Protecting the brain of the preterm infant

Protecting the brain of the preterm infant

A few years ago targeted echocardiography (or functional echo) became all the rage. As trainees in this field have become spread across this country and others it is natural that attention would turn to other deficiencies in Neonatology. The new thing on the block appears to be Neonatal Neurocritical Care with the concept being that building teams devoted to the pursuit of better neuro outcomes for babies is needed. I am not here to say otherwise but to acknowledge that this is a good thing for our field. Building a local expertise for such at risk infants is a wise plan as with anything if we focus and a small area and put lots of hours in you can only get better.

New CPS Statement

This past month the CPS released a new position statement entitled Neuroprotection from acute brain injury in preterm infants . As Chair of the committee and writer of this blog I thought it might be nice to point out the timely release of this statement. One of the authors Dr. Khorshid Mohammad was recently in Winnipeg for our POCUS workshop and spoke about neurocritical care for neonates as part of the meeting. I would encourage you to read through the new statement but wanted to point out a couple interesting recommendations that serve as a departure from practice (or at least my own).

Antenatal steroids should be given to those 34 0 – 34 6/7 weeks.

This is something that comes out of the literature that has looked more broadly at the group from 34 0/7 – 36 6/7 weeks. The recommendation really is an acknowledgement that if there is benefit it is likely coming from those infants just past the 34 week mark. Older infants may benefit but the numbers needed to treat are so high that it calls into question the real need for such treatment.

A new approach to treating hypotension

An approach that moves away from treating numbers is recommended. How many times have you been asked how low a blood pressure should be allowed to drift before starting inotropes? Evidence is mounting that early use of inotropes themselves is linked to IVH. A more nihilistic approach is favoured here by looking at measures of end organ impact before instituting such therapy. What is the urine output, perfusion and lactate should motivate treatment more than just the number itself. If you are fortunate enough to have targeted echocardiography at the ready it is recommended to utilize that modality to help guide your treatment as well.

I won’t go through the whole document as I would love for you to read it yourself and see how it may apply to your own centre. I think the statement is significant though in that it really does marshal in a new era in the field of neuroprotection. I am pleased that the CPS is taking a position on this and if you need any other guidance be sure to visit our webpage at the Fetus and Newborn Committee which can be found at:

https://www.cps.ca/en/documents/authors-auteurs/fetus-and-newborn-committee

The CPS Fetus and Newborn Committee: Lifting The Curtain!

The CPS Fetus and Newborn Committee: Lifting The Curtain!

Last week marked a changing of the guard at the Canadian Paediatric Society, as Dr. Thierry Lacaze stepped down as the chair of the Fetus and Newborn Committee. We produced many important position statements and practice points under his leadership and I hope to continue this trend.

The aim of this committee is to provide guidance across disciplines to all those who care for newborns. Topics we examine include everything from surfactant treatment, to approaches to the infant with jaundice and hypoglycemia, to how to manage infants born to opioid-dependent mothers.

I plan on using all the channels at my disposal, including digital and social media communications, to proactively inform and seek input from interested health care providers about the sorts of topics on the committee’s agenda.

It’s not uncommon for those outside of the organization to approach my colleagues and me with their feedback. “You should really work on this or that,” is a phrase I’ve grown accustomed to hearing. We are often doing just that, and I think it’s important for our colleagues to know.

As different locations across the country seek to put in place local guidelines based on CPS research, I think it would be helpful to know if there’s something new on the horizon that will impact their work. Why spend a lot of time developing a guideline based on a statement or practice point that is about to change?

My pledge to you

In my new role as chair, I promise to keep you apprised and informed about the topics on the committee’s agenda. When a document is likely to significantly affect the approach to patient care, I will do my best to alert you. If you have topics that you believe are in need of a national position or guideline, please send me an e-mail at [email protected] for consideration by the committee.

Recent publications

Supporting and communicating with families experiencing a perinatal loss
Leonora Hendson and Dawn Davies

This practice point focuses on circumstances that are likely to involve paediatric health professionals. Recommendations are provided for compassionate communication, bereavement, sibling care and counselling to support families.

Managing infants born to mothers who have used opioids during pregnancy,
Thierry Lacaze-Masmonteil, Pat O’Flaherty

This practice point focuses on the effects of opioid withdrawal and current management strategies in the care of infants born to mothers with opioid dependency.

Upcoming publications (in no particular order)

Hypothermia for newborns with hypoxic ischemic encephalopathy (revision)

Brigitte Lemyre, Vann Chau

This document reviews indications, contra-indications, discusses the requirements, in terms of expertise and specialized equipment, of units where hypothermia should take place. Additionally, the timing of the first MRI and when to do a follow-up MRI are clearly delineated.

Guidelines for vitamin K prophylaxis in newborns
Eugene Ng, Amanda Loewy

Clear recommendations are provided for provision of vitamin K dosing via the intramuscular route. The evidence for oral vitamin K is reviewed and a clear position is taken on its use in newborn care.

Facilitating discharge home of the healthy infant (revision)
Brigitte Lemyre, A. Jerfferies, P. O’Flaherty

This statement provides guidance for health care providers to ensure the safe discharge of health term infants who are born in hospital and who are ≥ 37 weeks’ gestational age.

Imaging of the term neonatal brain
Ann Jefferies, S. Sorokan, Steven Miller, Ken Poskitt

This position statement describes the principles, roles and limitations of three imaging modalities and makes recommendations for appropriate use in term neonates.