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.

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

Objective: To characterize relationships between social determinants of health (SDoH) and mortality among infants receiving extracorporeal membrane oxygenation (ECMO). Study design: Retrospectively, we identified infants born >34weeks gestation and >1.8 kilograms who received ECMO from 2010-2022. The primary predictor was the child opportunity index (COI). The outcome was in-NICU mortality. Due to interactions between SDoH and diagnoses, the main analyses were performed within the diagnostic cohort using multilevel socioecological factors. Results: Overall, 2254 neonates received ECMO [congenital diaphragmatic hernia (32%, CDH), meconium aspiration syndrome (27%, MAS), cardiac (13%) and other (28%, e.g., sepsis)]. Characteristics differed with MAS more common in lower COI and Black race, while CDH was more common in the White race. COI and maternal race/ethnicity were unrelated to in-NICU mortality. Conclusion: Despite epidemiological differences by SDoH, the primary outcome was consistent across groups, suggesting potential resilience to social risk factors and underscoring the importance of studying distinct cohorts separately.

Increasingly, more neonatal respiratory extracorporeal membrane oxygenation (ECMO) patients in the Extracorporeal Life Support Organization (ELSO) registry have a primary diagnosis of Other. These patients, in addition to those with persistent pulmonary hypertension (PPHN), represent heterogeneous groups. This study aimed to reclassify Other and PPHN patients into modern categories to improve understanding of ECMO indications and outcomes. Data on neonatal respiratory ECMO cases from January 2017 to July 2021 from the ELSO registry were reviewed. Runs with primary and/or secondary diagnosis codes of Other or PPHN were evaluated for reclassification into 13 modern categories. Characteristics and outcomes were described. Three thousand two hundred thirty-four ECMO runs were included: 1,316 (41%) classified as Other, 251 (8%) as PPHN. Survival was 74% for the Other group. In total, we reclassified 573 of 1,567 (37%) runs, with 253 of 1,567 runs (16%) reclassified into a modern category. Ninety-one of 253 (36%) had hypoxic ischemic encephalopathy and 82 of 253 (32%) had pulmonary hypoplasia. Following reclassification, survival ranged from 0% for alveolar capillary dysplasia to 92% for aspiration of non-meconium fluid. Contemporary neonates placed on ECMO for respiratory failure are diverse. Important distinctions are lost in the catch-all categories of Other and PPHN. Improvements in data entry and categorization are needed to effectively use the ELSO database.

Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is associated with fewer neurological complications and decreased mortality compared to veno-arterial (VA) ECMO in neonatal respiratory failure. The Crescent right atrial (RA) cannula is the only dual-lumen cannula for neonatal VV ECMO designed to have the tip in the right atrium. The purpose of this study is to describe the experience with early use of the Crescent RA cannula. We performed a retrospective cohort study of 58 neonates and infants cannulated from September 2021 through August 2023 at 15 institutions represented within the Children’s Hospital Neonatal Consortium (CHNC) ECMO Focus Group. Members provided information on patient characteristics, ECMO runs, complications, and outcomes. Data were analyzed with descriptive statistics. Imaging was used during cannulation in 79.3% of cases. Survival to discharge was 84.5%. There was one major cannula-related complication resulting in death. The most common complication was cannula malposition in 46.6% of patients, requiring surgical repositioning in 29.3% of the total cohort. Early use experience with the Crescent RA cannula suggests that it is effective and safe in most patients, but the cannula may require repositioning to achieve optimal ECMO support or if malpositioned. Based on these observations, we developed recommendations for cannulation and cannula surveillance.

Extracorporeal membrane oxygenation (ECMO) is an important rescue strategy for neonates with severe cardiorespiratory failure, yet its role in the management of hypoxic-ischemic encephalopathy (HIE) remains subject to debate. Historically, clinicians have been reluctant to offer ECMO to infants with significant neurological injury because of concerns related to poor neurodevelopmental outcomes and elevated risk of complications such as hemorrhage and stroke. Over the past two decades, however, accumulating evidence has suggested that many neonates with HIE not only tolerate ECMO well but may also achieve meaningful survival and functional recovery. In this state-of-the-art narrative review, we surveyed and synthesized observational studies, retrospective cohorts, and case series published since 2000 that evaluated ECMO in neonates with HIE. While randomized controlled trials dedicated exclusively to this population remain scarce, the available data indicate that ECMO can be safely implemented alongside standard therapies-including therapeutic hypothermia-without uniformly prohibitive rates of bleeding or adverse neurodevelopment. Although small sample sizes and single-center experiences limit the strength of these conclusions, survival rates in combined TH-ECMO cohorts are often reported above 80 to 90%, with a substantial proportion of survivors demonstrating acceptable early neurodevelopmental outcomes. Overall, the growing clinical acceptance of ECMO in HIE highlights the need for careful, individualized assessment of benefits and risks, as well as transparent discussions with families. Future multicenter collaborations focusing on robust longitudinal follow-up and evidence-based protocols will be essential to guide best practices and optimize outcomes for this high-risk neonatal population.

OBJECTIVE:To evaluate the relationship between cholestasis and outcomes in medical and surgical necrotizing enterocolitis (NEC). STUDY DESIGN:A retrospective analysis of prospectively collected data from 1472 infants with NEC [455 medical (mNEC) and 1017 surgical (sNEC)] from the Children's Hospital Neonatal Database. RESULTS:The prevalence of cholestasis was lower in mNEC versus sNEC (38.2% vs 70.1%, p < 0.001). In both groups, cholestasis was associated with lower birth gestational age [mNEC: OR 0.79 (95% CI 0.68-0.92); sNEC: OR 0.86 (95% CI 0.79-0.95)] and increased days of parenteral nutrition [mNEC: OR 1.08 (95% CI 1.04-1.13); sNEC: OR 1.01 (95% CI 1.01-1.02)]. For both groups, the highest direct bilirubin was associated with the composite outcome mortality or length of stay >75th percentile [mNEC: OR 1.21 (95% CI 1.06-1.38); sNEC: OR 1.06 (95% CI 1.03-1.09)]. CONCLUSION:Cholestasis with both medical NEC and surgical NEC is associated with adverse patient outcomes including increased mortality or extreme length of stay.

Objective Bronchopulmonary dysplasia (BPD) remains the most common late morbidity for extremely premature infants. Care of infants with BPD requires a longitudinal approach from the neonatal intensive care unit to ambulatory care though interdisciplinary programs. Current approaches for the development of optimal programs vary among centers. Study Design We conducted a survey of 18 academic centers that are members of the BPD Collaborative, a consortium of institutions with an established interdisciplinary BPD program. We aimed to characterize the approach, composition, and current practices of the interdisciplinary teams in inpatient and outpatient domains. Results Variations exist among centers, including composition of the interdisciplinary team, whether the team is the primary or consult service, timing of the first team assessment of the patient, frequency and nature of rounds during the hospitalization, and the timing of ambulatory visits postdischarge. Conclusion Further studies to assess long-term outcomes are needed to optimize interdisciplinary care of infants with severe BPD. Key Points

Chandhoke, Swati1; DiGeronimo, Robert2; Levy, Philip3; Hamrick, Shannon4; Zaniletti, Isabella5; Murthy, Karna6; Padula, Michael7; Grover, Theresa8; Moynihan, Katie9 Author Information

OBJECTIVES:To present recommendations and consensus statements with supporting literature for the clinical management of neonates and children supported with extracorporeal membrane oxygenation (ECMO) from the Pediatric ECMO Anticoagulation CollaborativE (PEACE) consensus conference.DATA SOURCES:Systematic review was performed using PubMed, Embase, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021, followed by serial meetings of international, interprofessional experts in the management ECMO for critically ill children.STUDY SELECTION:The management of ECMO anticoagulation for critically ill children.DATA EXTRACTION:Within each of eight subgroup, two authors reviewed all citations independently, with a third independent reviewer resolving any conflicts.DATA SYNTHESIS:A systematic review was conducted using MEDLINE, Embase, and Cochrane Library databases, from January 1988 to May 2021. Each panel developed evidence-based and, when evidence was insufficient, expert-based statements for the clinical management of anticoagulation for children supported with ECMO. These statements were reviewed and ratified by 48 PEACE experts. Consensus was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed 23 recommendations, 52 expert consensus statements, and 16 good practice statements covering the management of ECMO anticoagulation in three broad categories: general care and monitoring; perioperative care; and nonprocedural bleeding or thrombosis. Gaps in knowledge and research priorities were identified, along with three research focused good practice statements.CONCLUSIONS:The 91 statements focused on clinical care will form the basis for standardization and future clinical trials.

Objective Routine blood gas measurements are common in infants with severe bronchopulmonary dysplasia (sBPD) and are a noxious stimulus. We developed a guideline-driven approach to evaluate the care of infants with sBPD without routine blood gas sampling in the chronic phase of NICU care (after diagnosis at 36 weeks PMA).Study design We examined blood gas utilization and outcomes in our sBPD inpatient care unit using data collected between 2014 and 2020.Results 485 sBPD infants met inclusion criteria, and 303 (62%) never had a blood gas obtained after 36 weeks PMA. In infants who had blood gas measurements, the median number of total blood gases per patient was only 4 (IQR 1-10). We did not identify adverse effects on hospital outcomes in patients without routine blood gas measurements.Conclusions We found that patients with established BPD could be managed without routine blood gas analyses after 36 weeks PMA.

OBJECTIVE:This study aimed to determine neonatal neurodevelopmental follow-up (NDFU) practices across academic centers. STUDY DESIGN:This study was a cross-sectional survey that addressed center-specific neonatal NDFU practices within the Children's Hospitals Neonatal Consortium (CHNC). RESULTS:Survey response rate was 76%, and 97% of respondents had a formal NDFU program. Programs were commonly staffed by neonatologists (80%), physical therapists (77%), and nurse practitioners (74%). Median gestational age at birth identified for follow-up was ≤32 weeks (range 26-36). Median duration was 3 years (range 2-18). Ninety-seven percent of sites used Bayley Scales of Infant and Toddler Development, but instruments used varied across ages. Scores were recorded in discrete electronic data fields at 43% of sites. Social determinants of health data were collected by 63%. Care coordination and telehealth services were not universally available. CONCLUSION:NDFU clinics are almost universal within CHNC centers. Commonalities and variances in practice highlight opportunities for data sharing and development of best practices. KEY POINTS:· Neonatal NDFU clinics help transition high-risk infants home.. · Interdisciplinary neonatal intensive care unit follow-up brings together previously separated outpatient service lines.. · This study reviews the current state of neonatal NDFU in North America..

OBJECTIVE: Determine short-term outcomes following peritoneal drain (PD), laparotomy (LAP) after PD (PD-LAP), and LAP in extremely low birth weight (ELBW) infants with spontaneous intestinal perforation (SIP). STUDY DESIGN: ELBW infants with SIP were identified using the Children's Hospitals Neonatal Database. Mortality and length of stay (LOS) were compared among groups. RESULTS: Of 729 SIP infants from 6/2010-12/2016, 383(53%) received PD, 61(8%) PD-LAP, and 285(39%) LAP. PD infants had lower GA at birth, at SIP diagnosis and upon admission than PD-LAP or LAP; and higher sepsis rates than LAP. Bivariate analysis and Kaplan-Meier survival estimates suggested PD had increased mortality vs. PD-LAP and LAP (27%, 11.5%, and 15.8% respectively, p < 0.001). However, surgical approach was not significantly associated with mortality in multivariable analysis accounting for GA and illness severity. LOS did not differ by surgical approach. CONCLUSIONS: In ELBW infants with SIP, mortality, and LOS are independent of the initial surgical approach.

Introduction: Decannulation from veno-arterial extracorporeal life support may involve ligation or repair of the carotid artery; however, differences in outcomes are not clear. This study aimed to describe short-and long-term artery patency and neurodevelopmental outcomes in neonatal and pediatric patients who underwent carotid artery repair (CAR) versus ligation at decannulation.Methods: Patients supported on veno-arterial extracorporeal life support during the first 15 mo of life from 2010 to 2020 at a large, tertiary care children's hospital were included. Decannulation strategy, postdecannulation imaging, and follow-up visits were reviewed.Results: 74 patients were identified with median age at cannulation 2 d (interquartile range [IQR] = 1-21 d) and median weight 3.7 kg (interquartile range= 3.2-4.4 kg). Indications included congenital cardiac conditions (27%), congenital diaphragmatic hernia (19%), pulmonary hypertension (19%), meconium aspiration (16%), and pneumonia/sepsis (14%). Forty-two patients (57%) underwent CAR. Patients on extracorporeal life support >5 d were 95% less likely to undergo CAR (P < 0.001). Of CAR patients, 18 (43%) had doppler ultrasound performed within the 2-y follow-up period. Ten of 18 patients (55.6%) had >50% stenosis (3) or complete occlusion (7). Only 36% (27/74) had formal neurodevelopmental follow-up within 6 mo and 41% (30/74) within 2 y; however, no significant differences in function were seen between groups. Conclusions: Neonates and young toddler patients undergoing CAR following extracorporeal life support decannulation are at risk for partial or complete artery occlusion. In our study population, repair and ligation at decannulation appear to have similar neurodevelopmental outcomes; however, follow-up to assess function is not standardized. Longer term follow-up and risk stratification are needed to guide decannulation strategy.(c) 2023 Elsevier Inc. All rights reserved.

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.

OBJECTIVE:To develop a consensus guideline to meet nutritional challenges faced by infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN:The CDH Focus Group utilized a modified Delphi method to develop these clinical consensus guidelines (CCG). Topic leaders drafted recommendations after literature review and group discussion. Each recommendation was sent to focus group members via a REDCap survey tool, and members scored on a Likert scale of 0-100. A score of > 85 with no more than 25% outliers was designated a priori as demonstrating consensus among the group. RESULTS:In the first survey 24/25 recommendations received a median score > 90 and after discussion and second round of surveys all 25 recommendations received a median score of 100. CONCLUSIONS:We present a consensus evidence-based framework for managing parenteral and enteral nutrition, somatic growth, gastroesophageal reflux disease, chylothorax, and long-term follow-up of infants with CDH.