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Although the Covid-19 pandemic has not had a direct impact on neonates so far, it has raised concerns about resource distribution and showed that planning is required before the next crisis or pandemic. Resource allocation must consider unique Neonatal Intensive Care Unit (NICU) attributes, including physical space and equipment that may not be transferable to older populations, unique skills of NICU staff, inherent uncertainty in prognosis both antenatally and postnatally, possible biases against neonates, and the future pandemic disease’s possible impact on neonates. We identified the need for a validated Neonatal Severity of Illness Prognostic Score to guide triage decisions. Based on this score, triage decisions are the responsibility of an informed triage team not involved in direct patient care. Support for the distress experienced by parents and staff is needed. This paper presents essential considerations in developing a practical framework for resources and triage in the NICU before, during and after a pandemic.

Purpose Infants with short bowel syndrome (SBS) wean from parenteral nutrition (PN) support at variable rates. Small bowel length is a predictor, but the importance of the ileocecal valve (ICV) and colon are unclear. We aim to determine if the ICV and/or colon predict enteral autonomy. Methods Infants from a single intestinal rehabilitation program were retrospectively reviewed. Etiology of SBS, intestinal anatomy, and duration of nutritional support were collected for three years. The primary outcome was time to full enteral nutrition. ANCOVA and Cox proportional hazards model were used, with p Results 55 infants with SBS were included. After accounting for the effect of small bowel, PN duration was shorter for infants with the ICV compared to those without (mean 218 vs. 538 days, p = 0.003), and had a more significant effect on infants with ≤50% of small bowel. Increased small bowel length was a positive predictor of weaning. Patients with ≤50% of colon spent less time on PN with the ICV, compared to without (mean 220 vs 715 days, p = 0.009). Conclusions Preservation of the ICV was associated with shorter duration of PN support, while colon was not. Small bowel length is a positive predictor of enteral autonomy. Level of Evidence Level III retrospective comparative study Type of Study Retrospective review

Urine sodium (UNa) is a measure of total body sodium in infants with intestinal failure (IF) but can be misleading as it does not reflect volume status. Urine sodium to urine creatinine ratio (UNa:UCr) may offer a more accurate measure, but is not routinely used. This study compares UNa:UCr to UNa as a maker of sodium status in infants with IF.A retrospective review of infants with IF, from a single center, from 2018 to 2020 was conducted (REB H20-00,816). IF etiology, intestinal anatomy, nutritional intake, urine electrolytes and anthropometrics were collected. Linear mixed effects models adjusting for repeated measures were used to associate UNa and UNa:UCr with weight gain and sodium intake.Twenty-two infants with a median gestational age of 31 weeks were included. IF etiology included gastroschisis (41%), necrotizing enterocolitis (23%), and intestinal perforation (14%). Infants had an average of 3 paired UNa and UNa:UCr measures for a total of 74 paired measurements. UNa:UCr more strongly correlated with sodium intake compared to UNa (R = 0.25, p = 0.032 vs. R = 0.10, p = 0.38). Overall, neither UNa (p = 0.21) nor UNa:UCr (p = 0.16) were significantly correlated with weight gain. However, for infants receiving ≤50% nutrition enterally, weight gain correlated with UNa (p = 0.01) and UNa:UCr (p = 0.01). UNa:UCr35 predicted adequate growth regardless of enteral intake (92% sensitivity, 59% specificity).UNa:UCr is a measure of total body sodium that correlates with sodium intake in infants with IF. Our study indicates UNa:UCr35 is associated with adequate growth and can be used to guide further validation studies.

Multidisciplinary intestinal rehabilitation (IR) teams have transformed care in pediatric intestinal failure (IF).1 Although most children with IF are identified in the neonatal intensive care unit (NICU), IR teams may not be involved at this stage. We describe our collaborative model, blending NICU and IR expertise to optimize care. Over 6 years, the NeoCHIRP (Neonatal Children's IR Program) team followed 164 babies for weekly visits (median, 8; range, 1-27). Bedside rounds included CHIRP team physician and surgeons, neonatologist champion, attending neonatologist and fellow, NICU dietitian, bedside nurse, and family. Medical and nutrition status, nutrition history, and laboratory data were discussed, and a nutrition plan to support IR, considering the child's other medical needs, was created to guide the next week's management. Typical issues addressed included parenteral nutrition (PN) composition, enteral nutrition plan, oral feeding, management of small-intestinal bacterial overgrowth and sodium status, and cholestasis. A total of 164 babies were followed by the NeoCHIRP team. Of 153 survivors, IF resolved by discharge in 89% (136 of 153). Seventeen of 153 babies (11%) went on to require home PN and were transferred from NICU directly to the CHIRP team. By discharge, 99% of babies were orally fed (69/136, 50% fully, 67/136, 49% partially), and cholestasis improved or resolved in 80/105 (76%). Eleven babies (7%) died; four deaths were unrelated to IF, but in seven babies, IF was at least a contributing factor. In this high-risk cohort, most babies achieved good outcomes, and those who required longer-term IR transitioned smoothly to the CHIRP team.

Background: Necrotizing enterocolitis remains a leading cause of morbidity and mortality in premature infants. The role of prophylactic probiotics in its prevention is unclear. This study evaluates the effect of routine probiotics on the incidence and severity of necrotizing enterocolitis in infants with very low birth weight in the neonatal intensive care unit. Methods: This retrospective cohort study compared infants cared for at a single institution before and after implementation of routine probiotic administration (2014– 2018). Babies born after July 2016 received probiotics containing Bifidobacterium and Lactobacillus daily until 35 weeks corrected gestational age. Baseline characteristics, necrotizing enterocolitis incidence and severity, infections, mortality, and length of stay were compared between groups. Results: Of the 665 infants included in the study, 310 received probiotics and 355 did not. The 2 groups did not differ with regard to gestational age, birth anthropometrics, mode of delivery, comorbidities, and type of enteral feed. The incidence of necrotizing enterocolitis (Bell’s stage 2 of 3) was similar between groups (4% v. 5%, p = 0.35), as was its severity (p = 0.10). In addition, there were no significant differences in mortality and length of stay between the groups. Significantly fewer infants receiving probiotics developed infections (27% v. 34%, p = 0.046), with the rate of urinary tract infections having the largest reduction. Conclusion: The routine use of Bifidobacterium and Lactobacillus probiotics in infants with very low birth weight did not significantly affect the incidence and severity of necrotizing enterocolitis. However, the use of probiotics was associated with fewer overall infections.

Background Many children with intestinal failure (IF) start their course in the NICU with medical or surgical conditions limiting enteral feeding. Multidisciplinary intestinal rehabilitation teams have improved outcomes in pediatric IF patients, but this is not well described in neonates. Objectives NeoCHIRP represents a unique IR Team; this study describes its roles in collaborating neonatal and IR care. Design/Methods Retrospective descriptive chart review of neonates at risk for IF in one NICU, of patients admitted between April 1, 2013 and March 31, 2019. All neonates at risk for IF were evaluated weekly by a multidisciplinary Neonatal Children’s IR program in the NICU (NeoCHIRP) that is composed of surgeons, dieticians, neonatologists, IR paediatrician, nurses and patient families, to evaluate nutritional status, and provide recommendations. Data collected included weight, patient characteristics, number of NeoCHIRP visits, type of recommendations, cholestasis interventions, successful oral tolerance, and survival. Results There were 163 patients, 105 males, 58 females with 1-27 weekly visits (mean= 9.1) and gestational age between 23-43 4/7 weeks (median= 35). There were 153 survivors discharged from the NICU and 10 deaths (3 from IF related complications.) Enteral autonomy was achieved by 139/163 patients (85.3%.) Common recommendations made were enteral feeds (96.3%), parenteral nutrition (95%) or sodium management (93.9%.) Recommendations for oral stimulation were made in 79.1%, of which 40.5% (66/163) were exclusively orally fed and 20.2% partially orally fed by discharge. Cholestasis interventions were made in 66.9% and conjugated bilirubin (CB) 30 at final visit. Evaluation of patient weights showed increased z-scores in only 23/153 (15%) from birth to discharge versus increased z-scores in 51/141 (36.2%) from NeoCHIRP consult to discharge. Conclusion A Multidisciplinary Neonatal Intestinal Failure Team is a useful collaborative model to support NICU medical management, by minimizing poor weight gain, cholestasis and oral aversion. Recommendations made for all NeoCHIRP patients in enteral, parenteral and sodium management resulted in improved weight gain of patients.

ObjectivesTo identify the probability of survival and severe neurodevelopmental impairment (sNDI) at which perinatal physicians would or would not offer or recommend resuscitation at birth for extremely preterm infants.MethodsA Delphi process consisting of five rounds was implemented to seek consensus (>80% agreement) amongst British Columbia perinatal physicians. The first-round consisted of neonatal and maternal-fetal-medicine Focus Groups. Rounds two to five surveyed perinatal physicians, building upon previous rounds. Draft guidelines were developed and agreement sought.ResultsBased on 401 responses across all rounds, consensus was obtained that resuscitation should not be offered if survival probability 70 to 90% and resuscitation standard care if survival without sNDI >90%.ConclusionsThis physician consensus-based, objective framework for the management of an anticipated extremely preterm infant is a transparent alternative to existing guidelines, minimizing gestational-ageism and allowing for individualized management utilizing up-to-date data. Further input from other key stakeholders will be required prior to guideline implementation.

Objective To explore ethics education needs in Canadian Neonatal Perinatal Medicine (NPM) training programs. Methods A retrospective review of NPM trainees' performance at the National NPM Objective Structured Clinical Examination (OSCE) was undertaken for 2012 to 2017 and two distinct cross-sectional online surveys were carried out. One survey targeted recently graduated neonatologists (RGNs) who completed 2 years' training in a Canadian NPM program between 2010 and 2015; the other survey was sent to Canadian NPM training program directors (PDs). The domains of interest were: perception of education, ethics and communication topics, educational strategies, assessment of trainees' competencies, and barriers to neonatal ethics education. Results NPM trainees generally performed less well in stations involving ethics and communication relative to other domains on the National OSCE. Forty-seven RGNs (44.3%) and 12 PDs (92.3%) completed the survey. Over 90% of PDs and RGNs agreed on the importance of training in ethics and communication. Both groups highly valued training on topics related to communication. Preferred teaching strategies were experiential: observation and feedback. PDs mentioned the importance of using validated tools to regularly and formally assess trainees. They recognized challenges in regard to financial resources, physical space, and faculty training in patient-physician communication. Conclusions National OSCE results indicate the need to improve neonatal ethics and communication training in Canadian NPM programs. RGNs and PDs identified important topics, as well as teaching and evaluation strategies. These results can be used to develop a training program for ethics and communication in NPM.

PURPOSE OF REVIEW There is uncertainty regarding optimal dosing for parenteral amino acids in preterm infants and wide variability exists in clinical practice. There is new data from clinical trials trying to address these concerns. We review the recent evidence on parenteral high-dose amino acid intake in very low birth weight (VLBW) neonates with a focus on relevant clinical outcomes. RECENT FINDINGS Preterm infants often receive less protein than intended in the first week of life. Parenteral amino acid administration in doses that exceed requirements, however, leads to increased oxidation and higher blood urea concentrations. Amino acid doses greater than 3.5 g/kg/day have not shown to improve mortality, neonatal morbidities including sepsis, necrotizing enterocolitis, chronic lung disease, growth parameters or neurodevelopmental outcomes at 2 years of age. SUMMARY Parenteral amino acid administration in VLBW infants should be initiated soon after birth at a dose of at least 1.5 g/kg/day to maintain anabolism. The maximum dose for parenteral amino acid should be between 2.5 and 3.5 g/kg/day, with adequate nonprotein calories and micronutrients to ensure efficient protein utilization and growth.

In this 3-year prospective grounded theory study in three pediatric settings, we aimed to develop a conceptualization of best practice health care providers (BPHCPs) in interaction with parents of children with complex, chronic, life-threatening conditions. Analysis of semistructured interviews with 34 parents and 80 health care professionals (HCPs) and 88 observation periods of HCP/parent interactions indicated that BPHCPs shared a broad worldview; values of equity, family-centered care, and integrity; and a commitment to authentic engagement. BPHCPs engaged in direct care activities, in connecting behaviors, and in exquisitely attuning to particularities of the situation in the moment, resulting in positive outcomes for parents and HCPs. By focusing on what HCPs do well, findings showed that not only is it possible for HCPs to practice in this way, but those who do so are also recognized as being the best at what they do. We provide recommendations for practice and initial and ongoing professional education.

Rapidly involuting congenital hemangiomas (RICH) are the commonest variety of congenital hemangioma, often diagnosed antenatally as high-flow arteriovenous shunts causing hemodynamic compromise to the fetus. The postnatal management of such patients is often challenging. We present the case of an infant boy who was delivered prematurely at 29 weeks of gestation due to fetal compromise by a RICH, with features of high-output cardiac failure and major systemic hemodynamic steal from peripheral organs. Two early angioembolizations were required to manage his high-output cardiac failure. To our knowledge, this infant is the smallest and earliest newborn case of successful angioembolization for a complex, life-threatening vascular anomaly. We discuss the interventional dilemmas regarding the optimal timing of delivery and early embolization.

There are concerns around safety and tolerance of powder human milk fortifiers to optimize nutrition in preterm infants. The purpose of this study was to evaluate the tolerance and safety of a concentrated preterm formula (CPF) as a liquid human milk fortifier (HMF) for premature infants at increased risk of feeding intolerance. We prospectively enrolled preterm infants over an 18-month period, for whom a clinical decision had been made to add CPF to human milk due to concerns regarding tolerance of powder HMF. Data on feed tolerance, anthropometry, and serum biochemistry values were recorded. Serious adverse events, such as mortality, necrotizing enterocolitis (NEC), and sepsis, were monitored. A total of 29 babies received CPF fortified milk during the study period. The most common indication for starting CPF was previous intolerance to powder HMF. Feeding intolerance was noted in 4 infants on CPF. The growth velocity of infants was satisfactory (15.9 g/kg/day) after addition of CPF to feeds. The use of CPF as a fortifier in preterm babies considered at increased risk for feed intolerance seems well tolerated and facilitates adequate growth. Under close nutrition monitoring, this provides an additional option for human milk fortification in this challenging subgroup of preterm babies, especially in settings with limited human milk fortifier options.

Moral distress is a well-recognized and ubiquitous aspect of health care professional practice in the neonatal intensive care unit (NICU) context. We used interpretive description methodology to guide a critical exploration of the dynamics of moral distress experience as reflected in the accounts of 28 health care professionals working in this setting. We learned about the kinds of clinical scenarios which triggered distressing experiences, and that the organizational and relational context of clinical work constituted a complex and dynamic working environment that profoundly affected both the individual and the collective experiences with moral distress in these situations. These findings shed light on possibilities for supporting NICU practitioners and developing the collaborative team cultures that may reduce the risk of unresolved effects of moral distress to the benefit of patients as well as the professionals who care for them.

BACKGROUND: Guidelines for resuscitation of infants at the threshold of viability (ToV) based on gestational age (GA) are criticized for ‘gestational ageism’ and become outdated. If probability of survival and neurodevelopmental outcomes were considered instead of GA, bias could be minimized. OBJECTIVES: The study objective is to identify the probability of survival and severe neurodevelopmental impairment (sNDI) at which perinatal health care providers (pHCPs) would or would not provide or recommend resuscitation for infants at the ToV. DESIGN/METHODS: A Delphi process consisting of five rounds was implemented to seek consensus (>80% agreement) amongst pHCPs in BC. The first-round consisted of 2 Neonatology and 2 Maternal-Fetal-Medicine (MFM) Focus Groups. Rounds 2–4 involved surveys of pHCPs, building upon results of previous rounds. For round 5, draft ToV statements were developed and agreement sought. RESULTS: Focus Groups (20 participants) agreed: (1) guidelines are useful; (2) sNDI is important in decision-making. There were 403 survey responses in Rounds 2–5. The final survey had 148 responses (45% paediatricians, 24% obstetricians, 18% (all) neonatologists, 13% (most) MFM). Consensus was reached for the following statements: 1. If expected chance of survival < 5%, resuscitation should not be offered (93% Agree). 2. If expected chance of survival < 10%, resuscitation should not be recommended (87% Agree). 3. If expected chance of survival without sNDI > 10% but < 70%, well-informed, capable parent(s) should decide about resuscitation (87% Agree). 4. If expected chance of survival without sNDI > 70% but < 90%, resuscitation is recommended (81% Agree). 5. If expected chance of survival without sNDI > 90%, the baby should be resuscitated, even against parental wishes (84% Agree). CONCLUSION: Objective ToV guidelines based on pHCP’s consensus can be developed. The above five statements form the basis for revised BC ToV management guidelines, which can be rapidly updated with local outcome data.

Background/Purpose Neonates with intestinal pathology may require staged surgery with creation of an enterostomy and mucous fistula (MF). Refeeding (MFR) of ostomy output may minimize fluid and electrolyte losses and reduce dependence on parenteral nutrition (PN), though a paucity of evidence exists to support this practice. The purpose of this study was to assess the outcomes of infants undergoing MFR and document associated complications. Methods With REB approval, infants with intestinal failure undergoing MFR between January 2000 and December 2012 were identified. A chart review was conducted and relevant data were collected. Descriptive statistics were used. Results Twenty-three neonates underwent MFR. Mean gestational age and birth weight were 35weeks and 2416grams. Pathologies included intestinal atresia (n=12), necrotizing enterocolitis (n=5), meconium ileus (n=4), and other (n=6). Seven patients were able to wean from PN. Four patients had complications: 3 had perforation of the MF, 1 had bleeding. Four patients died, with one death directly attributable to MFR. Conclusions In this cohort MF refeeding was associated with significant complications and ongoing PN dependence. With advances in intestinal rehabilitation and PN, the benefit of MF refeeding must be weighed against the potential complications.

Background Fathers whose infants are cared for in the neonatal intensive care unit have unique support needs. No tool has been developed to evaluate systematically the support needs of fathers. Purpose To establish the content validity and initial reliability of the Fathers' Support Scale: Neonatal Intensive Care Unit (FSS:NICU). Methods Items for the FSS:NICU were derived from themes from qualitative interviews. For phase 1, the FSS:NICU was reviewed by 10 neonatologists from across Canada and by 19 fathers whose infants had been admitted to the NICU. Using a binary scale, each item on the FSS:NICU was evaluated for relevance and clarity. Percentage agreement between raters was calculated. For phase 2, item reliability and test-retest reliability of the FSS:NICU was evaluated on 116 fathers on NICU patients. Of those, 72 fathers were seen on two occasions one week apart. The Beck Depression Inventory Short Form was also administered at the first assessment. Internal consistency was analyzed using Cronbach's alpha. Test re-test reliability was assessed using Pearson's r . Correlations between Beck Depression Inventory and FSS:NICU sections scores were evaluated with Pearson's r . Findings In phase 1, percentage agreement between neonatologists was 60–100% resulting in 13 changes in question thematic structure, 7 changes in question wording, and the addition of 9 questions to the scale. Agreement between the fathers ranged from 32 to 100%. Two questions were re-worded, and 6 were dropped: the scale finally comprised 33 questions. In phase 2, internal consistency (Cronbach's alpha) was 0.82 ( N = 116). Test-retest reliability ( N = 72) for the full scale score was 0.81. Implications. This study established the initial content validity and reliability of the FSS:NICU for determining support needs of fathers whose infants were admitted to the NICU. The FSS:NICU is a relevant tool validated by fathers which can be used to improve support for and communication between fathers and the NICU staff.

Paediatric practitioners interact with industry representatives for many purposes but most often to receive information on new and existing products. While practitioners believe they are immune to the marketing influences exerted by these representatives, research has demonstrated otherwise. The literature suggests that the public is aware of such influences and that most people feel industry influence on practitioners is inappropriate. National guidelines go some way toward regulating practitioner–industry interactions, although they are not always clear or sufficient. The present practice point explores the context for these relationships, raises some ethical issues specific to paediatric practitioners and provides recommendations for maintaining professional integrity in the patient–physician relationship. Paediatric practitioners have a professional duty to ensure that their own interactions with industry are conducted with the best interests of the patient front and centre.

Les praticiens en pédiatrie interagissent avec des représentants de l’industrie pour bien des motifs, mais la plupart du temps, ils recherchent de l’information sur les nouveaux produits et ceux déjà existants. Ils se pensent à l’abri des influences publicitaires qu’exercent ces représentants, mais les recherches démontrent qu’il en est autrement. D’après les publications, la population est au courant de ces influences, et la plupart des gens les trouvent inappropriées. Les lignes directrices nationales contribuent jusqu’à un certain point à réglementer les interactions entre les praticiens et l’industrie, mais elles ne sont pas toujours claires ni suffisantes. Le présent point de pratique aborde le contexte de ces relations, soulève certains enjeux déontologiques propres aux praticiens en pédiatrie et contient des recommandations pour assurer le maintien de l’intégrité professionnelle dans le cadre de la relation entre le patient et le médecin. Dans leurs interactions avec l’industrie, les praticiens en pédiatrie ont le devoir professionnel de respecter, d’abord et avant tout, l’intérêt du patient.

Background Human milk fortifier (HMF) is used in neonatal units throughout North America to facilitate growth of preterm infants. Little data is available on the gastrointestinal side effects and potential adverse events. The purpose of this paper was to present a series of infants presenting with bowel obstruction associated with HMF. Methods Cases of HMF obstruction were collected between January 2010 and December 2012. Charts were reviewed and relevant data was collected. Results During the study period, 7 premature infants presented with bowel obstruction secondary to intestinal concretions of HMF. All babies were premature with gestational ages from 25 to 27weeks. Birth weight was less than 1000 grams in all patients. Patients presented with feeding intolerance, bilious aspirates, abdominal distension, and obstipation. Four of the patients presented with acute deterioration and required urgent surgical intervention. Conclusions HMF is an important source of nutritional support in infants, which is felt to be safe. We present a series of infants where its use has resulted in significant complications. HMF should be used with caution in infants, especially those with a history of necrotizing enterocolitis. Further research should examine the calcium, protein, and fatty acid concentration tolerable in the gastrointestinal tract of infants.

OBJECTIVE. This qualitative study aimed at understanding the experiences of fathers of very ill neonates in the NICU. METHODS. Sixteen fathers of very ill and/or very preterm infants who had been in the NICU for >30 days were interviewed by a male physician. Fathers were asked about their level of comfort with or concerns about staff communication regarding their infant, about accessing information, and about more general perceptions of their experience in the neonatal intensive care unit. Interviews were audiotaped and transcribed for analysis. Coding used content analysis with construction of themes by 3 researchers. RESULTS. The overarching theme for fathers was a sense of lack of control. Their world view, as a “backdrop” theme, provided context for all of the themes. Four other interrelated subthemes were identified, including information; communication, particularly with the health care team; fathers’ various roles; and external activities. Fathers reported that relationships with friends/family/health care team, receiving information consistently, and receiving short written materials on common conditions were ways of giving them support. The fathers said that speaking to a male physician was a positive and useful experience. CONCLUSIONS. Fathers experience a sense of lack of control when they have an extremely ill infant in the NICU. Specific activities help fathers regain a sense of control and help them fulfill their various roles of protectors, fathers, partners, and breadwinners. Understanding these experiences helps the health care team offer targeted supports for fathers in the NICU.

Diagnosis and treatment of an anuric premature infant with severe respiratory compromise and a normal renal ultrasound (US), is a difficult task that requires a multidisciplinary approach. A 29-week gestation premature male infant, born after 5 weeks of worsening oligohydramnios, was ventilated for respiratory distress and remained anuric. Intensive clinical investigations and pediatric nephrology consultation that predicted very poor prognosis were followed by progressive renal failure, electrolyte imbalance, respiratory failure, ventricular arrhythmia, and finally cardiac arrest and death on day 5. In view of the predicted poor outcome, and after discussion with the parents, a decision was made not to start peritoneal dialysis (PD), and to offer only palliative therapy, with comfort care alone. Pre and postnatal diagnosis lead, in this case, to an ethical challenge that focuses on the question of futility. Copyright © 2006 John Wiley & Sons, Ltd.

OBJECTIVES: To assess Internet use and perceptions of formation reliability by parents in a neonatal intensive care unit (NICU). STUDY DESIGN: A standardized questionnaire study. RESULTS: A total of 100 parents were approached and 90% participated. In all, 79% owned a computer, 85.5% had Internet access, and 75.5% regularly spent >1 to 2 hour/day on the computer. There was a significant reduction in the proportion of parents using the Internet after birth of their baby (before birth: nonmedical searches 84% and medical searches 47%; after birth: nonmedical searches 40% and medical searches 29%; p

Alpha thalassemia with the absence of 4 α-globin genes leads to fetal hydrops and fetal death from anemia. Historically considered a lethal condition, optimal in utero management of homozygous α-thalassemia is unclear. A fetus of Filipino descent at 26 weeks gestation presented with ultrasound evidence of anemia. Cordocentesis confirmed anemia and homozygous α-thalassemia (--/--). Intrauterine transfusion corrected anemia but fetal growth restriction and oligohydramnios persisted. Intrauterine exchange transfusion improved hemoglobin parameters, fetal growth, and oligohydramnios. The late preterm infant was delivered with classic limb reduction defects. Hemoglobin Bart's is nonfunctional for oxygen transport, and intrauterine exchange transfusion may be effective first-line therapy and further investigation is warranted.

To describe the outcomes of gastroschisis (GS) patients managed with and without a multidisciplinary team during the postoperative period in Canada.The Canadian Pediatric Surgery Network (CAPSNet) collects patient data from all Canadian tertiary perinatal centres. The outcomes of 396 GS patients born between 2005 and 2009 who were managed with and without a multidisciplinary team were analyzed.Significantly more parenteral nutrition (PN) days (P=0.003) and longer lengths of stay (P=0.018) were observed among patients in centres with multidisciplinary teams. Higher mortality rate and earlier death were observed in centres without multidisciplinary teams, especially for high-risk patients, although this was not statistically significant. With regard to low-risk patients, those in centres with multidisciplinary teams had significantly more PN days (P=0.019).GS patients managed by multidisciplinary teams had significantly more PN days and longer lengths of stay compared with patients who were not managed by multidisciplinary teams. This difference may be due to improved survival of high-risk patients in centres with multidisciplinary teams, and a uniform feeding approach for all patients.Décrire l’évolution des patients ayant un gastroschisis (GS) traités ou non par une équipe multidisciplinaire pendant la période postopératoire au Canada.Le Réseau canadien de chirurgie pédiatrique (CAPSNet) collige les données sur les patients de tous les centres périnatals de soins tertiaires au Canada. L’évolution de 396 patients ayant un GS nés entre 2005 et 2009 et qui ont été traités ou non par une équipe multidisciplinaire a été analysée.Les patients hospitalisés dans des centres dotés d’équipes multidisciplinaires passaient considérablement plus de jours sur alimentation parentérale (AP) (P=0,003) et étaient hospitalisés plus longtemps (P=0,018). Bien que ce résultat ne soit pas significatif, le taux de mortalité était plus élevé et les décès, plus rapides dans les centres ne disposant pas d’une équipe multidisciplinaire, surtout chez les patients à haut risque. Pour ce qui est des patients à faible risque, ceux qui étaient traités dans des centres disposant d’une équipe multidisciplinaire passaient considérablement plus de jours sur AP (P=0,019).Les patients ayant un GS traités par une équipe multidisciplinaire passaient considérablement plus de jours sur AP et étaient hospitalisés plus longtemps que ceux qui n’étaient pas traités par une telle équipe. Cette différence peut être attribuable au meilleur taux de survie des patients à haut risque dans les centres disposant d’équipes multidisciplinaires et à une approche uniforme en matière d’alimentation pour tous les patients.

Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.

Background Surgical interventions are common in infants admitted to the neonatal intensive care unit (NICU). Despite our awareness of the broad impact of surgical site infection (SSI), there are little data in neonates. Our objective was to determine the rate and clinical impact of SSI in infants admitted to the NICU. Methods Provincial population-based study of infants admitted to a tertiary care NICU. SSI, explicitly defined, was included if it occurred within 30days of a skin/mucosal-breaking surgical intervention. Results Among 724 infants who underwent 1039 surgical interventions very low birth weight (VLBW) infants were over-represented. The overall SSI rate was 4.3 per 100 interventions [CI 95% 3.2 to 5.7], up to 19 per 100 dirty interventions (wound class 4) [CI 95% 4.0 to 46]. Rates were higher in infants following gastroschisis closure (13 per 100 infants [CI 95% 5.8 to 24]), whereas they were generally low following a ligation of a ductus arteriosus. Infants with SSI required longer hospitalization after adjusting for co-morbidities (p Conclusions Data from this relatively large contemporary study suggest that SSI rates in the NICU setting are more comparable to the pediatric age group. However, VLBW infants and those undergoing gastroschisis closure represent high risk groups.

Therapeutic hypothermia has been widely applied to improve the survival/neurodevelopmental outcomes among infants with moderate-to-severe hypoxic ischemic encephalopathy (HIE). Due to their critical condition and concerns over feeding tolerance, it is not uncommon to withhold enteral feeds and provide parenteral nutrition (PN) during hypothermia and early rewarming. Here we report 2 infants with HIE undergoing therapeutic hypothermia, and receiving PN, who exhibited early elevated triglyceride levels. Hypertriglyceridemia can be associated with neurologic complications, ranging from altered mental status, or irritability to seizures. Given the possible altered lipid metabolism under hypothermic conditions, we advocate close monitoring of lipid tolerance and conducting further prospective trials to elucidate lipid metabolism in these infants.

OBJECTIVES: This study compares two versus one blood culture in the diagnosis and treatment of coagulase-negative staphylococcus (CONS) in babies with suspected sepsis. STUDY DESIGN: The study was performed at British Columbia's Children's Hospital Neonatal Intensive Care Unit between March 1999 to March 2000. One hundred pairs of cultures were drawn from two percutaneous sites from babies more than 48 hours old at the time of a sepsis screen. CONS cultured from both sites was regarded as evidence of infection. Positive culture from only one of the two sites was regarded as contaminant. The difference in rates of diagnosed CONS infection and reduction in antibiotic usage when using two versus one blood culture was calculated. RESULTS: In 5% of babies, cultures from a second site did not substantiate the diagnosis of CONS when compared to the result from a single culture. The resultant reduction in antibiotic use was 8.2%. CONCLUSIONS: Two blood cultures reduce the number of children diagnosed with CONS infection and reduce antibiotic usage.

Background According to the principles of family-centered care, fully informed parents and health care professionals are partners in the care of sick neonates. Aim The aim of this study was to assess the attitudes of Canadian neonatologists towards the authority of parents to make life-and-death decisions for their babies. Study design We interviewed 121 (74%) of the 164 practicing neonatologists in Canada (June 2004–March 2005), using scripted open-ended questions and common clinical scenarios. Data analysis employed interpretive description methodology. Main outcome measure The main outcome measure was the intention of neonatologists to limit parental life-and-death decision-making authority, when they disagree with parental decisions. Results Neonatologists' self-rated respect for parental decision-making authority was 8/10. Most neonatologists thought that parents should be either primary decision-makers or part of the decision-making team. Fifty-six percent of neonatologists would limit parental decision-making authority if the parents' decision is not in the baby's “best interest”. In response to common neonatal severe illness scenarios, up to 18% of neonatologists said they would limit parental decision-making, even if the chance of intact survival is very poor. For clinical scenarios with equally poor long-term outcomes, neonatologists were more likely to comply with parental wishes early in the life of a baby, particularly with documented brain injury. Conclusions Canadian neonatologists espouse high regard for parental decision-making authority, but are prepared to limit parental authority if the parents' decision is not thought to be in the baby's best interest. Although neonatologists advise parents that treatment can be started at birth, and stopped later, this was only for early severe brain injury.

There is great debate regarding the extent of intensive care interventions for extremely premature newborns. In this report, we describe Canadian neonatologists' attitudes towards delivery room resuscitation decisions in neonates at the threshold of viability.We interviewed neonatologists (N = 121) practising in Canadian tertiary care neonatal units between June 2004 and April 2005, and asked whether they would support a parental request not to initiate resuscitation for newborns of 23 to 26 weeks' gestation. Bivariate analyses were performed to identify sociodemographic or cultural factors that might affect resuscitation decisions.Most Canadian neonatologists would support a parental request not to initiate resuscitation of an infant at 23 and 24 weeks' gestation (98% and 80%, respectively). However, we observed heterogeneity across the country in attitudes primarily at 25 weeks, but also at 24 weeks' gestation. At 24 weeks' gestation, decisions also appear to be significantly related to personal experience with a disabled close friend or relative. For newborns of 25 weeks' gestation, neonatologists are divided: a majority (76%) would strongly advocate resuscitation and/or resuscitate a "viable" fetus against parental wishes, and a minority (24%) would agree not to initiate treatment. At 26 weeks' gestation, more than 97% would not support a request not to initiate resuscitation.Attitudes of Canadian neonatologists towards resuscitation of newborns at the threshold of viability primarily differ at 25 weeks and to a lesser extent at 24 weeks of gestation. Our findings highlight important nuances in relation to existing national guidelines.

The purpose of this study was to review the clinical and ultrasound experience of renal tract abnormalities associated with cocaine exposure in utero. We undertook a 3-year chart review of all infants admitted to British Columbia's Children's Hospital neonatal intensive care unit and Sunny Hill Health Centre for Children in order to identify patients with the diagnostic code for maternal drug or substance use. There were 136 neonates with a positive history or urine drug screen. Renal ultrasound scans had been performed on 79 patients. Ultrasound abnormalities were found in 11 patients (14%) and included horseshoe kidney (2), unilateral abnormal small kidney (1), duplex kidney (1), and renal tract dilation (8). Clinical findings were glandular (2) and juxtaglandular (1) hypospadias with chordee. The patients with hypospadias did not have other abnormalities or abnormal renal ultrasound scans. In our population of infants exposed to cocaine in utero we detected an increased incidence of hypospadias and an increased incidence of renal tract abnormalities. We conclude that cocaine exposure in utero may well be a risk factor for renal tract anomalies. However, a larger, longer-term prospective study is necessary before definitive recommendations can be given for routine screening by ultrasound of all infants exposed to cocaine in utero.

To the Editor.— We have discovered recently a major problem with the pulse oximeters which we have been using in our Neonatal Intensive Care Unit. We felt that there was some urgency in alerting other neonatologists and pediatricians to this problem. The incident which led us to discover this problem involved a low birth weight infant who on admission was stabilized according to our Nursery protocol. In these very small neonates, who are at greatest risk of skin breakdown and yet require close monitoring, we recently have used the Fastrac monitor (SensorMedics Corporation, Anaheim, CA) which combines transcutaneous Pco2 and pulse oximetry.

Reflecting on the 1994 meeting of the Society for Pediatrics Research (SPR), one thought that disturbs me is the difficulty that we as physicians have with the use/misuse of language. I do not mean the obvious errors in the use of words. Rather it is both how we use language to influence opinion and our use of euphemisms. First, I want to elaborate on how, in practice, language influences opinion; how the words chosen to express our thoughts may have an unintentional potential to influence practice.

Dexamethasone (Dex) is an effective drug in the treatment of bronchopulmonary dysplasia (BPD) and there is some evidence that early Dex may be better at reducing inflammation and minimizing lung damage. However Dex is a potent drug with potential serious side effects. We wished to identify which babies develop severe BPD and would therefore be potential candidates for early Dex. We retrospectively studied all babies 30%.

Accurate Canadian prevalence data on drug use in pregnancy is lacking as self reporting is likely to be unreliable and urine screening detects only recent drug exposure. The purposes of this epidemiologic study were to assess:(1) prevalence of drug use in pregnancy, using meconium testing (2) correlation with self-reporting (3) demographics of pregnant drug users.

EFFECT OF AN ACTIVE EDUCATIONAL PROGRAM ON THE INCIDENCE OF COAGULASE NEGATIVE STAPHYLOCOCCI IN BLOOD CULTURES FROM AN INTENSIVE CARE NURSERY. † 1128

A retrospective study of all infants weighing 701 to 1,500 g born at 11 neonatal intensive care centers during 1983 and 1984 was performed to determine whether two specific 28-day outcomes, survival and survival without the need for supplemental oxygen, varied among the centers. Survival without the need for supplemental oxygen was chosen as a reflection of infants surviving without chronic lung disease. There were 1,776 live-born infants delivered during the 2-year study period. Of these infants, 85% (1,512) survived 28 days, a range of 80% to 92% at the individual centers. A total of 60% (1,056) of the infants were alive without supplemental oxygen on day 28, a range of 5l% to 70% at the individual centers. Multivariate analysis demonstrated that both survival on day 28 (χ2 = 23.9, P < .01) and survival without supplemental oxygen on day 28 (χ2 = 44.2, P < .0001) varied significantly among centers after the effects of birth weight, gender, and race were taken into account. Female gender, nonwhite race, and increased birth weight were factors associated with improved rates of survival and survival without supplemental oxygen. The magnitude of outcome variation among centers was estimated by using the logistic regression models to predict what the outcomes would be if each center were to treat a standardized population consisting of all 1,776 study infants. Predicted survival rates varied by as much as 15% and the predicted rates for survival without supplemental oxygen varied by nearly 17% between centers with the highest and lowest rates. The differences in outcomes observed at the centers did not correlate with the number of live births at the centers or with the scores on a simple respiratory practices questionnaire. It was concluded that 28-day outcomes for very low birth weight infants vary significantly among different neonatal intensive care centers. Potential sources of this variation include undetected population differences in neonatal disease severity and differences in the techniques of both obstetrical and neonatal care.

We compared the effect of salbutamol and placebo in a double-blind study of preterm infants with bronchopulmonary dysplasia, using a randomized, crossover design with several replicates per subject. Sixty-two tests were performed on 20 ventilator-dependent infants weighing less than 1500 gm. Patients were entered as early as the first week of life and studied for at least 4 weeks or until extubation. Each subject was his own control subject and was randomly assigned to a placebo-salbutamol or salbutamol-placebo sequence administered on 2 consecutive days of each week. Static compliance, expiratory resistance of the respiratory system, and changes in transcutaneous oxygen and carbon dioxide tension were measured. Static compliance improved by 0.240 ml/cm H2O/kg (35.3%) after salbutamol and by 0.010 ml/cm H2O/kg (2.8%) after placebo (p less than 0.0001). The presence of a predetermined decrease in carbon dioxide tension correlated with large changes in static compliance per kilogram and with the need for a high level of fractional inspired oxygen. The magnitude of the clinical and physiologic improvement observed, and the early response suggest that long-term bronchodilator therapy starting as early as the second week of life may be beneficial for very low birth weight infants with early bronchopulmonary dysplasia.