The use of projected autonomy in antenatal shared decision-making for periviable neonates: a qualitative study.

BACKGROUND: In this study, we assessed the communication strategies used by neonatologists in antenatal consultations which may influence decision-making when determining whether to provide resuscitation or comfort measures only in the care of periviable neonates. METHODS: This study employed a qualitative study design using inductive thematic discourse analysis of 'naturally occurring data' in the form of antenatal conversations around resuscitation decisions at the grey zone of viability. The study occurred between February 2017 and June 2018 on a labor and delivery unit within a large Midwestern tertiary care hospital. Participants included 25 mothers who were admitted to the study hospital with anticipated delivery in the grey zone of viability and practicing neonatologists or neonatology fellows who partnered in antenatal consultation. We used a two-stage inductive analytic process to focus on how neonatologists' discourses constructed SDM in antenatal consultations. First, we used a thematic discourse analysis to interpret the recurring patterns of meaning within the transcribed antenatal consultations, and second, we theorized the subsequent effects of these discourses on shaping the context of SDM in antenatal encounters. RESULTS: In this qualitative study, that included discourse analysis of real-time audio conversations in 25 antenatal consults, neonatologists used language that creates projected autonomy through (i) descriptions of fetal physiology (ii) development of the fetus's presence, and (iii) fetal role in decision-making. CONCLUSION: Discourse analysis of real-time audio conversations in antenatal consultations was revelatory of how various discursive patterns brought the fetus into decision-making, thus changing who is considered the key actor in SDM.

Differences in the attitudes towards resuscitation of extremely premature infants between neonatologists and obstetricians: a survey study in China.

Objectives: Neonatologists and obstetricians are crucial decision-makers regarding the resuscitation of extremely preterm infants (EPIs). However, there is a scarcity of research regarding the differing perspectives on EPI resuscitation between these medical professionals. We aim to determine the differences and influential factors of their attitudes towards EPIs resuscitation in China. Methods: This cross-sectional study was conducted in public hospitals of 31 provinces in Chinese mainland from June to July 2021. Influential factors of binary variables and those of ordinal variables were analyzed by modified Poisson regression models and multinomial logistic regression models due to the invalid parallel line assumption of ordinal logistic regression models. Results: A total of 832 neonatologists and 1,478 obstetricians who were deputy chief physicians or chief physicians participated. Compared with obstetricians, neonatologists delivered a larger proportion of infants of <28-week gestational age (87.74% vs. 84.91%) and were inclined to think it inappropriate to use 28 weeks as the cutoff of gestational age for providing full care to premature infants [63.34% vs. 31.60%, adjusted prevalence ratio = 1.61 (95% CI: 1.46-1.77)], and to suggest smaller cutoffs of gestational age and birth weight for providing EPIs resuscitation. Notably, 46.49% of the neonatologists and 19.01% of the obstetricians believed infants ≤24 weeks' gestation should receive resuscitation. Conclusions: In China, notable disparities exist in attitudes of neonatologists and obstetricians towards resuscitating EPIs. Strengthening collaboration between these two groups and revising the pertinent guidelines as soon as possible would be instrumental in elevating the resuscitation rate of EPIs.

Excessive workload and insufficient night-shift remuneration are key elements of dissatisfaction at work for French neonatologists.

AIM: Neonatologists are exposed to ethical issues and unplanned emergencies that require 24-h in-house coverage. These elements may affect quality of life at work, which we surveyed. METHODS: This was a self-administered, voluntary and anonymous cross-sectional survey of French neonatologists. An online questionnaire was sent to members of the French Society of Neonatology from June to October 2022. RESULTS: Of approximately 1500 possible responses, 721 were analysed, with a response rate of 48%. Respondents were mostly women (77%), aged 35-50 years (50%), and hospital practitioners (63%). Reported weekly working time was over 50 h for 80%. Among the 650 neonatologists with on-call duty, 47% worked ≥5 shifts per month. For 80% of practitioners, on-call duty was perceived to have a negative impact on personal life; 49% indicated having sleep disorders. The mean satisfaction score at work was 5.7 ± 1.7 on a scale of 0-10. The main reasons for dissatisfaction were excessive working hours and insufficient remuneration for on-call duty. CONCLUSION: This first evaluation of the quality of life at work of French neonatologists showed high workload. The working conditions and specificities of NICU activity may have significant consequences for their mental health.

Moral distress among neonatologists working in neonatal intensive care units in Greece: a qualitative study.

BACKGROUND: Working as a neonatologist in a neonatal intensive care unit (NICU) is stressful and involves ethically challenging situations. These situations may cause neonatologists to experience high levels of moral distress, especially in the context of caring for extremely premature infants (EPIs). In Greece, moral distress among neonatologists working in NICUs remains understudied and warrants further exploration. METHODS: This prospective qualitative study was conducted from March to August 2022. A combination of purposive and snowball sampling was used and data were collected by semi-structured interviews with twenty neonatologists. Data were classified and analyzed by thematic analysis approach. RESULTS: A variety of distinct themes and subthemes emerged from the analysis of the interview data. Neonatologists face moral uncertainty. Furthermore, they prioritize their traditional (Hippocratic) role as healers. Importantly, neonatologists seek third-party support for their decisions to reduce their decision uncertainty. In addition, based on the analysis of the interview data, multiple predisposing factors that foster and facilitate neonatologists' moral distress emerged, as did multiple predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. The predisposing factors that foster and facilitate neonatologists' moral distress thus identified include the lack of previous experience on the part of neonatologists, the lack of clear and adequate clinical practice guidelines/recommendations/protocols, the scarcity of health care resources, the fact that in the context of neonatology, the infant's best interest and quality of life are difficult to identify, and the need to make decisions in a short time frame. NICU directors, neonatologists' colleagues working in the same NICU and parental wishes and attitudes were identified as predisposing factors that are sometimes associated with neonatologists' constraint distress and sometimes associated with their uncertainty distress. Ultimately, neonatologists become more resistant to moral distress over time. CONCLUSIONS: We concluded that neonatologists' moral distress should be conceptualized in the broad sense of the term and is closely associated with multiple predisposing factors. Such distress is greatly affected by interpersonal relationships. A variety of distinct themes and subthemes were identified, which, for the most part, were consistent with the findings of previous research. However, we identified some nuances that are of practical importance. The results of this study may serve as a starting point for future research.

Pitfalls and Limitations of Platelet Counts and Coagulation Tests in the Neonatal Intensive Care Unit.

The assessment of hemostasis and the prediction of bleeding risk are of great importance to neonatologists. Premature infants are at an increased risk for bleeding, particularly intra-cranial hemorrhages (most commonly intra-ventricular hemorrhages (IVH)), gastrointestinal hemorrhages, and pulmonary hemorrhages. All severe bleeding, but especially severe IVH, is associated with poor neurodevelopmental outcomes, and other than prenatal steroids, no intervention has reduced the incidence of this serious complication. As a result, there is a need in neonatology to more accurately identify at-risk infants as well as effective interventions to prevent severe bleeding. Unfortunately, the commonly available tests to evaluate the hemostatic system were established using adult physiologic principles and did not consider the neonate's different but developmentally appropriate hemostatic system. This review will describe the changes in the platelet count and tests of hemostasis throughout development, the limitations of these tests to predict neonatal bleeding and the utility of treating abnormal results from these tests with platelet and/or fresh frozen plasma (FFP) transfusions in non-bleeding infants.

Evaluación del dolor neonatal y opinión de los profesionales sobre el uso de un sistema automático para su valoración / Evaluation of neonatal pain and opinion of professionals regarding the use of an automatic assessment system

Objetivo: conocer las características de la evaluación del dolor neonatal en las unidades neonatales (UCIN) y la opinión de los profesionales sobre el uso de un sistema automático de valoración. Método: estudio transversal (2017). Población: enfermeras y médicos de UCIN de hospitales españoles. Recogida de datos mediante cuestionario online que incluía variables del perfil del profesional, frecuencia de evaluación del dolor, escala de valoración utilizada, formación recibida, dificultades percibidas para valorar el dolor, opinión sobre la evaluación del dolor y sobre el uso de un sistema automático de evaluación. Análisis estadístico descriptivo. Programa Jamovi 1.2.7®. Resultados: 133 respuestas. El 83,5% fueron mujeres, edad media de 40 años (9,43). El 88% de hospitales fueron de tercer nivel, 44,1% profesionales de Enfermería, 72% con experiencia en UCIN superior a seis años. El 66,9% valora según el estado del neonato, el 29,3% con escala propia de la unidad, el 72,6% considera que existe un componente subjetivo en la valoración, el 48,1% no recibió formación para valorar dolor. El 93,2% encontró útil un sistema automático, para el 36,1% no sería fiable. El 23,3% opina que un sistema automático no puede sustituir la percepción humana. Conclusiones: no se aplica un protocolo consensuado para la evaluación del dolor en neonatos, existe variabilidad, a veces no se mide por falta de tiempo y cuando se mide el dato puede ser subjetivo. La mayoría considera que el uso de un sistema automático de evaluación del dolor neonatal puede resultar útil, aunque algunos dudan de su fiabilidad por desconocimiento de la tecnología aplicada actual.(AU)

Objective: to understand the characteristics of the evaluation of neonatal pain in Neonatal Intensive Care Units (NICUs) and the opinion of professionals about the use of an automatic assessment system. Method: a cross-sectional study (2017). Population: NICU nurses and doctors from Spanish hospitals. Data collection through online questionnaire which included variables of the professional profile, frequency of pain assessment, evaluation scale used, training received, difficulties perceived to assess pain, opinion about pain evaluation and about the use of an automatic assessment system. Descriptive statistical analysis; Jamovi 1.2.7® program. Results: there were 133 answers: 83.5% were women, with a mean age of 40 (9.43) years. 88% from tertiary level hospitals; 44.1% were Nursing professionals, and 72% with >6 years’ experience at the NICU. Of these respondents, 66.9% assessed pain according to the status of the newborn, 29.3% with a scale specific to the unit, 72.6% considered that there was a subjective component in the assessment, 48.1% did not receive any training to assess pain. An automatic system was regarded as useful by 93.2%, but for 36.1% it would not be reliable, and 23.3% reckoned that an automatic system could not replace human perception. Conclusions: no protocol by consensus was applied for pain assessment in newborns, there was variability, sometimes it was not measured due to lack of time, and when it was measured, data could be subjective. The majority considered that the use of an automatic pain assessment system could be useful, although some doubted its reliability due to lack of knowledge of the technology currently applied.(AU)

The neonatal transfer process through the lens of neonatologists at public hospitals in South Africa.

BACKGROUND: Neonatal care is provided by various levels of healthcare facilities in South Africa. Intensive care for neonates is only provided at the higher levels, hence the need for transfers from lower-level to higher-level facilities (e.g. primary hospitals to tertiary hospitals) or across levels of facilities, particularly when life-threatening situations arise (e.g. cardiac deterioration, respiratory deterioration and desaturation). AIM: The aim of the study was to explore neonatologists' views regarding the neonatal transfer process and to describe the preparedness of advanced life support (ALS) paramedics to undertake such transfers. SETTING: The setting consisted of neonatologists from three provinces i.e. KwaZulu-Natal, Gauteng and Western cape. METHOD: A qualitative descriptive design was utilised in this study. Semistructured interviews were conducted on the public health hospitals in three provinces (N = 9; n = 3) with neonatologists (N = 7; n = 7) who were involved in the transfers of critically ill neonates. The process of thematic analysis was used. RESULTS: The themes that emerged in this study were: an awareness of local contextual realities related to neonatal transfers, challenges evident within the context of neonatal transfers, decision-making around the transfer of ill neonates, ALS paramedic preparedness for transfers and good clinical governance. CONCLUSION: The study found that there was a need to be aware of local contextual realities confronting neonatal transfers, a need for greater preparedness for paramedics to undertake these transfers, a need for a sound referral processes and a need for coordinated transfer effort between paramedics, hospital staff and transport team members for the successful transfer of critically ill neonates. CONTRIBUTION: The findings highlight the challenges confronting the neonatal transfer process in South Africa through the lens of neonatologist at public hospitals. Hence, the study reinforces the preparedness and coordination of the transfer process, along with more efficient communication between paramedics, hospital staff and the transfer team.

The care of critically ill infants and toddlers in neonatal intensive care units across Italy and Europe: our proposal for healthcare organization.

Numerous studies have shown that critically ill infants and toddlers admitted to paediatric intensive care units (PICUs) have a lower mortality than those admitted to adult ICUs. In 2014, there were only 23 registered PICUs in Italy, most of which were located in the north. For this reason, in Italy and elsewhere in Europe, some neonatal ICUs (NICUs) have begun managing critically ill infants and toddlers. Our proposal for healthcare organization is to establish "extended NICUs" in areas where paediatric intensive care beds are lacking. While some countries have opted for a strict division between neonatal and paediatric intensive care units, the model of "extended NICUs" has already been set up in Italy and in Europe. In this instance, the management of critically ill infants and toddlers undoubtedly falls upon neonatologists, who, however, must gain specific knowledge and technical skills in paediatric critical care medicine (PCCM). Postgraduate residencies in paediatrics need to include periods of specific training in neonatology and PCCM. The Italian Society of Neonatology's Early Childhood Intensive Care Study Group is supporting certified training courses for its members involving both theory and practice. CONCLUSION: Scientific societies should promote awareness of the issues involved in the intensive management of infants and toddlers in NICUs and the training of all health workers involved. These societies include the Italian Society of Neonatology, the European Society of Paediatric and Neonatal Intensive Care, and the Union of European Neonatal and Perinatal Societies. They should also act in concert with the governmental institutional bodies to establish the standards for the "extended NICUs." WHAT IS KNOWN: • The mortality of critically ill infants and toddlers admitted to PICUs is lower than that for those admitted to adult ICUs. • In Italy, there are only a handful of PICUs, located mainly in the north. WHAT IS NEW: • Critically ill infants and small toddlers can be managed in "extended NICUs" in areas with a lack of paediatric intensive care beds. • "Extended NICUs" is our proposal for healthcare organization to compensate for the paucity of paediatric intensive care beds, but neonatologists must be trained to provide them with specific knowledge and technical skills in PCCM.

Variations in umbilical cord clamping practices in the United States: a national survey of neonatologists.

OBJECTIVE: Since the first publication of the American College of Obstetricians and Gynecologists committee opinion in 2012, and following the update in 2017, multiple institutions in the United States (US) adopted the practice of delayed cord clamping (DCC) and/or umbilical cord milking (UCM) in preterm and term infants. However, there have been variations reported in practices with regard to method of placental transfusion, timing of cord clamping and gestational age thresholds. Furthermore, the optimal cord clamping practice in situations of depressed infants needing resuscitation or in higher-risk delivery situations, such as placental abruption, intrauterine growth restriction, multiple gestation, chorioamnionitis, maternal human immunodeficiency virus syndrome/hepatitis or maternal general anesthesia is often debated. An evaluation of these variations and exploration of associated factors was needed to optimally target opportunities for improvement and streamline research activities. The objective of this survey, specifically aimed at neonatologists working in the US was to identify and describe current cord clamping practices and evaluate factors associated with variations. STUDY DESIGN: The survey was distributed electronically to the US neonatologists in August 2019 with a reminder email sent in October 2019. Clinicians were primarily identified from Perinatal Section of AAP, with reminders also sent through various organizations including California Association of Neonatologists, Pediatrix and Envision national groups. Descriptive variables of interest included years of experience practicing neonatology, affiliation with a teaching institution, level of the neonatal intensive care unit (NICU) and practicing region of the US. Questions on variations in cord management practices included information about center specific guideline/protocol, cord clamping practices, gestational age threshold of placental transfusion, performance of UCM and practice in higher-risk delivery situations. RESULTS: The response rate was 14.8%. Among 517 neonatologists whom responded, majority (85.5%) of the practices had a guideline and performed (81.7%) DCC in all gestational ages. The cord clamping practice was predominantly DCC and it was categorized as reporting clamping times <60 s in 46.6% and ≥60 s in 48.7% of responses. A significant association was detected between time of delay in cord clamping and region of practice. The Northeast region was more likely to clamp the cord in <60 s than other regions in the US. More than half of the providers responded not performing any UCM (57.3%) in their practice. Significant associations were detected between performance of UCM and all queried demographic variables independently. Clinicians with >20 years of experience were more likely from institutions performing UCM compared to the providers with fewer years of experience. However, teaching hospitals were less likely to perform UCM compared to non-teaching hospitals. Similarly, practices with level IV NICUs were less likely to perform UCM compared to practices with level III units. Hospitals in the Midwest region of US were less likely to perform UCM compared to hospitals in the Western region. Significant variations were also noticed for not providing placental transfusion in higher-risk deliveries. Demographic and professional factors were noted to be associated with these differences. CONCLUSION: Although the majority of practices have a guideline/protocol and are performing DCC in all gestational ages, there are variations noted with regard to timing, method, and performance in higher-risk deliveries. Demographic and professional factors play an important role in these variations. Future research needs to focus on the modifiable factors to optimize the procedure and impact of DCC.

The neonatal transfer process through the lens of neonatologists at public hospitals in South Africa

Background: Neonatal care is provided by various levels of healthcare facilities in South Africa. Intensive care for neonates is only provided at the higher levels, hence the need for transfers from lower-level to higher-level facilities (e.g. primary hospitals to tertiary hospitals) or across levels of facilities, particularly when life-threatening situations arise (e.g. cardiac deterioration, respiratory deterioration and desaturation). Aim: The aim of the study was to explore neonatologists' views regarding the neonatal transfer process and to describe the preparedness of advanced life support (ALS) paramedics to undertake such transfers. Setting: The setting consisted of neonatologists from three provinces i.e. KwaZulu-Natal, Gauteng and Western cape. Method: A qualitative descriptive design was utilised in this study. Semistructured interviews were conducted on the public health hospitals in three provinces (N = 9; n = 3) with neonatologists (N = 7; n = 7) who were involved in the transfers of critically ill neonates. The process of thematic analysis was used. Results: The themes that emerged in this study were: an awareness of local contextual realities related to neonatal transfers, challenges evident within the context of neonatal transfers, decision-making around the transfer of ill neonates, ALS paramedic preparedness for transfers and good clinical governance Conclusion: The study found that there was a need to be aware of local contextual realities confronting neonatal transfers, a need for greater preparedness for paramedics to undertake these transfers, a need for a sound referral processes and a need for coordinated transfer effort between paramedics, hospital staff and transport team members for the successful transfer of critically ill neonates. Contribution: The findings highlight the challenges confronting the neonatal transfer process in South Africa through the lens of neonatologist at public hospitals. Hence, the study reinforces the preparedness and coordination of the transfer process, along with more efficient communication between paramedics, hospital staff and the transfer team.

Nigerian neonatologists perception and experience with retinopathy of prematurity.

BACKGROUND: Retinopathy of Prematurity (ROP) is an avoidable condition that affects premature infants exposed to oxygen stresses at or soon after birth. In low- and middle-income countries, like Nigeria, neonatal mortality rates are high and very few infants live to develop ROP. With recent better care, ROP is now being diagnosed. OBJECTIVE: This study aimed to characterize what Nigerian neonatologists understand about ROP. METHODS: At a joint meeting of Nigerian pediatric ophthalmologists and neonatologists in Kebbi State held 26-29 July 2018, questionnaires collected attendees' perspective and experience with ROP including causes, risk factors and experiences. RESULTS: Fifty-one neonatologists out of 71 returned a completed questionnaire (response rate: 71.8%). The male:female ratio was 1:1.8, and approximately 40% were aged 41-50 years (n=20, 39.22%). Only 3 (6.39%) had experience managing infants below 500g that survived. A majority managed babies with a mean weight of 913g ± 300.37 and age of 27.87 weeks ±2.37. Most had no access to oxygen monitors (n=39,78%). Most had 10 babies to one monitor and used average settings of 90-95%. One third had seen a case of ROP (n=15,29.41%). Only 5.88% (n=3) were unaware of uncontrolled oxygen use as a risk factor. Only 4 (8.89%) had a functional screening team. None were aware of local screening guidelines. CONCLUSIONS: Regular educational programs, collaborative clinical presentations and webinars about ROP targeted at the neonatologists and parents, including establishment of screening programs across country will likely help reduce the burden of ROP blindness in Nigeria.

NeoAct: A Randomized Prospective Pilot Study on Communication Skill Training of Neonatologists.

Background: This randomized interventional study evaluated the impact of a 1-day experiential communication skills training on neonatologists' performance in doctor-parents-communication. Methods: 17 neonatologists with different levels of professional experience from the Medical University of Vienna were randomized into one of two study groups: The intervention group (IG) as opposed to the control group (CG) participated in a 1-day experiential communication training. Eight weeks after the training, participants' communication skills were assessed during an objective structured clinical examination (OSCE). Neonatologists were assessed in a simulated conversation by how effectively they performed when conveying complex health-related information to parents of ill infants. Participants in the control group (CG) were assessed first during the OSCE and received their communication training later on. Self-assessment questionnaires before and after the workshop and OSCE were completed. Results: The study determined that neonatologists in the IG subjectively perceived that their competence level regarding their communication skills had increased after the workshop, while this was not reflected by their performance during the OSCE assessment. Discussion: A 1-day experiential communication skills training significantly increased physicians' self-evaluation concerning their communicative competence. This perceived competence did not manifest itself in increased communication skills during the OSCE. Conclusion: Repeated training is needed.

Effects of parent-provider communication during infant hospitalization in the NICU on parents: A systematic review with meta-synthesis and narrative synthesis.

OBJECTIVE: To synthesize and analyse the literature on the effects of parent-provider communication during infant hospitalization in the neonatal (intensive) care unit (NICU) on parent-related outcomes. METHODS: Systematic review with meta-synthesis and narrative synthesis. Databases (PubMed, PsycINFO, Cochrane Library, CINAHL, Web of Science, Scopus) were searched in October/November 2019. Studies reporting, observing, or measuring parent-related effects of parent-provider communication in the NICU were included. Study quality was assessed using the Quality Assessment Tool for Studies with Diverse Designs. Qualitative studies were meta-synthesized using deductive and inductive thematic analysis. Quantitative studies were analysed using narrative synthesis. RESULTS: 5586 records were identified; 77 were included, reporting on N = 6960 parents, N = 693 providers, and N = 300 NICUs. Analyses revealed five main (positive and negative) effects of parent-provider interaction on parents' (1) coping, (2) knowledge, (3) participation, (4) parenting, and (5) satisfaction. Communication interventions appeared impactful, particularly in reducing parental stress and anxiety. Findings confirm and refine the NICU Communication Framework. CONCLUSIONS: Parent-provider communication is a crucial determinant for parental well-being and satisfaction with care, during and following infant hospitalization in the NICU. R. Practice Implications: Providers should particularly consider the impact on parents of their day-to-day interaction - the most occurring form of communication of all.

Knowledge, attitudes and practices of neonatal professionals regarding pain management.

Pain management is an important issue which impacts the prognosis of neonates in neonatal intensive care units. Evidence has shown that professionals' knowledge and attitudes regarding pain management can impact the quality of their practice. The purpose of this study was to evaluate the knowledge, attitudes, and practices of neonatal professionals regarding neonatal pain management. A cross-sectional study was performed involving neonatal physicians and nurses, using a research questionnaire to investigate the knowledge and attitudes of professionals as well as to assess their practice of pain management. Research found an apparent discrepancy between the knowledge levels of neonatologists and nurses regarding pain assessment and management, with nurses displaying weaker professional knowledge and more negative attitudes toward pain management than did neonatologists. Additionally, research revealed a lack of knowledge and negative attitudes among participants regarding the provision of sufficient opioid analgesics to sick infants during invasive procedures and even for dying neonates. There is an urgent need for continuing education regarding neonatal pain management with the goal of empowering neonatal professionals; further research is needed into the question of how to translate education into more reliable practice.Conclusion: This research provides useful information regarding the knowledge, attitudes, and clinical practice of neonatal pain management among neonatologists and nurses and points out some differences in the knowledge levels of these two groups. What is Known: •Neonates can perceive and respond to pain stimuli by showing their biological signals similarly to children and adults. •Untreated or insufficient pain management for high-risk neonates has short-term. negative effects and may also induce long-term negative effects. What is New: •The level of knowledge, the attitudes, and the practices regarding neonatal pain in intensive care are different among neonatal professionals. •There is an urgent need to provide interdisciplinary continuing education to improve the knowledge of neonatal professionals and encourage them to more highly prioritize neonatal pain management.

Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist / Treinamento em ecocardiografia funcional na unidade de terapia intensiva neonatal: comparando as medidas e resultados com o cardiologista pediátrico

Abstract Objectives: Functional echocardiography is a valuable tool in the neonatal intensive care unit, but training programs are not standardized. The aim was to report an functional echocardiography training program for neonatologists and to describe the agreement of their measurements with the pediatric cardiologist. Methods: Functional echocardiography training lasted 32 h. After training program, the neonatologists performed functional echocardiography in the neonatal intensive care unit and were required to measure left cardiac chambers dimensions, left ventricle systolic function, right and left ventricular output, ductus arteriosus diameter, and flow pattern. Images were recorded by the equipment and reviewed offline by the pediatric cardiologist. The Bland-Altman test was used for quantitative variables and the kappa test, for qualitative variables. Results: Twenty-two trained neonatologists performed 100 functional echocardiography exams. Ductus arteriosus identification and flow pattern had substantial agreement (kappa = 0.91 and 0.88, respectively), as well as its diameter (mean difference = 0.04 mm). The mean difference for the aortic root was −1.2 mm; left atrium, 0.60 mm; left ventricle diastolic diameter, −0.90 mm; left ventricle systolic diameter, −0.30 mm. Shortening fraction and ejection fraction correlated well with broad limits of agreement, −2.96% (14.88; −20.82%) and −-3.43% (15.54; −22.40%), respectively. Right and left ventricular output had broad limits of agreement, 16.69 mL/kg/min (222.76; −189.37) and 23.57 mL/kg/min (157.88; −110), respectively. There was good agreement between interpretations of normal or low cardiac output (76.7% for right ventricular output; 75.7% for left ventricular output). Conclusion: This functional echocardiography training program enabled neonatologists to obtain adequate skills in performing the images, obtaining good agreement with the cardiologist in simple hemodynamic measurements and ductus arteriosus evaluation.

Resumo Objetivos: A ecocardiografia funcional é uma ferramenta valiosa na unidade de terapia intensiva neonatal, mas os programas de treinamento não são padronizados. Nosso objetivo foi relatar um programa de treinamento em ecocardiografia funcional para neonatologistas e descrever a concordância de suas medidas com o cardiologista pediátrico. Métodos: O treinamento em ecocardiografia funcional durou 32 horas. Após o programa de treinamento, os neonatologistas faziam ecocardiografia funcional na unidade de terapia intensiva neonatal e mediam as dimensões das câmaras cardíacas esquerdas, função sistólica do ventrículo esquerdo, débito cardíaco do ventrículo direito e débito cardíaco do ventrículo esquerdo, diâmetro do canal arterial e o padrão de fluxo. As imagens foram registradas no equipamento e revisadas offline pelo cardiologista pediátrico. O teste de Bland-Altman foi usado para variáveis quantitativas e o teste Kappa para variáveis qualitativas. Resultados: Foram feitas por 22 neonatologistas treinados 100 ecocardiografias funcionais. A identificação do canal arterial e o padrão de fluxo apresentaram concordância substancial (Kappa = 0,91 e 0,88, respectivamente), bem como seu diâmetro (diferença média = 0,04 mm). A diferença média foi de -1,2 mm para a raiz da aorta, 0,60 mm para o átrio esquerdo, -0,90 mm para o diâmetro diastólico do ventrículo esquerdo e de -0,30 mm para o diâmetro sistólico do ventrículo esquerdo. A fração de encurtamento e a fração de ejeção apresentaram boas correlações, com amplos limites de concordância, respectivamente -2,96% (14,88; -20,82%) e -3,43% (15,54; -22,40%). Os débitos cardíacos do ventrículo direito e do ventrículo esquerdo apresentaram amplos limites de concordância, 16,69 mL/kg/min (222,76; -189,37) e 23,57 mL/kg/min (157,88; -110), respectivamente. Houve boa concordância entre a interpretação de débito cardíaco normal ou baixo (76,7% de débito ventricular direito; 75,7% de débito ventricular esquerdo). Conclusão: Esse programa de treinamento em ecocardiografia funcional permitiu aos neonatologistas obter habilidades adequadas na realização das imagens, com boa concordância com o cardiologista em medidas hemodinâmicas simples e avaliação do canal arterial.

Neonatologists and neonatal nurses have positive attitudes towards perinatal end-of-life decisions, a nationwide survey.

AIM: Perinatal death is often preceded by an end-of-life decision (ELD). Disparate hospital policies, complex legal frameworks and ethically difficult cases make attitudes important. This study investigated attitudes of neonatologists and nurses towards perinatal ELDs. METHODS: A survey was handed out to all neonatologists and neonatal nurses in all eight neonatal intensive care units in Flanders, Belgium in May 2017. Respondents indicated agreement with statements regarding perinatal ELDs on a Likert-scale and sent back questionnaires via mail. RESULTS: The response rate was 49.5% (302/610). Most neonatologists and nurses found nontreatment decisions such as withholding or withdrawing treatment acceptable (90-100%). Termination of pregnancy when the foetus is viable in cases of severe or lethal foetal problems was considered highly acceptable in both groups (80-98%). Physicians and nurses do not find different ELDs equally acceptable, e.g. nurses more often than physicians (74% vs 60%, p = 0.017) agree that it is acceptable in certain cases to administer medication with the explicit intention of hastening death. CONCLUSION: There was considerable support for both prenatal and neonatal ELDs, even for decisions that currently fall outside the Belgian legal framework. Differences between neonatologists' and nurses' attitudes indicate that both opinions should be heard during ELD-making.

Functional echocardiography training in the neonatal intensive care unit: comparing measurements and results with the pediatric cardiologist.

OBJECTIVES: Functional echocardiography is a valuable tool in the neonatal intensive care unit, but training programs are not standardized. The aim was to report an functional echocardiography training program for neonatologists and to describe the agreement of their measurements with the pediatric cardiologist. METHODS: Functional echocardiography training lasted 32h. After training program, the neonatologists performed functional echocardiography in the neonatal intensive care unit and were required to measure left cardiac chambers dimensions, left ventricle systolic function, right and left ventricular output, ductus arteriosus diameter, and flow pattern. Images were recorded by the equipment and reviewed offline by the pediatric cardiologist. The Bland-Altman test was used for quantitative variables and the kappa test, for qualitative variables. RESULTS: Twenty-two trained neonatologists performed 100 functional echocardiography exams. Ductus arteriosus identification and flow pattern had substantial agreement (kappa=0.91 and 0.88, respectively), as well as its diameter (mean difference=0.04mm). The mean difference for the aortic root was -1.2mm; left atrium, 0.60mm; left ventricle diastolic diameter, -0.90mm; left ventricle systolic diameter, -0.30mm. Shortening fraction and ejection fraction correlated well with broad limits of agreement, -2.96% (14.88; -20.82%) and --3.43% (15.54; -22.40%), respectively. Right and left ventricular output had broad limits of agreement, 16.69mL/kg/min (222.76; -189.37) and 23.57mL/kg/min (157.88; -110), respectively. There was good agreement between interpretations of normal or low cardiac output (76.7% for right ventricular output; 75.7% for left ventricular output). CONCLUSION: This functional echocardiography training program enabled neonatologists to obtain adequate skills in performing the images, obtaining good agreement with the cardiologist in simple hemodynamic measurements and ductus arteriosus evaluation.

Survey of a nutrition management method for very low birthweight infants: Status before wide use of breast milk banks in Japan.

BACKGROUND: The importance of breast-feeding for very low birthweight (VLBW) infants has been pointed out. Some overseas studies suggested that the standardization of enteral nutrition (EN) leads to improved prognosis in VLBW infants. In Japan, however, physicians in charge of infants are responsible for making nutrition management decisions on an individual basis. We conducted an online survey to clarify the course of nutrition management of VLBW infants currently implemented in Japan. METHODS: We mailed a notice to 300 representative neonatologists throughout Japan requesting their participation in the online survey. On the survey website, neonatologists responded to questions regarding the nutritional strategy for five birthweight groups (less than 500 g, 500-749 g, 750-999 g, 1,000-1,249 g and 1,250-1,499 g). RESULTS: Responses were recieved from 137 neonatologists. The first choice for EN up to 1 week after birth was breast milk regardless of birthweight (92.0% for 1,250-1,499 g to 95.6% for 500-999 g). More than 30% of the respondents answered that they fast infants who weigh <750 g at birth or feed them with other mothers' breast milk until their own mother's milk becomes available. The lower the birthweight, the later EN is started, and the greater the number of days to establish EN. CONCLUSION: The lower the birthweight, the more difficult it is to feed infants their own mother's milk and the later the EN is started. If donor milk is supplied in a stable manner, it takes fewer days to establish EN.

Neonatologist performed point-of-care bowel ultrasound: Is the time right?

INTRODUCTION: This review acquaints neonatal clinicians using point-of-care ultrasound with a range of pathological bowel ultrasound findings, with the aim to promote utility of this skill as a diagnostic assessment tool in diseased neonatal intestinal states. OVERVIEW: A range of normal and pathological bowel ultrasound findings are illustrated with case examples from our neonatal intensive care unit. The technical challenges of lack of familiarity with sonographic appearance of bowel (healthy and diseased), occurrence of gas artefacts and requirements of high-resolution linear transducer probes are described to allow the development of skills amongst neonatologists trained in point-of-care ultrasound. Plain abdominal radiography continues to remain the standard investigation to differentiate benign bowel states such as continuous positive airway pressure (CPAP) belly syndrome in preterm infants from life-threatening pathological intestinal states such as necrotising enterocolitis. Although plain radiography is the gold standard modality in the evaluation of neonatal diseased bowel states, real-time point-of-care bowel ultrasound performed in conjunction can provide valuable information on bowel peristalsis, bowel wall thickness and bowel vascularity. Abnormal configuration of superior mesenteric vessels on colour Doppler can alert the clinician to the diagnosis of neonatal intestinal malrotation-a time critical emergency. CONCLUSION: Further research is needed to explore true-negative and true-positive predictive values of bowel ultrasound. However, with expansion of knowledge, appropriate training of techniques, neonatologists will be able to enhance their diagnostic acumen by performing point-of-care bowel ultrasound in conjunction with plain radiography in the evaluation of broad array of neonatal intestinal states.