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The prevalence of cow's-milk protein allergy (CMPA) is between 2% and 3% and symptoms vary depending on underlying immune mechanism at play. Breast milk is the optimal nutrition for premature infants and breast milk fortifiers (BMF) are commonly used to optimise growth and nutrition. BMF are typically derived from cow's milk and, as such, preterm infants are exposed to cow's milk in the first weeks of life. Previously, preterm infants were suspected to have a higher risk of allergen development because of early antigen exposure and increased gut permeability. The primary aim of the present study was to evaluate the prevalence of CMPA among very preterm (32 weeks) and/or very low birth weight (VLBW) infants. The secondary aim was to describe feeding practices, specifically the breastfeeding rates and specialist, non-standard formula use in this cohort over the first 6 months of life.This was a retrospective study performed in a large tertiary maternity hospital (8500 deliveries/year and 110 very preterm infants/year) in Dublin, Ireland over a 3-year period, 2017-2020. Infants born very preterm and/or VLBW who were followed in the outpatient clinic until 6 months corrected gestational age (CGA) were included. Hospital ethical approval was obtained.One hundred and forty-four infants were included with a median birth weight of 1338 g. No infant had a diagnosis of CMPA when leaving the neonatal intensive care unit (NICU) but, by 6 months CGA, this increased to 1.4% (n = 2). Upon discharge from the NICU, 88 infants (61%) were receiving at least some breast milk, decreasing to 13 (9.1%) at 6 months CGA. Those who were receiving exclusive breast milk at discharge were significantly more likely to still be receiving any breast milk at three (p ≤ 0.001) and 6 months ( p ≤ 0.001) CGA compared to those combined feeding or exclusively formula feeding. At 6 months CGA, 18.9% (n = 27) were attending a dietician and 31.5% (n = 45) were using specialist, non-standard infant formula.The prevalence of CMPA in this cohort was 1.4%, which is similar to the reported prevalence of CMPA in the general paediatric population. Infants who were discharged from NICU exclusively breastfeeding were more likely to be receiving any breast milk at outpatient follow-up. This highlights the importance of on going dietetic and lactation support in the outpatient setting for this vulnerable cohort.

Objective The aim of this study was to evaluate infants, born to women with SARS-CoV-2 detected during pregnancy, for evidence of haematological abnormalities or hypercoagulability in umbilical cord blood. Study design This was a prospective observational case-control study of infants born to women who had SARS-CoV-2 RNA detected by PCR at any time during their pregnancy (n = 15). The study was carried out in a Tertiary University Maternity Hospital (8,500 deliveries/year) in Ireland. This study was approved by the Hospital Research Ethics Committee and written consent was obtained. Umbilical cord blood samples were collected at delivery, full blood count and Calibrated Automated Thrombography were performed. Demographics and clinical outcomes were recorded. Healthy term infants, previously recruited as controls to a larger study prior to the outbreak of COVID-19, were the historical control population (n = 10). Results Infants born to women with SARS-CoV-2 had similar growth parameters (birth weight 3600 g v 3680 g, p = 0.83) and clinical outcomes to healthy controls, such as need for resuscitation at birth (2 (13.3%) v 1 (10%), p = 1.0) and NICU admission (1 (6.7%) v 2 (20%), p = 0.54). Haematological parameters (Haemoglobin, platelet, white cell and lymphocyte counts) in the COVID-19 group were all within normal neonatal reference ranges. Calibrated Automated Thrombography revealed no differences in any thrombin generation parameters (lag time (p = 0.92), endogenous thrombin potential (p = 0.24), peak thrombin (p = 0.44), time to peak thrombin (p = 0.94)) between the two groups. Conclusion In this prospective study including eligible cases in a very large population of approximately 1500 women, there was no evidence of derangement of the haematological parameters or hypercoagulability in umbilical cord blood due to COVID-19. Further research is required to investigate the pathological placental changes, particularly COVID-19 placentitis and the impact of different strains of SARS-CoV-2 (particularly the B.1.1.7 and the emerging Delta variant) and the severity and timing of infection on the developing fetus.

Premature infants are at high risk of haemorrhage and thrombosis. Our understanding of the differences between the neonatal and adult haemostatic system is evolving. There are several limitations to the standard coagulation tests used in clinical practice, and there is currently a lack of evidence to support many of the transfusion practices in neonatal medicine. The evaluation of haemostasis is particularly challenging in neonates due to their limited blood volume. The calibrated automated thrombogram (CAT) is a global coagulation assay, first described in 2002, which evaluates both pro- and anti-coagulant pathways in platelet-rich or platelet-poor plasma. In this review, the current applications and limitations of CAT in the neonatal population are discussed.Conclusion: CAT has successfully elucidated several differences between haemostatic mechanisms in premature and term neonates compared with adults. Moreover, it has been used to evaluate the effect of a number of haemostatic drugs in a pre-clinical model. However, the lack of evidence of CAT as an accurate predictor of neonatal bleeding, blood volume required and the absence of an evidence-based treatment algorithm for abnormal CAT results limit its current application as a bedside clinical tool for the evaluation of sick neonates. What is Known:• The Calibrated automated thrombogram (CAT) is a global coagulation assay which evaluates pro- and anti-coagulant pathways.• CAT provides greater information than standard clotting tests and has been used in adults to evaluate bleeding risk. What is New:• This review summarises the physiological differences in haemostasis between neonates and adults described using CAT.• The haemostatic effect of several drugs has been evaluated in neonatal plasma using CAT.

A post hoc appraisal of the PDA RCT to assess the relationship between early patent ductus arteriosus (PDA) shunt elimination and chronic lung disease or death (CLD/Death). Infants 0.05). A persistent PDA beyond Day 8 was associated with CLD/Death (aOR 6.5 [1.7–25.5]). Early shunt elimination in preterm infants with a PDA may reduce respiratory morbidity when compared to infants with prolonged shunt exposure.

BackgroundA study of premature babies, less than 32 weeks gestation, found that the median number of medicines per patient at discharge was 2.5 (range 2 to 7), with 28% of babies discharged on more than 3 medicines (1). Medication administration to infants can cause anxiety and concern for parents/carers who worry about making mistakes. A systematic review of carers for all ages has estimated the administration error rate at home to be between 2 and 33% (2) while a rate of 66.3% was recorded in medication administered to premature infants where parents were responsible for administration (3). It has also been reported that up to 90% of carers will administer a medicine incorrectly at some point (2).The aim of this study is to work with healthcare professionals (HCPs) and parents/carers to co-design resources aimed at improving medication safety and reducing parental anxiety for those giving medications to neonates at home.MethodsWork Package 1: Project management and co-ordination phase: preparation of protocols and survey material and ethics approval applications.Work Package 2: Stakeholder engagement phase, e-surveys and focus groups: An electronic-survey (e-survey) will be developed by a multi-disciplinary study management group (SMG).This will be circulated to HCPs involved in the care of neonates and parents/carers whose babies had recently been discharged from hospital. A small number of parents/carers will be invited to take part in focus groups.Work Package 3: Co-design of resources and quantitative evaluation: Parents/carers willing to co-design educational and information resources to support safe administration of medicines to neonates following discharge will be recruited. A quantitative evaluation of the effect of the resource will be conducted with a new group of caregivers to measure specific outcome(s).DiscussionThis study aims to co-develop, with healthcare professionals (HCPs) and parents/carers, resources aimed at improving medication safety and reducing parental anxiety for those giving medications to neonates at home. Co-development of resources with HCPs and parents, ensures that the project outcomes are relevant and useful, leading to a reduction in parental anxiety.Trial registrationISRCTN registry Ref 17332620

Background and Aims: Infants born to mothers with gestational diabetes mellitus (GDM) have impaired myocardial performance and are at risk of pulmonary hypertension. We aimed to assess myocardial deformation and left ventricular (LV) rotational mechanics in this population. Methods: We studied 40 infants of mothers with GDM and 40 control infants. Three echocardiograms were carried out over the first 3 days after birth. Results: GDM infants had a lower gestation at birth and a thicker septal wall, a higher LV eccentricity index (indicating septal bowing), and a lower PAATi (indicating higher pulmonary vascular resistance) (all p < 0.05). GDM infants had lower LV strain, systolic and early diastolic strain rates, lower right ventricular (RV) strain, and early diastolic strain rates over the study period (all p < 0.05). By day 3, GDM infants had higher twist, torsion, and higher LV twist and untwist rates (all p < 0.05). GDM status was an independent predictor of LV and RV function and pulmonary vascular resistance (p < 0.01). Conclusion: Infants of mothers with GDM demonstrate important changes in myocardial function in addition to pulmonary vascular resistance that do not resolve by hospital discharge. The observed LV twist increase in GDM infants may be a compensatory mechanism for the lower longitudinal function in this cohort.

Extracellular vesicles (EVs) are cell-derived membrane-bound particles, extensively investigated across many fields to improve the understanding of pathophysiological processes, as biomarkers of disease and as therapeutic targets for pharmacological intervention. We aim to describe the current knowledge of EVs detected in the body fluids of human neonates, both term and preterm, from birth to 4 weeks of age. To date, EVs have been described in several neonatal body fluids, including cerebrospinal fluid, umbilical cord blood, neonatal blood, tracheal aspirates and urine. These studies demonstrate some important roles of EVs in the neonatal population, particularly in haemostasis. Moreover, some studies have demonstrated the pathophysiological mechanisms and the identification of potential biomarkers of neonatal disease. We must continue to build on this knowledge, evaluating the role of EVs in neonatal pathology, particularly in prematurity and during the perinatal adaption period. Future studies should use larger numbers, robust EV characterisation techniques and always correlate the findings to clinical outcomes. IMPACT: This article summarises the current knowledge of the effect of EVs in neonates. It describes the potential compensatory role of EVs in neonatal haemostasis. It also describes the role of EVs as mediators of pathology and as potential biomarkers of perinatal and neonatal disease.

Antimicrobial prophylaxis is widely recommended for pregnant women who have preterm premature rupture of the membranes. Erythromycin prophylaxis was used during an initial period (control) and then changed to intravenous amoxicillin for 48 h, followed by 5 days of oral amoxicillin along with a single dose of azithromycin (case). Healthcare records were reviewed retrospectively. The primary outcome was latency (between membrane rupture and delivery) and the secondary outcomes were mode of delivery, maternal high dependency unit (HDU) admission, and several laboratory parameters. There were 78 women in the case group (amoxicillin and azithromycin) and controls were selected on a 1:1 ratio. There was no statistically significant difference between cases and controls with respect to group B Streptococcus or E.coli carriage, previous preterm birth, assissted fertility and parity. No babies had a positive blood culture with Group B Streptococcus. There was a longer latency to delivery for those prescribed amoxicillin and azithromycin (median = 5.5 days), compared with controls on erythromycin (median = 2 days, p < .001). There was no difference in the mode of delivery or maternal HDU admission. Given the potential sequelae of preterm birth, this warrants further prospective investigation in a randomised control trial. IMPACT STATEMENT What is already known on this subject? Antimicrobial prophylaxis is recommended for women who have preterm premature rupture of the membranes (PPROM). It has been shown to increase latency of delivery. However there are different regimens recommended in North America (amoxicillin and a macrolide) and the United Kingdom (macrolide monotherapy). What do the results of this study add? This study has shown that in our population, women who were prescribed the PPROM regimen of amoxicillin with azithromycin had a longer median latency from time of rupture of membranes to delivery, than women in a historical control group who were prescribed erythromycin monotherapy. What are the implications of these findings for clinical practice and/or further research? This retrospective study has shown that there may be a difference in latency between different antimicrobial prophylaxis regimens for PPROM. A randomised control trial, with sufficient patient numbers, is needed to determine the best regimen for prophylaxis, and would allow harmonisation of international guidelines.

Aim Extremely premature babies are at risk of osteopenia of prematurity (OOP) as bone mineralisation in utero increases exponentially after 24 weeks gestation. Our aim was to assess the bone health of very low birth weight (VLBW) infants. We wanted to establish the incidences of OOP and rib fracture. We also looked at which biochemical markers best predicted OOP. Bone health in this vulnerable population is an important aspect of management which should not be overlooked. Methods This was an observational study which included all VLBW infants, born in a national maternity hospital, over a 5-year period. All X-rays performed on these infants were reviewed. Data were also collected on biochemical markers associated with bone health. The medical records of infants with rib fractures were reviewed looking for causes of bone fragility. Results Of the 609 VLBW infants included in the study, only two cases of definitive rib fractures were found. This represents a rib fracture incidence of 3 per 1000. Thirty-nine percent of VLBW babies showed radiological evidence suggestive of OOP. Conclusion Our findings show a lower rate of rib fracture in preterm infants compared to previous evidence. We also showed that these fractures were not evident on the final X-ray prior to discharge. This implies that when an ex-preterm infant presents to the emergency department with a rib fracture there should be an even higher suspicion for non-accidental injury than previously thought.

There is a dearth of longitudinal data describing the evolution of cardiopulmonary hemodynamics in infants with Down syndrome (DS) beyond infancy. We hypothesized that babies with DS, independent of the presence of congenital heart disease (CHD), demonstrate biventricular systolic and diastolic impairment and sustained elevation of pulmonary pressures compared with controls over the first 2 years of age.This was a prospective observational cohort study of 70 infants with DS (48 with CHD and 22 without CHD) and 60 controls carried out in 3 tertiary neonatal intensive care units in Dublin, Ireland. Infants with DS with and without CHD and non-DS controls underwent serial echocardiograms at birth, 6 months, 1 year, and 2 years of age to assess biventricular systolic and diastolic function using deformation analysis. Pulmonary vascular resistance was assessed using pulmonary artery acceleration time and left ventricular (LV) eccentricity index.Infants with DS exhibited smaller LV (birth: 27 ± 4 vs 31 ± 2 mm, P lt; .01; 2 years: 43 ± 5 vs 48 ± 4 mm, P lt; .01) and right ventricular (birth: 28 ± 3 vs 31 ± 2 mm, P lt; .01; 2 years: 40 ± 4 vs 44 ± 3 mm, P lt; .01) lengths and lower LV (birth: -19% ± 3% vs -22% ± 2%, P lt; .01; 2 years: -24% ± 2% vs -26% ± 2%, P lt; .01) and right ventricular (birth: -19% ± 4% vs -22% ± 3%, P lt; .01; 2 years: -29% ± 6% vs -33% ± 4%, P lt; .01) systolic strain over the 2-year period. Pulmonary artery acceleration time was lower in the DS group throughout the study period (birth: 44 ± 10 vs 62 ± 14 ms, P lt; .01; 2 years 71 ± 12 vs 83 ± 11 ms, P lt; .01). No differences were observed between DS infants with and without CHD (all P gt; .05).Infants with DS exhibit impaired maturational changes in myocardial function and pulmonary vascular resistance. Such novel findings provide valuable insights into the pathophysiology affecting cardiorespiratory morbidity in this population.

Background To ascertain if undergraduate medical students attain adequate knowledge to practice in paediatrics, we designed the minimum accepted competency (MAC) examination. This was a set of MCQ’s designed to test the most basic, ‘must know’ knowledge as determined by non-faculty paediatric clinicians. Only two-thirds of undergraduate students passed this exam, despite 96% of the same cohort passing their official university paediatric examination. We aim to describe the psychometric properties of the MAC examination to explore why there was a difference in student performance between these two assessments which should, in theory, be testing the same subject area. We will also investigate if the MAC examination is a potentially reliable method of assessing undergraduate knowledge. Methods The MAC examination was sat by three groups of undergraduate medical students and paediatric trainee doctors. Test item analysis was performed using facility index, discrimination index and Cronbach’s alpha. Results Test item difficulty on the MAC between each group was positively correlated. Correlation of item difficulty with the standard set for each item showed a statistically significant positive relationship. However, for 10 of the items, the mean score achieved by the candidates did not even reach two standard deviations below the standard set by the faculty. Medical students outperformed the trainee doctors on three items. 18 of 30 items achieved a discrimination index > 0.2. Cronbach’s alpha ranged from 0.22–0.59. Conclusion Despite faculty correctly judging that this would be a difficult paper for the candidates, there were a significant number of items on which students performed particularly badly. It is possible that the clinical emphasis in these non-faculty derived questions was juxtaposed with the factual recall often required for university examinations. The MAC examination highlights the difference in the level of knowledge expected of a junior doctor starting work in paediatrics between faculty and non-faculty clinicians and can identify gaps between the current curriculum and the ‘hidden curriculum’ required for real world clinical practice. The faculty comprises physicians in employment by the University whose role it is to design the paediatric curriculum and deliver teaching to undergraduate students. Non-faculty clinicians are paediatric physicians who work soley as clinicians with no affiliation to an educational institution. The concept of a MAC examination to test basic medical knowledge is feasible and the study presented is an encouraging first step towards this method of assessment.

Background Coronavirus disease 2019 (COVID-19) infection during pregnancy has been associated with adverse perinatal outcomes. We aim to evaluate the neonatal outcomes including the incidence of preterm birth, admission to the neonatal unit and incidence of congenital anomalies in this cohort. We will also describe these outcomes in the context of the B.1.1.7. variant outbreak, the dominant variant in Ireland since January 2021, which has had a greater impact on pregnant patients. Methods This was a retrospective study of liveborn infants, delivered between 1st March 2020 and 1st March 2021, to women with a severe acute respiratory syndrome coronavirus 2 diagnosis during pregnancy, in a tertiary maternity hospital (8,500 deliveries/year). Clinical data were collected, and analyses were performed to evaluate the impact of maternal symptom status, time from diagnosis to delivery and the B.1.1.7. variant on neonatal outcome. Results In total 133 infants (1.6%) were born to women with severe acute respiratory syndrome coronavirus 2 identified during pregnancy. The median birth weight was 3.45 kg and gestational age at birth was 39.3 weeks. 14 infants (10.5%) were preterm. 22 infants (16.5%) required admission to the neonatal unit and 7 (5.3%) were small for gestational age. There was no difference in growth, preterm birth or neonatal unit admission based on maternal symptom status or infection after the outbreak of B.1.1.7. as the dominant strain. Conclusions Following a COVID-19 infection in pregnancy, there was no increase in the incidence of preterm birth or neonatal intensive care unit admission compared with 5-year hospital data. Maternal symptom status did not influence neonatal outcomes. Further studies to evaluate the impact of COVID-19 in early pregnancy, the variants of concern, particularly the emerging Delta variant and COVID-19 placentitis are required.

To assess the influence of diastolic dysfunction on the evolution of pulmonary hypertension in neonates with Down Syndrome over the early newborn period.This was a prospective observational cohort study. Echocardiography was performed three times over the first week of life in both Down syndrome and control cohorts. Measurements of pulmonary arterial pressure in addition to left ventricular (LV) and right ventricular systolic and diastolic function were collected.Seventy babies with Down syndrome and 60 control infants were enrolled. Forty-eight of the infants with Down syndrome (69%) were born with congenital heart disease (CHD). Echocardiography surrogates of pulmonary hypertension and myocardial function remained significantly impaired in the Down syndrome group in comparison with control infants (all P .01). In the Down syndrome group, LV early diastolic strain rate was independently associated with measures of pulmonary hypertension while controlling for gestational age, cesarean delivery, and the presence of CHD (P .01).Intrinsic LV diastolic impairment is directly associated with higher indices of pulmonary hypertension in infants with Down syndrome and may be a contributing factor to its evolution.

Neonatal encephalopathy (NE) is associated with abnormality of neurological function and involves multiorgan dysfunction. There are long-term complications such as cerebral palsy and developmental delay. Cardiac, renal, neurological and other organ dysfunctions are well described. Haematological dysfunction is relatively common and includes anaemia, thrombocytopenia, monocyte and neutrophil activation, hypofibrinogenemia and coagulopathy. There is a lack of consensus definitions of hematological parameters and optimal levels for intervention due to the lack of interventional studies in term neonates and the lack of knowledge of the optimal values during therapeutic hypothermia. However, derangements in hematological values are also associated with neurodevelopmental outcomes. This article outlines the different hematological complications associated with NE and therapeutic hypothermia and suggests a framework for management.

The public health strategy during the SARS-CoV-2 (COVID19) pandemic of 2020-2021 led to profound changes in social behaviour, affecting not only familial but also wider social interactions. These changes may have altered viral and bacterial interchange.

ObjectiveLeft ventricle (LV) rotational mechanics is an emerging tool to characterise LV function, but warrants further evaluation in neonates. The aim of this study was to compare LV rotational mechanics between term and extremely preterm babies over the first week of age.MethodsIn this prospective study, we serially assessed LV rotational parameters in 50 term infants and compared them with a historical dataset of 50 preterm infants born ResultsThere was no change in LV twist, LV torsion, basal rotation or apical rotation in term infants over the study period (all p>0.05). LV twist and torsion were higher in preterm infants, and increased over time. In preterm infants, basal rotation evolved from anticlockwise to clockwise rotation. Apical rotation remained anticlockwise in both groups (all p>0.05). LV twist rate (LVTR) and untwist rate was higher in preterm infants and increased over the three time points (all p>0.05). There was a strong positive correlation between LV torsion and LV untwist rate (LVUTR) in the entire cohort during the third scan.ConclusionTerm infants exhibit minimal LV twist which remains unchanged over the first week of age. This is in contrast to premature infants who demonstrate increasing indices of twist, torsion, LVTR and LVUTR over the first week, likely as a compensatory mechanism for reduced LV compliance.

23 February 2021. The protocol was withdrawn because it is out of date and does not meet the current methodological standards of Cochrane.

Objectives: The genomic epidemiology of group b streptococcus (GBS) isolates from the Rotunda maternity hospital, Dublin, 2008-2017, was investigated. Methods: Whole genome sequences of isolates (invasive, n = 114; non-invasive, n = 76) from infants and women were analysed using the PubMLST database (https://pubmlst.org/sagalactiae/). Results: Serotypes III (36%), Ia (18%), V (17%), II (11%) and Ib, (9%) and sequence types (ST) 17 (23%), ST-23 (14%), ST-1 (12%) and ST-19 (7%) were most common. Core genome MLST (cgMLST) differentiated isolates of the same ST, grouped STs into five lineages congruent with known clonal complexes and identified known mother-baby pairs and suspected linked infant cases. Clonal complex (CC) 17 accounted for 40% and 22% of infant and maternal invasive cases, respectively and 21% of non-invasive isolates. CC23 and CC19 were associated with maternal disease (30%) and carriage (24%), respectively. Erythromycin (26%) and clindamycin (18%) resistance increased over the study period and was associated with presence of the erm(B) gene (55%), CC1 (33%) and CC19 (24%). A multi-resistant integrative conjugative element incorporated in the PI-1 locus was detected in CC17, an ST-12 and ST-23 isolate confirming the global dissemination of this element. All isolates possessed one or more pilus islands. Genes encoding other potential protective proteins including Sip, C5a peptidase and Srr1 were present in 100%, 99.5% and 65.8% of isolates, respectively. The srr2 gene was unique to CC17. Conclusions: The PubMLST.org website provides a valuable framework for genomic GBS surveillance to inform on local and global GBS epidemiology, preventive and control measures.

BackgroundIt is recognised that newly qualified doctors feel unprepared in many areas of their daily practice and that there is a gap between what students learn during medical school and their clinical responsibilities early in their postgraduate career. This study aimed to assess if undergraduate students and junior paediatric doctors met a Minimum Accepted Competency (MAC) of knowledge.MethodsThe knowledge of undergraduates and junior paediatric doctors was quantitatively assessed by their performance on a 30-item examination. The items within this examination were designed by non-academic consultants to test ‘must-know’ knowledge for starting work in paediatrics. The performance of the students was compared with their official university examination results and with the performance of the junior doctors.ResultsThere were a total of 478 participants. Mean examination score was 45.9% for students and 64.2% for doctors (significantly higher [p

Background: Early onset group B streptococcal (GBS) disease can cause significant neonatal morbidity and mortality. There is currently no Irish national guideline for GBS screening, and protocols vary across maternity units. Polymerase chain reaction (PCR) testing at induction or labour onset informs triage for antibiotic prophylaxis; however, there are human and infrastructural resource requirements to enable widespread implementation. Aim: Our aim was to identify current standard practices for GBS prevention in Irish obstetric and neonatal services and to utilise this data to inform the need for, and potential impact of implementation of, a national guideline. Methods: A questionnaire on GBS screening, management and existing resources was completed by an informed staff member from each of the 19 Irish maternity units, including questions regarding timing and method of screening, antibiotic usage, and neonatal management. Results: One unit (5.2%) performs routine GBS screening at 35–37 weeks of gestation. Twelve units (63%) screen for GBS following spontaneous rupture of membranes (SROM) after 37 weeks, of which two (17%) perform PCR and ten (83%) culture testing. Seventeen units (89.3%) have access to a GeneXpert PCR machine, and of these, two (11.7%) use the machine for rapid GBS testing. Two units screen patients for GBS at either the start of labour or induction of labour. Four units (21%) use the neonatal early onset sepsis (EOS) calculator. Sixteen units (84%) do not treat asymptomatic infants born to GBS-positive mothers. Conclusion: There is a lack of consistency in the methods for GBS screening and disease prevention across the country, highlighting the need for a national guideline accompanied by an implementation plan and budget to standardise care.

A patent ductus arteriosus (PDA) in preterm infants is associated with increased ventilator dependence and chronic lung disease, necrotizing enterocolitis, intraventricular haemorrhage, and poor neurodevelopmental outcome. Randomised controlled trials of early PDA treatment have not established a drop in the aforementioned morbidities. Those trials did not physiologically categorise PDA severity. Incorporating the specific physiological features of a haemodynamic significant PDA may evolve our understanding of this phenomenon, allowing accurate triaging using echocardiography and targeted treatment. Our group has recently demonstrated that a PDA severity score (PDAsc) derived at 36-48 hours of age can accurately predict the later occurrence of chronic lung disease or death (CLD/Death). Using echocardiography, we assessed PDA characteristics, as well as left ventricular diastolic function and markers of pulmonary overcirculation, and from this formulated a PDAsc. Gestation was also incorporated into the score. We hypothesise that in preterm infants at high risk of developing CLD/Death based on a PDAsc, early treatment with Ibuprofen compared with placebo will result in a reduction in CLD/Death. This is a single centre double-blind two arm randomised controlled trial conducted in the neonatal intensive care unit in the Rotunda Hospital, Dublin. Echocardiogram is carried out in the first 36-48 hours of life to identify preterm infants with a PDAsc ≥ 5.0 and these infants are randomised to Ibuprofen or placebo. Primary outcomes are assessed at 36 weeks post menstrual age. This pilot study’s purpose is to assess the feasibility of performing the trial and to obtain preliminary data to calculate a sample size for a definitive multi-centre trial of early PDA treatment using a PDAsc. We aim to recruit a total of 60 infants with a high risk PDA over three years. Trial Registration: ISRCTN ISRCTN13281214 (26/07/2016) and the European Union Drug Regulating Authorities Clinical Trials Database 2015-004526-33 (03/12/2015).

BackgroundThis study aimed to evaluate how undergraduate students and junior paediatric doctors performed against an examination of knowledge set by non-academic consultants at a “must –know “ level for starting in paediatrics. We named this the Minimum Accepeted Competency (MAC) examination.MethodsExamination (comprised of 30 MCQ questions) was delivered to undergraduates also to new junior paediatric doctors. Results of this examination ascertained if participants had reached a clinician determined MAC, were compared with official university examination results and compared students to junior doctor performance.ResultsTotal of 478 participants. Mean MAC score was 45.9% for students and 64.2% for doctors (significantly higher [p

Extracellular vesicles (EVs) are cell-derived membrane-bound particles, extensively investigated across many fields to improve the understanding of pathophysiological processes, as biomarkers of disease and as therapeutic targets for pharmacological intervention. We aim to describe the current knowledge of EVs detected in the body fluids of human neonates, both term and preterm, from birth to 4 weeks of age. To date, EVs have been described in several neonatal body fluids, including cerebrospinal fluid, umbilical cord blood, neonatal blood, tracheal aspirates and urine. These studies demonstrate some important roles of EVs in the neonatal population, particularly in haemostasis. Moreover, some studies have demonstrated the pathophysiological mechanisms and the identification of potential biomarkers of neonatal disease. We must continue to build on this knowledge, evaluating the role of EVs in neonatal pathology, particularly in prematurity and during the perinatal adaption period. Future studies should use larger numbers, robust EV characterisation techniques and always correlate the findings to clinical outcomes. IMPACT: This article summarises the current knowledge of the effect of EVs in neonates. It describes the potential compensatory role of EVs in neonatal haemostasis. It also describes the role of EVs as mediators of pathology and as potential biomarkers of perinatal and neonatal disease.

An Electronic Health Record (EHR) has been introduced to four Irish maternity units, with further implementations planned. Previous studies indicate that healthcare professionals are concerned that EHRs may increase time spent on documentation and medication-related tasks.To determine the impact of an EHR on task time distribution in a Neonatal Intensive Care Unit (NICU).A pre-post, time and motion study. An electronic data collection tool was used to collate time spent on direct care, professional communication, reviewing charts, documentation, and medication-related tasks. Interruptions and contact with the patient zone were quantified. Statistical significance was assessed using two-sample proportion tests, two-sample t-tests, and two-sample Wilcoxon rank-sum tests. A Bonferroni correction set significance at p ≤ 0.0025.63 doctors and nurses participated, with 169.23 h of data collected. There were no significant changes to nurses' task time distribution. The proportion of time spent by doctors on professional communication increased from 15.4% to 26.0% (p 0.001). Significant increases to median task times were seen for both doctors and nurses. Interruptions to tasks decreased post-implementation (p 0.001), as did frequency of contact with the patient zone (p 0.001).The EHR did not redistribute time towards documentation and medication-related tasks. A reduction in interruptions to tasks may streamline workflow. Decreased contact with the patient zone may improve patient safety through reduced potential for pathogen transmission.

Introduction Infants born very preterm ( Extracellular vesicles, comprising of lipid-bound nanoparticles released from cells (including platelets), may potentially play a role in modulating neonatal haemostasis. We aimed to characterize phospholipid (PL)-dependent plasma thrombin generation in platelet-rich (PRP) and platelet-poor plasma (PPP) in premature infants in both umbilical cord blood & peripheral neonatal blood using calibrated automated thrombography (CAT). Methods In this prospective observational study, PRP and PPP was prepared by centrifugation from citrated umbilical cord blood and peripheral neonatal blood collected from premature infants (24 - 31 weeks) and healthy term controls (>37 weeks). No samples were collected from heparinised lines. Parameters of plasma thrombin generation in PRP were assessed using CAT, with thrombin generation stimulated by tissue factor only (TF; final concentration 1pM). CAT was also repeated in PPP using only TF and no exogenous PL (rendering the assay dependent upon the endogenous PL content of plasma). Results In the analysis of umbilical cord blood PRP, plasma thrombin generation was accelerated in the preterm infant group with a significantly shorter time to peak TG observed. The other parameters of TG were similar in both groups (Table 1). In the subset of infants from whom peripheral blood samples were available, there was further evidence of enhanced plasma TG in preterm PRP relative to term infants (Table 2). In this subgroup, the lag time and time to peak thrombin were significantly shorter in the preterm group and peak thrombin was significantly higher. TG was also assessed in both PPP and PRP prepared from umbilical cord blood samples in a subgroup of infants (n=10 term, n=6 preterm) using 1pM TF only, rendering the assay dependent on the phospholipid content of plasma. No difference was observed in any CAT parameters, suggesting that neonatal PPP phospholipid content (potentially from circulating extracellular vesicles) is sufficient to support thrombin generation in the absence of exogenous phospholipid. Conclusion These preliminary data suggest that neonatal PRP, measured in both umbilical cord blood and peripheral neonatal blood, has similar thrombin generation or may even be hypercoagulable, compared with healthy term controls. Moreover, neonatal plasma phospholipid appears to support thrombin generation in the absence of exogenous phospholipid. This ongoing prospective study aims to further characterize the platelet-dependency of neonatal thrombin generation and evaluate the potential role of extracellular vesicles in neonatal haemostasis. Figure 1 Figure 1. Disclosures Maguire: Actelion: Research Funding; Bayer Pharma: Research Funding. Ni Ainle: Leo Pharma: Research Funding; Actelion: Research Funding; Daiichi-Sankyo: Research Funding; Bayer Pharma: Research Funding.

This pilot study assessed the diagnostic accuracy and potential impact of a rapid PCR-based screening test for the detection of group B Streptococcus (GBS) at the onset of labour for the purpose of optimising intrapartum antibiotic prophylaxis (IAP). Vaginal and rectal swabs from a convenience sample of 158 women were analysed by conventional broth-enriched culture and a rapid PCR test. Overall, GBS carriage was 18.98% by culture and 19.62% by PCR. PCR for the detection of GBS had a sensitivity of 93.1%, specificity of 96.67% and area under the curve (AUC) of 0.95. Only 19.3% GBS-positive women received IAP. Three-fourths of babies born to GBS-positive mothers did not receive surveillance for early-onset GBS disease. Of the women who received IAP, only 32.5% were GBS carriers. Seventy-four percent of the GBS-positive mothers delivered more than 5 h after recruitment, which gives adequate swab to delivery interval for appropriate antibiotic prophylaxis in labour. Impact statement What is already known about this subject: Appropriate intra-partum treatment of colonized mothers reduces the risk of GBS transmission to neonates. Universal ante partum screening of pregnant women or IAP based on risk factors in labour for GBS prevention fail to accurately identify and treat the woman who actually harbors GBS in the birth canal in labour. A PCR based rapid test, allows for real-time assessment of GBS carriage in labour.This study highlights the fact that a large number of GBS carriers in labour, who could potentially infect their babies, do not receive IAP, and most of their babies do not receive added surveillance in the neonatal period for EOGBS disease. It also confirms that PCR testing at onset of labour is a highly sensitive and reliable test that identifies the women who are GBS carriers in labour and hence need IAP. What the implications are of these findings for clinical practice and/or further research: Timely provision of IAP for the appropriate woman is possible by adopting universal GBS screening at the onset of labor using GBS-PCR. This would involve additional costs to health care facilities and added work to laboratory personnel.

Aim To compare the opinion of paediatric consultants to paediatric Senior House Officer’s (SHO’s) with regards their perceived level of preparedness for starting clinical work in paediatrics. Methods A 10 item five-point Likert scale questionnaire (1=strongly disagree, 5= strongly agree) was administered to paediatric consultants examining how well they felt their SHO was performing. A similar 10 item questionnaire was administered to current paediatric SHO’s examining how well prepared they felt they were to perform in these areas when they commenced work in paediatrics. There were 5 questions which appeared on both questionnaires and they relate to; procedures, clinical examination, teamwork, history taking and out-patient consultations. Results 50 consultants completed the questionnaire and expressed satisfaction with all aspects of their SHO’s performance. 75 SHO’s completed the questionnaire and rated their undergraduate preparation for the job relatively poorly in the following areas; procedures, emergencies, prioritising and out-patient work. From the results above we can ascertain that consultants and SHO’s have answered similarly with regards their ability/preparation to perform for the skills of clinical examination and history taking. However, they answered the questions on procedures, teamwork and out-patient work significantly differently. Conclusion There is a discrepancy between consultant opinion of ability and SHO’s feeling of preparedness for some of the same skills. The reason for this difference in opinion should be explored further in future studies. SHO’s have identified areas of initial weakness which they feel could have been improved by better preparation. More work, focusing on these specific aspects of undergraduate paediatric education needs to be done to improve graduates preparedness for the role of paediatric SHO.

Aims The neonatal service of Temple Street Children’s University Hospital (TSCUH) includes St. Michael’s B ward (SMB; 8 beds) and the HDU (6 beds). Admissions to the HDU are restricted to transfers from maternity hospitals (Brennan & Murphy, 2018). The new children’s hospital (NCH) will establish a single entity to integrate the services currently provided by TSCUH, OLCHC, and the NCH Tallaght (Department of Health, 2017). The aim of this study is to produce qualitative analysis of the patient population/resource use in the neonatal HDU/SMB in order to plan for delivery of care in the NCH. Methods Using the nursing admissions books, data was retrospectively collected for 6 months of admissions (July to December 2017). Results In the HDU (N=59), 15% of patients had a CGA of In SMB (N=279), 2% of patients had a CGA of Conclusion The neonatal ward in TSCUH offers a unique service, allowing access to specialist care that is not available in the maternity hospitals, and providing a high level of support to term/premature newborns. It is clear that a specialised neonatal ward is necessary to safely care for this patient population, along with separation from the significant burden of infection that is present on high-turnover general wards. We recommend the inclusion of a similar unit in the NCH. References 1. Brennan, K, Murphy, J. (2018, March 9). Admissions criteria St Michaels B High Dependency Unit. Dublin: Temple Street Children’s University Hospital. 2. Department of Health (2017). The new children’s hospital. Retrieved June 2, 2018, from https://health.gov.ie/future-health/reforming-our-hospitals/the-new-childrens-hospital/

Introduction Overnight blood transfusion carry increased risk of transfusion complication due to availability of less staff to monitor the patient and there is likely to be fewer medical and laboratory staff available to respond to the complication.As per hospital protocol non urgent red blood transfusions should be done during working hours so that there is less work load on night duty doctor, nurses and lab personnel. Other reason to order transfusion during working hours so that out of hours charges should be avoidable which is 150 Euros, as not always blood packs supply is available in the hospital.The aim of the audit to know why red blood cell transfusion top- ups were ordered out of hours and to see how can it can be avoided, thereby saving cost. Methods Data was collected retrospectively from July 2017 till September 2017. The total of 77 transfusions took place on 26 patients as some patient had multiple transfusions. The collected data was entered directly into audit tool on excel sheet. The questionnaire includes the following questions: gestation, date of birth, weight at delivery,reason for transfusion, general status,haemoglobin level at the time of transfusion,the time of FBC taken and resulted, in working hours or out of hours, the time when blood transfusion ordered and collected, in working hours or out of hours, day of life at transfusion. The charts of patients were collected and reviewed.The guidelines used for this audit was the Neonatal administration and transfusion specific blood/blood components 2016 issued by Rotunda Hospital Results Out of 77 transfusions, 40 (52%) were collected during the working hours while 37(48%)were collected out of hours. Nearly (40)52% patients were stable at the time of transfusion and 25(32%) were unstable and 12(16%) were not recoreded.Median gestation and weight was at birth was 28+3 weeks and 1.14 kg respectively. Median Day of Life at transfusion was 22. Median Hb level before transfusion was 104.5. Conclusion A significant proportion of out of hour’s orders are collected 5 to 7pm - could there be time savings made to get these within the 5 pm cut off.More than half times when patients got transfused out of hours were stable. Could there be introduction of new guidelines in terms transfusing treatment in stable patients.Out of hours transfusions carries risk of increased work load on staff and costs more if transfusion pack is not available in the hospital.

Background The Maternal & Newborn Clinical Management System (MN-CMS) project is a national electronic health record (EHR) that is being introduced to all 19 maternity units in the Republic of Ireland. Currently 4 units are operating with the MN-CMS electronic record. Medical students do not routinely receive training on using EHR’s prior to commencing clinical practice and this may serve as a barrier to accessing important clinical information required for education during their rotations. Aim We sought to develop an online training module to serve as an induction to the MN-CMS record and seek feedback from the medical students about its use to further improve the module Methods Royal College of Surgeons Medical students undergoing an Obstetrics & Gynaecology/Neonatology rotation at the Rotunda Hospital were surveyed as to their familiarity and preparedness for using an EHR. The initial group had a classroom based powerpoint presentation and a post presentation paper questionnaire. A video induction module for the EHR was created using PanoptoTM software and hosted on their Moodle education platform. A repeat survey was conducted of a new group of students using a surveymonkey© questionnaire. Results In the initial group (n=58) 57% of students had heard of the MN-CMS project and 62% had used an EHR previously. 93% found the induction lecture relevant with 79% satisfied with the teaching provided. In the group with access to the Moodle induction tutorial there was a 51% response to the surveymonkey (22/43) 36% had heard of the MN-CMS project, 59% had used and EHR, but only 22% were aware of the induction tutorial. 76% were satisfied with the teaching provided. The students polled after access to the Moodle induction video were more likely to want access to a precourse induction (50% vs 40%) as opposed to a first day classroom induction (50% vs 60%). Half of the students in the second group wished for an expanded Moodle induction. Conclusion Comments from the first group suggested that it would be valuable to have the induction online. When accessed the Moodle hosted induction tutorial was well received and students found the material useful. There was a disappointing response to the surveymonkey questionnaire as compared to the paper classroom version which may underscore the benefit of the online tutorial. Based on these findings incoming students will receive precourse email notification of the tutorial and a repeat assessment will be performed.

Introduction Neonatal intensive care units are high risk areas for medication errors. The complexity of the medication use process for high-alert medications in sick neonates leads to multiple opportunities for error. A medication safety bundle was designed to assist with the prescribing, preparation and administration of four high alert continuous infusions - HACIs (morphine, dopamine, insulin and heparin), with the aim to reduce medication errors. Pharmaceutical care issues (PCIs) identified before and after the implementation of the medication safety bundle were compared. Method The bundle of medication safety strategies was implemented in a level III NICU in Dublin. The medication safety bundle involved implementing: (i) Standard concentration infusions and drug monographs- this replaced the process of diluting medications using multiple variations of the rule of 6; (ii) An electronic calculator to aid the prescribing process- this generated printed prescriptions and syringe labels; (iii) smart pump technology with an associated drug library, thus eliminating the use of the ml/hr option on syringe pumps. The NICU clinical pharmacist provided training to NICU nurses and prescribers. PCIs were collected prospectively before and after implementation by the NICU clinical pharmacist. Descriptive statistics were generated for PCIs in the two time periods. Binary logistic regression analyses were used to examine the association between medication safety bundle implementation and the occurrence of PCIs (SPSS 23, IBM Corp.) Results Prescriptions of HACIs were recorded on 178 days. The medication safety bundle was used on 56 days. A total of 191 patients required ≥ 1 HACI. Prior to the implementation of the bundle, on review of 292 orders, there were 60 PCIs per 100 orders. After implementation, on review of 217 orders, there were 19 PCIs per 100 orders (OR 0.15 95% Confidence Interval 0.10–0.23). Analyses adjusting for gestation at delivery, age, weight, staffing ratio and unit occupancy did not alter the findings. There was a large reduction in incomplete prescriptions and labels. A shift in the nature of PCIs was noted post implementation, with new issues related to selection of the wrong infusion routes or bypassing smart pump functionality. Conclusion Implementation of this medication safety bundle was associated with a reduction in the number and a shift in the nature of PCIs associated with the prescribing, preparation and administration of HACIs. This study provides useful data to inform a future study to assess the effectiveness of this medication safety bundle on a broader scale.

BACKGROUND Speckle tracking echocardiography (STE) is a validated method to measure longitudinal deformation in premature infants, but there is a paucity of data on STE-derived circumferential and radial strain in this population. We assessed the feasibility and reproducibility of circumferential and radial deformation measurements in premature infants. METHODS In a prospective study of 40 premature infants (