0.01) or 6 ml/kg (p<0.001). Only at a VT level of 6 ml/kg was the median PTPdi lower than that at baseline (p<0.01).

Low VT levels (4 ml/kg) during VTV increase the WOB in ventilated infants born at term or near term. The results suggest that a VT level of 6 ml/kg could be used to reduce the WOB.

Prospective observational study.

Two tertiary perinatal centres.

Thirty infants, median gestational age 30 (23–34) weeks.

The first five inflations delivered via a face mask and t-piece device were examined using respiratory function monitoring.

Inflation pressures, inflation times and expiratory volumes were recorded and comparison made of inflations during which the infant made an inspiratory effort (active inflation) or did not (passive inflation).

Overall, the median expired tidal volume was 2.5 (0–19.8) ml/kg and was lower for passive (median 2.1 ml/kg, range 0–19.8 ml/kg) compared with active (median 5.6 ml/kg, range 1.2–12.2 ml/kg) inflations (ratio of geometric means 1.85, 95% CI 1.18 to 28%) (p=0.007). Overall, the median face mask leak was 54.5% and was lower for active (34.5%) compared with passive (60.7%) inflations (mean difference in % leak: 12.4%, 95% CI 0.9 to 24%) (p=0.0354). There was a significant positive correlation between the expiratory volumes and the inflation pressures (R2 between subjects 0.19, p=0.04) and a negative correlation between the expiratory tidal volumes and the face mask leaks (R2 between subjects=0.051, p<0.001), but there was no significant correlation between the inflation times and the expiratory tidal volumes.

The expired tidal volume, inflation pressures and times during the first five inflations during resuscitation were variable. The expired tidal volumes were significantly greater if the infant inspired during the inflation.

In a prospective study, proximal, middle and tip segments of PCVLs indwelling for more than 24 h in term and preterm infants were sent for culture at line removal. Definite CRS was considered as a positive peripheral blood culture plus any line segment growing the same organism in an infant with clinical signs of sepsis.

189 lines were removed from 143 neonates: 142 (75%) were from well infants and 47 (25%) were from neonates with suspected clinical sepsis. The overall CRS rate was 7.9% (15 of 189 line episodes). In well infants, bacterial colonisation rates were significantly higher for proximal segments than for tips (p=0.004). Comparative rates of segmental culture positivity and their positive predictive values for definite CRS were similar for all segments. The diagnosis of CRS was not improved beyond a sole line tip culture by additional middle or proximal segmental cultures or by combinations of the three segments.

In well infants, the proximal segments of PCVLs were more often colonised than line tips, but in clinically septic infants preferential culture of proximal or middle segments or combinations of the three segments did not permit better prediction of definite CRS than the culture of the line tip alone. Further studies prior to antibiotic therapy are indicated in babies with suspected CRS.

The authors asked 24 participants (consultants, fellows and nurses) to administer positive pressure ventilation to a modified leak-free, term newborn manikin using a self-inflating bag (SIB) and a Neopuff T-piece device. Recordings were made before and after the participants were informed about their percentage of mask leak and asked to correct this. Airway pressure and flow were measured using a Florian monitor, and the force applied to the head was measured using a concealed custom-made load cell weighing scale.

There were no differences in the mean (SD) force applied to the head between devices used and before or after the attempt to correct the mask leak (SIB before 2215 (892) and after 2195 (989) g; Neopuff before 1949 (957) and after 2028 (909) g). There was a large variation in force with both devices before and after the attempt (coefficient of variation: SIB before 40% and after 45%; Neopuff before 50% and after 45%). There was no correlation between mask leak and the difference in force used before and after the attempt to correct the mask leak using both devices.

During mask ventilation of a manikin, the authors observed that large forces were exerted on the head with either an SIB or a Neopuff, but these forces did not increase during the attempt to minimise the mask leak.

Double-blind randomised controlled trial.

Tertiary level neonatal intensive care unit (NICU).

Eighty mothers expressing breast milk for their infants (mean gestational age 28 weeks) based in NICU and the amounts expressed fell short of the prescribed target.

Mothers were randomised to receive domperidone or metoclopramide for 10 days (10 mg three times a day).

Total milk volume daily for up to 10 days before the medication, 10 days during the trial and up to 10 days after medication. Adverse side effects were also recorded.

Mothers produced more milk in the domperidone group and achieved a mean of 96.3% increase in milk volume (mean increase/pretrial volume) compared with a 93.7% increase for metoclopramide. After adjusting for the amount of milk produced prior to medication, the mean amount of milk produced while taking medication for those on domperidone was 31.0 ml/24 h (95% CI –5.67 to 67.6) greater than the mean for those on metoclopramide. Seven mothers taking metoclopramide reported side effects and three taking domperidone; a further eight women (of 29) who had a follow-on prescription for metoclopramide also reported side effects.

Oral domperidone and metoclopramide increased the volume of milk produced by mothers who are expressing to feed their babies in NICU. There were small differences in milk output between the two medications and in the incidence of side effects, but the differences were non-significant.

Prospective, randomised controlled study.

Tertiary neonatal intensive care unit.

The study enrolled 80 preterm infants with gestational age ≤28 weeks, birth weight <1000 g, postnatal age 48 to 96 h, and had echocardiographically confirmed significant PDA. Seventy extremely low birthweight (ELBW) preterm infants received either intravenous or oral ibuprofen randomly as an initial dose of 10 mg/kg, followed by 5 mg/kg at 24 and 48 h.

The success rate and the safety of the drugs in ELBW preterm infants were the major outcomes.

PDA closure rate was significantly higher with oral ibuprofen (83.3% vs 61.7%) after the first course of the treatment (p=0.04). Although the primary closure rate was marginally higher in the oral ibuprofen group, the need for a second course of ibuprofen during the whole hospitalisation was similar between groups: 11 of 36 in oral versus 15 of 34 in intravenous groups (p=0.24) because of a higher reopening rate in the oral group. In addition to no increase in side effects with oral ibuprofen use, the need for postnatal steroid use for chronic lung disease was significantly lower in oral ibuprofen group (p=0.001).

Oral ibuprofen is as effective as intravenous ibuprofen for PDA closure even in ELBW infants.

Retrospective review of medical staff resuscitation assessments over an 8-year period from 2003 to 2010.

A network-lead tertiary neonatal service with over 11 000 deliveries annually.

Neonatal medical staff: junior (speciality trainee(ST) of years 1–3) and senior trainees (ST 4–8 with tier 2 on-call responsibilities).

A standardised criterion-referenced assessment was performed by two NLS instructors. Junior trainee assessment focused on the basic airway skills learnt on an NLS course. Senior trainees demonstrated resuscitation of a baby with meconium-stained liquor, focusing on advanced life support, including intubation of the mannequin.

Assessment outcomes were pass/fail; fails were categorised as algorithm failure, technical skills failure or both. For trainees who failed the first assessment, the outcome of the second assessment following appropriate feedback was recorded.

Two hundred and sixty-two assessments were performed: 160 junior and 102 senior trainees; 98/160 (61%) of junior and 57/102 (56%) of senior trainees passed their first assessment; 69% of junior trainees who failed the first assessment had a second assessment recorded. There was a 79% pass rate at second assessment; 89% of senior trainees who failed a first assessment had a second assessment recorded. There was an 85% pass rate at second assessment. The majority of trainees who failed an assessment had problems with both the resuscitation algorithm and technical skills.

Significant numbers of trainees who have been formally trained in neonatal resuscitation skills previously do not pass the standardised resuscitation assessment, thus require an additional input to maintain their competence in neonatal resuscitation.

The authors analysed DTI images of three term infants with acute unilateral cortical arterial ischaemic stroke. Probabilistic tractography was used to define separate thalamic regions of interests (ROIs). The authors evaluated the three eigenvalues (EV) and apparent diffusion coefficient (ADC) values in the ROIs.

The ADC and EV in voxels of ROIs placed within the nuclei corresponding to ischaemic cortex were significantly lower than those in the unaffected contralesional thalamic nuclei.

Our findings support the concept of acute network injury in neonatal stroke. ADC and EV were altered in specific thalamic regions that corresponded to the specific cortical areas affected by the primary ischaemic injury.

Photographs of normal, acholic and indeterminate infant stools were shown to paediatric professionals who have regular contact with jaundiced babies at three London teaching hospitals. Each stool was classified as ‘healthy’ or ‘suspect’.

One-third of the stools were not correctly identified by physicians and nurses.

Experienced professionals often do not recognise stool colour associated with biliary obstruction. The authors propose that stool colour cards similar to those used in Japan and Taiwan may improve early detection of hepatobiliary disease at a minimal cost.

10 Neonatal Intensive Care Units (NICUs) in New South Wales (NSW) and Australian Capital Territory (ACT), Australia.

Retrospective analysis of prospectively collected data as part of NICUs' data collection in NSW and ACT.

Premature infants born at 22⁺⁰ to 31⁺⁶ weeks' gestation between January 1997 and December 2006 and admitted to one of the 10 NICUs in NSW and ACT.

Actuarial day-by-day survival to discharge from NICU.

Survival to discharge after initiation of neonatal intensive care ranges from 30.0% at 23 weeks' gestation to 98.8% at 31 weeks. Actuarial day-by-day survival increased across all gestations. This improvement was most notable among the babies who were born <26 weeks gestation.

Preterm infants who survive the first few postnatal days have considerable chances of long-term survival. It is important to revise the information stored regarding chances of survival so it covers chances at regular intervals, especially after the first few days of life.

Observational study.

Neonatal Unit, Middlemore Hospital, Auckland, New Zealand.

30 preterm infants <30 weeks' gestational age.

Cord clamping was immediate in 17 infants and delayed by 30–45 s in 13.

Infants in the two groups did not differ significantly in terms of gestational age, gender or use of antenatal steroids. Median flow in the SVC in the first 24 h was significantly higher in the group with delayed clamping (median 91 ml/kg/min; IQR 81–101) compared with 52 ml/kg/min (IQR 42–100) in the immediate clamping group (p=0.028). Fewer infants in the delayed group had low flow (1 compared with 9; p=0.017). All three infants with intraventricular haemorrhage (IVH) (of any grade) had low flow.

Blood flow in the SVC was higher in infants where delayed cord clamping was performed. The relationship of IVH, low flow and timing of cord clamping requires further study.

32 mothers and their singleton term neonates selected as small for gestational age (st-SGA=8) or appropriate for gestational age (st-AGA=24).

Nitric oxide, high-sensitive C reactive protein (hs-CRP), uric acid, blood lipids and protein levels were analysed in maternal and cord blood.

Applying customised criteria yielded 16 ct-AGA, 13 ct-SGA and 3 ct-LGA (large for gestational age) babies. Both st-SGA and ct-SGA babies had higher nitric oxide and hs-CRP levels. Their mothers had lower albumin fractions. st-SGA babies also had higher triglyceride and cholesterol levels. ct-LGA babies and mothers had higher uric acid levels, and the mothers had higher triglyceride levels.

Customised growth criteria better identify babies submitted to unfavourable intrauterine environments. The authors suggest that combined with maternal biochemistry, these growth criteria can be used to screen for adverse fetal programming.

Six neonatal intensive care units (NICUs).

762 neonates admitted to six NICUs during a 28-month observational study for whom at least one serum sample was taken on admission.

Positive and negative predictive values at different PCT cut-off levels.

The overall probability of an NS was doubled or more if PCT was >0.5 ng/ml. In very-low-birth-weight (VLBW) infants, a cut-off of >2.4 ng/ml gave a positive predictive value of NS near to 50% with a probability of a false-positive diagnosis of NS in about 10% of the patients.

In VLBW neonates, a serum PCT value >2.4 ng/ml prompts early empirical antibiotic therapy, while in normal-birth-weight infants, a PCT value ≤2.4 ng/ml carries a low risk of missing an NS.

Retrospective review of routinely collected patient data.

14 out-born infants were referred for cooling during a 12-month period. Nine infants were managed with the servo-controlled system during transport. Cooling was commenced in all infants before 6 h of life. Median time from team arrival to the infant having a temperature in the target range (33–34°C) was 45 min. Median temperature during transfer was 33.5°C (range 33–34°C). Temperature on arrival at the cooling centre ranged from 33.4°C to 33.8°C.

Servo-controlled cooling during transport is feasible and provides an optimal level of thermal control.

To assess the reliability of linear sonographic cerebellar vermis measurement.

Cranial ultrasounds of 110 infants ranging from 24 to 41 weeks' gestation were retrospectively reviewed. Cerebellar vermian height, craniocaudal diameter and superior and inferior vermis widths were independently measured on the first midline sagittal image by three neonatal sonologists of varying experience. Interobserver and intraobserver reliability were calculated using the intraclass correlation coefficient (ICC) (2 way mixed model, SPSS V.15.0).

61 images were technically adequate. Interobserver ICCs (95% CI) were: cerebellar vermian height 0.88 (0.82 to 0.92); craniocaudal diameter 0.91 (0.86 to 0.94); superior vermis width 0.84 (0.77 to 0.89); inferior vermis width 0.92 (0.89 to 0.95). Intraobserver ICCs were similar.

With adequate images, linear ultrasound measurements of cerebellar vermis are reliable.

Left and right ventricular peak systolic (S'), early diastolic (E') and late diastolic (A') myocardial velocities were measured using TDI alongside standard echocardiography (including peak diastolic atrioventricular flow, E). E/E' ratio was calculated for both ventricles.

UK neonatal intensive care unit.

43 neonates were prospectively recruited into three groups: term (n=16), preterm (30–36 weeks, n=12) and very preterm (<30 weeks, n=15).

Myocardial velocities increased with increasing gestation. Right ventricular velocities were significantly greater than left. E/E' ratio decreased with increasing gestation. Left E/E' ratio was higher than right in each group.

TDI is feasible in preterm neonates and enables the acquisition of myocardial velocities. With increasing gestation, higher myocardial velocities and lower E/E' ratios were found. The addition of TDI to standard neonatal echocardiography may provide additional information about cardiac function.