Mark W Davies

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Abstract: Preterm infants are at risk of exhausting their body iron stores much earlier than healthy term newborns. It is widespread practice to give enteral iron supplementation to preterm and low birth weight infants to prevent iron deficiency anaemia. However, it is unclear whether supplementing preterm and low birth weight infants with iron improves growth and neurodevelopment. It is suspected that excess exogenous iron can contribute to oxidative injury in preterm babies, causing or exacerbating conditions such as necrotising enterocolitis and retinopathy of prematurity. Additionally, the optimal dose and timing of commencement and cessation of iron supplementation are uncertain.

Abstract: Humidified High Flow Nasal Cannula (HHFNC) has been increasingly adopted as a new means of respiratory support throughout the world. However, evidence to support its safety and efficacy is limited. The aim of the present survey was to determine current practices regarding the usage of HHFNC by neonatologists in Australia and New Zealand.

Abstract: To determine the effects on weight gain and temperature control of transferring preterm infants from incubators to open cots at a weight of 1600 g versus a weight of 1800 g.

Abstract: While indications for the use of nasal continuous positive airway pressure (NCPAP) and its associated risks and benefits are extensively investigated, the best strategy for the withdrawal of NCPAP remains unknown. In a survey of Australian and New Zealand Neonatologists, 56% stated that their approach to NCPAP weaning was "ad hoc" (Jardine 2008). At what point an infant is considered stable enough to attempt to start withdrawing their NCPAP is not clearly established. The criteria for a failed attempt at NCPAP withdrawal is also not clear.

Abstract: A key criterion for discharging preterm infants home from nurseries is their ability to maintain temperature once transferred from incubators to open cots. The timing of transfer is important given the preterm infant's immature thermoregulatory mechanisms.

Abstract: Very preterm neonates are prone to brain injury if cerebral blood flow fluctuates. Partial liquid ventilation (PLV) may benefit any lung disease but giving 30 mL/kg of perfluorocarbon when starting PLV increases cortical cerebral blood flow velocity. We aimed to determine if varying the initial dose of perfluorocarbon alters the effect on cerebral blood flow velocity when starting PLV.

Abstract: BACKGROUND: The incubator environment is essential for optimal physiological functioning and development of the premature infant but the infant is ultimately required to make a successful transfer from incubator to open cot in order to be discharged from hospital. Criteria for transfer lack a systematic approach because no clear, specific guideline predominates in clinical practice. Practice variation exists between continents, regions and nurseries in the same countries, but there is no recent review of current practices utilised for transferring premature infants from incubators to open cots. OBJECTIVE: To document current practice for transferring premature infants to open cots in neonatal nurseries. DESIGN: A descriptive, cross-sectional survey. SETTINGS: Twenty-two neonatal intensive care units and fifty-six high dependency special care baby units located in public hospitals in Australia and New Zealand. PARTICIPANTS: A sample of 78 key clinical nursing leaders (nurse unit managers, clinical nurse consultants or clinical nurse specialists) within neonatal nurseries identified through email or telephone contact. METHODS: Data were collected using a web-based survey on practice, decision-making and strategies utilised for transferring premature infants from incubators to open cots. Descriptive statistics (frequencies and crosstabs) were used to analyse data. Comparisons between groups were tested for statistical significance using Chi-squared or Fisher's exact test. RESULTS: Significant practice variation between countries was found for only one variable, nursing infants clothed (p=0.011). Processes and practices undertaken similarly in both countries include use of incubator air control mode, current weight criterion, thermal challenging, single-walled incubators and heated mattress systems. Practice variation was significant between neonatal intensive care units and special care baby units for weight range (p=0.005), evidence-based practice (p=0.004), historical nursery practice (p=0.029) and incubator air control mode (p=0.001). Differences in these variables were also found between nurseries in metropolitan and rural locations. CONCLUSIONS: Practice variation exists however; many practices are uniformly performed throughout neonatal nurseries in Australian and New Zealand. Commonality was seen between countries and in nurseries with a neonatal intensive care unit. Variation was significant between neonatal intensive care units and special care baby units and nurseries in metropolitan and rural locations.

Abstract: BACKGROUND: Very preterm neonates can have severe lung disease and are prone to brain injury if cerebral blood flow fluctuates. Partial liquid ventilation (PLV) may benefit the lung disease, but it is unknown whether the administration of intratracheal perfluorocarbon when starting PLV affects haemodynamics or cerebral blood flow. OBJECTIVES: To determine if haemodynamics or cerebral blood flow are affected in preterm lambs receiving a dose of perfluorocarbon when starting PLV. METHODS: Sixteen preterm lambs were randomised to either PLV or conventional mechanical ventilation. An intratracheal loading dose of 30 ml/kg of perfluorocarbon liquid (PLV group) or air (sham group) was instilled over 20 min. Data were collected continuously for 30 min from the start of dosing. Results: Cortical cerebral blood flow velocity, measured continuously with laser Doppler, was increased in the PLV group during the administration of perfluorocarbon and immediately thereafter (p = 0.0026); the highest mean increase in the PLV group was 27%. There was no difference in cortical cerebral blood flow variability (p = 0.96). There was a slightly lower mean arterial blood pressure in the PLV group; the heart rate did not differ between groups. The PaCO(2) was higher in the PLV group at 30 min - the difference between groups was not statistically significant (difference between means = 5.5 mm Hg, 95% confidence interval -2.7 to 13.7). CONCLUSIONS: Preterm lambs receiving a dose of tracheal perfluorocarbon at the start of PLV have an increased cortical cerebral blood flow velocity, but no change in cortical cerebral blood flow variability.

Abstract: To assess if neonatal endotracheal tube (ETT) position improved with introduction of the NeoBar.

Abstract: Abstract The questions that must be asked about any health-care intervention, including the use of immersion in the second stage of labour with birth into the water, are: is it useful?, does it do any harm? and do any benefits outweigh any harms? There is little subjective evidence (and no reliable, objective evidence) of any benefit to the mother or baby from water birth. There are reports of uncommon, yet significant, adverse outcomes for babies including deaths and significant morbidity directly attributed to water birth. There are also sound physiological mechanisms that can readily explain the significant adverse outcomes reported. It remains unknown whether any benefits from water birth outweigh any harms given the small number of underpowered studies available. An appropriately sized randomised controlled trial of good quality remains the only reliable way to assess both the efficacy and the safety of water births. Babies should not be born into water unless enrolled in such trials.

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Abstract: AIMS: To determine if: time from blood culture inoculation to positive growth (total time to positive) and time from blood culture machine entry to positive growth (machine time to positive) is altered by delayed entry into the automated blood culture machine, and if the total time to positive differs by the concentration of organisms inoculated into blood culture bottles. METHODS: Staphylococcus epidermidis, Escherichia coli and group B beta-haemolytic streptococci were chosen as clinically significant representative organisms. Two concentrations (> or =10 colony-forming units per millilitre and <1 colony-forming units per millilitre) were inoculated into PEDS BacT/Alert blood culture bottles and randomly allocated to one of three delayed automated blood culture machine entry times (30 min/8.5 h/15.5 h). RESULTS: For all organisms at all concentrations, except the Staphylococcus epidermidis, the machine time to positive was significantly decreased by delayed entry. For all organisms at all concentrations, the mean total time to positive significantly increased with increasing delayed entry into the blood culture machine. Higher concentrations of group B beta-haemolytic streptococci and Escherichia coli grew significantly faster than lower concentrations. CONCLUSION: Bacterial growth in inoculated bottles, stored at room temperature, continues although at a slower rate than in those blood culture bottles immediately entered into the machine. If a blood culture specimen has been stored at room temperature for greater than 15.5 h, the currently allowed safety margin of 36 h (before declaring a result negative) may be insufficient.

Abstract: BACKGROUND: The use of central venous catheters is recognised as a risk factor for nosocomial infection. Prophylactic antibiotics may be effective in preventing catheter-related blood stream infection in newborns but may also have the undesirable effect of promoting the emergence of resistant strains of micro-organisms. OBJECTIVES: To determine the effect of prophylactic antibiotics on mortality and morbidity in neonates with central venous catheters. SEARCH STRATEGY: Searches were done of the Cochrane Neonatal Review Group Specialised Register, MEDLINE from 1950 to April 2007, CINAHL from 1982 to April 2007, and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2 2007). Previous reviews (including cross references) were also searched. SELECTION CRITERIA: Randomised controlled trials or quasi-randomised controlled trials of adequate quality in which either individual newborn infants or clusters of infants were randomised to receive prophylactic antibiotics (not including antifungals) versus placebo or no treatment. Infants must have had central venous catheters, been full term infants less than 28 days old or preterm infants up to 44 weeks (postmenstrual) corrected age. DATA COLLECTION AND ANALYSIS: Criteria and methods used to assess the methodological quality of the trials: standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. The review authors extracted data independently. Attempts were made to contact study investigators for additional information as required. MAIN RESULTS: Three small studies have been included in this review. Prophylactic antibiotics in neonates with central venous catheters had no effect on overall mortality (typical RR 0.68, 95% confidence interval 0.31, 1.51). Prophylactic antibiotics in neonates with central venous catheters decreased the rate of proven bacterial sepsis (typical RR 0.38, 95% confidence interval 0.18, 0.82). Prophylactic antibiotics in neonates with central venous catheters decreased the rate of suspected or proven bacterial septicaemia (typical RR 0.40, 95% confidence interval 0.20, 0.78). No resistant organisms colonising infants were identified in any of the studies. No pooled data were available for other important outcome measures such as chronic lung disease or neurodevelopmental outcome. AUTHORS' CONCLUSIONS: Prophylactic systemic antibiotics in neonates with a central venous catheter reduces the rate of proven or suspected septicaemia. However, this may not be clinically important in the face of no significant difference in overall mortality and the lack of data on long-term neurodevelopmental outcome. Furthermore, there is a lack of data pertaining to the potentially significant disadvantages of this approach such as the selection of resistant organisms. The routine use of prophylactic antibiotics in infants with central venous catheters in neonatal units cannot currently be recommended.

Abstract: Introduction The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal. Case presentation A female infant with a complicated gastroschisis developed signs of short bowel syndrome post surgery. She was treated with a combination of parenteral nutrition and enteral feeds. A central venous line was inserted through a scalp vein. The tip was noted to be in a vessel at the level of the mandible. She subsequently became unwell with large milky pharyngeal aspirates and episodes of bradycardia. Chest radiography revealed aspiration. The central venous line was removed because of presumed extravasation. This is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant. Conclusion This complication may have been prevented by recognising that the tip of the catheter was not correctly placed. When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.

Abstract: INTRODUCTION: The insertion of percutaneous central venous catheters is a common procedure in neonatal intensive care nurseries. Placement of the catheter tip in a large central vein is most desirable. Occasionally, due to difficult venous access, catheter tips are left in places that are less than ideal. CASE PRESENTATION: A female infant with a complicated gastroschisis developed signs of short bowel syndrome post surgery. She was treated with a combination of parenteral nutrition and enteral feeds. A central venous line was inserted through a scalp vein. The tip was noted to be in a vessel at the level of the mandible. She subsequently became unwell with large milky pharyngeal aspirates and episodes of bradycardia. Chest radiography revealed aspiration. The central venous line was removed because of presumed extravasation. This is the first reported case of parenteral nutrition extravasation into the pharynx causing aspiration in an infant. CONCLUSION: This complication may have been prevented by recognising that the tip of the catheter was not correctly placed. When catheters are in unusual positions it may be useful to obtain a second radiograph from a different angle or an ultrasound scan to confirm the positioning of the catheter tip.

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Abstract: BACKGROUND: The use of incubators in helping to maintain a thermoneutral environment for preterm infants has become routine practice in neonatal nurseries. As one of the key criteria for discharging preterm infants from nurseries is their ability to maintain temperature; the infant will need to make the transition from incubator to open cot at some time before discharge. The timing of this transition is important because, when an infant is challenged by cold, the infant attempts to increase its heat production to maintain body temperature. The increase in energy expenditure may affect weight gain. The practice of transferring infants from incubators to open cots usually occurs once a weight of around 1700 - 1800 g has been reached; however, this practice varies widely among neonatal units. This target weight appears to be largely based on tradition or the personal experience of clinicians, with little consideration of the infant's weight or gestational age at birth. OBJECTIVES: The main objective was to assess the effects on weight gain and temperature control of a policy of transferring preterm infants from incubator to open cot at lower versus higher body weight. SEARCH STRATEGY: Searches were undertaken of MEDLINE from April 2007 back to 1950, CINAHL from April 2007 back to 1982 and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. SELECTION CRITERIA: Trials in which preterm infants were allocated to a policy of transfer from incubators to open cots at a lower body weight versus at a higher body weight. DATA COLLECTION AND ANALYSIS: Quality assessments and data extraction for included trials were conducted independently by the reviewers. Data for individual trial results were analysed using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, meta-analysis could not be undertaken. MAIN RESULTS: Five studies were identified as potentially eligible for inclusion in this review. Three studies were excluded as neither random nor quasi-random allocation to the exposure was employed. Two small quasi-randomised studies, involving 74 preterm infants are included in this review. These studies compared the transfer of infants to open cots at 1600 - 1700 g vs. 1800- 1900 g, and 1700 g vs. 1800 g. Data for only two prespecified outcomes could be included in this review. No statistically significant difference was shown for either return to incubator [one trial (N = 60) RR 2.00; 95% CI 0.40 to 10.11] or daily weight gain measured in g/kg/day [one trial (N = 14) MD 1.00 g/kg/day; 95% CI -2.89, 4.89]. Due to insufficient data, meta-analysis was not performed and effects on clinically important outcomes could not be adequately assessed. AUTHORS' CONCLUSIONS: There is currently little evidence from randomised trials to inform practice on the preferred weight for transferring preterm infants from incubators to open cots. There is a need for larger randomised controlled trials to address this deficiency.

Abstract: OBJECTIVE: To determine the inspired gas temperature at points from the endo-tracheal tube (ETT) circuit manifold to the tip of the ETT in a model neonatal lung. DESIGN: A model lung attached to standard ventilator circuit, autofeed chamber and humidifier was ventilated using typical pressure-limited, time cycled settings. Temperatures were measured at various distances along the ETT using a K-type thermocouple temperature probe. RESULTS: The inspired gas temperature dropped from the circuit temperature probe site (40 degrees C) to the proximal end of the ETT (37 degrees C). The temperature dropped further as it passed through the exposed part of the ETT (34 degrees C) but then warmed again on entering the lung model so that the inspired gas at the distal end of the ETT was 37 degrees C. Statistically significant differences were found with a one-way ANOVA P-value of <0.0001. The differences between each pair of mean temperatures were statistically significant (all P<0.001) except when comparing the proximal end of the ETT with midway down the ETT (Bonferroni's Multiple Comparison Test, P>0.05). CONCLUSIONS: Inspired gas temperature drops as it passes through the circuit temperature probe site, the proximal end of the ETT and the exposed part of the ETT. The inspired gas rewarms on entering the model lung and exits the ETT at the desired temperature. The effect of measuring temperature closer to the patient, setting the circuit temperature higher and/or increasing the ambient temperature through which the circuit passes, need to be evaluated.

Abstract: BACKGROUND: Respiratory mortality and morbidity remain major consequences of extreme prematurity. Percutaneous transfer of oxygen and carbon dioxide is possible in the newborn human. Perfluorocarbon (PFC) liquids have excellent oxygen and carbon dioxide carrying capacity. Animals can breath immersed in perfluorocarbon liquids and maintain adequate gas exchange. Our hypothesis is that the combination of spontaneous tidal perfluorocarbon breathing and respiration through the skin immersed in perfluorocarbon will allow adequate gas exchange in the preterm newborn. In this pilot study we aimed to observe the effects of immersion in FC-77 perfluorocarbon liquid on the preterm lamb. PILOT DATA: Four preterm lambs at 100-115 days gestation were delivered using a modified EXIT procedure. Immediately after complete delivery, the catheterised lamb was immersed in warm, oxygenated FC-77 perfluorocarbon liquid. Physiological monitoring was done for up to 60 min. All lambs were warmed adequately and seemed to have centrally intact circulation initially. All had little or no respiratory effort and there was no appreciable lung expansion. All had severe respiratory acidosis. DISCUSSION: For the provision of immediate ex utero care to the 'fetus' there are three requirements: adequate gas exchange surfaces and sufficient oxygen and carbon dioxide gradients, a functioning circulation, and an environment capable of keeping the lamb warm (thus minimising metabolic demand, oxygen consumption and carbon dioxide production). In this pilot study the greatest initial problem was the severe and rapidly worsening respiratory acidosis. The major problem was a lack of respiratory drive. No lung expansion from the outset would yield zero contribution to gas exchange from the lungs. An intact central circulation does not necessarily mean that the pulmonary circulation, respiratory drive and/or the skin circulation are adequate. For adequate gas exchange to occur it will require a 'breathing' animal with expanded alveoli. If the transition from the normal in utero state to immersion in PFC was immediate, and lung expansion was achieved, it could still be possible to achieve adequate gas exchange through the skin and lungs of the extremely preterm newborn. HYPOTHESIS: Given the potential for gas exchange across the skin of the extremely preterm infant we hypothesise that the immersion of extremely preterm infants in PFC liquid will allow optimal percutaneous gas exchange to occur. Given some lung gas exchange with less injurious liquid ventilation (spontaneous or mechanical) we hypothesise that the combination of skin and lung gas exchange will provide sufficient gas exchange to support life.

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Abstract: BACKGROUND: Continuous positive airway pressure (CPAP) is a widely accepted method of respiratory support used in the care of preterm infants. It remains unknown as to what is the best strategy for the withdrawal of CPAP once it has been commenced. The aim of the present survey was to establish the current practices for withdrawal of nasal CPAP used by Australian neonatologists. A secondary aim was to establish what criteria clinicians use as an indicator for failure off CPAP. METHODS: Surveys were sent to all 124 Australian neonatologists identified by the list of centers in the Australia and New Zealand Neonatal Network. RESULTS: A total of 124 surveys were sent; 86 (69%) replies were received, of which 84 (68%) of the respondents had completed the questionnaire. Seventy-one percent of respondents used a graded-time-off CPAP. The majority of babies for whom they used graded-time-off CPAP were deemed to be chronic (79%) or had chronic neonatal lung disease (73%). A total of 74% of respondents had the level of CPAP gradually reduced. CONCLUSIONS: At least 48% of Australian neonatologists use graded-time-off CPAP. At least 50% of Australian neonatologists wean the level of CPAP prior to cessation. Neonatologists have similar criteria for recommencing CPAP, with the majority considering increased oxygen requirement, increased work of breathing, increased frequency of apnea and increased severity of apnea important indicators.

Abstract: BACKGROUND: Umbilical artery catheters are often used in unwell neonates. Infection related to the use of these catheters may cause significant morbidity and mortality. The use of prophylactic antibiotics has been advocated for all newborns with umbilical artery catheters in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm, such as the emergence of antibiotic resistant organisms, may outweigh benefit. OBJECTIVES: The primary objective was to assess whether prophylactic antibiotics reduce mortality and morbidity in neonates with umbilical artery catheters. Two different policies regarding the prophylactic use of antibiotics in neonates with umbilical artery catheters were reviewed: 1) a policy of prophylactic antibiotics for the duration of catheterisation (or other fixed duration of antibiotic treatment) versus placebo or no treatment among neonates with umbilical artery catheters; 2) a policy of continuing versus discontinuing prophylactic antibiotics among neonates with umbilical artery catheters who had been started on antibiotics at the time of catheterisation but whose initial cultures to rule out sepsis are negative. SEARCH STRATEGY: MEDLINE (January 1950 to May 2007), CINAHL (1982 to May 2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), the Cochrane Neonatal Group Specialised Register and reference lists of articles were searched. SELECTION CRITERIA: Randomised and some non-randomised (i.e., quasi-randomised trials) controlled trials of adequate quality in which newborn infants with umbilical artery catheters are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewer authors independently assessed trial quality. MAIN RESULTS: Two quasi-randomised trials have been included. However, given their poor quality, we have not pooled the results. There were no statistically significant differences in important outcomes in either study. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to support or refute the use of prophylactic antibiotics when umbilical artery catheters are inserted in newborn infants, and no evidence to support or refute continuing antibiotics once initial cultures rule out infection in newborn infants with umbilical artery catheters.

Abstract: BACKGROUND: Intubation is associated with bacterial colonisation of the respiratory tract and, therefore, may increase the risk of acquiring an infection. The infection may prolong the need for mechanical ventilation and increase the risk of chronic lung disease. The use of prophylactic antibiotics has been advocated for all mechanically ventilated newborns in order to reduce the risk of colonisation and the acquisition of infection. However, there is the possibility that the harm this may cause might outweigh the benefit. OBJECTIVES: To assess the effects of prophylactic antibiotics on mortality and morbidity in intubated, ventilated newborn infants who are not known to have infection. In separate comparisons, two different policies regarding the prophylactic use of antibiotics in intubated, ventilated infants were reviewed: 1) among infants who have been intubated for mechanical ventilation, a policy of prophylactic antibiotics for the duration of intubation versus placebo or no treatment 2) among intubated, ventilated infants who have been started on antibiotics at the time of intubation but whose initial cultures to rule out sepsis were negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: MEDLINE (January 1950 to March 2007), CINAHL (1982 to March 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2007), the Cochrane Neonatal Group Specialised Register and reference lists of articles were searched. SELECTION CRITERIA: Randomised controlled trials of sufficient quality in which mechanically ventilated newborn infants are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: Two studies met the criteria for inclusion in this review. One was of insufficient quality to draw any meaningful conclusions. The other was of fair quality and found no significant differences between treatment and control groups in any of the reported outcomes, however, the rates of septicaemia were not reported. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to support or refute the use of prophylactic antibiotics when starting mechanical ventilation in newborn infants, or to support or refute continuing antibiotics once initial cultures have ruled out infection in mechanically ventilated newborn infants.

Abstract: The objective of this paper is to establish a reference range of central venous pressure (CVP) values during the first 4 days of life in very low birth weight (VLBW) infants. A prospective observational study with continuous monitoring of CVP in VLBW newborns who had an umbilical venous catheter (UVC) positioned in or near the right atrium is conducted. All UVCs were inserted as part of normal care of the infants. The mean CVP (mCVP) was monitored for 72 h from recruitment, or until the UVC was removed. The mean mCVP was calculated for each infant. The median of the mean mCVPs was then calculated. Data were analysed in 17 infants. The median gestational age was 27 weeks and median birth weight was 940 g. Sixteen were mechanically ventilated and of these, six also received continuous positive airway pressure (CPAP) during the study period. One infant received no respiratory support. One infant died during the study period. The lowest mean mCVP was 2.8 mmHg and the highest was 13.9 mmHg. The median mean mCVP was 4.9 mmHg (interquartile range 4.4-6.1). The normal range of CVP in VLBW infants during the first 4 days of life is wider than previously suggested.

Abstract: BACKGROUND: Breast milk provides optimal nutrition for newborn infants, and the ideal way for infants to receive breast milk is through suckling at the breast. Unfortunately, this may not always be possible, as there are numerous reasons why a newborn infant may not be able to breastfeed and, as a result, require supplemental feeding. Currently, there are a variety of ways in which newborn infants can receive supplemental feeds. Traditionally, bottles and nasogastric tubes have been used; however, more recently, cup feeding has become a popular practice in many nurseries in an attempt to improve breastfeeding rates. There is no consistency to guide the choice of supplementation. OBJECTIVES: To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in newborn infants who are unable to fully breastfeed. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2006), CINAHL (1982 - April 2006) and MEDLINE (1966 - April 2006). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials comparing cup feeding to other forms of enteral feeding for the supplementation of newborn infants. DATA COLLECTION AND ANALYSIS: Quality assessments and data extraction for included trials were conducted independently by the review authors. Outcomes reported from these studies were: weight gain, proportion not breastfeeding at hospital discharge, proportion not feeding at three months of age, proportion not feeding at six months of age, proportion not fully feeding at hospital discharge, proportion not fully breastfeeding at three months of age, proportion not fully breastfeeding at six months of age, average time per feed (minutes), length of stay and physiological events of instability such as bradycardia, apnea, and low oxygen saturation. For continuous variables such as weight gain, mean differences and 95% confidence intervals were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% confidence intervals were reported. MAIN RESULTS: Four studies were eligible for inclusion. The experimental intervention was cup feeding and the control intervention was bottle feeding in all four studies included in this review. There was no statistically significant difference in the incidence of not breastfeeding at hospital discharge in three included studies (typical RR 0.82, 95% CI 0.62, 1.09) and not breastfeeding at three months in two included studies (typical RR 0.88, 95% CI 0.76, 1.03) or six months for the one study that reported this outcome (RR 0.91, 95% CI 0.78, 1.05). There was a statistically significant difference in not fully breastfeeding at hospital discharge (from three included studies) in favour of cup feeding (typical RR 0.75, 95% CI 0.61, 0.92). However, this was not statistically significant at three months (one study, RR 1.18, 95% CI 0.88, 1.58) or six months (one study, RR 1.31, 95% CI 0.89, 1.92). There was no statistically significant difference in weight gain from one study that reported this outcome (MD -0.60, 95% CI -3.21, 2.01). In the one study that assessed it, there was a significantly increased length of hospital stay in the cup fed infants [mean difference between groups was 10.1 days (95% CI 3.9, 16.3)]. Time to full breastfeeding was not assessed in any study. AUTHORS' CONCLUSIONS: Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.

Abstract: AIM: There are currently two dexamethasone regimes used in our nursery. We aimed to retrospectively compare the cumulative dose of dexamethasone that infants on each regime received and the requirement for further courses. METHODS: Infants receiving dexamethasone between 1 January 2000 and 31 December 2004, with a gestational age of <30 weeks or a birthweight of <1000 g, were identified and then a chart review of these infants was undertaken. Demographic data were obtained and compared as was the total dose of dexamethasone and number of courses that each infant received. Some clinical outcome measurements were also obtained. RESULTS: A total of 119 infants were identified. The total dexamethasone dose received was 1.92 mg/kg less for infants commencing on the 2-week course compared with the 6-week course (difference between medians, Mann-Whitney test, P=0.005). Infants having the 2-week course had 17 days less steroid treatment (difference between medians, Mann-Whitney test, P=0.0001). Seventeen (46%) subjects who started on a 2-week course of steroids and 18 (22%) who started on a 6-week course required at least one further course of steroids (Fisher's exact test, P=0.01). There were no significant differences in the short-term outcome measures of neonatal chronic lung disease. CONCLUSION: Infants who received the 2-week course of dexamethasone had a 27% reduction in total steroid dose compared with infants receiving a 6-week course with similar short-term outcomes. However, our study was limited by its retrospective nature and possible confounding factors.

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Abstract: BACKGROUND: Perfluorocarbon (PFC) vapour in the expired gases during partial liquid ventilation should be prevented from entering the atmosphere and recovered for potential reuse.This study aimed to determine how much PFC liquid could be recovered using a conventional humidified neonatal ventilator with chilled condensers in place of the usual expiratory ventilator circuit and whether PFC liquid could be recovered when using the chilled condensers at the ventilator exhaust outlet. METHODS: Using a model lung, perfluorocarbon vapour loss during humidified partial liquid ventilation of a 3.5 kg infant was approximated. For each test 30 mL of FC-77 was infused into the model lung. Condensers were placed in the expiratory limb of the ventilator circuit and the amounts of PFC (FC-77) and water recovered were measured five times. This was repeated with the condensers placed at the ventilator exhaust outlet. RESULTS: When the condensers were used as the expiratory limb, the mean (+/- SD) volume of FC77 recovered was 16.4 mL (+/- 0.18 mL). When the condensers were connected to the ventilator exhaust outlet the mean (+/- SD) volume of FC-77 recovered was 7.6 mL (+/- 1.14 mL). The volume of FC-77 recovered was significantly higher when the condenser was used as an expiratory limb. CONCLUSION: Using two series connected condensers in the ventilator expiratory line 55% of PFC liquid (FC-77) can be recovered during partial liquid ventilation without altering the function of the of the ventilator circuit. This volume of PFC recovered was just over twice that recovered with the condensers connected to the ventilator exhaust outlet.

Abstract: BACKGROUND: The loss of perfluorocarbon (PFC) vapour in the expired gases during partial liquid ventilation should be minimized both to prevent perfluorocarbon vapour entering the atmosphere and to re-use the recovered PFC liquid. Using a substantially modified design of our previously described condenser, we aimed to determine how much perfluorocarbon liquid could be recovered from gases containing PFC and water vapour, at concentrations found during partial liquid ventilation, and to determine if the amount recovered differed with background flow rate (at flow rates suitable for use in neonates). METHODS: The expiratory line of a standard ventilator circuit set-up was mimicked, with the addition of two condensers. Perfluorocarbon (30 mL of FC-77) and water vapour, at concentrations found during partial liquid ventilation, were passed through the circuit at a number of flow rates and the percentage recovery of the liquids measured. RESULTS: From 14.2 mL (47%) to 27.3 mL (91%) of the infused 30 mL of FC-77 was recovered at the flow rates studied. Significantly higher FC-77 recovery was obtained at lower flow rates (ANOVA with Bonferroni's multiple comparison test, p < 0.0001). As a percentage of the theoretical maximum recovery, 64 to 95% of the FC-77 was recovered. Statistically significantly less FC-77 was recovered at 5 Lmin(-1) (ANOVA with Bonferroni's multiple comparison test, p < 0.0001). Amounts of perfluorocarbon vapour recovered were 47%, 50%, 81% and 91% at flow rates of 10, 5, 2 and 1 Lmin(-1), respectively. CONCLUSION: Using two condensers in series 47% to 91% of perfluorocarbon liquid can be recovered, from gases containing perfluorocarbon and water vapour, at concentrations found during partial liquid ventilation.

Abstract: BACKGROUND: Napkin dermatitis is a common condition that occurs in otherwise healthy infants. It causes discomfort to infants, anxiety to parents and caregivers and contributes to the load on the health care system. A large variety of napkins, both disposable and non-disposable, are available. Evidence is required to assist carers and health care workers in making informed decisions when balancing the pros and cons of different napkin choices. OBJECTIVES: To assess whether disposable napkins prevent napkin dermatitis in infants. SEARCH STRATEGY: We searched the Skin Group Specialised Register (up to June 2003), the Cochrane Central Register of Controlled Trials in (The Cochrane Library, Issue 3, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to February 2003) and CINAHL (from 1982 to November 2004). We searched reference lists of articles. We contacted lead investigators in the area and companies that manufacture disposable napkins for access to unpublished trials. SELECTION CRITERIA: Randomised controlled trials in which disposable napkins were compared with other types of disposable napkins or non-disposable napkins, in infants up to two years of age, for preventing napkin dermatitis. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data. The same two authors independently assessed trials for methodological quality. Attempts were made to contact trial authors of the trials identified for clarification of methods and results of published trials. MAIN RESULTS: We identified 28 studies of the effects of various napkin types on napkin dermatitis. Seventeen studies from nine reports were included. Eleven studies were excluded due to methodology that did not fit the inclusion criteria of this review. Due to the poor reporting of methodology and results of the studies found in this review, there were no quantitative data available for analysis (or meta-analysis). Although the included studies appeared to favour cellulose-core disposable napkins over cloth, absorbent gelling material over cellulose-only core napkins, breathable outer shell over occlusive outer shell napkins and linings impregnated with formulations over plain linings, all of these studies were open to bias due to flawed methodology. AUTHORS' CONCLUSIONS: There is not enough evidence from good quality randomised controlled trials to support or refute the use and type of disposable napkins for the prevention of napkin dermatitis in infants.

Abstract: AIM: We aimed to determine the laboratory detection time of bacteraemia in neonatal blood cultures, and whether this differed by: organism; samples deemed to represent true bacteraemia versus contaminants; and blood cultures collected from an infant <48 h of age (early) or >or=48 h of age (late). METHODS: A retrospective audit of all positive blood cultures collected from neonates in the Grantley Stable Neonatal Unit, Royal Women's Hospital, Brisbane, between 1 January 2000 and 31 December 2004 was undertaken. The bacteraemia detection method used was the BacTAlert system with Peds bottles. RESULTS: Two hundred and three positive blood cultures were included in the analysis. One hundred and sixteen (57%) were deemed septicaemia, 87 (43%) were deemed contaminants. The median (interquartile range) time to positivity for positive blood cultures deemed septicaemia and contaminants were 15.9 (11.6, 22.2) and 30.2 (20.4, 43.9) h, respectively. Fifty-six (28%) positive blood cultures were collected when infants were <48 h of age and 147 (72%) were collected in infants >or=48 h of age. Post hoc analysis revealed that the time to positivity for early septicaemia was 13.7 (11, 16.7) h; early contaminant was 25.2 (19.2, 33.8) h; late septicaemia was 17.2 (12.2, 23.4) h; and late contaminant was 37.9 (21.7, 51.2) h. The time to positivity for: Group B streptococcus was 9.3 (8.2, 11.0) h; Escherichia coli was 11.3 (10.0, 13.5) h; and coagulase-negative staphylococci was 28.9 (20.5, 41.2) h. CONCLUSION: The incubation time for positive blood cultures significantly differs by organism type and whether they are considered early or late septicaemia versus contaminants. We recommend that: infants who are <48 h of age at the time of blood culture collection, who remain clinically well and have negative cultures 36 h after the initial collection can safely have their antibiotic treatment ceased; infants who are >or=48 h of age at the time of collection should continue antibiotic treatment for at least 48 h before cessation is considered.

Abstract: OBJECTIVES: To review the arterial carbon dioxide tensions (PaCO(2)) in newborn infants ventilated using synchronized intermittent mandatory ventilation (SIMV) in volume guarantee mode (using the Dräger Babylog 8000+) with a unit policy targeting tidal volumes of approximately 4 mL/kg. METHODS: Data on ventilator settings and arterial PaCO(2) levels were collected on all arterial blood gases (ABG; n = 288) from 50 neonates (<33 weeks gestational age) ventilated using the Dräger Babylog 8000+ ventilator (Dräger Medizintechnik GmbH, Lübeck, Germany) in SIMV plus volume guarantee mode. Data were analysed for all blood gases done on the entire cohort in the first 48 h of life and a subanalysis was done on the first gas for each infant (n = 38) ventilated using volume guarantee from admission to the nursery. The number of ABG showing severe hypocapnoea (PaCO(2) < 25 mmHg) and/or severe hypercapnoea (PaCO(2) > 65 mmHg) were determined. RESULTS: The mean (SD) PaCO(2) during the first 48 h was 46.6 (9.0) mmHg. The mean (SD) PaCO(2) on the first blood gas of those infants commenced on volume guarantee from admission was 45.1 (12.5) mmHg. Severe hypo- or hypercapnoea occurred in 8% of infants at the time of their first blood gas measurement, and in <4% of blood gas measurements in the first 48 h. CONCLUSIONS: Infants ventilated with volume guarantee ventilation targeting approximately 4 mL/kg (range: 2.9-5.1) have acceptable PaCO(2) levels at the first blood gas measurement and during the first 48 h of life; and avoid severe hypo- or hypercapnoea over 90% of the time.

Abstract: BACKGROUND: Umbilical venous catheters are often used in unwell neonates. Infection related to the use of these catheters may cause significant morbidity and mortality. The use of prophylactic antibiotics has been advocated for newborns with umbilical venous catheters in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm may outweigh benefit. Prophylactic antibiotics may be effective in preventing catheter-related blood stream infection, but may have the undesirable effect of promoting the emergence of resistant strains of micro-organisms. A policy of prophylactic antibiotic use should take into account this possibility, and has been used as a basis for arguing against its implementation. OBJECTIVES: The primary objective was to assess whether prophylactic antibiotics, in neonates with umbilical venous catheters, reduce mortality and morbidity. In separate comparisons, we planned to review two different policies regarding the prophylactic use of antibiotics in neonates with umbilical venous catheters: 1) Among neonates with umbilical venous catheters, a policy of prophylactic antibiotics for the duration of catheterisation (or other fixed duration of antibiotic treatment) versus placebo or no treatment; 2) Among neonates with umbilical venous catheters who had been started on antibiotics at the time of catheterisation, but whose initial cultures to rule out sepsis are negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: We searched MEDLINE (January 1966 to April 2005), CINAHL (1982 to April 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2005). SELECTION CRITERIA: Randomised controlled trials or quasi-randomised trials in which newborn infants with umbilical venous catheters are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: One study, of poor quality, met the criteria for inclusion in this review. Twenty-nine term infants, who had umbilical venous catheters inserted specifically for transfusion procedures for hyperbilirubinaemia or polycythaemia, allocated non-randomly (quasi-randomised - alternate allocation) to treatment (n = 15) or control (n = 14) groups. Those in the treatment group received penicillin and gentamicin for three days. 5/15 infants given antibiotics and 5/14 control infants having positive blood cultures three days after catheter insertion. All positive blood cultures were considered contaminated, due to lack of corroborating clinical and haematological evidence of infection. Therefore, no infants were identified with evidence of septicaemia. AUTHORS' CONCLUSIONS: There is insufficient evidence from randomised trials to support or refute the use of prophylactic antibiotics when umbilical venous catheters are inserted in newborn infants. There is no evidence to support or refute continuing antibiotics once initial cultures rule out infection in newborn infants with umbilical venous catheters.

Abstract: BACKGROUND: The use of peripheral intravenous cannulae is common in newborn babies. Many of them require an intravenous line only for medications and not for fluid. Currently there is little uniformity in methods used to maintain cannula patency. OBJECTIVES: The object of this review was to determine which method was better for maintaining intravenous lines used in neonates for intravenous medication only: intermittent flushing or continuous infusion SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), CINAHL (from 1982 to June 2004) and MEDLINE (from 1966 to June 2004) . SELECTION CRITERIA: Randomised controlled trials comparing continuous infusion to intermittent flushing to maintain patency of intravenous cannulas. Units of randomisation might include individual catheters or individual babies. DATA COLLECTION AND ANALYSIS: Three reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Two studies were eligible for inclusion. In one study only one of our primary outcomes was available: the duration of cannula patency for the first cannula used per infant was slightly longer in the continuous infusion group, but not significantly so, with a mean difference of -4.3 hours (95% CI -18.2 to 9.7).In the second study, only one of our primary outcomes was available: the mean (SD) number cannulas used per infant in the first 48 hours was less in the intermittent flush group with a mean difference of -0.76 cannulas (95% CI -1.37 to -0.15). No results were available for any of our other primary outcomes: in the published report, results were reported per catheter rather than per infant, a number of infants received more than one intravenous catheter (39 infants received an unknown number of catheters). The overall duration of cannula patency was significantly longer in the intermittent flush group with a mean duration of patency in the intermittent flush group of 2.1 days (SD 1.0) compared with the continuous infusion group where the mean duration of patency was 1.0 days (SD 0.5) - Student's t test P value 0.0003. AUTHORS' CONCLUSIONS: It is difficult to draw reliable conclusions given the way the data were analysed and reported in the two included studies. The reliability of the results is uncertain. However, given the caution in interpreting these data, it should also be noted that the use of intermittent flushes was not associated in either study with a decreased cannula life or any other disadvantages, thus lending some support for the use of intermittent flushing of cannulas in a selected population in neonatal nurseries.

Abstract: BACKGROUND: Napkin dermatitis (nappy or diaper rash) is a non-specific term used to describe inflammatory eruptions (rashes) in the napkin area. Most infants develop napkin dermatitis at least once during their infancy. Topical vitamin A has been suggested as a treatment for napkin dermatitis. OBJECTIVES: To determine if treatment with topical vitamin A is successful in either preventing napkin dermatitis, or producing resolution or decreasing the severity of napkin dermatitis. SEARCH STRATEGY: We searched the Cochrane Skin Group Specialised Register (May 2005); Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005); Ovid MEDLINE from 1966 to August 2005; EMBASE (2003 to May 2005); Ovid OLDMEDLINE (1950 to 1965); and CINAHL (1982 to August 2005). We also searched reference lists of articles. SELECTION CRITERIA: Randomised controlled trials, where the topical application of medication containing vitamin A (or its derivatives) was compared with either placebo, no treatment or other topical medication, for the prevention or treatment of napkin dermatitis in infants aged from zero to two years. DATA COLLECTION AND ANALYSIS: Two authors (AJD and MWD) identified and checked titles and abstracts obtained from the searches, and reviewed the full text where necessary. They decided which trials met the inclusion criteria, and recorded their methodological quality. They assessed studies as either adequate, unclear or inadequate using the following key criteria: (a) randomisation (method of generation and concealment of allocation); (b) blinding; (c) loss to follow-up. MAIN RESULTS: We did not find any studies for the treatment of napkin dermatitis. We found only one study comparing the use of topical application of medication containing vitamin A, with another topical medication or placebo, to prevent napkin dermatitis. This included study, of 114 newborn infants, reported no significant differences between groups with regard to the severity or duration of napkin dermatitis. AUTHORS' CONCLUSIONS: For the treatment of napkin dermatitis there is no evidence to support or refute the use of topical vitamin A preparations. For the prevention of napkin dermatitis there is no evidence to suggest that topical vitamin A alters the development of napkin dermatitis. Further RCTs are required to determine whether topical vitamin A is efficacious in treating or preventing napkin dermatitis.

Abstract: BACKGROUND/PURPOSE: In gastroschisis it is proposed that gut reduction may be achieved without intubation or general anesthesia (GA) through ward reduction. The authors aimed to determine if ward reduction decreased morbidity and duration of treatment. METHODS: Infants born from January 1, 1995, to December 31, 2001, with gastroschisis were managed with either reduction under GA in the operating theatre (OT group)--up to September 1999, or ward reduction (when eligible) in the neonatal unit without GA/ventilation (ward reduction [WR] group)--from September 1999. RESULTS: Of the 37 infants, 31 were eligible for ward reduction-15 from the OT group, 16 from the WR group. All infants in the OT group had at least 1 episode of ventilation and 1 GA: 62% of infants in the WR group avoided ventilation (P = .0002) and 81% avoided GA (P < .0001). Infants who had ward reduction had significantly shorter durations of ventilation and oxygen therapy. Septicemia occurred in 31% of the WR group and 7% of the OT group (P = .17). Infants who had ward reduction left intensive care 16 days earlier (P = .02) and tended to reach full enteral feeds 8 days sooner (P = .06) and be discharged from hospital 15 days earlier (P = .05). CONCLUSIONS: Infants who had ward reduction do better in terms of avoiding GA/ventilation, establishing feeds, and going home earlier. A randomized, controlled trial comparing the 2 approaches is feasible, safe, and worthwhile.

Abstract: OBJECTIVE: To determine whether the need for respiratory support can be predicted by oxygen requirement within the first 72 h in term and near-term infants. METHODS: To mimic the population of infants that would often be delivered outside a tertiary centre we studied a retrospective cohort of infants > or = 32 weeks requiring oxygen, divided into three groups: cot oxygen only, nasal continuous positive airway pressure (NCPAP) only, or intermittent positive pressure ventilation (IPPV). We recorded each infant's peak fraction of inspired oxygen (FiO2)--i.e. FiO2 in the first 72 h in the cot oxygen only group or maximum FiO2 prior to commencing the highest level of respiratory support. The peak FiO2 was used as a diagnostic test to predict any respiratory support or IPPV--sensitivity and specificity were calculated and receiver operating characteristic (ROC) curves plotted (FiO2 0.21-1.00) to identify the best balance point for prediction. RESULTS: The cohort included 592 infants: 516 cot oxygen only, 46 NCPAP only and 30 IPPV. The proportion ventilated increased with increasing peak FiO2--above 0.45 the proportion of infants ventilated exceeded 50%. To predict any respiratory support, the cut-point balancing sensitivity and specificity was a FiO2 > or = 0.35-58/136 required respiratory support (sensitivity = 0.76, specificity = 0.85, positive predictive value (PPV) = 43%, negative predictive value (NPV) = 96%). To predict IPPV the cut-point was a FiO2 > or = 0.5-28/47 treated with IPPV (sensitivity = 0.93, specificity = 0.97, PPV = 60%, NPV = 100%). CONCLUSION: The need for respiratory support can be predicted by oxygen requirement within the first 72 h in term and near-term infants with reasonable sensitivity and excellent specificity.

Abstract: BACKGROUND: Intravenous albumin infusion to treat hypoalbuminaemia is used in intensive care nurseries. Hypoalbuminaemia occurs in a number of clinical situations including prematurity, the acutely unwell infant, respiratory distress syndrome (RDS), chronic lung disease (CLD), necrotising enterocolitis (NEC), intracranial haemorrhage, hydrops fetalis and oedema. Fluid overload is a potential side effect of albumin administration. Albumin is a blood product and therefore carries the potential risk of infection and adverse reactions. Albumin is also a scarce and expensive resource. OBJECTIVES: The primary objective was to assess whether albumin infusions, in preterm neonates with low serum albumin, reduces mortality and morbidity. A secondary objective was to assess whether albumin infusion is associated with significant side effects. SEARCH STRATEGY: Searches were made of MEDLINE from 1966 to April 2004, CINAHL from 1982 to April 2004 and the current Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library issue 1, 2004). Previous reviews (including cross references) and abstracts were also searched. SELECTION CRITERIA: All randomised controlled trials in which individual patients were allocated to albumin infusion versus control were included. Cross-over studies were excluded. Quasi randomised trials were excluded. Participants were preterm infants who had hypoalbuminaemia. Types of interventions included albumin infusion versus placebo (e.g. crystalloid) or no treatment. DATA COLLECTION AND ANALYSIS: The reviewers worked independently to search for trials for inclusion and to assess methodological quality. Studies were assessed using the following key criteria: blinding of randomisation, blinding of intervention, completeness of follow up and blinding of outcome measurement. MAIN RESULTS: Only two small studies were found for inclusion in this review and only one reported clinically relevant outcomes - it found no significant differences for our primary outcome measure of death (RR 1.5 [95% confidence interval 0.3 - 7.43]) or secondary outcome measures of intraventricular haemorrhage, patent ductus arteriosus, necrotising enterocolitis, bronchopulmonary dysplasia, duration of mechanical ventilation and duration of oxygen therapy. REVIEWERS' CONCLUSIONS: There is a lack of evidence from randomised trials to determine whether the routine use of albumin infusion, in preterm neonates with low serum albumin, reduces mortality or morbidity, and no evidence to assess whether albumin infusion is associated with significant side effects. There is a need for good quality, double-blind randomised controlled trials to assess the safety and efficacy of albumin infusions in preterm neonates with low serum albumin.

Abstract: BACKGROUND: Umbilical artery catheters are often used in unwell neonates. Infection related to the use of these catheters may cause significant morbidity and mortality. The use of prophylactic antibiotics has been advocated for all newborns with umbilical artery catheters in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm may outweigh benefit. OBJECTIVES: The primary objective was to assess whether prophylactic antibiotics, in neonates with umbilical artery catheters, reduce mortality and morbidity. In separate comparisons, we planned to review two different policies regarding the prophylactic use of antibiotics in neonates with umbilical artery catheters: 1) among neonates with umbilical artery catheters, a policy of prophylactic antibiotics for the duration of catheterisation (or other fixed duration of antibiotic treatment) versus placebo or no treatment; 2) among neonates with umbilical artery catheters who had been started on antibiotics at the time of catheterisation but whose initial cultures to rule out sepsis are negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: We searched MEDLINE (January 1966 to February 2004), CINAHL (1982 to February 2004), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2004), the Cochrane Neonatal Group Specialised Register and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials of adequate quality in which newborn infants with umbilical artery catheters are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: No study met the criteria for inclusion in this review. REVIEWERS' CONCLUSIONS: There is no evidence from randomised trials to support or refute the use of prophylactic antibiotics when umbilical artery catheters are inserted in newborn infants, or to support or refute continuing antibiotics once initial cultures rule out infection in newborn infants with umbilical artery catheters.

Abstract: BACKGROUND: Acute lung injury (ALI), and acute respiratory distress syndrome (ARDS), are syndromes of severe respiratory failure. Adults with ALI or ARDS have high mortality and significant morbidity. Partial liquid ventilation (PLV) may be better (i.e., cause less lung damage) for these patients than other forms of respiratory support. Uncontrolled studies in adults have shown improvement in gas exchange and lung compliance with partial liquid ventilation. OBJECTIVES: To assess whether partial liquid ventilation reduces morbidity and mortality in adults with ALI or ARDS. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Issue 2, 2004; MEDLINE (1966 to May 2004); and CINAHL (1982 to May 2004); intensive care journals and conference proceedings; reference lists and unpublished literature. SELECTION CRITERIA: Randomized controlled trials which compared partial liquid ventilation with other forms of ventilation, in adults (16 years old or greater) with ALI or ARDS, reporting one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit, or stay in hospital; infection; long term cognitive impairment or health related quality of life; long term lung function; or cost. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated the quality of the relevant studies and extracted the data from the included studies. MAIN RESULTS: Problems with the inadequacy of the primary report of the one included study do not allow us to report any quantitative results for patients with ALI or ARDS. The only outcome we considered to be of clinical significance and reported for all enrolled patients (i.e., patients with ALI and ARDS and less severe respiratory insufficiency) was 28 day mortality. There was no statistically significant difference between groups for this outcome with a relative risk for 28 day mortality in the PLV group of 1.15 (95% confidence intervals of 0.64 to 2.10). REVIEWERS' CONCLUSIONS: There is no evidence from randomized controlled trials to support or refute the use of partial liquid ventilation in adults with ALI or ARDS; adequately powered, high quality randomized controlled trials are still needed to assess its efficacy. Clinically relevant outcome measures should be assessed (especially mortality at discharge and later, duration of respiratory support and hospital stay, and long term cognitive and quality of life outcomes) and the studies should be published in full.

Abstract: The warming and humidification of inspired gases for ventilated neonates are routine. There are no data on the temperature of the gas at the airway opening in ventilated neonates. Is the inspired gas temperature at the airway opening, as expected and set on the humidifier, around 37 degrees C? We aimed to measure temperature at the airway opening and compare this with the circuit temperature. This was an observational study in a neonatal intensive care unit. Twenty-five mechanically ventilated infants were studied. All had humidifiers with chamber temperature set at 36 degrees C and the circuit temperature set at 37 degrees C. Two temperature probes were inserted and rested at the circuit-exit and at the airway opening, and temperatures were measured for 2 min in each infant. At this time, the circuit temperature was also noted. The mean (SD) temperature at the airway opening in infants nursed in incubators was 34.9 (1.2) degrees C, compared with radiant warmers where the mean (SD) was 33.1 (0.5) degrees C. The mean (SD) difference in temperature from the circuit temperature probe to the airway opening was greater under radiant warmers, with a mean (SD) drop of 3.9 (0.6) degrees C compared with a mean (SD) drop of 2.0 (1.3) degrees C in the incubators. In conclusion, the temperature at the circuit temperature probe does not reflect the temperature at the airway opening. Inspired gas temperatures are lower than the expected 37 degrees C with the normal circuits and usual humidifier settings.

Abstract: A simple mount capable of securely holding a variety of intracranial probes to the skull was constructed from commonly available clinical consumables. Using this device the cerebral cortical blood flow of preterm lambs was measured using a laser Doppler flow probe, and cerebral pH and cortical electrical impedance were measured in newborn piglets using pH electrodes and Ag/AgCl wire electrodes. In both studies, the mount held the various probes for periods up to 6 h with no dislodgement or probe failure. The simple mount presented here can be adapted to a wide variety of intracranial probes and will hold them securely to the skull.

Abstract: BACKGROUND: Bacterial colonisation of the respiratory tract is associated with intubation and may increase the risk of acquiring infection. This may prolong the need for mechanical ventilation and increase the risk of chronic lung disease. The use of prophylactic antibiotics has been advocated for all mechanically ventilated newborns in order to reduce the risk of colonisation and acquired infection. Countering this is the possibility that harm may outweigh benefit. OBJECTIVES: To assess the effects of prophylactic antibiotics in reducing mortality and morbidity in intubated and ventilated newborn infants who are not known to have infection. In separate comparisons, we reviewed two different policies regarding the prophylactic use of antibiotics in intubated, ventilated infants: 1) among babies who are being intubated for mechanical ventilation, a policy of prophylactic antibiotics for the duration of intubation versus placebo or no treatment. 2) among intubated, ventilated babies who had been started on antibiotics at the time of intubation but whose initial cultures to rule our sepsis are negative, a policy of continuing versus discontinuing prophylactic antibiotics. SEARCH STRATEGY: We searched MEDLINE (January 1966 to May 2003), CINAHL (1982 to May 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003), the Cochrane Neonatal Group Specialised Register and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials of sufficient quality in which mechanically ventilated newborn infants are randomised to receive prophylactic antibiotics versus placebo or no treatment. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality. MAIN RESULTS: One study, of insufficient quality, met the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence from randomised trials to support or refute the use of prophylactic antibiotics when commencing mechanical ventilation in newborn infants, or to support or refute continuing antibiotics once initial cultures rule out infection in mechanically ventilated newborn infants.

Abstract: BACKGROUND: Acute lung injury, and acute respiratory distress syndrome, are syndromes of severe respiratory failure. Children with acute lung injury or acute respiratory syndrome have high mortality and significant morbidity. Partial liquid ventilation is proposed as a less injurious form of respiratory support for these children. Uncontrolled studies in adults have shown improvement in gas exchange and lung compliance with partial liquid ventilation A single uncontrolled study in six children with acute respiratory syndrome showed some improvement in gas exchange during three hours of partial liquid ventilation. OBJECTIVES: To assess whether partial liquid ventilation reduces either mortality or morbidity, or both, in children with acute lung injury or acute respiratory syndrome. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library issue 2, 2003; MEDLINE (1966 to April 2003); and CINAHL (1982 to April 2003); intensive care journals and conference proceedings; reference lists and 'grey literature'. SELECTION CRITERIA: Randomized controlled trials which compared partial liquid ventilation with other forms of ventilation, in children (28 days - 18 years) with acute lung injury or acute respiratory syndrome, reporting one or more of the following: mortality; duration of mechanical ventilation, respiratory support, oxygen therapy, stay in the intensive care unit, or stay in hospital; infection; or long term cognitive impairment or neurodevelopmental progress or other long term morbidities. DATA COLLECTION AND ANALYSIS: Two reviewers independently evaluated the quality of the relevant studies and extracted the data from the included studies. MAIN RESULTS: Only one study enrolling 182 patients (only reported as an abstract in conference proceedings) was identified and found eligible for inclusion: the authors report only limited results. The trial was stopped prematurely and therefore under-powered to detect any significant differences. The only outcome of clinical significance available was 28 day mortality: there was no statistically significant difference between groups with a relative risk for 28 day mortality in the partial liquid ventilation group of 1.54 (95% confidence intervals of 0.82 to 2.9). REVIEWERS' CONCLUSIONS: There is no evidence from randomized controlled trials to support or refute the use of partial liquid ventilation in children with acute lung injury or acute respiratory syndrome: adequately powered, high quality randomized controlled trials are still needed to assess its efficacy. Clinically relevant outcome measures should be assessed (mortality at discharge and later, duration of respiratory support and hospital stay, and long-term neurodevelopmental outcomes) and the studies should be published in full.

Abstract: BACKGROUND: The use of incubators in helping to maintain a thermoneutral environment for preterm infants has become routine practice in neonatal nurseries. As one of the key criteria for discharging preterm infants from nurseries is their ability to maintain temperature, the infant will need to make the transition from incubator to open cot at some time before discharge. The timing of this transition is important because when an infant is challenged by cold, the infant attempts to increase its heat production to maintain body temperature. The increase in energy expenditure may affect weight gain. The practice of transferring infants from incubators to open cots usually occurs once a weight of around 1700-1800 g has been reached; however, this practice varies widely between neonatal units. This preferred weight mark appears to be largely based on tradition or the personal experience of clinicians, with little consideration of the infant's weight or gestational age at birth. OBJECTIVES: The main objective was to assess the effects on weight gain and temperature control of a policy of transferring preterm infants from incubator to open cot at lower versus higher body weight. SEARCH STRATEGY: Searches were undertaken of MEDLINE from June 2003 back to 1966, CINAHL from June 2003 back to 1987 and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. SELECTION CRITERIA: Trials in which preterm infants were randomly allocated to a policy of transfer from incubators to open cots at a lower body weight versus at a higher body weight. DATA COLLECTION AND ANALYSIS: Quality assessments and data extraction for included trials were conducted independently by the reviewers. Data for individual trial results were analysed using relative risk (RR) and mean difference (MD). Results are presented with 95% confidence intervals (CI). Due to insufficient data, meta-analysis could not be undertaken. MAIN RESULTS: Four studies were identified as potentially eligible for inclusion in this review. Two studies were excluded as random allocation to the exposure was not employed. One study is pending, awaiting additional information from the authors. Therefore, one study involving 60 preterm infants, employing a matched-pairs design, which compared the transfer of infants to open cots at 1700 g versus 1800 g, is included in this review. Only two outcomes could be included from this study; return to incubator and daily weight gain. No statistically significant difference was shown for either return to incubator (RR 2.00, 95% CI 0.40 to 10.11) or daily weight gain [MD 4.00 g/day (95% CI -5.23, 13.23)]. Due to small numbers, effects on clinically important outcomes could not be adequately assessed. REVIEWERS' CONCLUSIONS: There is currently little evidence from randomised trials to inform practice on the preferred weight for transferring preterm infants from incubators to open cots. There is a need for larger randomised controlled trials to address this deficiency.

Abstract: OBJECTIVE: To determine whether perfluorocarbon liquid can be condensed from gases containing perfluorocarbon vapour and whether the amount recovered varies with background flow rate. DESIGN AND SETTING: Bench-top experimental study in a neonatal laboratory. INTERVENTIONS: The expiratory limb of a standard ventilator circuit set-up was mimicked, with the addition of a chilled water jacket (Liebig) condenser. Perfluorocarbon vapour was passed through the circuit at a number of flow rates. MEASUREMENTS AND RESULTS: Perfluorocarbon vapour was passed through the circuit and the percentage recovery of liquid measured. More than 60% of the perfluorocarbon vapour was recovered at all flow rates (1, 2, 5 and 10 l/min), with significantly higher recovery obtained (up to 74%) at low flow rates (1 l/min). CONCLUSIONS: Using a simple condenser, more than 60% of perfluorocarbon liquid can be recovered without altering the function of an expiratory limb of a ventilator circuit.

Abstract: BACKGROUND: Epinephrine is a cardiac stimulant with complex effects on the heart and blood vessels. It has been used for decades in all age groups to treat cardiac arrest and bradycardia. Despite formal guidelines for the use of epinephrine in neonatal resuscitation, the evidence for these recommendations has not yet been rigorously scrutinised. While it is understood that this evidence is in large part derived from animal models and the adult human population, the contribution from work in the neonatal population remains unclear. In particular, it remains to be determined if any randomised studies in neonates have helped to establish if the administration of epinephrine in the context of apparent stillbirth or extreme bradycardia might influence mortality and morbidity. OBJECTIVES: Primary objective: ~bullet~To determine if the administration of epinephrine to apparently stillborn and extremely bradycardic newborns reduces mortality and morbidity Secondary objectives: ~bullet~To determine the effect of intravenous versus endotracheal administration on mortality and morbidity ~bullet~To determine the effect of high dose versus standard dose epinephrine on mortality and morbidity, where high dose is defined as any dose greater than the current recommended standard dose of 0.1 to 0.3ml/kg of a 1:10,000 solution of epinephrine ~bullet~To determine whether the effect of epinephrine on mortality and morbidity varies with gestational age, i.e. term (greater than or equal to 37 weeks) versus pre-term (less than 37 weeks) SEARCH STRATEGY: Searches were made of Medline from 1966 to December 2002, CINAHL (from 1982), Current Contents (from 1988), EMBASE, and the Cochrane Controlled Trials Register (2002, issue 4). Bibliographies of conference proceedings were reviewed and unpublished studies were sought by hand searching the conference proceedings of the Society for Pediatric Research and the European Society for Pediatric Research from 1993 to 2002. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials of newborns, both pre-term and term, receiving epinephrine for unexpected apparent stillbirth or extreme bradycardia. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: We found no randomised, controlled trials evaluating the administration of epinephrine to the apparently stillborn or extremely bradycardic newborn infant. Similarly, we found no randomised, controlled trials which addressed the issues of optimum dosage and route of administration of epinephrine. Current recommendations for the use of epinephrine in newborn infants are based only on evidence derived from animal models and the human adult literature. Randomised trials in neonates are urgently required to determine the role of epinephrine in this population.

Abstract: OBJECTIVES: To assess the effect that infant to staff ratios, in the first three days of life, have on the survival to hospital discharge of very low birthweight infants (<1500 g), having adjusted for initial risk and unit workload. DESIGN: In a retrospective analysis of a cohort of patients, the number of infants per nurse per shift were averaged for the first three days after admission and related to risk of mortality by logistic regression analysis. Infant to staff ratio was divided into terciles of low (1.16-1.58), medium (1.59-1.70), and high (1.71-1.97) infants per staff member. SUBJECTS: 692 very low birthweight infants admitted to the Intensive Care Nursery, Royal Women's Hospital, Brisbane over a four year period from January 1996 to December 1999. MAIN OUTCOME MEASURES: Survival to hospital discharge, adjusted for initial risk using the Clinical Risk Index for Babies (CRIB) score, and adjusted for unit workload using dependency scores. RESULTS: There were 80 deaths among the 692 babies analysed for the study period. The odds of mortality, adjusted for initial risk and infant dependency scores (unit workload), were improved by 82% when an infant/staff ratio of greater than 1.71 occurred, suggesting improved survival with the highest infant/staff ratio. The low and medium staffing levels corresponded with similar odds ratios for mortality. CONCLUSIONS: Infants exposed to higher infant to staff ratios have an improved adjusted risk of survival to hospital discharge.

Abstract: The present paper reports a retrospective cohort of preterm infants admitted to our hospital who delivered outside the normal geographical catchment area of the mother's local level three neonatal nursery. Nineteen mothers had 21 preterm infants (23.1-34.9 weeks, 500-2330 g born) where 14 infants required ventilation (median 57 h, range 3-428). Eighteen survivors had a median length of stay of 41 days (range 3-91). Twelve of 19 mothers were interviewed: all described isolation, loneliness, poor social support and significant financial hardship related to getting their infants back to a local hospital or home. To avoid these problems, we recommend confining travel to within a short distance from home or local maternity unit after 22 weeks.

Abstract: OBJECTIVE: We believed that intercostal catheters were often inserted too far into the thoracic cavity in neonatal patients. The aim of this study was to determine the average distance from the catheter tip to the midline, of intercostal catheters inserted in our neonatal unit and the incidence of catheters that were inserted too far into the thoracic cavity. METHODS: During a two year period we examined the chest X-rays of all infants who had an intercostal catheter inserted using an Argyle 10 French trocar thoracic catheter for drainage of a pneumothorax. For each initial chest X-ray following the insertion of the intercostal catheter we measured the horizontal distance in mm from catheter tip to the midline. The tip to midline distance was zero if the tip was at the midline and negative if it crossed the midline. To standardise the tip to midline distance for different size infants we measured the distance in 'inter-vertebral' units. RESULTS: During the two year period, 13 of 24 intercostal catheters (54%) crossed the midline (i.e. were inserted too far). The mean (+/- SD) tip to midline distance was -1.29 (+/- 13.9) mm with a range varying between -40 to 34 mm with a calculated 'inter-vertebral' units mean (+/- SD) tip to midline distance of -0.32 (+/- 1.9) range -4.6 to 4.0. CONCLUSIONS: Fifty four percent of the intercostal catheters inserted in our unit were inserted too far. As the distance markings on the Argyle intercostal catheters are marked from the last side-hole rather than from the tip of the catheter, Argyle intercostal catheters may be inadvertently inserted two centimetres further than they should be.

Abstract: OBJECTIVES: To examine the fate of research presented at the first annual Perinatal Society of Australia and New Zealand (PSANZ) Congress in 1997, by determining: the rate of publication in peer-reviewed biomedical journals; publication rate by discipline; journals in which work was published; concordance for aims, conclusions, authors and number of study subjects; and time from presentation to publication. METHODS: A MEDLINE search was conducted for any publication in a peer-reviewed journal resulting from a publishable abstract from the proceedings of the first annual PSANZ Congress in 1997. Searching was completed 42 months post-congress. The concordance of aims, conclusions, authors and number of subjects between abstract and published paper was determined. RESULTS: There were 172 publishable abstracts in the proceedings of the PSANZ Congress in 1997, and 78 (45%) were published as 83 articles. Basic sciences had the highest publication rate (67%) and midwifery the lowest (20%). Articles were published in 41 journals, with one-third of the articles in three paediatric journals. There was a match with aims in 75%, and with conclusions in 65%. There were 47/77 with the same number of subjects, 20/77 with more and 10/77 with fewer. There were 22 articles with one author added, 12 had more than one author added, 11 had one author removed and five had more than one author removed. Median time-to-publication was 18 months (interquartile range 9-26 months). CONCLUSIONS: A publication rate of 45% is comparable to other conferences. Basic science and neonatology had the highest publication rates. There were considerable differences between abstract and published article in terms of aims, conclusions, number of subjects and authors.

Abstract: There are limited data on the volumes used to ventilate infants with respiratory distress syndrome (RDS). There are no data on the volumes to aim for to avoid hypocapnia or unacceptable levels of hypercapnia. In this pilot study we measured minute volumes (MV) in ventilated infants to determine whether MV can predict arterial carbon dioxide (PaCO(2)) within acceptable parameters. Low birth weight infants (n = 14) mechanically ventilated for RDS had lung function recorded (n = 53) as an arterial blood gas was taken. MVs were plotted against PaCO(2) giving the regression equation for prediction of PaCO(2) (mm Hg) with MV (ml/kg/min): PaCO(2) = 58.3 - 0.075 x MV, r = 0.62, r(2) = 0.38, p < 0.001, residual variance (s(2)) of 52.7 (s = 7.26). 95% CI give a predicted PaCO(2) +/- 15 mm Hg for a given MV. A MV of 200 ml/kg/min predicts a PaCO(2) of 43 mm Hg (95% Cl 29-58). PaCO(2) correlates reasonably well with MV. Setting appropriate MVs may allow closer targeting of PaCO(2), and prevent over- or under-ventilation.

Abstract: OBJECTIVE: The aims of this study were to determine in two institutions the frequency of clotted coagulation profile specimens in neonatal patients, the proportion of patients who had the test repeated if the coagulation profile specimen clotted and the number of abnormal results in the tests that were repeated. METHODS: The number of neonatal coagulation profiles (i.e. prothrombin time and activated partial thromboplastin time) were identified from the pathology databases at the Royal Women's Hospital and at the Mater Mother's Hospital. Each specimen that clotted and the number of tests that were repeated were identified and counted. Data from the tests that were repeated were analysed and compared with normal ranges for neonates. RESULTS: There were 746 specimens that were sent for a coagulation profile of which 45 (6.0%) clotted. Of the 45 clotted specimens, 31 (69%) were repeated. From the 31 repeated specimens, 6 clotted, 1 was an 'insufficient' specimen, and 24 were able to be processed. From the 24 processed specimens 17 (71%) had an abnormal result, 11 of which had a mildly elevated prothrombin time and the other six had a severe clotting abnormality. CONCLUSIONS: If a neonatal patient's coagulation profile specimen clots it should not be assumed that the infant's clotting is normal, and another specimen should be sent for analysis.

Abstract: OBJECTIVE: To investigate the effects of inhaled nitric oxide (iNO) and partial liquid ventilation (PLV) on oxygenation and pulmonary haemodynamics in acute lung injury (ALI), and to assess their effects on lung function, systemic haemodynamics and lung injury. METHODS: Using saline lung lavage, ALI was induced in 18 piglets. A control group was ventilated with conventional mechanical ventilation (CMV) for 2 h. An iNO-first group received iNO for the first hour and then iNO with PLV. A PLV-first group received PLV for the first hour and then PLV with iNO. Variables were measured at baseline, 5 min postlavage, and at 1 h and 2 h postlavage. RESULTS: During the first hour, both treatment groups showed improvement in oxygenation index (OI). At 2 h, the dif-ferences in OI were statistically significant (P = 0.037), with a mean +/- SD of 23.8 +/- 20.7 in the control group, 4.4 +/- 0.9 in the PLV-first group and 6.5 +/- 3.1 in the iNO-first group. The OI was similar in both treatment groups (P = 0.178). At 2 h, the pulmonary artery pressure (PAP) was significantly different (P = 0.04) between groups, with a mean +/- SD PAP of 36.3 +/- 7.2 mmHg in the control group, 27.4 +/- 4.0 mmHg in the PLV-first group and 30.0 +/- 4.1 mmHg in the iNO-first group. The PAP was similar in both treatment groups (P = 0.319). CONCLUSION: In ALI, oxygenation and pulmonary hypertension are improved with PLV and iNO given together, regardless of the order in which they are commenced.

Abstract: BACKGROUND: Gastroschisis is a congenital anterior abdominal wall defect with the abdominal contents protruding through the defect. Reduction of the abdominal contents is required within hours after birth as the infant is at risk not only of water and heat loss from the exposed bowel but also of compromised gut circulation with ischaemia and infarction. To avoid the complications of general anaesthetic and mechanical ventilation it has been proposed that the reduction of abdominal contents can be achieved without endotracheal intubation or anaesthesia. OBJECTIVES: To determine which approach to the immediate surgical treatment of gastroschisis has the better outcomes: ward reduction without general anaesthetic or reduction and repair of the abdominal wall defect under general anaesthesia. SEARCH STRATEGY: Searches were made of MEDLINE from 1966 to March 2002, CINAHL from 1982 to March 2002, and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). Previous reviews including cross references, abstracts, and conference and symposia proceedings published in Pediatric Research (from 1990 to 1994) were also searched, especially for any unpublished data. SELECTION CRITERIA: Randomised, controlled trials (RCT) comparing ward reduction with reduction under general anaesthesia, for neonates with gastroschisis. Outcomes considered were: mortality, duration of total parenteral nutrition, time to full enteral feeds, need for a silo, infection, gastro-intestinal tract perforation, length of bowel lost/resected, need for a general anaesthesia, need for and duration of mechanical ventilation and respiratory support, duration of oxygen therapy, need for further operative procedure after initial reduction, duration of hospital stay, cosmetic outcome, nutritional status, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review. MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence from RCTs to support or refute the practice of ward reduction for the immediate management of gastroschisis. There is an urgent need for RCTs to compare ward reduction versus reduction under general anaesthesia in infants with gastroschisis. Initial trials would best be limited to those infants with uncomplicated gastroschisis (using pre-defined selection criteria excluding infants that are unstable, have gut perforation, necrosis or atresia, have other organs requiring reduction besides bowel, or are considered to need a silo prior to any reduction. Trials should use adequate pain relief and specify a pre-defined time period after which manual reduction is abandoned.

Abstract:

Abstract: BACKGROUND: Metabolic or mixed (metabolic and respiratory) acidosis are commonly encountered problems in the low birth weight (LBW) infant after delivery, and they may contribute to mortality and morbidity. Causes for the lactic acidosis are multiple and include maternal, placental and fetal factors. It is unclear whether metabolic acidaemia in the first 24 hours of life in LBW infants should be corrected by rapid infusion of alkali. OBJECTIVES: The main objective was to assess the short and long-term effects of the rapid correction of early (first 24 hours) metabolic acidaemia in LBW (<2500g birth weight) neonates. SEARCH STRATEGY: Searches were undertaken of MEDLINE from October 2001 back to 1966 and the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001). The title and abstract of each retrieved study were examined to assess eligibility. If there was uncertainty, the full paper was examined. SELECTION CRITERIA: Types of studies All randomised controlled trials where short or long term effects of treatment with alkalising agents by rapid infusion were compared with placebo or no treatment, or where rapid infusion of alkalising agents was compared with slow infusion. Types of participants Newborn infants with birth weight <2500g and less than 24 hours of age with proven metabolic acidaemia (on arterial blood gas). Types of interventions Rapid correction of acidaemia with alkalising agents (sodium bicarbonate and/or THAM) given as a bolus over 5 minutes or less compared with either placebo, no intervention or slow infusion (>5 minutes). Types of outcome measures 1) maximal oxygen requirement in first 24 hours 2) duration of oxygen therapy 3) need for and duration of assisted ventilation 4) intraventricular haemorrhage and/or periventricular leucomalacia 5) survival to discharge 6) long term survival (to 24 months of age) 7) neurological and developmental outcome at 24 months of age DATA COLLECTION AND ANALYSIS: Each reviewer assessed eligibility, trial quality and extracted data separately, then compared and resolved differences. Study authors were contacted for additional information if necessary. MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review. REVIEWER'S CONCLUSIONS: There is no evidence available from randomised controlled trials to support or refute the rapid correction of metabolic acidaemia, in LBW infants in the first 24 hours of life, as compared with slow or no correction.

Abstract: OBJECTIVE: To compare measured tidal volumes with and without perfluorocarbon (perfluorooctyl bromide) vapor, by using tidal volumes in the range suitable for neonates ventilated with partial liquid ventilation. We also aimed to determine the correction factor needed to calculate tidal volumes measured in the presence of perfluorooctyl bromide vapor. DESIGN: Prospective, experimental study. SETTING: Neonatal research laboratory. INTERVENTIONS: Reproducible tidal volumes from 5 to 30 mL were produced with a rodent ventilator and drawn from humidifier chambers immersed in a water bath at 37 degrees C. Control tidal volumes were drawn from a chamber containing oxygen and water vapor, and the perfluorocarbon tidal volumes were drawn from a chamber containing oxygen, water vapor, and perfluorooctyl bromide vapor. MEASUREMENTS AND MAIN RESULTS: Tidal volumes were measured by a VenTrak respiratory mechanics monitor with a neonatal flow sensor and a Dräger pneumotachometer attached to a Dräger neonatal ventilator. All tidal volumes measured with perfluorooctyl bromide vapor were increased compared with control. The VenTrak-measured tidal volumes increased by 1.8% to 3.5% (an overall increase of 2.2%). The increase was greater with the Dräger hot-wire anemometer: from 2.4% to 6.1% (an overall increase of 5.9%). Regression equations for mean control tidal volumes (response, Y) vs. mean perfluorooctyl bromide tidal volumes (predictor, X) are as follows: for the VenTrak, Y = -0.026 + (0.978 x X), r =.9999, p <.0001; and for the Dräger, Y = 0.251 + (0.944 x X), r =.9996, p <.0001. CONCLUSIONS: The presence of perfluorooctyl bromide vapor in the gas flowing through pneumotachometers gives falsely high tidal volume measurements. An estimate of the true tidal volume allowing for the presence of perfluorooctyl bromide vapor can be made from regression equations. Any calculation of lung mechanics must take into account the effect of perfluorooctyl bromide vapor on the measurement of tidal volume.

Abstract: BACKGROUND: Tracheal gas insufflation (TGI) is a technique where a continuous flow of gas is instilled into the lower trachea during conventional mechanical ventilation. TGI can improve carbon dioxide removal with lower ventilation pressures and smaller tidal volumes, potentially decreasing secondary lung injury and chronic lung disease (CLD). OBJECTIVES: To assess whether, in mechanically ventilated neonates, the use of tracheal gas insufflation reduces mortality, CLD and other adverse clinical outcomes without significant side effects. SEARCH STRATEGY: Searches were made of MEDLINE 1966 to December 2001, CINAHL 1982 to December 2001, the Cochrane Controlled Trials Register (Cochrane Library, Issue 4, 2001) and conference and symposia proceedings. SELECTION CRITERIA: Randomised controlled trials (RCT) that include newborn infants who are mechanically ventilated, and compare TGI during conventional mechanical ventilation (CMV) with CMV alone. Primary outcomes - mortality, CLD and neurodevelopmental outcome; secondary outcomes - air leak, intraventricular haemorrhage, periventricular leukomalacia, duration of mechanical ventilation, duration of respiratory support, duration of oxygen therapy, duration of hospital stay, retinopathy of prematurity, immediate adverse effects. DATA COLLECTION AND ANALYSIS: Each reviewer assessed eligibility, trial quality and extracted data separately. Study authors were contacted for additional information if necessary. MAIN RESULTS: Only one small study was found to be eligible. This study found no evidence of effect on mortality, CLD or age at first extubation. The total duration of ventilation was 9.3 days shorter in the TGI group (95% CI from 15.7 to 2.9 days shorter). The age at complete weaning from ventilation was 26 days shorter in the TGI group (95% CI from 46 to 6 days shorter). There was no evidence of effect on the total duration of respiratory support, oxygen therapy or hospital stay. REVIEWER'S CONCLUSIONS: There is evidence from a single RCT that TGI may reduce the duration of mechanical ventilation in preterm infants - although the data from this small study do not give sufficient evidence to support the introduction of TGI into clinical practice. The technical requirements for performing TGI (as performed in the single included study) are great. There is no statistically significant reduction in the total duration of respiratory support or hospital stay. TGI cannot be recommended for general use at this time.

Abstract: BACKGROUND: Gastro-oesophageal reflux (GOR) is common in newborn infants. A common first line management is the use of feed thickeners. OBJECTIVES: In newborn infants with GOR, to evaluate the use of feed thickeners in reducing signs and symptoms of GOR, acid episodes on pH monitoring and histological evidence of oesophagitis. SEARCH STRATEGY: We searched MEDLINE from 1966 to December 2001, the Cochrane Controlled Trials Register, The Cochrane Library, Issue 1, 2002. CINAHL from 1982 to December 2001, and conference and symposia proceedings published in Pediatric Research 1990 to 1994. We also searched conference proceedings for the European Society for Paediatric Gastroenterology and Nutrition (ESPGAN) and the North American Society for Pediatric Gastroenterology and Nutrition (NASPGAN) from 1994 to December 2001. We did not restrict the searches to the English language. SELECTION CRITERIA: All randomised controlled trials that examine the effects of thickening formulas on treating gastro-oesophageal reflux in neonates. The eligible studies were to compare thickened feeds to no intervention (unthickened feeds). DATA COLLECTION AND ANALYSIS: Two independent reviewers identified potential studies from the literature search. Quality was independently assessed by two independent reviewers. MAIN RESULTS: No studies fulfilled the requirements for inclusion in the systematic review. REVIEWER'S CONCLUSIONS: There is no evidence from randomised controlled trials to support or refute the efficacy of feed thickeners in newborn infants with GOR. Given the absence of evidence, we cannot recommend using thickening agents for management of GOR in newborn infants.

Abstract: BACKGROUND: Following a period of mechanical ventilation, post-extubation upper airway obstruction can occur in newborn infants, especially after prolonged, traumatic or multiple intubations. The subsequent increase in upper airway resistance may lead to respiratory insufficiency and failure of extubation. The vasoconstrictive properties of epinephrine, and its proven efficacy in the treatment of croup in infants, has led to the routine use of inhaled nebulized epinephrine immediately post-extubation in some neonatal units. It is also recommended for neonates with post-extubation tracheal obstruction and stridor in neonatal and respiratory textbooks and reviews. OBJECTIVES: The primary objective was to assess whether nebulized epinephrine administered immediately after extubation in neonates weaned from IPPV decreases the need for subsequent additional respiratory support. SEARCH STRATEGY: Searches were of: MEDLINE from 1966 to September 2000; CINAHL from 1982 to September 2000; Current Contents from 1994 to September 2000; and the Cochrane Controlled Trials Register (Cochrane Library Issue 3, 2000). These searches were updated to September 2001 for this review update. Previous searches up to March 1999 included the Oxford Database of Perinatal Trials, expert informants and journal hand searching mainly in the English language, previous reviews including cross references, abstracts, and conference and symposia proceedings. SELECTION CRITERIA: All randomised and quasi-randomised control trials in which nebulized epinephrine was compared with placebo immediately post-extubation in newborn infants who have been weaned from IPPV and extubated, with regard to clinically important outcomes (i.e. need for additional respiratory support, increase in oxygen requirement, respiratory distress, stridor or the occurrence of side effects). DATA COLLECTION AND ANALYSIS: No studies met our criteria for inclusion in this review. MAIN RESULTS: No studies were identified which looked at the effect of inhaled nebulized epinephrine on clinically important outcomes in infants being extubated. REVIEWER'S CONCLUSIONS: Implications for practice: There is no evidence either supporting or refuting the use of inhaled nebulized racemic epinephrine in newborn infants. Implications for research: randomised controlled trials are needed comparing inhaled nebulized racemic epinephrine with placebo in neonates post-extubation. This should be looked at both as a routine treatment post-extubation and as specific treatment for post-extubation upper airway obstruction. Study populations should include the group of infants at highest risk for upper airway obstruction from mucosal swelling because of their small glottic and sub-glottic diameters (ie those infants with birthweights less than 1000 grams).

Abstract: BACKGROUND: Experimental animal data and uncontrolled, observational studies in human infants have suggested that hyperventilation and hypocapnia may be associated with increased pulmonary and neurodevelopmental morbidity. Protective ventilatory strategies allowing higher levels of arterial CO2 (permissive hypercapnia) are now widely used in adult critical care. The aggressive pursuit of normocapnia in ventilated newborn infants may contribute to the already present burden of lung disease. However, the safe or ideal range for PCO2 in this vulnerable population has not been established. OBJECTIVES: To assess whether, in mechanically ventilated neonates, a strategy of permissive hypercapnia improves short and long term outcomes (esp. mortality, duration of respiratory support, incidence of chronic lung disease and neurodevelopmental outcome). SEARCH STRATEGY: Standard strategies of the Cochrane Neonatal Review Group were used. Searches were made of the Oxford Database of Perinatal Trials, MEDLINE, CINAHL, and Current Contents. Searches were also made of previous reviews including cross-referencing, abstracts, and conference and symposia proceedings published in Pediatric Research. SELECTION CRITERIA: All randomised controlled trials in which a strategy of permissive hypercapnia was compared with conventional strategies aimed at achieving normocapnia (or lower levels of hypercapnia) in newborn infants who are mechanically ventilated were eligible. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Neonatal Review Group were used. Trials identified by the search strategy were independently reviewed by each author and assessed for eligibility and trial quality. Data were extracted separately. Differences were compared and resolved. Additional information was requested from trial authors. Only published data were available for review. Results are expressed as relative risk and risk difference for dichotomous outcomes, and weighted mean difference for continuous variables. MAIN RESULTS: Two trials involving 269 newborn infants were included. Meta-analysis of combined data was possible for three outcomes. There was no evidence that permissive hypercapnia reduced the incidence of death or chronic lung disease at 36 weeks (RR 0.94, 95% CI 0.78, 1.15), intraventricular haemorrhage grade 3 or 4 (RR 0.84, 95% CI 0.54, 1.31) or periventricular leukomalacia (RR 1.02, 95% CI 0.49, 2.12). There were no differences in any other reported outcomes when the strategy of permissive hypercapnia/minimal ventilation was compared to routine ventilation in newborn infants. Long term neurodevelopmental outcomes were not reported. One trial reported that permissive hypercapnia reduced the incidence of chronic lung disease in the 501 to 750 gram subgroup. REVIEWER'S CONCLUSIONS: This review does not demonstrate any significant overall benefit of a permissive hypercapnia/minimal ventilation strategy compared to a routine ventilation strategy. At present, therefore, these ventilation strategies cannot be recommended to reduce mortality, or pulmonary and neurodevelopmental morbidity. Ventilatory strategies which target high levels of PCO2 (> 55 mmHg) should only be undertaken in the context of well-designed controlled clinical trials. These trials should aim to establish the safe, or ideal, range for CO2 in ventilated newborns, and examine the role of protective ventilatory techniques in achieving this target.

Abstract: BACKGROUND: Following a period of mechanical ventilation, post-extubation upper airway obstruction can occur in newborn infants, especially after prolonged, traumatic or multiple intubations. The subsequent increase in upper airway resistance may lead to respiratory insufficiency and failure of extubation. The vasoconstrictive properties of epinephrine, and its proven efficacy in the treatment of croup in infants, has led to the routine use of inhaled nebulised epinephrine immediately post-extubation in some neonatal units. It is also recommended for neonates with post-extubation tracheal obstruction and stridor in neonatal and respiratory textbooks and reviews. OBJECTIVES: The primary objective was to assess whether nebulised epinephrine administered immediately after extubation in neonates weaned from IPPV decreases the need for subsequent additional respiratory support. SEARCH STRATEGY: Searches were made using MeSH search terms 'epinephrine' and 'exp infant, newborn'. Databases searched included: MEDLINE from1966 to September 2000; CINAHL from 1982 to September 2000; Current Contents from 1994 to September 2000; and the Cochrane Controlled Trials Register, The Cochrane Library 2000 Issue 3. Previous searches up to March 1999 have included the Oxford Database of Perinatal trials, expert informants and journal hand searching mainly in the English language, expert informant searches in the Japanese language by Prof. Ogawa, previous reviews including cross references, abstracts, and conference and symposia proceedings. SELECTION CRITERIA: All randomised and quasi-randomised control trials in which nebulised epinephrine was compared with placebo immediately post-extubation in newborn infants who have been weaned from IPPV and extubated, with regard to clinically important outcomes (i.e. need for additional respiratory support, increase in oxygen requirement, respiratory distress, stridor or the occurrence of side effects). DATA COLLECTION AND ANALYSIS: No studies met our criteria for inclusion in this review. MAIN RESULTS: No studies were identified which looked at the effect of inhaled nebulised epinephrine on clinically important outcomes in infants being extubated. REVIEWER'S CONCLUSIONS: Implications for practice: There is no evidence either supporting or refuting the use of inhaled nebulised racemic epinephrine in newborn infants. Implications for research: randomised controlled trials are needed comparing inhaled nebulised racemic epinephrine with placebo in neonates post-extubation. This should be looked at both as a routine treatment post-extubation and as specific treatment for post-extubation upper airway obstruction. Study populations should include the group of infants at highest risk for upper airway obstruction from mucosal swelling because of their small glottic and sub-glottic diameters (ie those infants with birthweights less than 1000 grams).

Abstract: This study aims to confirm the relationship between gestational age (GA) and transverse cerebellar diameter (TCD), to define the prediction of GA by TCD, and assess the reliability of TCD measurements. Infants were included in the study if they had a routine cranial ultrasound scan by day 3, and the TCD was measured. Infants were excluded from the study if the GA was not known, if there was any cranio-spinal malformation or grade 3 or 4 intraventricular haemorrhage (IVH). The GA assessment was an early pregnancy scan or certain dates. Cranial ultrasound scans were done with a LOGIQ 500 scanner (GE Medical Systems, Waukesha, WI, USA) with a 7 MHz curvilinear sector probe (GE LOGIQ-C721; GE Medical Systems). The posterior fossa was scanned using the asterion as the acoustic window with the TCD measured in the coronal plane. Intra- and interobserver reliability were assessed. A total of 221 infants of known GA had their TCD measured. The linear regression for GA versus TCD is: GA(weeks) = (0.470 x TCD(millimetres)) + 13.162 (r = 0.89, r(2) = 0.79, P < 0.001). The 95% confidence interval predicts GA to +/- 2.33 weeks for a given TCD. Intra- and interobserver intraclass correlation coefficients are 0.98 and 0.99, respectively. Transverse cerebellar diameter correlates closely with GA and predicts GA to +/- 2.33 weeks. Measurements of TCD have excellent reproducibility.

Abstract: OBJECTIVES: Primary: to determine whether nasal continuous positive airway pressure (CPAP) delivered through binasal prongs results in a greater proportion of extremely low birthweight infants being successfully extubated, after a period of intermittent positive pressure ventilation, than nasal CPAP delivered by a single nasal prong. Secondary: to evaluate the effect of mode of delivery of nasal CPAP after extubation on the need for endotracheal reintubation, weight gain, rates of feeding intolerance, sepsis, suspected sepsis, cranial ultrasound abnormalities, retinopathy of prematurity, chronic lung disease, and the duration of assisted ventilation and care in the tertiary neonatal unit. DESIGN AND SETTING: Randomised, controlled, clinical trial conducted at the neonatal intensive care unit of the Royal Women's Hospital, Melbourne, Australia. PATIENTS: Infants of birth weight less than 1000 g, ventilated, requiring < 50% oxygen and ventilator rate less than or equal to 20/minute, and considered by the clinical management team to be ready for extubation. INTERVENTION: Infants were randomly allocated to receive nasal CPAP delivered through binasal (Hudson) prongs or a single nasal prong. PRIMARY OUTCOME MEASURE: Failure of extubation as defined by the following criteria: (a) apnoea (more than one episode/hour over a six hour period or one episode requiring bag and mask ventilation); (b) absolute increase in oxygen requirement greater than 15% above that required before extubation; (c) respiratory acidosis (pH < 7.25 with PCO(2) > 6.67 kPa). RESULTS: Ten of the 41 (24%) infants randomised to binasal prongs reached predetermined failure criteria compared with 26 of the 46 (57%) infants randomised to a single nasal prong (p = 0.005). Four of 17 (24%) infants of birth weight less than 800 g extubated to binasal prongs reached failure criteria compared with 14 of 16 (88%) extubated to a single nasal prong (p < 0.001). There were no significant differences in any of the secondary outcomes. CONCLUSIONS: For extremely low birthweight infants ventilated using an endotracheal tube, nasal CPAP delivered through binasal (Hudson) prongs is more effective in preventing failure of extubation than that delivered through a single nasal prong.

Abstract: OBJECTIVE: To compare the effects of partial liquid ventilation with conventional mechanical ventilation on oxygenation and pulmonary mechanics in saline lavaged rabbits. METHODS: Following acute lung injury (saline-lavage), rabbits were assigned to continue conventional mechanical ventilation (n = 6) or commence partial liquid ventilation (n = 6). In both groups the inspired oxygen concentration was 100% throughout the study. The target PaCO2 of 40-60 mmHg was accomplished by keeping the tidal volume between 7 and 10 mL/kg. During the study the peak inspiratory pressure was adjusted to maintain the target PaCO2. Arterial blood gases were taken pre-lavage, immediately post-lavage (time = 0) and then hourly for 5 hours. Pulmonary mechanics were estimated by measuring compliance and resistance. Pulmonary function was measured pre-lavage, immediately post-lavage and at 1 and 5 hours. At 5 hours the rabbits were killed and the lungs were removed for histological examination. RESULTS: Baseline PaO2, compliance and resistance were not significantly different between groups. The partial liquid ventilation group had a higher PaO2 and a significantly better oxygenation index one hour after commencing partial liquid ventilation and a significantly higher PaO2 averaged over the three hours post-treatment. There were no significant differences in compliance, resistance or lung damage scores. CONCLUSIONS: In this experimental model of acute lung injury, partial liquid ventilation resulted in immediate and sustained increase in PaO2 over 3 hours without significant change in lung mechanics or histological lung damage.

Abstract: BACKGROUND: Following a period of mechanical ventilation, post-extubation upper airway obstruction can occur in newborn infants, especially after prolonged, traumatic or multiple intubations. The subsequent increase in upper airway resistance may lead to respiratory insufficiency and failure of extubation. The vasoconstrictive properties of epinephrine, and its proven efficacy in the treatment of croup in infants, has led to the routine use of inhaled nebulised epinephrine immediately post-extubation in some neonatal units. It is also recommended for neonates with post-extubation tracheal obstruction and stridor in neonatal and respiratory textbooks and reviews. OBJECTIVES: The primary objective was to assess whether nebulised epinephrine administered immediately after extubation in neonates weaned from IPPV decreases the need for subsequent additional respiratory support. SEARCH STRATEGY: Searches were made of Medline (MeSH search terms 'epinephrine' and 'exp infant, newborn'), the Oxford Database of Perinatal trials, expert informants and journal hand searching mainly in the English language, expert informant searches in the Japanese language by Prof. Ogawa, previous reviews including cross references, abstracts, and conference and symposia proceedings. SELECTION CRITERIA: All randomised and quasi-randomised control trials in which nebulised epinephrine was compared with placebo immediately post-extubation in newborn infants who have been weaned from IPPV and extubated, with regard to clinically important outcomes (i.e. need for additional respiratory support, increase in oxygen requirement, respiratory distress, stridor or the occurrence of side effects). DATA COLLECTION AND ANALYSIS: No studies met our criteria for inclusion in this review. MAIN RESULTS: No studies were identified which looked at the effect of inhaled nebulised epinephrine on clinically important outcomes in infants being extubated. REVIEWER'S CONCLUSIONS: Implications for practice: There is no evidence either supporting or refuting the use of inhaled nebulised racemic epinephrine in newborn infants. Implications for research: randomised controlled trials are needed comparing inhaled nebulised racemic epinephrine with placebo in neonates post-extubation. This should be looked at both as a routine treatment post-extubation and as specific treatment for post-extubation upper airway obstruction. Study populations should include the group of infants at highest risk for upper airway obstruction from mucosal swelling because of their small glottic and sub-glottic diameters (ie those infants with birthweights less than 1000 grams).

Abstract: OBJECTIVES: To investigate the bacteria and fungi contaminating toys in neonatal intensive care unit (NICU) cots, the colonization rates, and factors that influence them. METHODS: A cross-sectional, longitudinal bacteriologic survey of all toys in the cots of infants in an NICU. All the toys in an infant's cot were cultured weekly for 4 weeks. Data were collected on the infant's postnatal age, the type of cot, whether humidity was added, characteristics of the toy, and any infant infections. RESULTS: Over the 4-week period, there were 86 cultures from 34 toys of 19 infants. Bacteria were grown from 84/86 (98%): 84 of the cultures grew coagulase-negative Staphylococcus, 50 Micrococcus sp, 21 Bacillus sp, 13 methicillin-resistant Staphylococcus aureus, 12 diphtheroids, 4 group B streptococcus, 3 S aureus, 3 nonhemolytic streptococci, 3 group D streptococci, 4 alpha-hemolytic streptococci, and 2 coliforms. None grew fungi. The colonization rate did not differ with cot type, presence of humidity, size of the toy, toy fiber length, or the fluffiness score. Eight (42%) of the infants had positive blood culture results and 5/8 of the isolates (63%) were of the same type as that colonizing their corresponding toy. IMPLICATIONS: With time, all the toys in NICU cots became colonized with bacteria. Many were potentially pathogenic. Toys may be reservoirs for potential infantile nosocomial sepsis. infant, newborn, toys, infection, neonatal intensive care.

Abstract: AIMS: To establish normal ranges, in preterm infants < 33 weeks' gestation, for measurements of the lateral, third, and fourth ventricles and to assess intra-observer and inter-observer reliability. To assess the effect of head position during scanning on lateral ventricle size. To determine whether sex influences ventricle size. METHODS: A prospective study involving infants < 33 weeks' gestational age (GA) at birth. Cranial ultrasound scans were done during the first 3 days of life. Linear dimensions of the anterior horn width and thalamo-occipital distance of the lateral ventricles, the width of the third ventricle, and the width and length of the fourth ventricle were measured. Measurements were plotted against GA and reference ranges produced. All measurements were tested for intra-observer and inter-observer reliability. Head position and sex differences were studied. RESULTS: 120 infants with known GA (23(+1) to 32(+6) weeks) had their intracranial ventricles measured. Reference ranges obtained were-anterior horn width: 0-2.9 mm; thalamo-occipital distance: 8.7-24.7 mm; third ventricle width: 0-2.6 mm; fourth ventricle width: 3.3-7.4 mm; fourth ventricle length: 2.6-6.9 mm. Dependent and non-dependent lateral ventricles did not differ significantly in size. There was no clinically significant difference in ventricular size between sexes. CONCLUSIONS: Reference ranges for the measurement of the intracranial ventricles in preterm infants from 23 to 33 weeks' GA are provided and can be used in the diagnosis and assessment of ventricular enlargement in preterm infants. All measurements have good intra-observer and inter-observer reliability. Head position at the time of scanning does not influence the asymmetry of the lateral ventricular measurements. The infant's sex does not influence ventricular size.

Abstract: OBJECTIVES: Contamination by infusate of blood samples withdrawn from arterial lines has been recognized but not well documented for neonates. The aim of this study was to investigate, using in vitro and in vivo studies, the effects of different draw-up volumes (withdrawn from the line prior to the sample being taken) on the concentration of sodium. METHODS: In-vitro study: The tip of an umbilical artery catheter (dead space 0.6 mL), infused with half normal saline containing 1 unit/mL of heparin was placed in a beaker of normal saline. The line was flushed with 1 mL of this infusate just before each sample was taken. Volumes from 0.5 mL to 2.0 mL of infusate/normal saline were withdrawn in 0.1 mL increments from a three-way tap and discarded. A sample was then taken from the line into a blood gas syringe for analysis of the sodium concentration by the 860 Blood Gas Analyzer (Chiron Diagnostics, Bayer, Scoresby). Control samples were taken from the beaker. In-vivo study: A 22 gauge intravenous catheter was inserted into a vein of an adult male volunteer. The dead space was also 0.6 mL. The line was flushed with 5 mL of half-normal saline immediately before sampling. Draw-up volumes of 0.6, 0.9, 1.3, and 1.6 mL were withdrawn and discarded. 10 mL was used as a control. A 0.5-mL blood sample was then taken and the electrolyte concentrations analysed immediately. RESULTS: In-vitro: A minimum draw-up volume of 1.3 mL was required before the sodium concentration was not significantly different from the control samples. In-vivo: A minimum draw-up volume of 1.6 mL was required before the sodium concentration was not significantly different from the control samples. There were similar trends in the effect of draw-up volume for glucose, calcium, potassium, chloride and lactate. CONCLUSION:: A minimum volume of 1.6 mL should be withdrawn from neonatal arterial lines (dead space 0.6 mL) before taking blood for analysis.

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Abstract: During partial liquid ventilation perfluorocarbon vapour is present in the exhaled gases. The volumes of these gases are measured by pneumotachometers. Error in measuring tidal volumes will give erroneous measurement of lung compliance during partial liquid ventilation. We aim to compare measured tidal volumes with and without perfluorocarbon vapour using tidal volumes suitable for use in neonates. Tidal volumes were produced with a 100 ml calibration syringe from 20 to 100 ml and with a calibrated Harvard rodent ventilator from 2.5 to 20 ml. Control tidal volumes were drawn from a humidifier chamber containing water vapour and the PFC tidal volumes were drawn from a humidifier chamber containing water and perfluorocarbon (FC-77) vapour. Tidal volumes were measured by a fixed orifice, target, differential pressure flowmeter (VenTrak) or a hot-wire anenometer (Bear Cub) placed between the calibration syringe or ventilator and the humidifier chamber. All tidal volumes measured with perfluorocarbon vapour were increased compared with control (ANOVA p < 0.001 and post t-test p < 0.0001). Measured tidal volume increased from 7 to 16% with the fixed orifice type flow-meter, and from 35 to 41% with the hot-wire type. In conclusion, perfluorocarbon vapour flowing through pneumotachometers gives falsely high tidal volume measurements. Calculation of lung compliance must take into account the effect of perfluorocarbon vapour on the measurement of tidal volume.

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Abstract: OBJECTIVE: To evaluate and compare the accuracy and performance of two electrochemical glucose meters. To determine the user acceptability of these glucose meters and the ABL 620 Blood Gas Analyser (Radiometer, Copenhagen, Denmark) with an electrochemical glucose oxidase electrode for use in a Level 2 special care baby unit. METHODOLOGY: A total of 108 blood samples were collected from 47 babies at risk for hypoglycaemia. The blood glucose level was measured with two glucose meters, the Advantage Glucose Meter (Roche Diagnostics, Castle Hill, Australia) and the Precision-G Blood Glucose Testing System (Medisense, Melbourne, Australia), and the true blood glucose (TBG) measured with the ABL 620 blood gas analyser. Results from the glucose meters were compared with the TBG (as a percentage of the TBG). RESULTS: The mean (SD) percentage difference between the Advantage Glucose Meter and TBG was 4.5% (12. 5), and Precision-G Glucose Meter and TBG was 15.4% (12.4). The sample haematocrit did not significantly influence the glucose meter/TBG differences. There was an overall preference by the nursing staff for the Advantage Glucose Meter. CONCLUSIONS: The Advantage Glucose Meter was significantly more accurate than the Precision-G with similar precision. It was the preferred method of screening for neonatal hypoglycaemia.

Abstract: OBJECTIVE: To compare the transductal velocity ratio (TVR) of the persistent ductus arteriosus (PDA) with other echocardiographic criteria for haemodynamic significance of a PDA. METHODS: This was a prospective study (from January 1997 to August 1998) in the nurseries of the Royal Women's Hospital, Melbourne. Infants with a clinically suspected PDA were eligible and included if the echocardiogram showed a PDA with a structurally normal heart and the TVR had been measured. The PDA was assessed for evidence of left heart dilatation, the presence of reverse or absent diastolic flow in the descending aorta, the pattern of Doppler flow velocity waveform in the ductus arteriosus, and subjective assessment of ductal diameter on the real time image. The peak systolic velocity (PSV) was obtained from the pulmonary and aortic ends of the PDA, and the TVR calculated by dividing the PSV at the pulmonary end by the PSV at the aortic end. RESULTS: Forty two infants had 59 echocardiographs with their TVR calculated. Mean (SD) birth weight was 1008 (362) g. Mean (SD) gestational age at birth was 27.4 (2.2) weeks with a mean (SD) corrected gestational age of 28.7 (2.7) weeks. The mean TVR was decreased in those infants with a high left atrial diameter/aortic diameter (LA/Ao) ratio (1.9 v 2.8, p = 0.0032) or reverse/absent diastolic flow in the descending aorta (2.1 v 3.0, p = 0.02). This difference was greater if those two criteria were combined (1.7 v 3.4, p = 0.0027). The mean TVR was decreased in infants with a wide open duct seen on two dimensional imaging (1.5 v 3.0, p < 0.0001) or pulsatile flow seen on pulsed Doppler in the PDA (1.9 v 3.4, p = 0.0001). The LA/Ao and left ventricle internal diameter/aortic diameter (LVIDd/Ao) ratios were higher in the group with a TVR < 1.8 than in the other two groups; these differences were statistically significant. CONCLUSIONS: The TVR as a measure of the degree of constriction of a PDA is associated with other echocardiographic criteria for a haemodynamically significant PDA. A low TVR (signifying a poorly constricted duct) is associated with echocardiographic features of a significant left to right shunt, and vice versa. Further research is required to determine the usefulness of the TVR in predicting closure or likely continuing patency of a PDA and the need for treatment.

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Abstract: OBJECTIVE: To investigate the effect on oxygenation and lung damage of partial perfluorocarbon liquid high frequency oscillatory ventilation (PL-HFOV) versus high frequency oscillatory ventilation (HFOV) alone, in rabbits with acute lung injury, using high lung volume strategy HFOV. METHODS: Twelve adult New Zealand white rabbits were initially ventilated with HFOV after anaesthesia, sedation and paralysis. After induction of lung injury with saline lavage, all animals received a single sigh breath of 30 cmH(2)O for 30 seconds. They were then allocated to receive either HFOV alone (n = 6) or PL-HFOV (n = 6). Arterial blood gases were taken pre- and post-lavage and then hourly for 5 hours. The oxygenation index (OI, in cmH(2)O/mmHg) was calculated using the formula: OI = (MAP x F(I)O(2) x 100) / PaO(2). The lungs were then removed for histological examination to score lung injury. RESULTS: Two rabbits died in the PL-HFOV group and none in the HFOV group, p = 0.45 (Fisher's exact test). At one hour the oxygenation index (OI) was 4.5 in the HFOV group and 6.6 in the PL-HFOV group, p = 0.49 and the PaO(2) was 374 mmHg in the HFOV group and 311 mmHg in the PL-HFOV group, p = 0.39. Average OI over the first three hours was 3.6 in the HFOV group and 5.0 in the PL-HFOV group, p = 0.27 and the PaO(2) was 404 mmHg in the HFOV group and 337 mmHg in the PL-HFOV group, p = 0.12. The lung histology damage score was 2.33 in the HFOV group and 2.50 in the PL-HFOV group, p = 0.83. CONCLUSIONS: In this model of acute lung injury, using a high volume HFOV strategy to optimise lung recruitment, PL-HFOV did not result in any further improvement in oxygenation when compared with HFOV alone. The question of safety with PL-HFOV remains.

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Abstract: OBJECTIVE: Fetal measurement of transverse cerebellar diameter (TCD) has been shown to correlate well with gestational age (GA), even in the presence of growth retardation. The aim of this study was to define the normal range of TCD in preterm neonates in an Australian population between 23 and 32 weeks GA. METHODOLOGY: Infants admitted to the Royal Women's Hospital, Melbourne, having routine cranial ultrasound scans (< 1500 g and/or of gestational age </= 32 weeks at birth) had their TCD measured on a cranial scan performed during the first 3 days of life. The posterior fossa was examined through the asterion using a General Electric LOGIQ 500 scanner (GE Medical Systems, Waukesha, USA) and TCD measurement was taken in the coronal plane. RESULTS: 106 infants < 1500 g and/or of GA </= 32 weeks at birth had their TCD measured between 1 January 1997 and 30 November 1997. Transverse cerebellar diameter and associated 95% confidence intervals are described for infants between 23 and 32 weeks GA. The linear regression equation relating TCD and GA was: TCD (mm) = -12.9 + 1.61 x GA (weeks). R2 = 0.80, P < 0.001. CONCLUSION: This is the only study of TCD measurement using cranial ultrasound in a group of preterm newborns, and forms the basis for nomograms of TCD which can be used as a tool to assist in the assessment of GA, even in growth-retarded preterm newborns, and in the diagnosis of cerebellar hypoplasia.

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Abstract: OBJECTIVES: To ascertain the incidence of postextubation atelectasis (PEA) in neonates, to delineate any objective differences between those infants with PEA and those without, and to see if any of those differences were predictive of the need for a postextubation chest X-ray (CXR). METHODS: This is a retrospective review of all infants ventilated in 1994. For each separate period of extubation the medical, physiotherapy and nursing notes were examined. Data were collected on birthweight, gestational age, duration of ventilation, age at extubation, ventilation requirements pre-extubation, pre- and postextubation arterial carbon dioxide tensions (PaCO2) and oxygen requirements, the number of episodes of bradycardia and apnoea, the pulse and respiratory rates pre- and postextubation, and the use of nasal continuous positive airway pressure (NCPAP). It was routine practice throughout 1994 for all ventilated babies to have a CXR 6 h postextubation. Each postextubation CXR was examined by one of the authors (MWD) for the presence of atelectasis and other diagnoses. PEA was defined as any atelectasis present on the postextubation CXR that was not present on the pre-extubation CXR. RESULTS: The overall incidence of any PEA was 2.5% (6/236). In those babies with PEA, the increase in oxygen requirement at 1 and 6 h postextubation was higher (change in inspired oxygen (deltaFiO2) of 0.05 vs 0.015, P=0.043 and deltaFiO2 of 0.045 vs 0.0, P=0.033, respectively). There was a higher incidence of the need for NCPAP some time after extubation (2/4 vs 9/163, P<0.001). No infant with PEA required reintubation and ventilation. CONCLUSIONS: In this nursery the incidence of PEA is low with no significant morbidity. Postextubation CXRs should be performed on only those infants who have an increase in oxygen requirement postextubation or become symptomatic with new or increasing respiratory distress, and to follow up atelectasis on the most recent pre-extubation CXR.

Abstract: OBJECTIVES: The aim of this study was to determine the incidence of toxic trough serum gentamicin levels in neonates in the first week of life, with different dosage intervals. METHODS: This was a retrospective study of neonates born between 01.07.95 and 31.12.95, who received gentamicin. Data were collected on birth weight, gestation, gentamicin dose, the trough level of gentamicin, serum creatinine and urine output. A trough serum gentamicin level of > or =1.5 mg/L was considered toxic. RESULTS: One hundred and seventy infants met the study criteria. All 21 infants in group one (24-29 weeks) received gentamicin with a dosage interval of 24 h. Sixteen (76%) infants had toxic trough serum gentamicin levels. In group two (30-34 weeks) 8 infants had gentamicin q12hly and all (100%) had toxic trough serum gentamicin levels. Fourteen infants had gentamicin every 18 h and 13 (93%) had toxic trough serum gentamicin levels. Sixty-one infants had gentamicin q24hly and 25 (41%) had toxic trough serum gentamicin levels. The differences in proportions with toxic levels were statistically significant. In group three (> or =35 weeks) 29 infants had gentamicin q12hly and 25 (86%) had toxic trough serum gentamicin levels. Six infants had gentamicin every 18 h and 2 (33%) had toxic trough serum gentamicin levels. Thirty-one infants had gentamicin q24hly and 4 (13%) had toxic trough serum gentamicin levels. The differences in proportions comparing infants having gentamicin q12hly with those having it q24hly were statistically significant. CONCLUSIONS: A starting gentamicin dosage interval of 12 h in infants of any gestational age, or a starting dosage interval of 24 h for infants of less than 30 weeks gestational age, leads to most having toxic trough serum gentamicin levels. In infants of 30 weeks gestational age or greater, most have safe non-toxic trough serum gentamicin levels if started on a dosage interval of 24 h.

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Abstract: Objectives Partial liquid ventilation may benefit the lung disease in very preterm neonates but the administration of intratracheal perfluorocarbon when starting partial liquid ventilation may disturb cerebral blood flow and cause brain injury. I aimed to determine, in preterm lambs, if haemodynamics and cortical blood flow are affected by the instillation of the loading dose of perfluorocarbon at the start of partial liquid ventilation, compared with continuing conventional gas mechanical ventilation; and to determine if any effect differs by the volume of the perfluorocarbon dose. I aimed to determine in rabbits if the administration of perfluorocarbon affects cerebral blood flow and to determine if the effect varies by the method of administration of perfluorocarbon liquid including the dose volume, the rate of administration, the endotracheal tube portal of entry, whether PaCO2 is closely targeted, or by using volume-controlled ventilation. Methods Thirty-two preterm lambs were randomised to either partial liquid ventilation with an intratracheal loading dose of 30 mL/kg of perfluorocarbon liquid (PLV30 group, N = 8) or conventional mechanical ventilation (sham group, N = 8); or a loading dose of 20 mL/kg (PLV20 group, N = 8) or 40 mL/kg (PLV40 group, N = 8). The perfluorocarbon was instilled over 20 min. Data on respiratory mechanics, haemodynamics and cerebral blood flow were collected continuously for 30 minutes from the start of dosing. Thirteen rabbits were randomised to up to six episodes of different dosing strategies, including pressure-controlled ventilation with a sham dose of air over 20 min, 10 mL/kg of perfluorocarbon slowly over 20 min, 20 mL/kg of perfluorocarbon slowly over 20 min, 10 mL/kg of perfluorocarbon moderately fast over 10 min, 10 mL/kg of perfluorocarbon rapidly over 5 min, 10 mL/kg of perfluorocarbon slowly over 20 min via the endotracheal tube tip lumen, or 10 mL/kg of perfluorocarbon slowly over 20 min with the peak inspiratory pressure adjusted to maintain the PaCO2 between 45�50 mmHg; or volume-controlled ventilation with a sham dose of air over 20 min or 10 mL/kg of perfluorocarbon. Data on blood gases, haemodynamics, cortical cerebral blood flow and carotid flow were collected continuously for 30 minutes from the start of each dose. Results In preterm lambs: cortical cerebral blood flow increased with no significant changes in blood pressure, heart rate or oxygenation, but a slight increase in arterial carbon dioxide not statistically significant. Cortical cerebral blood flow increased in all three dose volume groups but there was no difference in this increase between groups. There were no differences in heart rate, blood pressure, or cortical cerebral blood flow variability. There was improvement in lung compliance in all three groups which was greatest in the group administered 30 mL/kg compared with either 20 or 40 mL/kg. In rabbits: carotid blood flow and the variability in cortical cerebral blood flow were increased with 20 mL/kg of perfluorocarbon; there were no differences in cerebral blood flow or its variability using 10 mL/kg compared with 20 mL/kg; cerebral blood flow did not differ with the rate of administration of 10 mL/kg of perfluorocarbon, but the variability of carotid blood flow was increased when the dose was given rapidly; increases in cerebral blood flow are similar regardless of the portal of entry of the perfluorocarbon dose (i.e., at the proximal end of the endotracheal tube versus its tip); if the peak inspiratory pressure was adjusted during perfluorocarbon dosing to maintain the PaCO2 between 45 and 50 mmHg or if volume-controlled ventilation was used then there was no increase in cerebral blood flow. Conclusions When the dose of perfluorocarbon was given cerebral blood flow increased, usually with an increase in PaCO2. The cerebral blood flow increased regardless of the dose volume of perfluorocarbon (from 10�40 mL/kg). The effects on cerebral blood flow could be mitigated by adjusting ventilation to closely target the PaCO2 or using volume-controlled ventilation. There was no advantage in giving the perfluorocarbon through a secondary lumen at the distal tip of the endotracheal tube. Implications The studies reported in this thesis were born out of a desire to ensure that if partial liquid ventilation was to be used in extremely preterm infants that we should first know whether the instillation of perfluorocarbon disturbs cerebral blood flow putting them at risk of brain injury and, if it does, then determine if the dose of perfluorocarbon can be given safely without any cerebral blood flow disturbance. I have shown that when perfluorocarbon is instilled into the lungs the cerebral blood flow increases. It is reassuring to know that there are ways of giving perfluorocarbon that can mitigate any increase in cerebral blood flow. Data from these studies will enable optimisation of the dosing method to be used.

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