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U životu mladunčadi mačića neonatalno razdoblje predstavlja prva dva do tri tjedna života. U tom razdoblju novorođenčad je u potpunosti ovisna o majci. Mladučad reagira samo na bol, dodir i miris, a razvijene su im samo motoričke funkcije. Smrtnost mačića u dobi od jednog do sedam dana je do 85 %, što je vrlo visok postotak uginuća. Glavni uzrok neonatalnog mortaliteta je hipoksija, gotovo uvijek praćena s hipotermijom, hipoglikemijom i dehidracijom. Ova četiri hitna stanja najčešće se pojavljuju odjednom i potrebno ih je rješavati pravilnim redoslijedom da ne bi prouzročili veću smrtnost. Za liječenje i dijagnosticiranje ova četiri hitna stanja potrebno je razumjeti fiziologiju novorođenčadi. Novorođenčad prespava 80 % tijekom dana, a jesti trebaju svaka dva do četiri sata. Centar za termoregulaciju nije potpuno razvijen do dobi od šest tjedana. Tjelesna temperatura novorođenčadi ovisi o temperaturi okoliša, imaju mali postotak masnog tkiva i stoga su skloni razvoju hipotermije, koju uvijek treba riješavati zbog začaranog kruga koji se može razviti ako se hrani hipotermično novorođenče prije hipoglikemije. Jetra nije potpuno razvijena do dobi od osam tjedana pa stoga procesi glukoneogeneze i glikogenolize nisu aktivni, a razina glukoze ovisi samo o gutanju, odnosno o hranjenju. Zbog nedostatno razvijenih bubrega i nemogućnosti koncentriranja urina, povećane propusnosti kože i smanjene mogućnosti autoregulacije protoka krvi kroz bubrege neonatalni su bolesnici skloni i razvoju dehidracije. Nerazvijena jetra i bubrezi tako utječu i na lijekove koji se mogu koristiti. Klinički znaci bolesnog mačića su: neprestalni plač, anemična ili cijanotična sluznica, proljev i slabost, nedobivanje na tjelesnoj težini, mršavljenje i bradikardija. Za svakog bolesnog neonatalnog pacijenta potrebno je napraviti kompletan pregled uz vađenje krvi i određivanje hematoloških i biokemijskih parametara. Tumačenje krvnih parametara je drugačije nego u odraslih jedinki i potrebno ga je u skladu s time tumačiti. U slučaju zastoja ili perzistentne bradikardije potrebno je napraviti ABCD protokol., The neonatal period represents the first two to three weeks of life. In that period, neonatal patients are completely dependent on the mother and thus neonatal mortality is very high. Neonatal patients have developed motoric function and react only to pain, touch and scent. Kitten mortality can be up to 85% between the ages of one and seven days, which is very concerning. The main cause of neonatal mortality is hypoxia, followed closely by hypothermia, hypoglycaemia and dehydration. These four emergencies commonly appear all at once but need to be resolved in the right order to avoid causing more damage. In order to treat and diagnose these four emergencies, the physiology of the neonatal period has to be understood. Neonatal patients sleep 80% of the day and must eat every two to four hours. The thermoregulation centre is not fully developed until the age of six weeks, making body temperature dependent on the ambient temperature, and the low percentage of fat tissue makes the animal to developing hypothermia. Hypothermia always needs to be resolved before hypoglycaemia because of the vicious circle that can develop if feeding a hypo- thermic neonatal patient. Since the liver is not fully developed until the age of eight weeks, the gluconeogenesis and glycogenolysis processes are not active during the neonatal period and glucose levels depend on ingestion alone. Neonatal patients are also prone to developing dehydration due to the underdeveloped kidneys and inability to concentrate urine, increased skin permeability and decreased possibility of blood flow autoregulation through the kidneys. The undeveloped liver and kidneys also dictate the types of drugs that can be used. Clinical signs of a sick kitten are constant crying, anaemic or cyanotic mucous membranes, diarrhoea and weakness, weight stagnation or loss, and bradycardia. A sick neonatal patient requires a full exam, with blood sampling and testing of haematology and biochemistry parameters. The interpretation of blood parameters is different than in adults. In case of the arrest or persistent bradycardia, the ABC + D protocol should be applied.

Infant cry is one of the first distinctive and informative life signals observed after birth. Neonatologists and automatic assistive systems can analyse infant cry to early-detect pathologies. These analyses extensively use reference expert-curated databases containing annotated infant-cry audio samples. However, these databases are not publicly accessible because of their sensitive data. Moreover, the recorded data can under-represent specific phenomena or the operational conditions required by other medical teams. Additionally, building these databases requires significant investments that few hospitals can afford. This paper describes an open-source workflow for infant-cry detection, which identifies audio segments containing high-quality infant-cry samples with no other overlapping audio events (e.g. machine noise or adult speech). It requires minimal training because it trains an LSTM-with-self-attention model on infant-cry samples automatically detected from the recorded audio through cluster analysis and HMM classification. The audio signal processing uses energy and intonation acoustic features from 100-ms segments to improve spectral robustness to noise. The workflow annotates the input audio with intervals containing infant-cry samples suited for populating a database for neonatological and early diagnosis studies. On 16 min of hospital phone-audio recordings, it reached sufficient infant-cry detection accuracy in 3 neonatal care environments (nursery—69%, sub-intensive—82%, intensive—77%) involving 20 infants subject to heterogeneous cry stimuli, and had substantial agreement with an expert’s annotation. Our workflow is a cost-effective solution, particularly suited for a sub-intensive care environment, scalable to monitor from one to many infants. It allows a hospital to build and populate an extensive high-quality infant-cry database with a minimal investment.

The French Society of Neonatology (SFN) conducted a national questionnaire survey on the simulation-based education neonatal curriculum for pediatric residents. The response rate was 93% for the pediatric curriculum coordinators and 97% for the neonatal intensive care unit medical directors and neonatal transport teams. The average hourly volume during the curriculum was 21 ± 17 h. Overall, 89% of regional pediatric curricula offered at least one simulation session. Each simulation program involved newborn resuscitation in the delivery room but often lacked a formalized program. Additionally, half of the neonatology departments provided simulation-based education. Simulation education is now common for training pediatric residents in neonatology in France but it is heterogeneous in the French territory.

ObjectiveINGR1D (INvestigating Genetic Risk for type 1 Diabetes) was a type 1 diabetes (T1D) genetic screening study established to identify participants for a primary prevention trial (POInT, Primary Oral Insulin Trial).MethodsThe majority of participants were recruited by research midwives in antenatal clinics from 18 weeks’ gestation. Using the NHS Newborn Bloodspot Screening Programme (NBSP) infrastructure, participants enrolled in INGR1D had an extra sample taken from their day 5 bloodspot card sent for T1D genetic screening. Those at an increased risk of T1D were informed of the result, given education about T1D and the opportunity to take part in POInT.ResultsBetween April 2018 and November 2020, 66% of women approached about INGR1D chose to participate. 15 660 babies were enrolled into INGR1D and 14 731 blood samples were processed. Of the processed samples, 157 (1%) had confirmed positive results, indicating an increased risk of T1D, of whom a third (n=49) enrolled into POInT (20 families were unable to participate in POInT due to COVID-19 lockdown restrictions).ConclusionThe use of prospective consent to perform personalised genetic testing on samples obtained through the routine NBSP represents a novel mechanism for clinical genetic research in the UK and provides a model for further population-based genetic studies in the newborn.

Objetivo: describir el proceso de diseño e implementación de un protocolo de atención para la primera hora de vida del recién nacido prematuro. Método: investigación participativa, que utilizó el marco de la ciencia de la implementación y los dominios del Consolidated Framework for Implementation Research. Estudio realizado en un hospital escuela del sureste de Brasil, con la participación del equipo multidisciplinario y de los gestores. El estudio se organizó en seis etapas, mediante del ciclo de mejora continua (Plan, Do, Check, Act): diagnóstico situacional; elaboración del protocolo; capacitaciones; implementación del protocolo; relevamiento de barreras y facilitadores; seguimiento y revisión del protocolo. Los datos fueron analizados mediante estadística descriptiva y análisis de contenido. Resultados: el primer protocolo de la Hora Dorada de la institución fue organizado por el equipo multidisciplinario a partir de un enfoque colectivo y dialógico. El protocolo priorizó la estabilidad cardiorrespiratoria, la prevención de hipotermia, hipoglucemia e infección. Después de cuatro meses de capacitación e implementación, el protocolo fue evaluado como una intervención de calidad, necesaria para el servicio, de bajo costo y de poca complejidad. La principal sugerencia de mejora fue realizar actividades educativas frecuentes. Conclusión: la implementación generó cambios e inició un proceso de mejora de la calidad de la atención neonatal, es necesario que la capacitación sea continua para lograr mayor adherencia y mejores resultados. Objective: describe the process of designing and implementing a care protocol for the first hour of life of premature newborns. Method: a participatory research study using an implementation science framework, the Consolidated Framework for Implementation Research (CFIR) was employed to determine drivers and facilitators of implementation success of the Golden Hour protocol for newborns at a large university hospital in southeastern Brazil. A multi-professional team, including first line providers and managers participated in six stages of quality improvement: situational diagnosis; protocol elaboration; training protocol implementation; barrier and facilitator assessment; and protocol monitoring and review. Qualitative and monitoring data collected across these six stages were analyzed using descriptive statistics and content analysis. Results: the institution’s Golden Hour protocol was organized by the multi-professional team based on a collective and dialogical approach. The protocol prioritized the infant’s cardiopulmonary stability, as well as prevention of hypothermia, hypoglycemia and infection. After four months of implementation, the care team was evaluated the protocol as a good quality intervention, necessary for the service, low-cost and not very complex. One suggested improvement recommended was to carry out refresher training to address staff turnover. Conclusion: implementation of the Golden Hour protocol introduced an appropriate and feasible neonatal care quality improvement process, which requires periodic refresher training to ensure greater adherence and better neonatal results. Objetivo: descrever o processo de elaboração e implementação de protocolo assistencial para a primeira hora de vida do recém-nascido prematuro. Método: pesquisa participativa, que utilizou referencial da ciência da implementação e os domínios do Consolidated Framework for Implementation Research. Estudo realizado em hospital universitário no sudeste do Brasil, com participação da equipe multiprofissional e gestores. O estudo foi organizado em seis etapas, por meio do ciclo de melhoria contínua (Plan, Do, Check, Act): diagnóstico situacional; elaboração do protocolo; treinamentos; implementação do protocolo; levantamento de barreiras e facilitadores; monitoramento e revisão do protocolo. Os dados foram analisados por estatística descritiva e análise de conteúdo. Resultados: o primeiro protocolo Hora Ouro da instituição foi organizado pela equipe multiprofissional a partir de uma abordagem coletiva e dialógica. O protocolo priorizou a estabilidade cardiorrespiratória, prevenção de hipotermia, de hipoglicemia e de infecção. Após treinamento e implementação por quatro meses, o protocolo foi avaliado como uma intervenção de qualidade, necessária ao serviço, de baixo custo e pouco complexa. A principal sugestão de melhoria foi realizar ações educativas frequentes. Conclusão: a implementação provocou mudanças e iniciou um processo de melhoria da qualidade da assistência neonatal, sendo necessária a manutenção dos treinamentos para maior adesão e melhores resultados.

Accurate estimation of gestational age is an essential component of good obstetric care and informs clinical decision-making throughout pregnancy. As the date of the last menstrual period is often unknown or uncertain, ultrasound measurement of fetal size is currently the best method for estimating gestational age. The calculation assumes an average fetal size at each gestational age. The method is accurate in the first trimester, but less so in the second and third trimesters as growth deviates from the average and variation in fetal size increases. Consequently, fetal ultrasound late in pregnancy has a wide margin of error of at least ±2 weeks’ gestation. Here, we utilise state-of-the-art machine learning methods to estimate gestational age using only image analysis of standard ultrasound planes, without any measurement information. The machine learning model is based on ultrasound images from two independent datasets: one for training and internal validation, and another for external validation. During validation, the model was blinded to the ground truth of gestational age (based on a reliable last menstrual period date and confirmatory first-trimester fetal crown rump length). We show that this approach compensates for increases in size variation and is even accurate in cases of intrauterine growth restriction. Our best machine-learning based model estimates gestational age with a mean absolute error of 3.0 (95% CI, 2.9–3.2) and 4.3 (95% CI, 4.1–4.5) days in the second and third trimesters, respectively, which outperforms current ultrasound-based clinical biometry at these gestational ages. Our method for dating the pregnancy in the second and third trimesters is, therefore, more accurate than published methods.

ObjectiveTo report the parent-reported behavioural outcomes of infants included in the Systemic Hydrocortisone To Prevent Bronchopulmonary Dysplasia in preterm infants study at 2 years’ corrected age (CA).DesignRandomised placebo-controlled trial.SettingDutch and Belgian neonatal intensive care units.PatientsInfants born InterventionInfants were randomly assigned to a 22-day course of systemic hydrocortisone (cumulative dose 72.5 mg/kg; n=182) or placebo (n=190).Main outcome measuresParent-reported behavioural outcomes at 2 years’ CA assessed with the Child Behavior Checklist (CBCL 1½−5).ResultsParents completed the CBCL of 183 (70% (183/262)) infants (hydrocortisone group, n=96; placebo group, n=87). Multiple imputation was used to account for missing data. Infants with critically elevated T-scores (>55) were found in 22.9%, 19.1% and 29.4% of infants for total, internalising and externalising problems, respectively; these scores were not significantly different between groups (mean difference −1.52 (95% CI −4.00 to 0.96), −2.40 (95% CI −4.99 to 0.20) and −0.81 (95% CI −3.40 to 1.77), respectively). In the subscales, we found a significantly lower T-score for anxiety problems in the hydrocortisone group (mean difference −1.26, 95% CI −2.41 to –0.12).ConclusionThis study found high rates of behaviour problems at 2 years’ CA following very preterm birth, but these problems were not associated with hydrocortisone treatment initiated between 7 and 14 days after birth in ventilated preterm infants.Trial registration numberNTR2768; EudraCT 2010-023777-19.

BackgroundPreterm infants commonly receive red blood cell (RBC), platelet and fresh frozen plasma (FFP) transfusions. The aim of this Neonatal Transfusion Network survey was to describe current transfusion practices in Europe and to compare our findings to three recent randomised controlled trials to understand how clinical practice relates to the trial data.MethodsFrom October to December 2020, we performed an online survey among 597 neonatal intensive care units (NICUs) caring for infants with a gestational age (GA) of ResultsResponses from 343 NICUs (response rate: 57%) are presented and showed substantial variation in clinical practice. For RBC transfusions, 70% of NICUs transfused at thresholds above the restrictive thresholds tested in the recent trials and 22% below the restrictive thresholds. For platelet transfusions, 57% of NICUs transfused at platelet count thresholds above 25×109/L in non-bleeding infants of GA of 9/L threshold was associated with a lower risk of harm in a recent trial. FFP transfusions were administered for coagulopathy without active bleeding in 39% and for hypotension in 25% of NICUs. Transfusion volume, duration and rate varied by factors up to several folds between NICUs.ConclusionsTransfusion thresholds and aspects of administration vary widely across European NICUs. In general, transfusion thresholds used tend to be more liberal compared with data from recent trials supporting the use of more restrictive thresholds. Further research is needed to identify the barriers and enablers to incorporation of recent trial findings into neonatal transfusion practice.

Objective: Clinically validate the Neonatal Skin Condition Score - Portuguese version with Portuguese newborns, verifying if the risk of skin injury in this population is influenced by their condition. Method: Observational, cross-sectional and methodological study, conducted from 2018 to 2021. The Neonatal Skin Risk Assessment Scale - Portuguese version and Neonatal Skin Condition Score were used in data collection. Of the latter, content validation and sensitivity of the items were improved. MANOVA was used to evaluate whether the effect of independent variables (intrinsic and extrinsic factors) on dependent variables (score of both scales) was statistically significant. Non-random sampling (n=167). Results: The items showed good sensitivity. MANOVA revealed that the factors had a significant effect on the scores of the two scales. Conclusion: The comparison of the scales shows clinical validity, revealing that better skin condition corresponds to a lower risk of injury, and the two scales can be applied concomitantly. RESUMEN Objetivo: Validar clínicamente el Neonatal Skin Condition Score - versión portuguesa con recién nacidos portugueses, comprobando si el riesgo de lesión cutánea en esta población está influenciado por su condición. Método: Estudio observacional, transversal y metodológico, realizado de 2018 a 2021. En la recolección de datos se utilizaron el Neonatal Skin Condition Score - versión portuguesa y el Neonatal Skin Condition Score. De estos últimos, se mejoró la validación del contenido y la sensibilidad de los ítems. La MANOVA se utilizó para evaluar si el efecto de variables independientes (factores intrínsecos y extrínsecos) sobre variables dependientes (puntuación de ambas escalas) fue estadísticamente significante. Muestreo no aleatorio (n=167). Resultados: Los artículos mostraron buena sensibilidad. La MANOVA reveló que los factores tuvieron un efecto significante en las puntuaciones de las dos escalas. Conclusión: La comparación de las escalas muestra validez clínica, revelando que una mejor condición de la piel corresponde a un menor riesgo de lesión, y las dos escalas se pueden aplicar concomitantemente. RESUMO Objetivo: Validar clinicamente a Neonatal Skin Condition Score - versão portuguesa com recém-nascidos portugueses, verificando se o risco de lesão da pele nessa população é influenciado pela sua condição. Método: Estudo observacional, transversal e metodológico, realizado de 2018 a 2021. Na coleta de dados, utilizaram-se a Neonatal Skin Risk Assessment Scale - versão portuguesa e a Neonatal Skin Condition Score. Desta última, realizou-se a validação de conteúdo e a estimação da sensibilidade dos itens. Utilizou-se a MANOVA para avaliar se o efeito das variáveis independentes (fatores intrínsecos e extrínsecos) sobre as dependentes (escoredas duas escalas) era estatisticamente significante. Amostragem não aleatória (n=167). Resultados: Os itens apresentaram boa sensibilidade. A MANOVA revelou que os fatores tiveram efeito significante sobre os escores das duas escalas. Conclusão: A comparação das escalas evidencia validade clínica, demonstrando que melhor condição da pele corresponde a menor risco de lesão, podendo as duas escalas ser aplicadas concomitantemente.

Background: Serious or life-threatening pediatric emergencies are rare. Patient outcomes largely depend on excellent teamwork and require regular simulation-based team training. Recommendations for pediatric simulation-based education are scarce. We aimed to develop evidence-based guidelines to inform simulation educators and healthcare stakeholders. Methods: A modified three-round Delphi technique was used. The first guideline draft was formed through expert discussion and based on consensus (n = 10 Netzwerk Kindersimulation panelists). Delphi round 1 consisted of an individual and team revision of this version by the expert panelists. Delphi round 2 comprised an in-depth review by 12 external international expert reviewers and revision by the expert panel. Delphi round 3 involved a revisit of the guidelines by the external experts. Consensus was reached after three rounds. Results: The final 23-page document was translated into English and adopted as international guidelines by the Swiss Society of Pediatrics (SGP/SSP), the German Society for Neonatology and Pediatric Intensive Care (GNPI), and the Austrian Society of Pediatrics. Conclusions: Our work constitutes comprehensive up-to-date guidelines for simulation-based team trainings and debriefings. High-quality simulation training provides standardized learning conditions for trainees. These guidelines will have a sustainable impact on standardized high-quality simulation-based education.

Studying brain development poses significant methodological challenges when working with vulnerable newborn infant populations. Non-invasive and wearable optical brain imaging technologies may allow for the cot-side study of newborn infants in clinical settings. This has particularly important implications for preterm infants in intensive care, for whom traditional neuroimaging techniques are not readily feasible. Wearable high-density diffuse optical tomography (HD-DOT) has emerged as a promising technology in this pursuit. In this thesis, I describe the development and application of wearable HD-DOT for newborn infants in clinical settings. Specifically, this technology is applied to study the features of functional brain connectivity (FC) associated with neonatal sleep states, active sleep and quiet sleep, in both term-born and preterm infants. HD-DOT is also electromechanically combined with electroencephalography (EEG) to concurrently study haemodynamic cortical and electrical cortical brain activity in the preterm infant. As a result of the constraints posed by lock-down conditions and a pause on clinical studies during the COVID-19 pandemic, the HD- DOT device is also used to study resting state functional connectivity (RSFC) in the adult brain in the home setting. Findings from this work demonstrate the potential of wearable HD-DOT, and combined EEG-HD-DOT, for the cot-side study of cerebral function during sleep in newborn infants, as well as at-home neuroimaging of resting-state networks in adults. This work was supervised by: Dr. Topun Austin, Department of Paediatrics, University of Cambridge, and Dr. Robert J. Cooper, Department of Medical Physics and Biomedical Engineering, UCL.

Objective: In Ecuador, studies on clinical daily practice problems focused on parenteral nutrition in neonates are scarce. Therefore, this research aimed to identify negative results associated with medications (NRAM) in neonates with parenteral nutrition (PN) in a third-level hospital in Ecuador. Material and methods: An observational, prospective, descriptive study was designed in the neonatology area of a tertiary-level public hospital, where, for over four months, the medical records, PN prescriptions, and pharmacy-managed databases of 78 patients were analyzed. Drug-related problems (DRPs) as possible causes of NRAM were classified through administrative, physicochemical, and clinical validation. Results: DRPs classified as follows were found: 78.81% by physicochemical, 17.62% by clinical, and 3.57% by administrative validation. The NRAM were 72% quantitatively uncertain, 16% needed, and 11% quantitatively ineffective. Conclusion: The NRAM associated with DRPs were statistically related to prematurity condition, APGAR score, PN time, and the number of medications administered, which suggests the need to create a nutritional therapy committee at the health facility.

Undescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam.A retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging.From 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5-180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6-171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%.The majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6-12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.

OBJECTIVE: To determine the effects of lower (≤0.3) versus higher (≥0.6) initial fractional inspired oxygen (FiO2) for resuscitation on death and/or neurodevelopmental impairment (NDI) in infants 80% was associated with decreased disability/death (14%, 7% to 21%) and cognitive scores >85 (10%, 3% to 18%, p=0.01). Multinomial regression analysis noted decreased death with 5-minute SpO2 ≥80% (odds (95% CI) 09.62, 0.98 to 0.96) and gestation (0.52, 0.41 to 0.65), relative to children without death or NDI. CONCLUSION: Initial FiO2 was not associated with difference in risk of disability/death at 2 years in infants

A recent shift in public attention to racism, racial disparities, and health equity have resulted in an abundance of calls for relevant papers and publications in academic journals. Peer-review for such articles may be susceptible to bias, as subject matter expertise in the evaluation of social constructs, like race, is variable. From the perspective of researchers focused on neonatal health equity, we share our positive and negative experiences in peer-review, provide relevant publicly available data regarding addressing bias in peer-review from 12 neonatology-focused journals, and give recommendations to address bias and knowledge gaps in the peer review process of health equity research.

The needs to assess preterm infant growth clinically differ from the needs to summarize growth for research. Clinically, growth assessments are used to understand individuals' growth relative to their individual genetic potential, morbidity status and nutrition care. Growth quantification for research purposes is used to quantify growth of groups using meaningful metrics. Historically, neonatology has lacked consistency in the use of growth metrics, over-used irrelevant categories and over-diagnosed growth failure. Understanding the numerous preterm infant expected growth patterns can help identify concerning growth.

[eng] Health across the life cycle is an important component of well-being and quality of life. Bad health is linked to negative child and adulthood socioeconomic outcomes such as educational achievement, future health, and earnings (Almond et al., 2005; Black et al., 2007; Almond and Currie, 2011; Currie and Vogl, 2013). This thesis contributes to two research lines in the field of health economics. The first line, with two chapters, focuses on health at birth outcomes, and the second one, also with two chapters, explores changes in workers' health and how health shocks can affect women’s labor market outcomes. With respect to the first research line, health outcomes at all stages of life are of relevance both for individuals and societies. There is vast literature showing that good health, especially health at birth, is associated with better outcomes in terms on wages, education attainment and human capital development. Health at birth can be influenced by many factors, for instance, stress during pregnancy that, according to the medical literature, has been demonstrated to have detrimental effects on newborns’ health (Rondó et al., 2003; Beydoun and Saftlas, 2008; Torche, 2011; Khashan et al., 2008). Economic literature assessing the effects of exogenous sources of stress (earthquakes, bombs, terrorist attacks) on birth outcomes is not very rich and has focused only on the general pregnant women population. The second chapter of this thesis focuses on assessing the effect of in-utero exposure to stress, generated by terrorist attacks, on the health of newborns of Muslim mothers. Another factor that can affect health at birth is mother's substance use/abuse. Chapter 3 explores how a public policy aimed at not criminalizing drug use may be linked to increased women's drug use and bad newborn's health. The results from these two chapters point to detrimental health at birth. Thus, Chapter 2 finds that in-utero exposure to stress is linked to low birth weight and complications during pregnancy. Likewise, Chapter 3 finds that the share of low birth weight and very low birth weight newborns raises significantly in provinces initially more exposed to drugs as a possible consequence of a policy that established maximum permissible amounts of possession of illicit substances for personal consumption in Ecuador. In addition, this chapter shows evidence that supports an increase in neonatal hospitalizations to medical conditions related to maternal drug use/abuse. With respect to the second research line, in Chapter 4, this dissertation explores how the traditional civil servant recruitment process, that uses public examinations as means of access, may affect workers sick leave behavior. In this setting, candidates have to take passing exams that require a huge load of material to study, and therefore time. Candidates working while preparing for public exams may find it difficult to spend enough time on both tasks. Thus, they might experience increased stress/anxiety related to public service entrance exams. Using novel administrative data, this chapter finds a significant increase in health-related work absences several months before the examination date. This effect is stronger for individuals working in the education sector as well as for calls offering a large number of positions. This effect is mostly driven by stress-related absences. This chapter also finds evidence consistent with a deterioration in public sector workers’ health. Finally, the last empirical chapter of this dissertation examines whether lockdown policies during the first wave of the Covid-19 pandemic differently hit formal employment for women as compared to those of men in the Ecuadorian labor market. The results show that the lockdown policy is associated with an increase in the number of unemployment spells of women working in the restricted economic activities, during the first wave of the Covid-19. In sum, this dissertation contributes to the literature studying the impact that exogenous events may have on health, with a particular focus on newborn's and worker's health.

Enabling individualized decision-making for patients requires an understanding of the family context (FC) by healthcare providers. The FC is everything that makes the family unique, from their names, preferred pronouns, family structure, cultural or religious beliefs, and family values. While there is an array of approaches for individual clinicians to incorporate the FC into practice, there is a paucity of literature guiding the process of collecting and integrating the FC into clinical care by multidisciplinary interprofessional teams. The purpose of this qualitative study is to explore the experience of families and Neonatal Intensive Care Unit (NICU) clinicians with information sharing around the FC. Our findings illustrate that there are parallel and overlapping experiences of sharing the FC for families and clinicians. Both groups describe the positive impact of sharing the FC on building and sustaining relationships and on personalization of care and personhood. The experience by families of revolving clinicians and the risks of miscommunication about the FC were noted as challenges to sharing the FC. Parents described the desire to control the narrative about their FC, while clinicians described seeking equal access to the FC to support the family in the best way possible related to their clinical role. Our study highlights how the quality of care is positively impacted by clinicians’ appreciation of the FC and the complex relationship between a large multidisciplinary interprofessional team and the family in an intensive care unit, while also highlighting the difficulties in its practical application. Knowledge learned can be utilized to inform the development of processes to improve communication between families and clinicians.

Breast milk, in addition to being the best food for babies, contributes to a reduction of up to 13% in infant mortality. Among the strategies to intensify breast feeding and maintenance e of lactation is the extraction of human milk in a neonatal environment. With the pandemic, new obstacles emerged, such as the distancing of mothers in neonatal units, resulting in losses, such as the reduction in milk extraction at the bedside in the neonatal environment. The purpose of this article was to report the experience of strategies and actions that favor the maintenance of lactation in mothers of premature newborns, with emphasis on milk extraction at the bedside in neonatal units. This es an Experience Report that used the Arco de Maguerez methodology, in the neonatal units of a tertiary hospital, in Fortaleza/Ceará, from February to August 2022. Was based on strategies for maintaining lactation in mothers of premature newborns with emphasis on milk extraction at the bedside. The challenges of maintaining lactation in mothers of premature newborns stand out as interruption of milking at the bedside, absence of a defined protocol, lack of awareness of the team, overcrowding, difficulty in the mother’s free access due to the worsening of the pandemic, low adherence of professionals to training. From the identified aspects, Standard Operating Procedure and Milk Expression Flow were developed in a neonatal environment, meetings, training, and sensitization with the teams, also involving the multiprofessional residency. Good neonatal practices are still a challenge, seen more clearly in the pandemic. This experience made it possible to identify gaps. With the work, it was possible to identify gaps, develop strategies, intensify knowledge, and direct actions to improve neonatal care., O leite materno além de ser a melhor alimentação para bebês, contribui para redução de até 13% da mortalidade infantil. Dentre as estratégias para intensificar o aleitamento materno e a manutenção da lactação encontra-se a extração de leite humano em ambiente neonatal. Com a pandemia, novos obstáculos surgiram, como o distanciamento das mães nas unidades neonatais e a redução na extração de leite a beira do leito em ambiente neonatal. O objetivo deste artigo foi relatar a experiência de estratégias e ações que favoreçam a manutenção da lactação em mães de recém-nascidos prematuros, com ênfase na extração de leite à beira do leito nas unidades neonatais. Trata-se de relato de experiência que utilizou a metodologia do Arco de Maguerez, nas unidades neonatais de um hospital terciário, em Fortaleza/Ceará, nos meses de fevereiro a agosto de 2022. Teve como base as estratégias para manutenção da lactação em mães de recém-nascidos prematuros com ênfase na extração de leite à beira leito. Destacam-se como desafios da manutenção da lactação em mães de recém-nascidos prematuros a interrupção da ordenha na beira do leito, a ausência de protocolo definido, a falta de sensibilização da equipe, a superlotação, a dificuldade no livre acesso da mãe de corrente do agravamento da pandemia e a baixa adesão dos profissionais aos treinamentos. A partir dos aspectos identificados foi desenvolvido o ‘Procedimento Operacional Padrão e Fluxo de Extração de Leite em Ambiente neonatal’, reuniões, treinamentos e sensibilização com as equipes, envolvendo também a residência multiprofissional. As boas práticas neonatais ainda são um desafio, observado de forma mais evidente na pandemia. Esta experiência possibilitou identificar lacunas, desenvolver estratégias, intensificar o conhecimento e direcionar ações para a melhoria da assistência neonatal.

Background: The use of cerebral oximetry monitoring in the care of extremely preterm infants is increasing. However, evidence that its use improves clinical outcomes is lacking.Methods: In this randomized, phase 3 trial conducted at 70 sites in 17 countries, we assigned extremely preterm infants (gestational age, Results: A total of 1601 infants underwent randomization and 1579 (98.6%) were evaluated for the primary outcome. At 36 weeks' postmenstrual age, death or severe brain injury had occurred in 272 of 772 infants (35.2%) in the cerebral oximetry group, as compared with 274 of 807 infants (34.0%) in the usual-care group (relative risk with cerebral oximetry, 1.03; 95% confidence interval, 0.90 to 1.18; P = 0.64). The incidence of serious adverse events did not differ between the two groups.Conclusions: In extremely preterm infants, treatment guided by cerebral oximetry monitoring for the first 72 hours after birth was not associated with a lower incidence of death or severe brain injury at 36 weeks' postmenstrual age than usual care. (Funded by the Elsass Foundation and others; SafeBoosC-III ClinicalTrials.gov number, NCT03770741.). Background The use of cerebral oximetry monitoring in the care of extremely preterm infants is increasing. However, evidence that its use improves clinical outcomes is lacking. Methods In this randomized, phase 3 trial conducted at 70 sites in 17 countries, we assigned extremely preterm infants (gestational age

Preterm infants have low circulating levels of leptin, a key trophic hormone that influences growth and development. While the clinical importance of prematurity-associated leptin deficiency is undefined, recent preclinical and clinical investigations have shown that targeted enteral leptin supplementation can normalize neonatal leptin levels. We tested the hypothesis that, independent of growth velocity, prematurity-related neonatal leptin deficiency predicts adverse cardiovascular and neurodevelopmental outcomes. In a planned 2-year longitudinal follow-up of 83 preterm infants born at 22 to 32 weeks’ gestation, we obtained blood pressures from 58 children and the Ages & Stages Questionnaire (ASQ-3) for 66 children. Based on univariate analysis, blood pressures correlated with gestational age at birth (R = 0.30, p < 0.05) and weight gain since discharge (R = 0.34, p < 0.01). ASQ-3 scores were significantly higher in female than male children. Utilizing best subset regression with Mallows’ Cp as the criterion for model selection, higher systolic blood pressure was predicted by rapid postnatal weight gain, later gestation at delivery and male sex (Cp = 3.0, R = 0.48). Lower ASQ-3 was predicted by lower leptin levels at 35 weeks postmenstrual age, earlier gestation at delivery and male sex (Cp = 2.9, R = 0.45). Children that had leptin levels above 1500 pg/mL at 35 weeks postmenstrual age had the highest ASQ-3 scores at 2 years. In conclusion, independent of growth velocity, higher leptin levels at 35 weeks’ gestation are associated with better developmental assessment scores in early childhood. While longer-term follow-up of a larger cohort is needed, these findings support investigations that have suggested that targeted neonatal leptin supplementation could improve the neurodevelopmental outcomes of preterm infants.

Peer reviewed: True, Funder: Nuffield Department of Medicine, University of Oxford, UK, INTRODUCTION: The informal social ties that health workers form with their colleagues influence knowledge, skills and individual and group behaviours and norms in the workplace. However, improved understanding of these 'software' aspects of the workforce (eg, relationships, norms, power) have been neglected in health systems research. In Kenya, neonatal mortality has lagged despite reductions in other age groups under 5 years. A rich understanding of workforce social ties is likely to be valuable to inform behavioural change initiatives seeking to improve quality of neonatal healthcare.This study aims to better understand the relational components among health workers in Kenyan neonatal care areas, and how such understanding might inform the design and implementation of quality improvement interventions targeting health workers' behaviours. METHODS AND ANALYSIS: We will collect data in two phases. In phase 1, we will conduct non-participant observation of hospital staff during patient care and hospital meetings, a social network questionnaire with staff, in-depth interviews, key informant interviews and focus group discussions at two large public hospitals in Kenya. Data will be collected purposively and analysed using realist evaluation, interim analyses including thematic analysis of qualitative data and quantitative analysis of social network metrics. In phase 2, a stakeholder workshop will be held to discuss and refine phase one findings.Study findings will help refine an evolving programme theory with recommendations used to develop theory-informed interventions targeted at enhancing quality improvement efforts in Kenyan hospitals. ETHICS AND DISSEMINATION: The study has been approved by Kenya Medical Research Institute (KEMRI/SERU/CGMR-C/241/4374) and Oxford Tropical Research Ethics Committee (OxTREC 519-22). Research findings will be shared with the sites, and disseminated in seminars, conferences and published in open-access scientific journals.

ObjectiveTo develop a clinical prediction model to diagnose neonatal sepsis in low-resource settings.DesignSecondary analysis of data collected by the Neotree digital health system from 01/02/2019 to 31/03/2020. We used multivariable logistic regression with candidate predictors identified from expert opinion and literature review. Missing data were imputed using multivariate imputation and model performance was evaluated in the derivation cohort.SettingA tertiary neonatal unit at Sally Mugabe Central Hospital, Zimbabwe.PatientsWe included 2628 neonates aged +0weeks and birth weight ≥ 1500 grams.InterventionsParticipants received standard care as no specific interventions were dictated by the study protocol.Main outcome measuresClinical early-onset neonatal sepsis (within the first 72 hours of life), defined by the treating consultant neonatologist.ResultsClinical early-onset sepsis was diagnosed in 297 neonates (11.3%). The optimal model included eight predictors: maternal fever, offensive liquor, prolonged rupture of membranes, neonatal temperature, respiratory rate, activity, chest retractions and grunting. Receiver operating characteristic analysis gave an area under the curve of 0.736 (95% confidence interval 0.701-0.772). For a sensitivity of 95% (92-97%), corresponding specificity was 11% (10-13%), positive predictive value 12% (11-13%), negative predictive value 95% (92-97%), positive likelihood ratio 1.1 (95% CI 1.0-1.1), and negative likelihood ratio 0.4 (95% CI 0.3-0.6).ConclusionsOur clinical prediction model achieved high sensitivity with modest specificity, suggesting it may be suited to excluding early-onset sepsis. Future work will validate and refine this model before considering it for clinical use within the Neotree.What is already known on this topicVarious clinical prediction models exist to diagnose neonatal sepsis. However, there is a paucity of literature on models in low-resource settings, particularly sub-Saharan Africa.What this study addsWe developed a clinical prediction model to diagnose clinical early-onset neonatal sepsis with over 2,500 neonates in a lower middle-income, low-resource neonatal unit. Our model is easy to implement, does not require laboratory tests and achieved high sensitivity with modest specificity in the derivation cohort.How this study might affect research, practice or policyOur model could support less experienced healthcare professionals avoid unnecessary antibiotic therapy in the absence of immediate local senior support. Before implementation, this model must be externally validated and its impact on sepsis-related neonatal morbidity and mortality must be assessed in future studies.

Introduction: Umbilical cord blood gas analysis provides information about intrapartum hypoxia and is considered an important measure of quality in maternity care. Universal measurement of umbilical cord pH (UC-pH), as part of umbilical cord blood gas analysis, has been recommended in Denmark since 2009. The recommendation is that UC-pH is measured from the umbilical cord artery (pHUA ) and vein (pHUV ). The aim of this study was to evaluate the national implementation of universal measurement of UC-pH.Material and methods: The study consisted of two parts. First, an evaluation of the implementation, that is, the proportion of births with measured UC-pH since the recommendation was introduced. Second, an evaluation of the cases in which UC-pH was missing. This analysis only involved births with gestational age ≥35 + 0 weeks.Results: In the period 2009 to 2018 there were 560 889 singleton, live births with registered gestational age in Denmark. The proportion of births with measured pHUA and pHUV increased from 12.4% in 2009 to 82.8% in 2015 and then declined to 76.9% in 2018 (p < 0.001). When comparing the group with missing pH from one or both vessels to the group with both pHUA and pHUV we found lower occurrence of pregnancy and births complications in the first group, body mass index ≥35 (unadjusted RR: 0.89, 95% CI: 0.85-0.93), pregnancy induced medical conditions (RR: 0.86, 95% CI: 0.84-0.89), fetal distress during birth (RR: 0.77, 95% CI: 0.76-0.79), emergency cesarean section (RR: 0.80, 95% CI: 0.78-0.83) and serious births events (RR: 0.80, 95% CI: 0.74-0.86). In contrast, the occurrence of placental insufficiency (RR: 1.07, 95% CI: 1.03-1.11), small for gestational age (RR: 1.36, 95% CI: 1.30-1.43, for Conclusions: The use of UC-pH measurement has increased markedly in Denmark since universal measurement was recommended in 2009. Missing UC-pH from one or both vessels was associated with less complicated pregnancies and with small for gestational age, hypothermia treatment and neonatal death. Introduction: Umbilical cord blood gas analysis provides information about intrapartum hypoxia and is considered an important measure of quality in maternity care. Universal measurement of umbilical cord pH (UC-pH), as part of umbilical cord blood gas analysis, has been recommended in Denmark since 2009. The recommendation is that UC-pH is measured from the umbilical cord artery (pH UA) and vein (pH UV). The aim of this study was to evaluate the national implementation of universal measurement of UC-pH. Material and methods: The study consisted of two parts. First, an evaluation of the implementation, that is, the proportion of births with measured UC-pH since the recommendation was introduced. Second, an evaluation of the cases in which UC-pH was missing. This analysis only involved births with gestational age ≥35 + 0 weeks. Results: In the period 2009 to 2018 there were 560 889 singleton, live births with registered gestational age in Denmark. The proportion of births with measured pH UA and pH UV increased from 12.4% in 2009 to 82.8% in 2015 and then declined to 76.9% in 2018 (p < 0.001). When comparing the group with missing pH from one or both vessels to the group with both pH UA and pH UV we found lower occurrence of pregnancy and births complications in the first group, body mass index ≥35 (unadjusted RR: 0.89, 95% CI: 0.85–0.93), pregnancy induced medical conditions (RR: 0.86, 95% CI: 0.84–0.89), fetal distress during birth (RR: 0.77, 95% CI: 0.76–0.79), emergency cesarean section (RR: 0.80, 95% CI: 0.78–0.83) and serious births events (RR: 0.80, 95% CI: 0.74–0.86). In contrast, the occurrence of placental insufficiency (RR: 1.07, 95% CI: 1.03–1.11), small for gestational age (RR: 1.36, 95% CI: 1.30–1.43, for UA and pH UV. Conclusions: The use of UC-pH measurement has increased markedly in Denmark since universal measurement was recommended in 2009. Missing UC-pH from one or both vessels was associated with less complicated pregnancies and with small for gestational age, hypothermia treatment and neonatal death.

Objetivo: é buscar na literatura os benefícios do posicionamento correto dos RNPT na UTIN, através de técnicas de posicionamento, realizadas pela equipe multiprofissional. Método: este estudo é caracterizado como revisão de literatura. Resultado: ao total foram selecionados 117 artigos, após a aplicação dos critérios de inclusão 76 artigos foram analisados, destes foram selecionados 14 artigos no total, após a leitura na íntegra. Conclusão: Portanto, os estudos demonstram que é necessário um posicionamento adequado, uma padronização para o bom DNPM, reduzindo assim os impactos negativos tanto a curto, médio e longo prazo.

RESUMO: Objetivo: apresentar um algoritmo de indicação de acessos venosos para recém-nascidos em Unidade de Terapia Intensiva Neonatal. Desenvolvimento: estudo descritivo realizado na Unidade de Terapia Intensiva Neonatal no sul do Brasil, no período de 2017 a 2020 em duas etapas de idealização: desenho do algoritmo; e a adequação baseada na aplicação conforme observações realizadas pelos enfermeiros envolvidos. O algoritmo desenvolvido contemplou a previsão de acesso venoso para pacientes com indicação de cirurgia abdominal e outras cirurgias, prematuros estratificados em idade gestacional superior e inferior a 30 semanas, cardiopatias com dependência ou não de canal arterial e hipoglicemia neonatal persistente. De acordo com a rede venosa, número de terapias prescritas, jejum, antibioticoterapia e drogas vasoativas, há indicação inicial de um tipo de cateter que pode ser seguido de outro de acordo com a necessidade. Conclusão: a participação do enfermeiro na indicação de acesso venoso integra as práticas interprofissionais e incrementa a assistência neonatal. ABSTRACT Objective: to present an algorithm for the indication of venous accesses for newborns in Neonatal Intensive Care Unit. Development: descriptive study conducted in a Neonatal Intensive Care Unit in southern Brazil, in the period from 2017 to 2020 in two stages of idealization: design of the algorithm; and the adequacy based on the application according to observations made by the nurses involved. The developed algorithm contemplated the prediction of venous access for patients with indication for abdominal and other surgeries, premature infants stratified in gestational age higher and lower than 30 weeks, heart diseases with dependence or not on arterial channel and persistent neonatal hypoglycemia. According to the venous network, number of prescribed therapies, fasting, antibiotic therapy and vasoactive drugs, there is an initial indication for one type of catheter that may be followed by another according to need. Conclusion: the participation of nurses in the indication of venous access integrates interprofessional practices and increases neonatal care. RESUMEN Objetivo: presentar un algoritmo para la indicación de accesos venosos para recién nacidos en la Unidad de Cuidados Intensivos Neonatales. Desarrollo: estudio descriptivo realizado en una Unidad de Cuidados Intensivos Neonatales en el sur de Brasil, en el período de 2017 a 2020 en dos etapas de idealización: diseño del algoritmo; y la adecuación basada en la aplicación de acuerdo con las observaciones realizadas por las enfermeras involucradas. El algoritmo desarrollado contemplaba la predicción de acceso venoso para pacientes con indicación de cirugías abdominales y de otro tipo, prematuros estratificados en edad gestacional superior e inferior a 30 semanas, cardiopatías con dependencia o no de canal arterial e hipoglucemia neonatal persistente. En función de la red venosa, el número de terapias prescritas, el ayuno, la antibioticoterapia y los fármacos vasoactivos, existe una indicación inicial para un tipo de catéter que puede ir seguida de otra según las necesidades. Conclusión: la participación del enfermero en la indicación de acceso venoso integra las prácticas interprofesionales e incrementa la asistencia neonatal.

Background: Postmenstrual age for surviving infants without congenital anomalies born at 24–29 weeks’ gestational age from 2005 to 2018 in the USA increased 8 days, discharge weight increased 316 grams, and median discharge weight z-score increased 0.19 standard units. We asked whether increases were observed in other countries. Methods: We evaluated postmenstrual age, weight, and weight z-score at discharge of surviving infants without congenital anomalies born at 24–29 weeks’ gestational age admitted to Vermont Oxford Network member hospitals in Austria, Ireland, Italy, Switzerland, the UK, and the USA from 2012 to 2020. Results: After adjustment, the median postmenstrual age at discharge increased significantly in Austria (3.6 days, 99% CI [1.0, 6.3]), Italy (4.0 days [2.3, 5.6]), and the USA (5.4 days [5.0, 5.8]). Median discharge weight increased significantly in Austria (181 grams, 99% CI [95, 267]), Ireland (234 [143, 325]), Italy (133 [83, 182]), and the USA (207 [194, 220]). Median discharge weight z-score increased in Ireland (0.24 standard units, 99% CI [0.12, 0.36]) and the USA (0.15 [0.13, 0.16]). Discharge on human milk increased in Italy, Switzerland, and the UK, while going home on cardiorespiratory monitors decreased in Austria, Ireland, and USA and going home on oxygen decreased in Ireland. Conclusions: In this international cohort of neonatal intensive care units, postmenstrual discharge age and weight increased in some, but not all, countries. Processes of care at discharge did not change in conjunction with age and weight increases.

Purpose - to devote the main peculiarities of teaching neonatology to students of the medical and psychological faculty (MPF). The main principles of distance learning are emphasized as problem-solving, interactivity and orientation on personal development. The advantages of problem-solving learning are declared; it helps students in the development of clinical thinking, of the ability to predict the occurrence of psychological problems, and develops optimal tactics in communication with parents and medical personnel. In teaching the neonatology cycle to MPF students, special emphasis is placed on certain pathological conditions in newborns, which require psychological support for families. The need to provide comprehensive medical and psychological assistance to mothers, the effectiveness of which is based on key professional competencies and in-depth clinical knowledge, is emphasized. A point is placed on the fact that in the process of training in neonatology, students of the MPF must understand their special role in preventing medical stress and medical trauma for both the child and the parents, since the environment of intensive neonatology contains numerous stress factors due to excessive sensory stimulation, such as light, sound and pain, which conflict with the requirements of the brain development of a newborn baby, especially in case of preterm birth. That is why it is important to providing complete information to the parents regarding the role of each member of the team of specialists in the organization of treatment and care of the child and the need to use developmental care that meets the needs of the early development of a premature child is also highlighted. The role of the future medical psychologist in providing support to parents with perinatal loss is also determined. This problem affects many families, most of whom are dealing with their loss often alone without adequate support and help. The problem of perinatal losses and recovery of mothers and families after them is the competence of medical psychologists. The underlined requirements for the teacher are the individual preparation of high-quality learning content, which may require additional time, but the involvement of the students themselves in the preparation of the necessary materials will even more increase the interactivity of the educational process. The possibilities of using the modern educational technologies are analyzed: these are «case technologies» in small groups, «business (role) games», an inverted classroom approach. No conflict of interests was declared by the authors., Цель - осветить основные аспекты при преподавании неонатологии студентам медико-психологического факультета (МПФ). Акцент сделан на основных принципах дистанционного обучения - проблемности, интерактивности и ориентации на развитие личности. Отмечены преимущества проблемного обучения, помогающего студентам развить клиническое мышление, сформировать умение прогнозировать возникновение психологических проблем, а также разработать оптимальную тактику в общении с родителями и медицинским персоналом. Для преподавания цикла неонатологии студентам МПФ особо отмечены некоторые патологические состояния у новорожденных детей, при которых особенно необходимо психологическое сопровождение семей. Определена потребность в оказании комплексной медико-психологической помощи матерям, эффективность которой базируется на ключевых профессиональных компетентностях и глубоких клинических знаниях. Сделан акцент на том, что в процессе обучения на цикле неонатологии студенты МПФ должны понять свою особую роль в предотвращении медицинского стресса и медицинской травмы как у ребенка, так и у родителей, поскольку пребывание в отделении интенсивной терапии новорожденных подразумевает наличие многочисленных факторов стресса из-за чрезмерной сенсорной стимуляции, такой как свет, звук и боль, которые противоречат потребностям развития мозга новорожденного ребенка, особенно при преждевременном рождении. Именно поэтому подчеркнута важность предоставления полной информации родителям о роли каждого члена команды специалистов в организации лечения и ухода за ребенком, а также необходимость применения развивающего ухода, отвечающего потребностям раннего развития недоношенного ребенка. Также определена роль будущего медицинского психолога в оказании помощи родителям при перинатальной потере. Эта проблема касается многих семей, большинство из которых часто переживают потерю без надлежащей поддержки и помощи. Проблема перинатальных потерь и восстановления матерей и семей после них является компетенцией медицинских психологов. Обозначенные требования к преподавателю - необходимость индивидуальной подготовки качественного контента занятия, которая может потребовать дополнительного времени, но привлечение самих студентов к подготовке необходимых материалов еще больше повысит интерактивность учебного процесса. Разобраны возможности применения новейших образовательных технологий: «кейс-технологии» в малых группах, «деловые (ролевые) игры», перевернутый аудиторный подход. Авторы заявляют об отсутствии конфликта интересов., Мета - висвітлити основні аспекти у викладанні курсу неонатології студентам медико-психологічного факультету (МПФ). Наведено основні принципи навчання в дистанційних умовах - проблемність, інтерактивність і орієнтація на особистісний розвиток. Описано переваги проблемного навчання, яке допомагає розвинути в студентів клінічне мислення, сформувати вміння прогнозувати виникнення психологічних проблем, а також розробити оптимальну тактику в спілкуванні з батьками та медичним персоналом. Для викладання циклу неонатології студентам МПФ особливо наголошено на окремих патологічних станах у новонароджених дітей, при яких особливо необхідний психологічний супровід родин. Підкреслено потребу в наданні комплексної медико-психологічної допомоги матерям, ефективність якої базується на ключових фахових компетентностях і глибоких клінічних знаннях. Зроблено акцент на тому, що в процесі навчання на циклі неонатології студенти МПФ повинні зрозуміти власну особливу роль у запобіганні медичному стресу та медичній травмі як у дитини, так і в батьків, оскільки середовище інтенсивної неонатології містить численні фактори стресу через надмірну сенсорну стимуляцію, такі як світло, звук і біль, які суперечать вимогам розвитку мозку новонародженої дитини, особливо при передчасному народженні. Саме тому висвітлено важливість надання повної інформації батькам стосовно ролі кожного члена команди фахівців в організації лікування та догляду за дитиною, а також необхідність застосування розвивального догляду, який відповідає потребам раннього розвитку недоношеної дитини. Також визначено роль майбутнього медичного психолога в наданні допомоги батькам при перинатальній втраті. Ця проблема стосується багатьох сімей, більшість з яких переживають втрату часто наодинці без належної підтримки та допомоги. Проблема перинатальних втрат та відновлення матерів і родин після них - це компетенція саме медичних психологів. Додатково окреслено вимоги до викладача - індивідуальна підготовка якісного контенту заняття, яка може потребувати додаткового часу, але залучення самих студентів до підготовки необхідних матеріалів ще більше підвищить інтерактивність навчального процесу. Розібрано можливості застосування новітніх освітніх технологій: «кейс-технології» у малих групах, «ділові (рольові) ігри», перевернуто аудиторний підхід. Автори заявляють про відсутність конфлікту інтересів.

Objective: To analyze the factors associated with breastfeeding of preterm infants at discharge. Method: Cross-sectional study with newborns with gestational age

IntroductionPerinatal asphyxia is one of the most frequent causes of neonatal mortality, affecting approximately four million newborns worldwide each year and causing the death of one million individuals. One of the main reasons for these high incidences is the lack of consensual methods of early diagnosis for this pathology. Estimating risk-appropriate health care for mother and baby is essential for increasing the quality of the health care system. Thus, it is necessary to investigate models that improve the prediction of perinatal asphyxia. Access to the cardiotocographic signals (CTGs) in conjunction with various clinical parameters can be crucial for the development of a successful model.ObjectivesThis exploratory work aims to develop predictive models of perinatal asphyxia based on clinical parameters and fetal heart rate (fHR) indices.MethodsSingle gestations data from a retrospective unicentric study from Centro Hospitalar e Universitário do Porto de São João (CHUSJ) between 2010 and 2018 was probed. The CTGs were acquired and analyzed by Omniview-SisPorto, estimating several fHR features. The clinical variables were obtained from the electronic clinical records stored by ObsCare. Entropy and compression characterized the complexity of the fHR time series. These variables' contribution to the prediction of asphyxia perinatal was probed by binary logistic regression (BLR) and Naive-Bayes (NB) models.ResultsThe data consisted of 517 cases, with 15 pathological cases. The asphyxia prediction models showed promising results, with an area under the receiver operator characteristic curve (AUC) >70%. In NB approaches, the best models combined clinical and SisPorto features. The best model was the univariate BLR with the variable compression ratio scale 2 (CR2) and an AUC of 94.93% [94.55; 95.31%].ConclusionBoth BLR and Bayesian models have advantages and disadvantages. The model with the best performance predicting perinatal asphyxia was the univariate BLR with the CR2 variable, demonstrating the importance of non-linear indices in perinatal asphyxia detection. Future studies should explore decision support systems to detect sepsis, including clinical and CTGs features (linear and non-linear).

Background and Objectives: Early neonatal sepsis is associated with a significant mortality rate despite modern treatment strategies. Our aim was to identify risk factors contributing to the occurrence of death in newborns with early neonatal sepsis. Materials and Methods: We conducted a retrospective cross-sectional study that included newborns with early sepsis who received care in the intensive and semi-intensive care units at the Institute of Neonatology, Belgrade, Serbia. Newborns with early neonatal sepsis who died comprised the case group, whereas those who survived made up the control group. The diagnostic and therapeutic approach to the septic condition was carried out independently of this study, according to valid hospital protocols and current good practice guidelines. The influence of a large number of variables on the examined dichotomous outcome, as well as the mutual interaction of potential predictor variables, was examined by binary logistic regression. Results: The study included 133 pregnant women and 136 newborns with early neonatal sepsis, of which 51 (37.5%) died, while the remaining 85 newborns (62.5%) survived. Newborns who died had a statistically significantly lower birth weight compared to those who survived (882.8 ± 372.2 g vs. 1660.9 ± 721.1 g, p = 0.000). Additionally, compared to newborns who survived, among the deceased neonates there was a significantly higher proportion of extremely preterm newborns (74.5% vs. 22.4%, p = 0.000). The following risk factors for the occurrence of death in early neonatal sepsis were identified: low birth weight, sepsis caused by gram-negative bacteria, and the use of double-inotropic therapy and erythrocyte transfusion during the first week. Conclusions: Pediatricians should pay special attention to infants with early neonatal sepsis in whom any of the identified risk factors are present in order to prevent a fatal outcome.

Introduction: In the new-born, persistent patent ductus arteriosus is associated with significant morbidity and mortality. Normally at birth, ductus arteriosus contracts causing intraluminal ischemic hypoxia that ultimately leads to closure and remodelling of the ductus. Currently, the medical management of PAD is based on the use of non-selective inhibitors of the cyclooxygenase enzyme that participates in the synthesis of prostaglandins, especially indomethacin, acetaminophen, and ibuprofen, which promote closure of the communication by up to 70% -93%. Materials and methods: Observational, retrospective, and analytical study in which records from the EpicLatino database were used. Results: 1243 patients were obtained, 52% of patients received some type of treatment and, 171 preterm patients received treatment with acetaminophen, with an increase in the trend in its use from the year 2015 to 2020. Conclusions: More treatment was used as lower the gestational age was. The use of indomethacin and ibuprofen has decreased from 2015 to 2020 due to the adverse effects they cause compared to acetaminophen.

Contains fulltext : 283130.pdf (Publisher’s version ) (Closed access) BACKGROUND: A Dutch committee for National Guidelines in Neonatology developed nineteen evidence- and consensus-based guidelines to be used in all Dutch neonatal intensive care units (NICUs). The primary goal was to make clinical practices more uniform and consistent. OBJECTIVE: This study investigated to what extent the guidelines were implemented and which factors played a role in implementation. STUDY DESIGN: A mixed method study design was used to investigate both the level and the process of implementation. A nationwide, multicenter, cross-sectional survey was performed using a validated instrument for measuring the level of implementation (Normalization MeAsure Development questionnaire, NoMAD). The number of implemented guidelines per NICU and the frequency and content of the amendments that NICUs made to the original consensus guidelines were analyzed. Through semi-structured interviews, perceived barriers and facilitators for implementation were explored. PARTICIPANTS: Fellows and neonatologists working at all ten Dutch level 3-4 NICUs were eligible. RESULTS: On an average, NICUs implemented 12.6 (of 19) guidelines (range 6-17). The Normalization Process Scale was 54 (of 65). Main influencing factors impeding implementation were guideline-related (e.g., unpractical, lengthy guidelines) and personal (e.g., an active representative responsible for local implementation). CONCLUSION: The implementation of our guidelines appears to be successful. Ways for improvement can be distinguished in personal, guideline-related and external factors. Empowerment of local representatives was considered most essential.

ObjectiveObservational studies in preterm infants suggest that systemic hydrocortisone improves pulmonary condition but may also lead to systemic adverse effects. We report the short-term pulmonary and systemic effects of hydrocortisone initiated in the second week.DesignRandomised placebo-controlled trial.SettingDutch and Belgian neonatal intensive care units.PatientsInfants born InterventionInfants were randomly assigned to a 22-day course of systemic hydrocortisone (cumulative dose 72.5 mg/kg; n=182) or placebo (n=190).Main outcome measuresData on extubation, ventilator settings, glucose levels, and blood pressure were recorded daily and analysed during the first 7 days of treatment using linear mixed-effects models.ResultsInfants in the hydrocortisone group (24.3%) failed extubation less often compared with placebo (38.6%, crude risk difference: −14.3% (95% CI: −23.4% to −4.8%)). The estimated difference in daily rate of change between hydrocortisone and placebo was −0.42 cmH2O (95% CI: −0.48 to −0.36) for mean airway pressure, −0.02 (95% CI: −0.02 to −0.01) for fraction of inspired oxygen, −0.37 (95% CI: −0.44 to −0.30) for respiratory index, 0.14 mmol/L (95% CI: 0.08 to 0.21) for blood glucose levels and 0.83 mm Hg (95% CI: 0.58 to 1.09) for mean blood pressure.ConclusionsSystemic hydrocortisone initiated between 7 and 14 days after birth in ventilated preterm infants improves pulmonary condition, thereby facilitating weaning and extubation from invasive ventilation. The effects of hydrocortisone on blood glucose levels and blood pressure were mild and of limited clinical relevance.Trial registration numberNetherlands Trial Register (NTR2768;https://www.trialregister.nl/trial/2640) and European Union Clinical Trials Register (EudraCT, 2010-023777-19).

Introduction Amplitude integrated electroencephalography (aEEG) is a widely tool used for neuromonitoring in the critical neonate. In the patient with perinatal asphyxia, its interpretation is key to identifying candidates for therapeutic hypothermia, detecting subclinical seizures and providing pronostic information. Our aim was to analyze the concordance in the interpretation of aEEG among neonatologists with different level of experience. Material and methods Unicenter retrospective study of newborns ≥35 weeks with perinatal asphyxia included consecutively over a two-year period and monitored with aEEG for at least 6h. The bedside neonatologist interpreted aEEG regarding background pattern, sleep-wake cycling, and seizures. The aEEG tracings were blindly reviewed by two neonatologists with different experience. The aEEG tracings were divided into periods of 0-3h and 3-6h of life, and the concordance (Cohen Kappa coefficient, k), between the two examiners and that of their consensus with the bedside neonatologist, was analyzed. Results Seventy-five newborns were included, 5 of them were not aEEG-monitored. 132 tracings were analyzed with a very good concordance between the two examiners in the three characteristics of the aEEG. The k for the bedside neonatologist was very good for background pattern (k=0.93), moderate (k=0.52) for sleep-wake cycling, and weak (k=0.32) for seizures. Conclusions This study supports that background pattern is easily interpreted compared to sleep-wake cycling or crisis, improving when targeted training on aEEG is received.

ObjectiveIn response to the increasing focus on family-centred care, neonatal intensive care unit (NICU) environments have gradually shifted towards the single-room design. However, the assumed benefits of this emerging design remain a subject of debate. Our goal was to evaluate the impact of single-room versus open-bay care on the risk of neonatal morbidity and mortality in preterm neonates.DesignRetrospective cohort study.SettingLevel III NICU.PatientsNeonates born Main outcome measuresMortality and morbidities of a cohort of neonates admitted to a new, single-room unit (SRU) were compared with a historical cohort of neonates admitted to an open-bay unit (OBU). Group differences were evaluated and multivariable logistic regression analyses were performed.ResultsThree-hundred and fifty-six and 343 neonates were admitted to the SRU and OBU, respectively. No difference in neonatal morbidities and mortality were observed between cohorts (bronchopulmonary dysplasia: OR 1.08, 95% CI 0.73 to 1.58, p=0.44; retinopathy of the prematurity stage ≥2: OR 1.36, 95% CI 0.84 to 2.22, p=0.10; intraventricular haemorrhage: OR 0.89, 95% CI 0.59 to 1.34, p=0.86; mortality: OR 1.55, 95% CI 0.75 to 3.20, p=0.28). In adjusted regression models, single-room care was independently associated with a decreased risk of symptomatic patent ductus arteriosus (adjusted OR 0.54, 95% CI 0.31 to 0.95). No independent association between single-room care and any of the other investigated outcomes was observed.ConclusionsImplementation of single-rooms in our NICU did not lead to a significant reduction in neonatal morbidity and mortality outcomes.

BACKGROUND: The main goal of neonatologist performed echocardiography is to timely assess hemodynamic changes in order to properly manage unsteady neonates. Detailed structural heart assessment remains the domain of pediatric cardiologists. Nonetheless, many neonatologists take on an additional role in diagnosis of congenital heart defects, mostly compelled by the lack of in-house pediatric cardiology services. The experience of neonatologist performed echocardiography in an Italian neonatal unit was reported and the risk benefit profile of this practice was discussed. MATERIAL AND METHODS: We retrospectively reviewed the echocardiograms undertaken by the neonatologist on infants admitted to the neonatal unit and postnatal ward of the Hospital San Pio in Benevento, over a 2-year period. Details of scans and concordance between neonatologist and cardiologist were analyzed. RESULTS: A total of 160 echocardiographic studies were done by the neonatologist on 136 infants. The ECG was requested in a minority of infants. The most common reason for performing the echocardiogram was admission to the neonatal care unit. Around half of the echocardiograms were normal. The remaining scans resulted in functional and structural abnormalities, transitional changes, and doubtful findings. Cardiac anomalies were significantly more likely found in cases of echocardiograms performed for fetal indications. Only 28 patients were eventually referred to the cardiology services. The inter-rater agreement was satisfactory. CONCLUSIONS: The hemodynamic assessment of sick infants, as well as triaging and referral of neonates with structural heart diseases are valuable advantages of the echocardiography run by neonatologists. Collaboration with pediatric cardiologists and robust training and accreditation programs are essential to ensure safety and quality service.

Premature and low birth weight newborns are at greater risk of developing nosocomial infections, including Candida spp infections. This is a systematic literature review to identify risk factors for developing candidemia in neonates. The search was performed in the VHL, Cochrane, Embase, Pubmed, Scielo, Scopus and Web of Science databases and the terms were: Candidemia, Candidiasis, Candida spp. Invasive Candidiasis, Risk Factors, Infant, Newborn and Neonatology. Meta-analysis was performed for risk factor using Comprehensive Meta Analysis. A total of 2218 articles were identified and 42 papers were included. The main risk factors were: low weight, previous surgery, intubation, mechanical ventilation, central venous catheter, antibiotics and parenteral nutrition. Low birth weight and neonatal units care assistance factors were the main predictors of Candidemia in neonates. Prospective studies are necessary with systematic follow-up during hospitalization to define measures to prevent infection, since retrospective studies have inherent selection and information bias.

High work relative value units (wRVU) per clinical full-time-equivalent (cFTE) productivity by Neonatologists have played a key role in enhancing departmental revenue in Pediatrics. However, such high productivity is not sustainable due to recent changes in trainee schedules and global daily codes and is likely to impact physician morale and wellness. Incentives based on wRVU benchmarks have the capacity to promote desirable behavior such as better documentation and in-person attendance in delivery room resuscitation and consults but comes at a cost of physician time providing care. An alternate method of funding academic Pediatric departments using time- or point-based staffing models, a reduction in productivity benchmarks for academic neonatologists through more accurate reporting of effort and physician leadership that promotes transparency and mutual respect are warranted to improve neonatologist well-being and morale.

ObjectiveTo determine if preterm birth is associated with adaptation of the hypothalamic–pituitary–adrenal (HPA) axis and whether HPA axis programming relates to the degree of prematurity (defined as extremely preterm birth at DesignThis study reports findings from a prospective birth cohort. Saliva cortisol concentrations were measured prevaccination and postvaccination, and in the morning and evening, at 4 months chronological age.SettingInfants born at a single Scottish hospital.Participants45 term-born, 42 very preterm and 16 extremely preterm infants.OutcomesCortisol stress response to vaccination (postvaccination minus prevaccination cortisol concentrations), diurnal slope (log-transformed morning minus log-transformed evening cortisol values) and mean log-transformed daily cortisol.ResultsCompared with infants born at term, infants born extremely preterm had a blunted cortisol response to vaccination (5.8 nmol/L vs 13.1 nmol/L, difference in means: −7.3 nmol/L, 95% CI −14.0 to −0.6) and a flattened diurnal slope (difference in geometric means: −72.9%, 95% CI −87.1 to −42.8). In contrast, the cortisol response to vaccination (difference in means −2.7 nmol/L, 95% CI −7.4 to 2.0) and diurnal slope at 4 months (difference in geometric means: −33.6%, 95% CI −62.0 to 16.0) did not differ significantly in infants born very preterm compared with infants born at term.ConclusionsInfants born extremely preterm have blunted cortisol reactivity and a flattened diurnal slope. These patterns of HPA axis regulation are commonly seen after childhood adversity and could contribute to later metabolic and neurodevelopmental phenotypes observed in this population.

Neonatologist-performed echocardiography (NPE) is recommended during shock. We aimed to assess factors associated with NPE utilisation in the NICU and physiological information obtained during management of shock.An Internet-based survey, sent to neonatologists with interest in haemodynamics, studying NPE utilisation in shock management through a real clinical case and correlating its use with responders' training and NICU settings.Fifty-nine completed surveys were received from the United Kingdom: 38%, Western Europe: 32%, Canada: 23% and other countries: 7%. Whilst managing the given clinical case, 90% of responders expected first NPE to exclude congenital heart disease-although only 61% could exclude it confidently (71% in trained clinicians vs. 29% without training; p 0.01). NPE utilisation prior to initiate treatment was significantly correlated with mean number of neonatologists able to perform NPE in the NICU (4.9 vs. 2.9 neonatologists per unit; p = 0.02). Similarly, for ongoing therapeutic guidance, NPE was more used in trained clinicians (p 0.01). 88% and 81% of responders studied a combination of multiple parameters to assess filling and systemic flow, respectively.Neonatologist-performed echocardiography during shock management differs with previous training and number of doctors able to perform echocardiography in NICU. This study highlighted the need for enhanced training implementation.

Objective To estimate the annual cost associated with obstetric events in women of reproductive age with immune-mediated inflammatory diseases, from the perspective of the National Healthcare System. Methods A cost-analysis was developed to estimate the impact associated with obstetric events in women of reproductive age with psoriasis (PSO), psoriatic arthritis (PsA), rheumatoid arthritis (RA) and axial spondyloarthritis (axSpA). The analysis considered complications during fertility and conception, in pregnancy and in the postpartum. All parameters were validated and agreed by a multidisciplinary expert panel. Unitary costs (€, 2019) were obtained from national, local databases. Results During fertility and conception, an annual cost per patient of €229 was estimated for a preconception consultation in a patient with PSO, of €3,642 for a preconception consultation in patients with PsA, RA and axSpA and €4,339 for assisted reproduction. Women with complications in pregnancy had an annual cost per patient of €1,214 for a miscarriage in the first trimester, €4,419 for a late miscarriage in the second trimester, €11,260 for preeclampsia €3,188 for restricted intrauterine growth and €12,131 for threat of premature delivery. In the postpartum, an annual cost per patient of €120,364, €44,709, and €5,507 were estimated associated with admissions to neonatology of premature infants of Conclusions This analysis provides insight on the economic burden of complications associated with women of reproductive age for immune-mediated diseases (PSO, PsA, RA, axSpA). Individualization of treatment, additional and close monitoring may reduce the risk and burden of these complications.

Motor disability is common in children born preterm. Interventions focusing on environmental enrichment and emotional connection can positively impact outcomes. The NICU-based rehabilitation (NeoRehab) program consists of evidence-based interventions provided by a parent in addition to usual care. The program combines positive sensory experiences (vocal soothing, scent exchange, comforting touch, skin-to-skin care) as well as motor training (massage and physical therapy) in a gestational age (GA) appropriate fashion. To investigate the acceptability, feasibility and fidelity of the NeoRehab program in very low birthweight (VLBW) infants. All interventions were provided by parents in addition to usual care. Infants (≤ 32 weeks' GA and/or ≤ 1500 g birthweight) were enrolled in a randomized controlled trial comparing NeoRehab to usual care (03/2019–10/2020). The a priori dosing goal was for interventions to be performed 5 days/week. The primary outcomes were the acceptability, feasibility and fidelity of the NeoRehab program. 36 participants were randomized to the intervention group and 34 allocated to usual care. The recruitment rate was 71% and retention rate 98%. None of the interventions met the 5 days per week pre-established goal. 97% of participants documented performing a combination of interventions at least 3 times per week. The NeoRehab program was well received and acceptable to parents of VLBW infants. Programs that place a high demand on parents (5 days per week) are not feasible and goals of intervention at least 3 times per week appear to be feasible in the context of the United States. Parent-provided motor interventions were most challenging to parents and alternative strategies should be considered in future studies. Further studies are needed to evaluate the relationship between intervention dosing on long term motor outcomes.

IntroductionNon-invasive high-frequency oscillatory ventilation (nHFOV) is an extension of nasal continuous positive airway pressure (nCPAP) support in neonates. We aimed to compare global and regional distribution of lung volumes during nHFOV versus nCPAP.MethodsIn 30 preterm infants enrolled in a randomised crossover trial comparing nHFOV with nCPAP, electrical impedance tomography data were recorded in prone position. For each mode of respiratory support, four episodes of artefact-free tidal ventilation, each comprising 30 consecutive breaths, were extracted. Tidal volumes (VT) in 36 horizontal slices, indicators of ventilation homogeneity and end-expiratory lung impedance (EELI) for the whole lung and for four horizontal regions of interest (non-gravity-dependent to gravity-dependent; EELINGD, EELImidNGD, EELImidGD, EELIGD) were compared between nHFOV and nCPAP. Aeration homogeneity ratio (AHR) was determined by dividing aeration in non-gravity-dependent parts of the lung through gravity-dependent regions.Main resultsOverall, 228 recordings were analysed. Relative VTwas greater in all but the six most gravity-dependent lung slices during nCPAP (all p0.05). Aeration was increased during nHFOV (mean difference (95% CI)=0.4 (0.2 to 0.6) arbitrary units per kilogram (AU/kg), p=0.013), mainly due to an increase in non-gravity-dependent regions of the lung (∆EELINGD=6.9 (0.0 to 13.8) AU/kg, p=0.028; ∆EELImidNGD=6.8 (1.2 to 12.4) AU/kg, p=0.009). Aeration was more homogeneous during nHFOV compared with nCPAP (mean difference (95% CI) in AHR=0.01 (0.00 to 0.02), p=0.0014).ConclusionAlthough regional ventilation was similar between nHFOV and nCPAP, end-expiratory lung volume was higher and aeration homogeneity was slightly improved during nHFOV. The aeration difference was greatest in non-gravity dependent regions, possibly due to the oscillatory pressure waveform. The clinical importance of these findings is still unclear.

Objective: Translate and adapt the Quantum Care for Parents- Neonatal Intensive Care Unit mobile application to Portuguese language and culture.Method: Methodological study that covered the stages of translation, synthesis of translations, retroversion, synthesis of retroversions, evaluation by 20 neonatology experts to validate content, and pilot test applied to 20 Portuguese parents with children hospitalized in the neonatology unit. The content validity was supported by the Lawshe Model and for the lexicographic analysis of the content of the experts' suggestions, the IRaMuTeQ software was used.Results: The evaluation criteria were semantic, cultural and conceptual equivalence between the original app and the translation. Content validity was good for the number of experts. The following classes emerged from the lexicographic analysis of the suggestions: Adequacy of information, Availability of Information to parents, Simplification of Information and Facilitation of Usability. In the pilot test, all items were classified as clear.Conclusion: The mobile application showed validity of content indicative of good adaptation to the Portuguese language and culture and, after the introduction of the experts' suggestions and pilot test, it is considered a good resource to support health education and parental health literacy in the unit neonatology. Objetivo: Traducir y adaptar a la lengua y cultura portuguesa la aplicación móvil Quantum Care for Parents - Neonatal Intensive Care Unit. Metodología: Estudio metodológico que contempló las etapas de traducción, síntesis de las traducciones, retroversión, síntesis de las retroversiones, evaluación por 20 expertos en neonatología para hacer la validación de contenidos y prueba piloto aplicada a 20 padres portugueses con hijos internados en la unidad de neonatología. La validez del contenido se apoyó en el Modelo de Lawshe y para el análisis lexicográfico del contenido de las sugerencias de los expertos se utilizó el software IRaMuTeQ. Resultados: Los criterios de evaluación fueron la equivalencia semántica, cultural y conceptual entre la app original y la traducción. La validez del contenido fue buena para el número de expertos. Del análisis lexicográfico de las sugerencias emergen las clases: Adecuación de la información, Disponibilidad de la información para los padres, Simplificación de la información y Facilitación del uso. En la prueba piloto, todos los elementos se clasificaron como claros. Conclusión: La aplicación móvil mostró validez de contenido indicativo de buena adaptación a la lengua y cultura portuguesa y, tras la introducción de las sugerencias de los expertos y de la prueba piloto, se considera un buen recurso de apoyo a la educación para la salud y para la alfabetización parental en salud en la unidad de neonatología. Objetivo: Traduzir e adaptar para a língua e cultura portuguesa a aplicação móvel Quantum Care for Parents- Neonatal Intensive Care Unit. Método: Estudo metodológico que contemplou as etapas de tradução, síntese das traduções, retroversão, síntese das retroversões, avaliação por 20 peritos em neonatologia para fazer a validação de conteúdo, e teste piloto aplicado a 20 pais portugueses com filhos internados na unidade de neonatologia. A validade de conteúdo foi suportada pelo Modelo de Lawshe e para a análise lexicográfica do conteúdo das sugestões dos peritos, recorreu-se ao software IRaMuTeQ. Resultados: Os critérios de avaliação foram a equivalência semântica, cultural e concetual entre a app original e a tradução. A Validade de Conteúdo foi boa para o número de peritos. Da análise lexicográfica das sugestões emergiram as classes: Adequação da informação, Disponibilização da Informação aos pais, Simplificação da Informação e Facilitação da Usabilidade. No teste piloto todos os itens foram classificados como claros. Conclusão: A aplicação móvel apresentou validade de conteúdo indicativa de boa adaptação à língua e cultura portuguesa e, após a introdução das sugestões dos peritos e teste piloto, considera-se um bom recurso de apoio à educação para a saúde e literacia parental em saúde, na unidade de neonatologia.

Objective: To determine the frequency of place of delivery and person detecting the anomaly among newborn babies presenting with delayed diagnosis of anorectal malformation (ARM). Methods: This is a Descriptive Cross-Sectional Study, conducted at Department of Paediatric Surgery, National Institute of Child Health (NICH) Karachi, from February 19, 2019 to August 18, 2019. All patients with ARM who were diagnosed beyond two hours of life (Delayed diagnosis) were included in the study. Chi square test was applied for comparison of categorical variables. Results: Total 110 patients were enrolled in this study. Nineteen (17.3%) patients were delivered at home, while 91 (82.7%) were delivered at the hospital. The first person detecting the anomaly was grandmother (n=25) or a non-medical person in 58 patients (52.7%), 52 were diagnosed by a medical personal either primarily in 31 cases (28.2%) or secondarily by a neonatologist in 21 cases (19.1%). Conclusion: It is concluded that Non-medical person detected ARM mainly despite the babies being delivered mostly at the hospital, indicating the need for meticulous neonatal examination. doi: https://doi.org/10.12669/pjms.38.1.4156 How to cite this:Perveen S, Ali S, Jabbar A, Fatima B. Place & Person involved in delivery: Factors leading to delay in diagnosis of Anorectal Malformation in Newborns. Pak J Med Sci. 2022;38(1):297-301. doi: https://doi.org/10.12669/pjms.38.1.4156 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background In case of extreme premature delivery at 24 weeks of gestation, both early intensive care and palliative comfort care for the neonate are considered treatment options. Prenatal counseling, preferably using shared decision making, is needed to agree on the treatment option in case labor progresses. This article described the development of a digital decision aid (DA) to support pregnant women, partners and clinicians in prenatal counseling for imminent extreme premature labor. Methods This DA is developed following the International Patient Decision Aid Standards. The Dutch treatment guideline and the Dutch recommendations for prenatal counseling in extreme prematurity were used as basis. Development of the first prototype was done by expert clinicians and patients, further improvements were done after alpha testing with involved clinicians, patients and other experts (n = 12), and beta testing with non-involved clinicians and patients (n = 15). Results The final version includes information, probabilities and figures depending on users’ preferences. Furthermore, it elicits patient values and provides guidance to aid parents and professionals in making a decision for either early intensive care or palliative comfort care in threatening extreme premature delivery. Conclusion A decision aid was developed to support prenatal counseling regarding the decision on early intensive care versus palliative comfort care in case of extreme premature delivery at 24 weeks gestation. It was well accepted by parents and healthcare professionals. Our multimedia, digital DA is openly available online to support prenatal counseling and personalized, shared decision-making in imminent extreme premature labor.

Intestinal obstruction is a common surgical cause of admission to the neonatal intensive care unit. Bilious vomiting, abdominal distension and feed intolerance are the hallmark features of presentation. The cause in these babies ranges from the proximal oesophageal atresia to the distal anorectal malformation and the approach and management of this wide differential remains a challenge for the surgeon and neonatologist combined. This short article provides an overview of approach, investigation and management of some of the surgically encountered causes of neonatal obstruction.

Real-time echocardiographic monitoring of blood flow in the ductus venosus and hepatic vein was undertaken during perinatal transition with intact umbilical cord of term born infants. Antegrade flow increased during inspiration, preferentially directing blood flow from the ductus venosus into the right atrium.Objective To investigate the effect of spontaneous breathing on venous return in term infants during delayed cord clamping at birth. Methods Echocardiographic ultrasound recordings were obtained directly after birth in healthy term-born infants. A subcostal view was used to obtain an optimal view of the inferior vena cava (IVC) entering the right atrium, including both the ductus venosus (DV) and the hepatic vein (HV). Colour Doppler was used to assess flow direction and flow velocity. Recordings continued until the umbilical cord was clamped and were stored in digital format for offline analyses. Results Ultrasound recordings were obtained in 15 infants, with a median (IQR) gestational age of 39.6 (39.0-40.9) weeks and a birth weight of 3560 (3195-4205) g. Flow was observed to be antegrade in the DV and HV in 98% and 82% of inspirations, respectively, with flow velocity increasing in 74% of inspirations. Retrograde flow in the DV was observed sporadically and only occurred during expiration. Collapse of the IVC occurred during 58% of inspirations and all occurred caudal to the DV inlet (100%). Conclusion Spontaneous breathing was associated with collapse of the IVC and increased antegrade DV and HV flow velocity during inspiration. Therefore, inspiration appears to preferentially direct blood flow from the DV into the right atrium. This indicates that inspiration could be a factor driving placental transfusion in infants.