Bronchopulmonary dysplasia (BPD) is a leading cause of chronic respiratory failure in infants. Severe BPD is associated with prolonged mechanical ventilation, pulmonary hypertension, and high morbidity and mortality. As disease severity increases, extracorporeal membrane oxygenation (ECMO) is being reconsidered as a potential rescue therapy. Historically, ECMO has been reserved for neonates with reversible respiratory failure and those who required mechanical ventilation for less than 14 days, while infants with BPD were excluded. However, advancements in ECMO technology, anticoagulation strategies, and ventilatory management have led to a reassessment of its role in this population. Emerging reports suggest ECMO may serve as a bridge to recovery or lung transplantation for select infants with severe BPD and refractory respiratory failure. Careful patient selection remains critical, considering factors such as pulmonary hypertension severity, right ventricular dysfunction, and potential for lung recovery.

Neurally Adjusted Ventilatory Assist (NAVA) is an innovative mode of ventilation that delivers support in synchrony with the infant's diaphragmatic electrical activity. This technology aims to improve patient-ventilator interaction, making its use in neonates with complex respiratory disease appealing. The use of NAVA in preterm infants is becoming more commonplace, but the specific role of NAVA in infants with established bronchopulmonary dysplasia (BPD), congenital diaphragmatic hernia (CDH), and those requiring extracorporeal membrane oxygenation (ECMO) support remain less clearly defined. Few studies have directly compared NAVA to conventional modes in those settings, but existing evidence suggests that NAVA may be feasible and beneficial, particularly by improving synchrony, reducing ventilator days, supporting post-extubation success, reducing sedation needs, and improving neurodevelopmental outcomes. We performed a narrative review of the current literature describing NAVA use in these three high-risk neonatal populations. Despite growing interest, high-quality evidence remains limited, and significant heterogeneity exists in the currently published literature. Further randomized prospective studies are needed to better define the role of NAVA in these complex patient populations and to evaluate long-term respiratory outcomes. This review aims to inform clinicians navigating the nuanced use of NAVA in advanced neonatal respiratory care.

This study aimed to characterize practices and decision-making for extracorporeal membrane oxygenation (ECMO) for congenital anomalies of the kidney and urinary tract (CAKUT). General practices (GP) section inquired about institutional practices and barriers, ECMO criteria, and dialysis. The hypothetical cases (HC) illustrated four clinical scenarios with varying degrees of renal severity for ECMO candidacy. Then, 99 (42 centers) and 91 (38 centers) physicians completed the GP and HC components, respectively. The majority considered ECMO on a case-by-case basis (66

Background:Femur fractures are a common cause of disability of children in low-and middle-income countries (LMICs). The introduction of flexible intramedullary nails improved the care of children with diaphyseal femoral fractures. Application of intramedullary nails is challenging in resource-limited settings due to implant cost and availability. Intramedullary Kirschner-wire (K-wire) fixation has been proposed as a low-cost alternative option for pediatric femur fractures. This study examines the non-inferiority of intramedullary K-wire to titanium elastic nail (TEN) for diaphyseal pediatric femur fractures. Methods:A randomized clinical trial was performed at a tertiary orthopaedic center in Dar es Salaam, Tanzania. Children (5-14 years) with acute diaphyseal femur fractures were randomly assigned to intramedullary K-wire or TEN fixation. The primary outcome was malunion. Secondary outcomes included modified RUST score (mRUST), PedsQL questionnaire, squat depth, and complications. Results:Of the 61 patients (33 K-wire, 28 TEN), 83% completed 1-year follow-up. This trial enrolled 61 of 160 planned patients (38% of target enrollment) and was therefore underpowered to establish non-inferiority. There were 5 cases of malunion (3 K-wire, 2 TEN; Risk difference 0.034, 95% CI -0.122-0.191, P = .52). No statistically significant difference was detected in mRUST score at 1-year follow-up (K-wire 16.00 vs. TEN 16.00, P-value = .38). Reoperation was required in 3 K-wire patients (9.1%) versus 0 TEN patients (P = .145). There were no statistically significant differences in PedsQL, squat depth, or clinical complications between groups. Conclusions:This study is the first prospective RCT assessing intramedullary K-wire versus TEN for the treatment of pediatric femoral shaft fractures in Africa. No statistically significant difference was detected in malunion, radiographic union, functional outcomes, or patient/parent reported outcome measures between groups. Although this study did not achieve its target sample size and therefore cannot formally claim non-inferiority, non-inferiority was not established. A trend toward higher reoperation rates in the K-wire group (9% vs. 0%) warrants evaluation in adequately powered future trials. Intramedullary K-wires may be considered as an alternative implant when TEN is unavailable, but the current evidence is insufficient to support a recommendation of equivalence. Key Concepts:(1)Intramedullary K-wire fixation showed no statistically significant difference in rates of malunion, radiographic union, and functional outcomes compared to titanium elastic nails for pediatric diaphyseal femur fractures in a low-resource setting; however, the study was underpowered and non-inferiority was not formally established.(2)Two independent randomized controlled trials, conducted on two different continents, have found no statistically significant difference in outcomes between intramedullary K-wires and titanium elastic nails for pediatric femoral shaft fractures, at a fraction of the implant cost, supporting their role as a viable alternative in resource-limited settings.(3)Although this study did not achieve its target sample size and therefore cannot formally claim non-inferiority, the results are consistent with K-wires being a safe and effective alternative to titanium elastic nails.(4)The substantial cost advantage of K-wires supports their use as a strategy to expand access to operative fixation in low- and middle-income countries.(5)Patient-reported and functional outcomes, including PedsQL quality-of-life scores and squat depth, showed no statistically significant difference between K-wire and titanium elastic nail groups at one-year follow-up; however, the study was underpowered, and these findings should be interpreted accordingly. Level of Evidence:Level I.

PURPOSE OF REVIEW:With the recent advances in neonatal care, resuscitation of periviable neonates and challenges to conducting clinical research and funding, efficient clinical trials with relevant outcomes are pivotal to direct the future of neonatology. RECENT FINDINGS:Parents of neonates in the Neonatal ICU are supportive and hold positive views of clinical research. Timing and who approaches the parents plays a great role in parents' perception of a clinical trial. Parents prefer a bigger role for the clinical team at least when introducing the idea of research. The consent process has evolved, and newer technology should be incorporated to make it simple and more clear. Consenting mothers in labor remains a point of contention as timing of consent and ability to retain information matters. Different types of consent can be used based on timing of intervention of a research trial, to allow for efficient and diverse enrollment. SUMMARY:The challenges inherent to conducting research in neonatology have not received the attention it deserves, especially when it comes to interventional trials, raising questions about equity of research in this patient cohort. Parents view research positively and are supportive provided that the timing is appropriate and language is clear.

Umbilical arterial catheters (UAC) in neonates are used for blood pressure monitoring, blood sampling, administration of fluids, nutrition, and medications. As UAC applications evolve, enteral nutrition practices vary in neonates in the presence of a UAC. The theoretical concern for mesenteric ischemia when a UAC is in place led to early nil per os approaches, delaying the initiation of enteral nutrition. More contemporary practices have favored introducing enteral feeding in neonates with UACs. However, there remains a paucity of data to guide clinical practice approaches regarding enteral feeding in neonates with a UAC in place. In this perspective article, we examine the physiological effects of UACs and review existing literature on feeding practices in neonates with a UAC. We offer an approach to managing enteral feeding in neonates with a UAC, addressing the central question: Is routine feeding in neonates with a UAC in place justified in current clinical practice?

The aim of this study is to provide an extensive review of the published literature regarding the use of nasogastric (NG) feeds at discharge in the neonatal population as well as our experience with the implementation of an NG feeds at discharge program in our level IV neonatal intensive care unit. We reviewed and compared the use of NG tubes at discharge and gastrostomy tubes in the neonatal population. We provide an extensive review of previous publications regarding programs of NG feeds at discharge in neonates across the United States and Europe including preterm neonates, neonates with chronic lung disease, and neurological injury. We also reviewed parents' perspectives on NG use at discharge in the neonatal population as well as the use of telehealth in remote monitoring of neonates discharged on NG feeds. We reviewed the economic benefits of such programs. We finally provide our center's algorithm and workflow as well as our center's experience. Twenty-five patients have been discharged so far from this program since its implementation in December 2020. Only 1 patient of the 25 patients discharged on NG tube feeds required gastrostomy tube placement. Discharge with NG tube feeds in a carefully selected population is safe, and feasible and can lead to increased parent satisfaction, besides offering a developmental advantage for the neonates when the only remaining inpatient need is achieving full oral feeds.

Multidisciplinary bronchopulmonary dysplasia (BPD) programs provide improved and consistent medical management, care of the developing infant, family support, and smoother transitions in care resulting in improved survival, pulmonary, and extra-pulmonary outcomes. This review summarizes the benefits of interdisciplinary BPD management, as well as strategies for initial programmatic development, program growth, and maintenance at centers across the United States factoring in institutional, provider, and parent reported goals that were derived from a consensus conference on BPD management.

Neonatal resuscitation, an early and critical intervention in human life, has dramatically evolved. This procedure has gone through phases from uncivilized practices that were sometimes based on myths to the current evidence-based approaches. In this review, we will shed light on the evolution of neonatal resuscitation from early centuries to the current day. Our goal is to highlight the value of clinical research and its role in invalidating hazardous practices and establishing evidence-based guidelines.

Purpose of review Recommendations made by several scientific bodies advocate for adoption of evidence-based interventions during the first 60 min of postnatal life, also known as the ‘Golden Hour’, to better support the fetal-to-neonatal transition. Implementation of a Golden Hour protocol leads to improved short-term and long-term outcomes, especially in extremely premature and extreme low-birth-weight (ELBW) neonates. Unfortunately, several recent surveys have highlighted persistent variability in the care provided to this vulnerable population in the first hour of life. Recent findings Since its first adoption in the neonatal ICU (NICU) in 2009, published literature shows a consistent benefit in establishing a Golden Hour protocol. Improved short-term outcomes are reported, including reductions in hypothermia and hypoglycemia, efficiency in establishing intravenous access, and timely initiation of fluids and medications. Additionally, long-term outcomes report decreased risk for bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). Summary Critical to the success and sustainability of any Golden Hour initiative is recognition of the continuous educational process involving multidisciplinary team collaboration to ensure coordination between providers in the delivery room and beyond. Standardization of practices in the care of extremely premature neonates during the first hour of life leads to improved outcomes. Video Abstract http://links.lww.com/MOP/A68.

Objective To describe characteristics, outcomes, and risk factors for death or tracheostomy with home mechanical ventilation in full-term infants with chronic lung disease (CLD) admitted to regional neonatal intensive care units. Study Design This was a multicenter, retrospective cohort study of infants born >= 37 weeks of gestation in the Children's Hospitals Neonatal Consortium. Results Out of 67,367 full-term infants admitted in 2010-2016, 4886 (7%) had CLD based on receiving respiratory support at either 28 days of life or discharge. 3286 (67%) were still hospitalized at 28 days receiving respiratory support, with higher mortality risk than those without CLD (10% vs. 2%, p < 0.001). A higher proportion received tracheostomy (13% vs. 0.3% vs. 0.4%, p < 0.001) and gastrostomy (30% vs. 1.7% vs. 3.7%, p < 0.001) compared to infants with CLD discharged home before 28 days and infants without CLD, respectively. The diagnoses and surgical procedures differed significantly between the two CLD subgroups. Small for gestational age, congenital pulmonary, airway, and cardiac anomalies and bloodstream infections were more common among infants with CLD who died or required tracheostomy with home ventilation (p < 0.001). Invasive ventilation at 28 days was independently associated with death or tracheostomy and home mechanical ventilation (odds ratio 7.6, 95% confidence interval 5.9-9.6, p < 0.0001). Conclusion Full-term infants with CLD are at increased risk for morbidity and mortality. We propose a severity-based classification for CLD in full-term infants. Future work to validate this classification and its association with early childhood outcomes is necessary.

Introduction: Reported rates of nerve injury after upper extremity (UE) gunshot wound (GSW) range from 15% to 45%. Many surgeons prefer initial observation; however, this may delay diagnosis of neurotmesis and surgical treatment. We aimed to determine the incidence of nerve transection in adults after upper extremity GSWs. Methods: This was a retrospective chart review approved by the institutional review board. Operative records of five orthopedic surgeons between 2014 to 2019 were filtered for ICD-10 and CPT codes cross-referenced to include both UE GSW assault and nerve injuries. Inclusion criteria consisted of age greater than 18 at time of injury, neurologic deficit on presentation, and surgical exploration nerve procedure. Records were reviewed for degree of nerve injury, procedure performed, and complications. Postoperative outcomes included nerve recovery, complications, and reoperation rate. Results: Of the 17 patients that fit the inclusion criteria, the incidence of complete nerve transection was 64.7% and the incidence of a complete or partial nerve transection was 70.6%. The most common location of GSWs was the hand (70.5%). Average time from date of injury to surgery was 26.1 days. There were 14 identifiable nerve injuries- complete transection in 11, partial transection in one, and contusion in two patients. Of patients with nerve transection, 72.7% sustained a fracture. Postoperative complications included stiffness, chronic pain, and wound infection. The re-operation rate was 29.4%. The average postoperative follow-up was 4.4 months. There was longer follow-up among nerve transection patients (5.3 months) compared to neuropraxia patients (2.68 months). Conclusion: This study demonstrates a higher incidence of nerve transection in upper extremity GSW patients than previously reported. Predictors of nerve transection are GSWs to the hand and associated fracture.

An infant is born at 36 weeks to a 27-year-old gravida 4, para 3 woman via precipitous vaginal delivery through meconium-stained amniotic fluid. The pregnancy had been complicated by diet-controlled gestational diabetes. The mother works as a daycare teacher and had traveled to Europe 12 weeks before delivery. She had clinical symptoms of an acute upper respiratory illness 3 weeks before delivery. The neonate’s physical parameters include weight of 2.085 kg (13th percentile), length of 43 cm (38th percentile), and head circumference of 31 cm (16th percentile).Initial blood glucose level is 23 mg/dL (1.28 mmol/L), and the neonate is given a D10 bolus and maintenance intravenous fluids are started. The neonate’s initial platelet count is 37 × 103/μL (37 × 109/L) with no active bleeding or oozing. He is noticed to be thrombocytopenic on subsequent complete blood cell counts. A sepsis evaluation is done, blood specimens for culture are drawn, and ampicillin and gentamicin are started. Initial C-reactive protein is 6 mg/dL (60 mg/L) and white blood cell count is 15,000/μL (15 × 109/L). An initial total bilirubin is 18.8 mg/dL (321.5 μmol/L) and direct bilirubin is 10 mg/dL (171 μmol/L). Results of a liver function panel are as follows: alanine aminotransferase (ALT) 117 U/L (1.9 μkat/L), aspartate aminotransferase (AST) hemolyzed, albumin 2.7 g/dL (27 g/L). Abdominal ultrasonography reveals hepatosplenomegaly. Result of urine cytomegalovirus (CMV) test is pending at the time of transport.The infant is transferred to our tertiary NICU for multidisciplinary management of neonatal direct hyperbilirubinemia and transaminitis. Physical examination findings are notable for hepatomegaly, splenomegaly, and petechiae on the abdomen and back. Admission laboratory findings are significant for calcium less than 5 mg/dL (1.25 mmol/L), magnesium 0.6 mg/dL (0.25 mmol/L), albumin 2 g/dL (20 g/L), total bilirubin 23 mg/dL (393 μmol/L), direct bilirubin greater than 16 mg/dL (273.6 μmol/L), ALT 106 U/L (1.7 μkat/L), AST <5 U/L (0.08 μkat/L), alkaline phosphatase 290 U/L (4.8 μkat/L), ammonia less than 10 μg/dL (7.1 μkat/L), and platelet count 82 × 103/μL (82 × 109/L). Coagulation profile shows an international normalized ratio of 1.6 and PTT of 37 seconds. A hepatitis panel is negative. Abdominal ultrasonography reveals hepatosplenomegaly and patent ductus venosus. Echocardiography findings are normal. Central access is established.Hepatology and infectious disease specialists are consulted on admission. For hepatology evaluation, α1-antitrypsin and cholestasis panel are negative. Serum ferritin is 1,951 ng/mL (1,951 μg/L). Because the direct reacting (or conjugated) bilirubin level is greater than 50% of the total bilirubin and there are no good data to guide therapy, phototherapy is started. Double volume exchange and intravenous immunoglobulin are not given at the time. Evaluation for infections includes repeat CMV, herpes simplex virus (HSV), toxoplasma immunoglobulin M, Epstein-Barr virus (EBV), adenovirus, and coxsackie virus. A lumbar puncture is deferred due to coagulopathy. No placental pathology is available.Genetics consultation on admission recommends the following: urine organic acids to assess for mevalonic acid and succinyl acetone, oxysterol to assess for Niemann-Pick disease, galactose-1-phosphate uridylyltransferase enzyme testing and galactose-1-phosphate red blood cells, transferrin isoelectric focusing, acylcarnitine profile, and plasma amino acids.The neonate is started on enteral feeds on day 4 and advanced to full volume feeds. The liver function test trends are studied (Fig 1) and the infant is started on ursodiol and fat-soluble vitamins. Feedings are fortified to 24 kcal with medium-chain triglycerides for poor weight gain. Head ultrasonography shows right grade 1 intraventricular hemorrhage and bilateral periventricular temporal lobe cyst without calcification. Magnetic resonance imaging of the brain shows medial temporal horn cysts, banding of the interventricular regions, immature white matter, and cerebellar vermis hypoplasia (Fig 2).The fetal-neonatal continuum of liver diseases allows the occurrence of cirrhosis in cases defined as neonatal acute liver failure (NALF). All neonatal liver failure is “acute” by definition. The common differential diagnostic considerations include viral infections (20%–30%), hemophagocytic lymphohistiocytosis, mitochondrial cytopathy, and gestational alloimmune liver disease, which is the most common cause. HSV is the most common viral agent associated with NALF. Neonates with HSV-associated NALF may have disseminated HSV with or without central nervous system infection. In either of those cases, neonates often lack cutaneous manifestations; therefore, a high index of suspicion is required. CMV is very rarely associated with NALF, but more often with less fulminant hepatitis and prominent cholestasis. Enterovirus should be a consideration in evaluating any neonate with a combination of necrotizing enterocolitis and NALF.In our case, the urine CMV result from the birth hospital was positive, consistent with a diagnosis of congenital CMV (CMV) and the neonate was subsequently started on ganciclovir. The repeat blood and urine samples tested for CMV at our NICU confirmed the diagnosis, and EBV polymerase chain reaction (PCR) (initially 350 copies/mL and then 1,500 copies/mL) was positive as well. Ganciclovir was switched to oral valganciclovir on postnatal day 6. The neonate failed the otoacoustic emissions test bilaterally. The eye examination performed as part of the evaluation for toxoplasmosis, other infections, rubella, CMV, and HSV (TORCH) syndrome showed posterior embryotoxon. Re-examination after the diagnosis of CMV was made showed no chorioretinitis.Human CMV is a human-specific DNA virus of the Herpesviridae family. In the developed world, congenital CMV is the leading nongenetic cause of sensorineural hearing loss (SNHL) in children and accounts for 21% and 24% of cases of hearing loss at birth and 4 years of age, respectively. (1) In addition, congenital CMV is the leading viral cause of neurodevelopmental delay.The clinical spectrum of congenital CMV varies widely, from asymptomatic infection to potentially life-threatening disseminated disease. Presentation can be with intrauterine growth restriction, preterm labor, petechiae, jaundice, hepatomegaly, splenomegaly, and microcephaly. Laboratory and imaging findings include thrombocytopenia, transaminitis, direct hyperbilirubinemia, SNHL, periventricular calcifications, and rarely, chorioretinitis. Radiographic findings are abnormal in 50% to 70% of children with symptomatic infections at birth and include intracranial calcifications, ventricular dilation, cysts, lenticulostriate vasculopathy, choroid plexus cyst, and echogenic bowel.Because infants with congenital CMV shed large amounts of virus in saliva and urine, saliva (at least 1 hour after breast feeding) or urine PCR is used for diagnosis. The treatment of symptomatic congenital CMV disease is with intravenous ganciclovir or the oral prodrug valganciclovir. Neonates receiving valganciclovir for 6 months had a 2.6-times higher likelihood of improved total hearing at 12 and 24 months than those who received only 6 weeks of valganciclovir treatment. (2) Neurodevelopmental outcomes on the language composite of the Bayley Scale III were improved with longer duration of therapy.Whether the infection with EBV in our case was a coincidence or contributed to the disease severity remains uncertain. EBV is a γ herpes virus associated with infectious mononucleosis, nasopharyngeal carcinoma, Burkitt lymphoma, B-cell lymphoma, and posttransplant lymphomas. Infection with EBV is extremely common and 90% of adults in the United States are seropositive before the age of 30 years. Purtilo and Sakamoto (3) reported that EBV reactivation in pregnancy is a much more common occurrence than primary infection due to the high rates of seroprevalence.Transmission of EBV is usually horizontal, requiring close contact with the saliva of an infected person; vertical transmission is felt to be rare. Several case reports of fetal outcomes of EBV infection during pregnancy have been published, but there is no specific syndrome that can be described as an outcome of EBV infection during pregnancy.In a cohort of 500 women whose serum samples were studied for EBV nuclear antigen early in pregnancy, 28 neonates had anomalies. Of these, 16 had minor anomalies and 12 had major anomalies including congenital heart disease, microcephaly, anencephaly, meningomyelocele, and achondroplasia. (4) In a case report by Brown and Stenchever, (5) severe congenital anomalies were described in an infant exposed to EBV infection from conception to delivery. Another case report described congenital anomalies such as cryptorchidism, micrognathia, cataract, and hypotonia in a male infant exposed to EBV during pregnancy. Two other reports described liver and bile duct anomalies in infants exposed to EBV during pregnancy. A case control study of 403 infants born to mothers with EBV infection at 12 to 14 weeks of gestation suggested an increased risk for leukemia.To our knowledge, this is the third case in literature to report coinfection with CMV and EBV in neonates. Two previous cases were reported by Joncas et al (Table). (6) Although congenital CMV could explain all of this infant’s findings, the severity may have been due to concurrent in utero infection with CMV and EBV.Our patient was discharged on postnatal day 17, with infectious disease, hepatology, ophthalmology, and audiology follow-up. Currently, at 2 years of age, he has not undergone brainstem auditory evoked response testing but has speech delay.

Pulmonary thromboembolism (PTE) in neonates is a serious yet underdiagnosed complication with challenging diagnostic workup. The incidence of neonatal thrombosis is 2.4 per 1000 NICU admissions of which 45 % to 55 % of cases occur in premature neonates. Venous thrombosis is more common than arterial thrombosis. The incidence of pulmonary thromboembolism (PTE) in the newborn period was about 14 % in one retrospective autopsy study. Our patient is a preterm infant who was on room air and presented with acute refractory hypoxemia at 3 weeks of life. The patient's pulmonary hypertension was unresponsive to maximal conventional therapies. However, a careful review of the initial echocardiogram obtained at the time of decompensation revealed a large bilateral pulmonary thromboembolism. After extensive multidisciplinary discussions, thrombolysis was used despite the risk of significant intracranial bleeding. This case highlights the cautious and successful use of thrombolysis in neonates with pulmonary thromboembolism leading to excellent clinical results and normal neurodevelopmental outcomes. The discussion focuses on the management of pulmonary thromboembolism in neonates.

OBJECTIVES:. To describe ventilation strategies used during extracorporeal membrane oxygenation (ECMO) for neonatal respiratory failure among level IV neonatal ICUs (NICUs). DESIGN:. Cross-sectional electronic survey. SETTING:. Email-based Research Electronic Data Capture survey. PATIENTS:. Neonates undergoing ECMO for respiratory failure at level IV NICUs. INTERVENTIONS:. A 40-question survey was sent to site sponsors of regional referral neonatal ECMO centers participating in the Children’s Hospitals Neonatal Consortium. Reminder emails were sent at 2- and 4-week intervals. MEASUREMENTS AND MAIN RESULTS:. Twenty ECMO centers responded to the survey. Most primarily use venoarterial ECMO (65%); this percentage is higher (90%) for congenital diaphragmatic hernia. Sixty-five percent reported following protocol-based guidelines, with neonatologists primarily responsible for ventilator management (80%). The primary mode of ventilation was pressure control (90%), with synchronized intermittent mechanical ventilation (SIMV) comprising 80%. Common settings included peak inspiratory pressure (PIP) of 16–20 cm H2O (55%), positive end-expiratory pressure (PEEP) of 9–10 cm H2O (40%), I-time 0.5 seconds (55%), rate of 10–15 (60%), and Fio2 22–30% (65%). A minority of sites use high-frequency ventilation (HFV) as the primary mode (5%). During ECMO, 55% of sites target some degree of lung aeration to avoid complete atelectasis. Fifty-five percent discontinue inhaled nitric oxide (iNO) during ECMO, while 60% use iNO when trialing off ECMO. Nonventilator practices to facilitate decannulation include bronchoscopy (50%), exogenous surfactant (25%), and noninhaled pulmonary vasodilators (50%). Common ventilator thresholds for decannulation include PEEP of 6–7 (45%), PIP of 21–25 (55%), and tidal volume 5–5.9 mL/kg (50%). CONCLUSIONS:. The majority of level IV NICUs follow internal protocols for ventilator management during neonatal respiratory ECMO, and neonatologists primarily direct management in the NICU. While most centers use pressure-controlled SIMV, there is considerable variability in the range of settings used, with few centers using HFV primarily. Future studies should focus on identifying respiratory management practices that improve outcomes for neonatal ECMO patients.

Neonatal toxic shock syndrome (TSS)-like exanthematous disease (NTED) is a syndrome first reported in Japan. Neonates develop systemic exanthema, thrombocytopenia, and fever usually during the first week of life. The disease is distinguished from frank TSS because affected infants are not severely ill and do not meet TSS criteria. Most infants are confirmed to be colonized with TSST-1 producing strains of S. aureus. Suggested diagnostic criteria for NTED include a skin rash with generalized macular erythema and one of the following symptoms: fever >38.0°C, thrombocytopenia <150 x103uL, or low positive C-reactive protein (1-5 mg/dL) in the absence of another known disease process. NTED is common in Japanese NICUs, but outside Japan, only one case has been reported in France. We describe the first case of NTED reported in North America.

Background Open tibia fractures are a major source of disability in low- and middle-income countries (LMICs) due to the high incidence of complications, particularly infection and chronic osteomyelitis. One proposed adjunctive measure to reduce infection is prophylactic local antibiotic delivery, which can achieve much higher concentrations at the surgical site than can safely be achieved with systemic administration. Animal studies and retrospective clinical studies support the use of gentamicin for this purpose, but no high-quality clinical trials have been conducted to date in high- or low-income settings. Methods We describe a protocol for a pilot study conducted in Dar es Salaam, Tanzania, to assess the feasibility of a single-center masked randomized controlled trial to compare the efficacy of locally applied gentamicin to placebo for the prevention of fracture-related infection in open tibial shaft fractures. Discussion The results of this study will inform the design and feasibility of a definitive trial to address the use of local gentamicin in open tibial fractures. If proven effective, local gentamicin would be a low-cost strategy to reduce complications and disability from open tibial fractures that could impact care in both high- and low-income countries. Trial registration ClinicalTrials.gov, Registration # NCT03559400 ; Registered June 18, 2018.