Point of Care Ultrasound in the NICU

Point of Care Ultrasound in the NICU

This post is meant to supplement an earlier post on the same topic.

Since introducing POC U/S in our unit there has been great enthusiasm and we will begin shortly introducing our nursing group to it’s use in order to enhance usage.  Now that we have had some exposure we took the time to capture some our thoughts on this technology in this accompanying video graciously supported by the Children’s Hospital Foundation in Winnipeg.  To watch this wonderful video by Dr. Ganesh Srinivasan a Neonatologist and technology aficionado in our institution click on the link below.

Michaela’s appliance: A Novel Appliance to Allow Successful use of CPAP in a premature infant with a cleft lip and palate.

What follows is a local news story that I had the pleasure of being involved in. I am posting on the blog not to show off in the least but rather highlight how true collaboration between professionals (who on the surface might not seem to be related) can accomplish incredible things. The strategy employed in this case had not been described before in the literature and thus it is my hope that this post may be shared at your local institutions and in the event a child with a cleft lip and palate is born and needs CPAP this appliance could be utilized.

If you would like further information on this approach please email me at [email protected] and I would be happy to provide you with assistance. The link to obtain the abstract and from there if you have personal or facility access to the full article can be found here: http://www.ncbi.nlm.nih.gov/pubmed/25794910

Within the last year a team of professionals from Dentistry, Neonatology and Respiratory Therapy came together to solve an unusual problem.  A baby had been born prematurely at 26 weeks gestational age and less than 2 lbs and relied on a ventilator to help her breathe.  As many of these children age, their reliance on a ventilator becomes less and they are changed to a non-invasive level of support called CPAP (continuous positive airway pressure). This consists of a mask put over the nose, which passes air into the lung thereby keeping a babies lungs inflated while we wait for continued development of their lungs.  In this case however this premature infant had been born with a complete unilateral cleft lip and palate.  Having this cleft created a leak, which makes the use of CPAP very challenging. The flow of air leaks out through the cleft instead of getting to the lungs to keep them inflated.  One day, one of our respiratory therapists John Minski asked the Neonatologist on service (Dr. Michael Narvey) whether we could use a 3D scanning and printing technology to create an appliance that would seal the palate and allow pressure to be maintained in the lungs through the flow of air in the nose.  Dr. Narvey had not heard of such a strategy being employed before but consulted Dr. Igor Pesun from the Faculty of Dentistry for an opinion and what came out of this discussion was a novel concept that we believe is the first of its kind.

A dental obturator was created to seal the palatal defect. Obturator 1A child who is as small as Michaela, made the use of current intra oral scanning technology not possible. An impression using conventional dental materials was used to record the anatomy of the palate. A model was made and used to fabricate the obturator that was connected to the CPAP tubing.obturator 2

Over a period of 4 days the obturator was used to maintain a palatal seal and allowed for sufficient pressure to be maintained to manage the child off the ventilator.  After this point she was deemed ready to transition to being off CPAP.

The collaboration between these services was instrumental in taking an idea from concept to reality.  We were able to demonstrate that a premature infant, who previously would have been forced to remain on a ventilator until they were ready to come off breathing support completely, could be managed with a novel airway appliance.  This type of approach has never been tried before in the literature and exemplifies some of the creative and innovative collaborative work happening at the Health Sciences Centre.  Finally it serves as a shining example of how different seemingly unrelated specialties can come together within the Faculty of Health Sciences at the University of Manitoba.

An under recognized killer.  The sofa!

An under recognized killer. The sofa!

This post is a re-release due to a furor on twitter over the last month of the release of a Johnson’s Baby (July 17) showing the infant sleeping with dad on a couch.  
Johnson and Johnson has since spoken out about the ad and clearly stated it was not their intention to show unsafe sleeping practices but as a company working in the field of newborn care I do believe there is a responsibility to demonstrate safe sleeping practices and as you will see when you read on the couch is not one of them…

One of the greatest achievements of the 1990s in infant health has to be the “Back to Sleep Campaign” which has undergone a name change to the Safe to Sleep Campaign.

The back to sleep campaign achieved incredible results in reducing the risk of SIDS.  Since its inception the program reduced the rate of SIDS by approximately 50% although annually in the US there remain approximately 4000 deaths per year.  SIDS is clearly a parent’s worst nightmare and it is important to disseminate any information that we can to try and further reduce SIDS in addition to the Safe to Sleep campaigns achievements.

Much of what I am writing, I would really encourage readers to incorporate into discharge planning whether you are working in an NICU or postpartum ward.  The advice is based on well done research and although not part of a randomized trial which is our gold standard, it has been found across many studies.  These risks are now accepted as modifiable factors and as part of our responsibility to advocate for our patients this is one thing we can and should talk about.

Smoking, Alcohol, Illicit Drug Use and Partner Violence

These have been identified as  risk factor for SIDS both prenatally and in the homes of newly born infants.  As it has been associated, it is not always clear whether smoking and drug use in and of themselves cause biochemical or developmental changes in the developing fetus that predisposes them to SIDS or if it a marker for something else such as socioeconomic status.  That being said there are many reasons to deter people from these factors so I would see this as a strong area for advocacy.

Co-sleeping

This has been appreciated as a risk factor for SIDS for many years although I suspect many parents are unaware of its risk.  I can understand how it can happen and why some mother’s who are wanting to encourage breastfeeding favour it. Having your infant with you such that the moment they wake you can turn to them and feed them is simple and avoids having to go back and forth from rooms particularly when you have a “snacker” on your hands and you are exhausted from the endless night time feeding.  This has and will likely continue to be cited as a risk though for SIDS and should be discouraged.  What remains a little unclear is whether co-sleeping by itself is actually a risk in the absence of other factors as outlined in the above paragraph.  A meta-analysis of multiple studies by Carpenter indicated that co-sleeping with or without the above factors placed infants at risk of SIDS although the risk was increased further when such factors were present.

Curiously Blair PS et al found exactly the opposite result that in the absence of risk factors of smoking, alcohol or drug use the practice of co-sleeping appeared to add no additional risk for SIDS.

So the jury is perhaps out as to whether co-sleeping in the absence of other risk factors increases the risk of SIDS given the conflicting studies but in the presence of uncertainty I would at least caution that the practice should be avoided if there is the potential for actual risk.

What has been consistent however is that the use of the sofa as a sleeping surface is one that should be avoided.  Avoidance should include even naps with your infant as it doesn’t take very long for an adverse outcome to be realized.  In previous studies in fact the risk has been estimated to be 67 times that of sleeping in a bed.  A recent well done study of 9073 sleep related deaths found that 1024 occurred while co-sleeping on sofas.  This study documented all deaths from 2004-2012 and demonstrated a 12.1% incidence of death in this environment.  As a probable explanation for the increased risk found with this position, more infants were likely to have been placed prone or side lying while sleeping on the sofa with a parent.  Suffocation in this position particularly if wedged in between the parent and the cushion would be far more likely.  The complete study can be found here. For risks while sleeping on sofas see the accompanying table.

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In the end as health care providers anticipatory guidance needs to be part of all of our practices.  We all talk about “Back to Sleep” but do all programs caution about the risks of napping or sleeping with your infants on a sofa?  We have a chance to make a real difference and eliminate over a 1000 deaths a year that are attributable to this position.  I know it is easy to take a quick nap with a child on the sofa but is the risk worth it?  That is something every parent needs to decide for themselves but the first thing is getting the information into their hands so they can make an informed decision!