Objective To assess the reliability of longitudinal strain (LS) and strain rate (SR) in the very low birth weight infants. Design/Methods LS and SR were measured in infants less than 28 weeks corrected gestational age using colour tissue Doppler at the mid segment of the LV free wall, the intra-ventricular septum and RV free wall from the apical 4-chamber view. Intra and inter-observer reliability was assessed using intra class correlation coefficient (ICC) and Bland-Altman Analysis. Results 48 infants with a mean (SD) gestation and birth weight of 26.9(1.3) weeks and 959(230) grams underwent an echocardiogram at 11(5) hours of life. The RV and septal walls demonstrated superior bias and agreement when compared to the LV free wall. Conclusions Assessment of LS and SR in preterm infants using colour tissue Doppler is feasible with the RV and septal wall providing better reliability results. Further study of those parameters in preterm disease states is warranted.

Introduction Physiological changes of the preterm heart during the transitioning period are a challenging area to assess. Colour Tissue Doppler derived longitudinal strain (LS) and strain rate (SR) as well as tricuspid annulus plane systolic excursion (TAPSE) and fractional area change (FAC) are novel echocardiographic techniques for the assessment of left (LV) and Right (RV) ventricular function. We aimed to assess the feasibility and reliability of measuring these indices in preterm infants less than 29 weeks gestation during the transitioning period. Methods A prospective study was conducted on 54 preterm infants, with a mean (SD) gestation and birth weight of 26.7 (1.4) weeks and 954 (231) grams. LS, SR, conventional markers and novel RV markers were measured at a mean of 10 and 45 h of life. Reliability was assessed by using intra class correlation coefficient (ICC) and Bland-Altman Analysis. Results Despite no significant change in conventional markers such as shortening fraction or ejection fraction, there was a significant increase in septal SR(-1.6 to -1.8, p = 0.002) and SRE(1.7 to 2.2, p = 0.002) across the two time points. RV function parameters including SR, SRA, TAPSE, and FAC demonstrated a significant increase across the two time points. Septal and RV function and dimension parameters demonstrated excellent reliability results. Conclusion Myocardial deformation including strain, strain rate was as well as RV markers and dimensions were feasible in infants less than 29 weeks gestation. Significant changes were seen using novel echocardiographic markers over the transitional period.

Background: Extremely preterm babies (delivered at <28 completed weeks of gestation) are frequently diagnosed with hypotension and treated with inotropic and pressor drugs in the immediate postnatal period. Dopamine is the most commonly used first-line drug. Babies who are treated for hypotension more frequently sustain brain injury, have long-term disability or die compared to those who are not. Despite the widespread use of drugs to treat hypotension in such infants, evidence for efficacy is lacking, and the effect of these agents on long-term outcomes is unknown. Hypothesis: In extremely preterm babies, restricting the use of dopamine when mean blood pressure (BP) values fall below a nominal threshold and using clinical criteria to determine escalation of support (‘restricted' approach) will result in improved neonatal and longer-term developmental outcomes. Research Plan: In an international multi-centre randomised trial, 830 infants born at <28 weeks of gestation, and within 72 h of birth, will be allocated to 1 of 2 alternative treatment options (dopamine vs. restricted approach) to determine the better strategy for the management of BP, using a conventional threshold to commence treatment. The first co-primary outcome of survival without brain injury will be determined at 36 weeks' postmenstrual age and the second co-primary outcome (survival without neurodevelopmental disability) will be assessed at 2 years of age, corrected for prematurity. Discussion: It is essential that appropriately designed trials be performed to define the most appropriate management strategies for managing low BP in extremely preterm babies.

Appropriate testing for fetomaternal haemorrhage (FMH) is critical in the prevention of morbidity and mortality due to haemolytic disease of the fetus and newborn (HDFN) in RhD negative women. The Kleihauer or acid elution (AE) test is widely used to assess the size of fetomaternal haemorrhage and to determine whether sufficient Anti-D immunoglobulin has been administered to prevent HDFN. This test is based on the principle that adult haemoglobin (HbA) is eluted from red cells in an acidic solution while the fetal haemoglobin (HbF) is not. However, in the presence of an elevated level of HbF of maternal origin, the AE test may be “positive” in the absence of a true FMH. We report two cases in which this situation arose antenatally, leading to difficulties in clinical interpretation. In both cases, specialised flow cytometry revealed the presence of elevated levels of HbF of maternal origin. While awaiting completion of specialised investigations, Anti-D was administered but was later found to have been unnecessary. Early awareness of the possibility of elevated maternal F cells ensures that samples can be sent to appropriate reference laboratories early to limit unnecessary Anti-D administration. The true prevalence of “false positive” AE tests due to elevated maternal HbF is unknown and is the subject of ongoing work in our laboratory, but should be considered in the differential diagnosis of an AE test remaining positive despite appropriate Anti-D administration.

Background and Aims To assess incidence, management and outcomes of Superior Vena Cava (SVC) syndrome in post PDA ligation patients in the Rotunda Hospital. PICC’s are used routinely in postoperative paediatric cardiac patients. Following placement, catheter-related thrombosis occurs in 8% to 45% of paediatric patients. Although uncommon, resultant SVC syndrome significantly complicates management of premature infants. Methods A retrospective chart review of infants undergoing PDA ligation from July 2011 to March 2012. Results 5 patients had PDA ligation within the study period. Average gestation at birth was 25+4 weeks and average birth weight was 0.754kg. Surgery was performed at an average weight of 1.027kg and 26.8 days. 9 PICC lines were inserted; mean of 1.8 per patient with removal following a mean of 12.5 days. 2 cases of catheter related thrombosis, post PDA ligation, resulted in SVC obstruction. Both patients had a PICC in situ at the time of surgery, the other 3 patients did not have PICC access during surgery. SVC thrombosis was detected at a mean of 15 days post operatively. One affected patient died subsequently due to complications. Conclusions Post-surgical catheter related thrombosis is well documented. SVC syndrome can infrequently result as a complication, which may cause severe respiratory compromise leading to high morbidity and mortality. As treatment of SVC syndrome is very difficult, especially in post operative patients and with a trend towards fewer PDA ligations, increased awareness in neonatal units may allow early diagnosis and thrombolytic therapy to prevent the progression of this syndrome.

Background: Advantages of early discharge of VLBW infants include cost savings, decreased exposure to nosocomial infections, and benefit for families. Aim: To evaluate the effect of discharge planning on duration of stay of VLBW infants. Methods: Retrospective review of VLBW infants from 1.1.1996 -31.12.2009. Results: 850 VLBW infants were discharged home alive, accounting for 49,917 hospital days. Mean LOS was 50.81 days (2009) and was significantly lower than 2004-2007 (p =.015), with no increase in readmissions. 5.6% (n=48) had delayed discharge (>42/40 CGA) which was less in 2009 than 2007 (2 vs 6 infants). Infants discharged >42/40 CGA had an earlier mean GA (28.5 vs. 29.3 weeks), lower mean BW (870g vs. 1144g) and mean LOS (117.9 days). Delayed discharge was significantly associated with NEC requiring surgery (42.9%), BPD (20.4%), discharge home on O2 (22.4%), or requiring an apnoea monitor. Overall LOS was associated with GA, and sepsis (CONS) (p< 0.05). The total incidence of sepsis decreased from 46 infants per year in 2007 to 25 infants in 2009. 197 infants were transferred to local hospitals. Mean LOS pre transfer was 31.96 days (2009) compared 38.21 days (2007), and significantly reduced compared to 2004-2008 (p =.026) with no corresponding increased combined LOS in Rotunda and local hospital (2007=67.3 days vs 2009= 57.4 days). Conclusions: Reduction in mean LOS for VLBW infants with improvement in discharge planning was associated with the appointment of a discharge coordinator. Discharge coordinators are cost effective and should be appointed in all neonatal units.

Background: Premature infants are predisposed to coagulopathy, which may increase intraventricular haemorrhage (IVH). Coagulation values vary by gestation in utero and are different to term values. Limited data exists in literature for coagulation parameters < 26/40 GA. Conservative estimates increase unnecessary blood products, while untreated coagulopathy could increase IVH. Aim: Describe distribution of day 1 PT, APTT and Fibrinogen for infants < 26/40 GA. Methods: Retrospective review of infants (< /= 26/40 GA) between 1.1.2004-31.12.2010. Clotting studies performed on < 26/40 GA in our hospital on day 1 of life. Values obtained from computerised laboratory system. Descriptive statistics performed. Results: Clotting values summarised in Table 1. Cases were excluded if value exceeded laboratory measurement capability (n=6) or not obtained on day 1. *Narrowing of range between 23-26 /40 GA **Laboratory reference range: PT 13.0+/−1.43, APTT 42.9+/− 5.8, FBG 2.83+/−0.58 Conclusions: Term reference ranges differ from coagulation values for < 26/40 GA. This large cohort provides normative values for interpretation of day 1 coagulation values. Further studies required to determine whether treatment of raised coagulation values is of therapeutic benefit.

Background: Evidence suggests that twins are disadvantaged in terms of long-term growth and neuro-developmental status. This may in part be due to the increased risk of prematurity that twins face, in particular late prematurity. Aim: We investigated neuro-developmental outcomes of a cohort of 40 pairs of late premature twins (32+ 0 to 36+ 6) at 2-3 years of age through a standardised developmental questionnaire, The Ages and Stages Questionnaire, 3rd edition. (ASQ) This group of children were compared to a control group of 40 pairs of term twins of similar age. Methods: The Ages and Stages questionnaire is a developmental assessment questionnaire which looks at 5 areas of development. Twins were recruited from 4 centres across Ireland. Parents were contacted via telephone. The ASQ was sent out to each twin pair between 2-3 years of age. Results: Both groups had mean scores in the normal range for all areas of development. The late pre-term group however, had statistically significant lower scores in the areas of communication, (mean 52.7 +/− 12.55 vs 58.6 +/−, p value less than 0.001), problem solving (mean 51.4 +/− 11.45 vs 57.7 +/− 3.89, p value less than 0.001) and fine motor (mean 43.6 +/− 10.94 vs 48.4 +/− 10.7, p value 0.01.) Conclusion: Tools such as the ASQ are able to detect significant differences in development between late pre-term twins and term twins. The ASQ tool may be a cost effective means of surveying large populations of late pre-term infants who would not otherwise have developmental surveillance.

Since the 1990s, there has been a re-emergence of cases of severe hyperbilirubinaemia and kernicterus. The current UK incidence of bilirubin encephalopathy is 0.9/100,000 with a higher reported incidence in some countries. Three otherwise healthy newborn infants, who presented with severe hyperbilirubinaemia, including one who developed kernicterus, are reported here. Some of the current challenges in newborn jaundice surveillance are highlighted.

Introduction Multiple births are high risk and remain a major complication for those undergoing assisted reproductive therapy (ART). In Ireland, more than one embryo is replaced during IVF treatment, leading to multiple births and increased socioeconomic costs. Aim To determine the incidence and outcome of multiple births in the Rotunda Hospital in recent years. Furthermore, to compare the outcomes of those following ART (IVF, ICSI and IUI) with those conceived naturally. Methods A retrospective audit was carried out of all liveborn multiple births greater than 500 g in the Rotunda Hospital between January 1st 2007 and December 31st 2007. Data was collected from the hospital information system, the Vermont Oxford Network and medical records. Information collected included whether the baby was born as a result of ART or not, NICU admission, birth weight. Results 405 babies were born of multiple pregnancies, 119 of these (∼29.4%) were a result of ART. 160/405 (39.5%) of multiples required NICU admission versus 863/8000 (10.7%) of singletons required NICU admission. 49/119 (∼41%) of ART multiples were admitted versus 109/279 (∼39%) of non-ART multiples, data is not available currently on the remaining 2 admissions. Multiple births accounted for 39 (31.4%) of the 124 liveborn babies ⩽1500 g. Conclusion Over a third of our multiples born ⩽1500 g are a product of ART. Elective single embryo transfer can significantly decrease multiple pregnancies associated with IVF. This has become standard practice in subgroups of women undergoing IVF in some European countries and should be considered in Ireland.

The neonatal multiple organ dysfunction score (NEOMOD) predicts mortality during the first 28 days of life, and provides information on organ functions influencing mortality.

Objective Our unit protocol for lower alarm settings is 87% and upper is 93% saturation. We audited compliance with these and how frequently spot saturation observations were within these values. Background The BOOST trial (1) showed that lower oxygen saturation targets of 91–94% versus 95–98%, significantly decreased the numbers with BPD, with NNT = 5. Method Twice daily recordings were taken on infants of gestational age 32 weeks or less, with a birth weight less than 1500 gm, on supplemental oxygen. Among the recorded measurements were spot oxygen saturations, oxygen saturation alarm settings, mode of ventilation, and fraction of oxygen administered. Results 16 infants were studied and 165 recordings were taken. The mean GA was 28.4 weeks (SD 2.25), and the mean CGA was 33.3 weeks (SD 4.61). The upper limit alarms were correct in 27%, and the lower in 83.6%. The upper was set at 100% in 38%. The saturations were within the unit’s target range 44% of the time, and were too high in 49%. There were 63 recordings in the subgroup with a CGA less than 34 weeks. The upper limit was correct in 46%, and high in 54%, the lower was correct in 84%. The upper was set at 100% in 30%. The saturations were within the unit’s target range in 74%, and too high in 18%. Conclusion The audit showed our compliance with the upper alarm settings is similar to that published in 2007 by Clucas (23.3%) (2). Our time within the target range was in keeping with that described in the AVIOx study (3).

A term male infant weighing 3460 g was delivered by vacuum extraction for fetal distress to a healthy 30 year old primagravida. Antenatal course was uneventful, and the baby was delivered in good condition (Apgar scores 9 and 10 at one and five minutes). A right parietal skull depression was noted clinically, separate from the site of ventouse application. Neurological …