The incidence of chronic lung disease is increasing, suggesting a need to explore novel ways to understand ventilator induced lung injury (VILI) in preterm infants. Mechanical power (MP) is a unifying measure of energy transferred to the respiratory system and a proposed determinant of VILI. The gold-standard method for calculating MP (geometric method) is not feasible in the clinical setting. This has prompted the derivation of simplified equations for calculating MP. To validate the agreement between a simplified calculation of MP (MPSimple) and the true MP calculated using the geometric method (MPRef). MPSimple and MPRef was calculated in mechanically ventilated preterm lambs (n = 71) and the agreement between both measures was determined using intraclass correlation coefficients (ICC), linear regression, and Bland-Altman analysis. A strong linear relationship (adjusted R2 = 0.98), and excellent agreement (ICC = 0.99, 95

Background Management of pneumothorax in neonates requiring retrieval poses unique challenges, including decision to insert an intercostal catheter (ICC). We aimed to report the proportion and characteristics of neonates transported with and without ICC insertion and the incidence of deterioration in neonates transported with pneumothorax. Methods A retrospective cohort study of neonates transported with pneumothorax between 2016 and 2020 in Victoria, Australia. Univariate analysis was performed on patient and clinical characteristics, followed by multivariate analysis to identify risks independently associated with ICC insertion. Results 174 neonates were included. Mean (SD) gestational age (GA) was 37.5 (2.8) weeks. Eighty-two neonates (47%) had ICC inserted. On multivariate analysis, risk factors independently associated with ICC insertion were mechanical ventilation (MV) preceding retrieval team arrival (OR 12, 95% CI 3.1 to 46.6, p<0.001) and radiographical mediastinal shift (MS) (OR 6.2, 95% CI 2.4 to 16.2, p<0.001). Increasing GA is negatively associated with ICC insertion (OR 0.66, 95% CI 0.5 to 0.8, p<0.001). No significant difference in incidence of deterioration between the ICC group and the no-ICC group was observed (8.5% vs 5.4%, p=0.55). Ninety-five neonates were treated with needle aspiration (NA); 40 (42%) subsequently avoided ICC insertion. Twelve (13%) neonates transported without ICC had insertion within 24 hours following transport. Conclusion Many neonates with pneumothorax are transported without ICC, with low incidence of deterioration and ICC insertion within 24 hours after transport. More than a third of neonates managed with NA avoided ICC insertion. The likelihood of ICC insertion is increased by lower GA, MV prior to retrieval team arrival and radiographical MS.

Feed establishment is challenging for many preterm infants. While interventions such as probiotics have reduced the incidence of necrotising enterocolitis,1 no intervention has previously been shown to reduce feed intolerance effectively and safely in preterm infants. Erythromycin2 and lactase3 are ineffective, and cisapride is associated with adverse effects.4 It is encouraging that this study of a novel therapy reports promising results. Comparing two doses of recombinant human (rh) insulin supplementation with placebo, the authors report a statistically significant reduction in the time to achieve full enteral feeds. The size of this effect, a mean difference of 4.0 days (p = 0.03 [CI 1.0–8.0]), seems clinically important. Despite the encouraging outcome, it is important to view these results within the context of a trial that was stopped early following a planned interim futility analysis. The investigators had prespecified that a conditional power of 35% was required for study continuation after the first 225 enrolments. As this, futility criterion was satisfied, 303 infants were enrolled, short of the 345 specified in the trial protocol. There was a slight imbalance in the numbers allocated to the three groups: 110 were randomised to the low dose, 95 to high dose and 98 to placebo. Similarly, there were imbalances in allocation within countries, important due to potential variation in feeding practices. Dropout was substantial, with only 86% of randomised infants reaching the primary endpoint. The most common reason was the cessation of sponsorship. While the statistical plan was published as supplementary material, information on missing data handling has been redacted, leaving some questions about data integrity. The interim futility analysis resulted in a misestimation of the eventual outcomes. There may be merits of stopping a trial early for futility, particularly to save resources.5 However, early termination reduced the precision of this study's estimates of effectiveness. The ethical implications of early trial cessation need to be carefully considered. In this study, some infants already exposed to the intervention had treatment termination without outcome assessment. In the absence of any indication of harm, the mid-treatment involuntary removal of participants, who have accepted the risks of being subjected to an investigational therapy, seems unfair. The author's conclusion that product safety has been demonstrated needs to be interpreted with caution, particularly as the product manufacturer funded the trial and contributed to the design and conduct of the study. Of the 293 infants included in the safety analysis, only 196 were exposed to the treatment. As the event rate of some serious events such as necrotising enterocolitis can be as low as 3%,6 this relatively small sample may not detect rare complications. Further, blood glucose levels were only measured at most twice a day prior to feeds. The potential of treatment-induced hypoglycaemia, even if brief, may have therefore not been adequately studied. These positive results from a well-written report of a multi-centre trial are appealing. However, prudent clinicians should cautiously analyse its conduct and conclusions, before introducing a new therapy to their vulnerable patients. https://ebneo.org/ebneo-commentary-enteral-recombinant-human-insulin-in-preterm-infants None declared.

AIM:The aim of this study was to evaluate dextrose gel in the management of neonatal hypoglycaemia in the postnatal wards at an Australian tertiary level perinatal centre. METHODS:An audit was performed before and after implementation of dextrose gel. Pre-implementation, neonatal hypoglycaemia was managed with feed supplementation alone, and dextrose gel was used in addition to feed supplementation in the post-implementation phase. Outcomes included admission to neonatal intensive care unit (NICU) for management of hypoglycaemia, proportion of neonates who achieved normoglycaemia (defined as blood glucose ≥2.6 mmol/L, with no clinical signs after one or two treatment attempts) and proportion of neonates with hypoglycaemia recurrence after normoglycaemia and one or two treatment attempts. RESULTS:NICU admission for treatment of hypoglycaemia reduced significantly post-implementation of dextrose gel (29/100 (29%) vs. 14/100 (14%), P = 0.01). No significant difference was seen in the proportion of neonates achieving normoglycaemia (71/100 (71%) vs. 75/100 (75%), P = 0.52), but hypoglycaemia recurrence was higher in the post-implementation group (22/71 (31%) vs. 37/75 (49%), P = 0.02). CONCLUSIONS:Dextrose gel is effective in the management of neonatal hypoglycaemia in the postnatal ward setting, reducing admission to NICU and mother-infant separation.

Introduction. Altered mental status, autonomic dysfunction, and neuromuscular abnormalities are a characteristic triad of serotonin syndrome. No laboratory tests confirm the diagnosis of serotonin syndrome. Case report. A 35-year-old woman took moclobemide, sertraline, and citalopram in a suicide attempt. She was conscious with mild tachycardia, hypertension, and tachypnea one hour after ingestion. In the second hour after ingestion diaphoresis, mydriasis, horizontal nystagmus, trismus, hyperreflexia, clonus, and tremor appeared. She became agitated and unresponsive. In the third hour after ingestion she became comatose and hyperthermic. She was anesthetized, paralyzed, intubated, and ventilated for 24 hours. Serum moclobemide, sertraline, and citalopram levels were above therapeutic levels. The serum serotonin level was within normal limits and the urinary 5-hydroxyindoleacetic acid:creatinine ratio was below the average daily value. The urinary serotonin:creatinine ratio was increased on arrival (1 mg/g). Discussion and conclusion. The urinary serotonin level is increased in serotonin syndrome due to a monoamine oxidase inhibitor and selective serotonin-reuptake inhibitors overdose. It is possible that urinary serotonin concentration could be used as a biochemical marker of serotonin syndrome.