Afifi J, et al. Atropine Versus Placebo for Neonatal Nonemergent Intubation: A Randomized Clinical Trial. J Pediatr. 2025;286:114719 I had thought this was a settled issue, Neil Finer showed many years ago that atropine alone decreased bradycardias during intubation. But as the authors of this new study point out, there is very little (or no) data about atropine as part of an intubation cocktail in the newborn. I have a bit of a beef with the introduction which suggests that the Kelly and Finer trial mentioned above was limited, as it did not "follow recommended premedication protocols".

There are a huge number of publications correlating medium term outcomes (by which I mean outcomes around 1 to 2 years of age) with findings in the neonatal period. Most have concerned various approaches to brain imaging, although other studies have evaluated EEG, NIRS, early structured physical examinations, counting how many complications the baby had, the type of feeding they received.... I am sure my readers could construct a longer list. There are several recent publications that have triggered this post, in the extremely preterm infant. In the preterm infant, brain injury on imaging is very common, yet most preterm babies actually function very well.

One of the pivotal RCTs in neonatology was the CAP study (Schmidt B, et al. Long-term effects of caffeine therapy for apnea of prematurity. N Engl J Med. 2007;357(19):1893–902). We performed that study because there was no data on the long term impacts of caffeine, and there was a worry that blocking adenosine receptors in babies having multiple hypoxic episodes might be a bad idea. Adenosine is an inhibitory neurotransmitter that is produced during hypoxia, and decreases the brain metabolic rate to protect against hypoxic damage. So giving caffeine to babies having a lot of apnoeas could potentially have been a bad idea.

One of the worst kinds of unethical research practice is to fail to publish results after a prospective study. Parents consent to research for altruistic motives, in the belief that their baby's participation will help the care of other, future, babies. Failing to carry through and publish, or at the very least, make results publicly available on the registration website, is an abuse of that consent.

There have been multiple publications concerning this issue recently, many from the tiny baby collaborative. The first 2 publications are about the overall approach to providing intensive care at extremely low GA: Bernardini LB, et al. It's the little things. A framework and guidance for programs to care for infants 22-23 weeks' gestational age. J Perinatol. 2025. This is a discussion of the many issues that should be addressed in centres trying to improve outcomes for these babies, including a recognition that they face specific challenges, require particular attention to detail, have unique physiologic limitations, and deserve an integrated caring approach with a committed team which includes obstetricians, nurses, all the allied health professionals, and parents.

A new single centre RCT of permissive hypotension (PH) compared to "standard treatment" (ST) of very preterm infants 24 to <30 weeks GA, with a mean BP lower than their GA has just appeared (Alderliesten T, et al. Treatment of Hypotension of Prematurity: a randomised trial. Arch Dis Child Fetal Neonatal Ed. 2025). In the intervention, PH, group, infants only received treatment if they developed signs of poor perfusion. In the ST group they immediately received a fluid bolus and a dopamine infusion, followed by adding dobutamine, then epinephrine, hydrocortisone was given if the baby needed more than just dopamine.

A recent confluence of 3 reviews, one on breastfeeding specifically in the NICU (Hilditch C, et al. Effect of Neonatal Unit Interventions Designed to Increase Breastfeeding in Preterm Infants: An Overview of Systematic Reviews. Neonatology. 2024;121(4):411-20) another on the evidence supporting the efficacy of lactation consultants (D'Hollander CJ, et al. Breastfeeding Support Provided by Lactation Consultants: A Systematic Review and Meta-Analysis.

I thought, as today is NEC awareness day, I would give an overview of recent research about NEC prevention strategies. Probiotics. I am sure my readers are aware of the major problems in the USA which have followed the occurrence of an episode of sepsis caused by a probiotic organism; with several preparations being no longer available. This has happened even though the data generally shows a reduction in late-onset sepsis overall with probiotic supplementation, or in some analyses, no difference in overall LOS frequency. I'm not aware of any study, or any systematic review, which has shown an increase in sepsis with probiotic prophylaxis.

In some pre-clinical models, erythropoietin acts as a neuroprotective agent, which led to the performance of clinical trials to determine whether there was a positive impact on outcomes of the preterm. The latest study has just been published, and it is another high quality trial from the NICHD NRN, and Robin Ohls. The article starts with a questionable assertion, "Erythropoiesis-stimulating agents (ESAs) such as erythropoietin...have shown evidence for neuroprotection in preterm infants". I think if that was true, they would not have done this trial! In fact the references they give for that statement show a very variable impact on outcomes, the figure below is from a SR/MA which included only erythropoietin studies, eliminating a darbepoietin (a long acting EPO analogue) group in the second study by Robin Ohls et al (2014).

Dutta S, et al. Seven-day versus 14-day antibiotic course for culture-proven neonatal sepsis: a multicentre randomised non-inferiority trial in a low and middle-income country. Arch Dis Child Fetal Neonatal Ed. 2025. This is a multicentre trial from India of neonates (0-28 d of age), term and preterm (down to 1kg b.wt) who had culture positive sepsis and were stable by 5 days of treatment. There is a detailed algorithm in the supplemental materials to define "clinical remission of sepsis", which looks quite fair. At 7 days of treatment of sepsis, with antibiotics to which the organism was shown to be sensitive, the babies were randomized to stopping the antibiotics, or continuing for 14ays.

In response to a couple of thoughtful comments to my previous post, I thought I would try to address the specific issue of the infant of 35 weeks. (Faix RG, et al. Whole-Body Hypothermia for Neonatal Encephalopathy in Preterm Infants 33 to 35 Weeks' Gestation: A Randomized Clinical Trial. JAMA Pediatr. 2025;179(4):396-406). There is clearly some room for discussion, not only are obstetric estimates of gestational age uncertain, but what is the real difference between an infant at 35 weeks and 6 days, compared to 36 weeks exactly? Should we really determine therapy based on whether the baby was born before or after midnight?

Current guidelines support the use of therapeutic hypothermia for term infants with hypoxic ischaemic encephalopathy. Both the Canadian and the US guidelines include infants born at 35 weeks gestation. However, the data supporting efficacy for those late preterm infants, is extremely limited, and less mature infants were excluded from all the major trials. The discussion section of this new publication reveals that the 2 RCTs which included babies of 35 weeks GA had a total n of 7. This lack of reliable information for a group of infants who are referred with acute encephalopathy led to the performance of an RCT by the NICHD network.

I wrote about this trial after last year's PAS meeting, mentioning that it looked like a potential significant improvement in respiratory care of the preterm The full publication confirms that is a real possibility. McEvoy CT, et al. Extended Continuous Positive Airway Pressure in Preterm Infants Increases Lung Growth at 6 Months: A Randomized Controlled Trial. Am J Respir Crit Care Med. 2025;211(4):610-8. The trial enrolled 100 preterm infants (24 to 32 weeks GA) who had at least 24 hours of CPAP and were considered ready to have the CPAP stopped (5 cmH2O, 21% O2, without tachypnoea or retractions or frequent apnoea, and tolerating breaks from CPAP during care procedures).

I used to do a series of shorter posts called "weekly updates" but I ran out of steam and have concentrated on longer posts in recent years. The last couple of weeks, with clinical service, I have had less time for a longer post, but a few things piqued my attention: Alexe PI, et al. Prematurity and Congenial Diaphragmatic Hernia: Revisiting Outcomes in a Contemporary Cohort. J Pediatr. 2025:114545. I thought I would write about this article before the title got corrected, (unless, that it, they really are discussing "congenial" diaphragmatic hernia).

I used to do a series of shorter posts called "weekly updates" but I ran out of steam and have concentrated on longer posts in recent years. The last couple of weeks, with clinical service, I have had less time for a longer post, but a few things piqued my attention: Alexe PI, et al. Prematurity and Congenial Diaphragmatic Hernia: Revisiting Outcomes in a Contemporary Cohort. J Pediatr. 2025:114545. I thought I would write about this article before the title got corrected, (unless, that it, they really are discussing "congenial" diaphragmatic hernia).

I used to do a series of shorter posts called "weekly updates" but I ran out of steam and have concentrated on longer posts in recent years. The last couple of weeks, with clinical service, I have had less time for a longer post, but a few things piqued my attention: Alexe PI, et al. Prematurity and Congenial Diaphragmatic Hernia: Revisiting Outcomes in a Contemporary Cohort. J Pediatr. 2025:114545. I thought I would write about this article before the title got corrected, (unless, that it, they really are discussing "congenial" diaphragmatic hernia).

I used to do a series of shorter posts called "weekly updates" but I ran out of steam and have concentrated on longer posts in recent years. The last couple of weeks, with clinical service, I have had less time for a longer post, but a few things piqued my attention: Alexe PI, et al. Prematurity and Congenial Diaphragmatic Hernia: Revisiting Outcomes in a Contemporary Cohort. J Pediatr. 2025:114545. I thought I would write about this article before the title got corrected, (unless, that it, they really are discussing "congenial" diaphragmatic hernia).

A few years ago, we published our experience with the use of hydrocortisone in newborn infants in septic shock (Altit G, et al. Corticosteroid Therapy in Neonatal Septic Shock-Do We Prevent Death? Am J Perinatol. 2018;35(2):146-51), like many such studies the numbers were small, but the 39 babies who received hydrocortisone in addition to their inotropic support had rapid haemodynamic improvement, within 6 hours of starting hydrocortisone, mean BP had increased by over 30%, urine output was better, and inotropic support was being weaned. They were, however, somewhat less likely to survive the episode (59% survival vs 78% without hydrocortisone) and to survive until discharge, neither of which comparisons were "statistically significant", and the babies who got hydrocortisone were sicker, less mature and more likely to have NEC, than the septic babies who did not get hydrocortisone.

When the platypus was first captured, killed, skinned and the pelt sent to a zoologist in London, George Shaw in 1799, he thought he was being scammed. He tried to find the stitches that had been used to cobble together the specimen. Being unable to do so, he then concluded that it was probably real, and was unique. It was what we would now consider an evolutionary innovation, it had features of previous organisms, such as laying eggs, and several new features, being venomous and producing milk to feed their young, once they have hatched.

Several trials of liberal versus more restrictive transfusion practices have been published, and overall, it seems that being very restrictive in transfusions has no negative impacts on clinical outcomes, and depending on the trial, some positive benefits of avoiding transfusion. One of the important studies of the Canadian Critical Care Trials Group was the TRICC trial, which enrolled critically ill adults with a hemoglobin less than 9 g/dl, who were randomized to a target hemoglobin of 7-9 vs 10-12 g/dl. In that trial the adults with the lower target did better, with a lower in-hospital mortality of 22%, vs 28% with more liberal transfusion.

We have known for a very long time that bilirubin can cause an encephalopathy leading to acute and chronic clinical impacts, the most severe chronic impacts being kernicterus, a disabling movement disorder and nerve deafness. What seems to be the case is that bilirubin bound to albumin doesn't cross the blood-brain barrier, and that the BBB, which appears to develop early, and be functional by 20 weeks, is easily disrupted in the newborn. Bilirubin staining of the basal ganglia has been shown on autopsy specimens at much lower concentrations than are associated with kernicterus in term babies.

A recurrent problem in the NICU is "bandwagon-jumping". An intervention with some preliminary positive data, and a possible physiologic rationale is widely adopted and made part of QI bundles with little or no reliable evidence that it is either effective or safe. One such is the hype surrounding fresh mother's milk. There are a small number of studies showing the following impacts.