Using the London Research Evaluation and Audit for Child Health (REACH) network, we designed, piloted and disseminated two surveys () across 25 London neonatal departments, assessing resident doctor experiences and current debriefing practices following significant neonatal resuscitations in the delivery room.
The first survey, sent to a nominated REACH local lead in each department, determined current local practices; triggers for debriefs, whether structured tools or guidelines were in...]]>
The potential contribution of ketones and lactate as alternative fuels for ATP production during transition after birth in term infants is well recognised, but data from preterm infants are more limited. Gordon Xin Hua Liu and colleagues measured both metabolites serially over the first week of life in 168 very low birth weight preterm infants<34 weeks gestation who were enrolled in the REACT study of continuous glucose monitoring. There were more than 2000 measurements of each metabolite. They found that neither metabolite contributed substantially as energy sources at this time. B-OH butyrate levels were low throughout and represented around 1% of ATP contribution. Lactate levels represented 8–9% during days 1–2, falling to 4%–5% by days 7–8. There was no relationship between simultaneous blood glucose concentrations, increasing macronutrient support or receipt of insulin with ketone or lactate concentrations. Their finding...]]>
The question remains of how best to evaluate these outcomes. Two years is widely accepted as the earliest age at which neurodevelopment can be reliably assessed. Examiner-administered tests, such as the Bayley Scales, are often considered the gold standard for such purposes, although the resources required to administer them can be...]]>
In this context, the study by Behboodi et al provides important data on body mass index (BMI) outcomes in children born VPT between 2011 and 2012 across multiple European cohorts.
While 5 years may seem a convenient age for follow-up, coinciding with school entry in...]]>
Ketones and lactate may contribute towards overall cerebral fuel availability in term infants, yet the availability of such cerebral fuels in very preterm infants is unclear. We undertook a prespecified substudy to explore ketone and lactate concentrations in the first week of life in infants recruited to the REACT trial (real-time continuous glucose monitoring in the newborn): an international multicentre randomised controlled trial of 182 very low birth weight infants investigating the use of continuous glucose monitoring in glycaemic care.
Ketone and lactate measurements were prospectively collected over the first week of life using the Nova Biomedical point-of-care meter. A longitudinal analysis was undertaken to explore lactate and ketone concentration trends across time and their relationships with blood glucose, baseline demographics, nutritional support and insulin treatment.
Data were available for 168 infants (85 females) including 2902 blood glucose, 2084 ketone and 2017 lactate samples. The mean (SD) gestational age was 27.4 (2.0) weeks. Lactate concentrations were higher initially, with mean (SD) 1.72 (1.26) mmol/L on day 2 and lowered to 1.19 (1.1) mmol/L on day 7. Ketone concentrations remained consistently low at 0.1 mmol/L. Neither simultaneous blood glucose concentrations, macronutrient intake nor receipt of insulin was consistently related to ketone or lactate concentrations.
In this cohort of very preterm infants, there were persistently low concentrations of ketones and relatively higher concentrations of lactate throughout the first week of life. Future research should evaluate changes in these metabolites during episodes of acute hypoglycaemia or hyperglycaemia over more prolonged periods of neonatal intensive care.
Central apnoea due to immaturity of the respiratory drive constitutes the main cause of frequent and prolonged desaturations in extremely preterm (EPT) infants <28 weeks. We investigated the impact of varying the duration of apnoea before backup ventilation (BUV) on the measures of oxygenation in EPT infants during nasal continuous positive airway pressure (nCPAP) therapy.
Single-centre randomised cross-over trial.
Level 3 neonatal intensive care unit.
24 EPT infants on nCPAP with BUV.
The primary outcome was the time spent within a predefined oxygen saturation (SpO2) target (88%–95% or ≥88% with fraction of inspired oxygen (FiO2) =0.21) during start of BUV after 4 s of apnoea duration (AD 4) or 16 s of apnoea duration (AD 16)
The study was successfully completed in 22 children (median gestational age 24+5 weeks, birth weight 628 g, postnatal age 48 days). Mean time spent within the SpO2 target didn’t differ between AD 4 and AD 16 (66.9% vs 67.2%, p=0.88). There were no differences in the time below or above the SpO2 target, prolonged (>30 s, >60 s, >120 s) and severe (<80%, <70%) episodes of hypoxaemias and cerebral tissue oxygenation. Mean FiO2, mean airway pressure, transcutaneous carbon dioxide pressure, heart rate and respiratory frequency did not differ while the rate of BUV was significantly higher during AD 4.
Reducing the time of apnoea until start of BUV didn’t improve the time spent within the SpO2 target in respiratory unstable EPT infants. Our data demand intensified efforts to specify these settings of non-invasive respiratory support that better achieve this important clinical goal.
DRKS00031911.
To assess the comparative effectiveness of different umbilical cord management strategies for preventing intraventricular haemorrhage (IVH) in preterm neonates.
A systematic review and meta-analysis.
PubMed, Scopus and Web of Science were searched from inception to March 2025 for relevant randomised controlled trials.
All preterm neonates born <37+0 weeks of gestation.
All umbilical cord management strategies, including immediate cord clamping (ICC), delayed cord clamping (DCC), intact umbilical cord milking (I-UCM), cut umbilical cord milking (C-UCM), intact cord stabilisation (ICS), physiology-based cord clamping and extrauterine placental perfusion.
Any grade IVH (grades I–IV) and severe IVH (grades III–IV).
Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% CIs. Analyses were stratified for very preterm (<32 weeks) and extremely preterm neonates (<28 weeks).
Forty-nine studies with 8706 neonates were included. Thirty-five direct comparisons between strategies were made, but no clear evidence of benefit or harm emerged. Certainty of evidence ranged from moderate to very low, often downgraded due to imprecision, risk of bias and inconsistency. The most frequent comparison was DCC versus ICC, with 14 studies (RR 0.90, CI 0.65 to 1.26) for any grade IVH and 11 studies (RR 1.14, CI 0.69 to 1.87) for severe IVH. The second most common comparison, DCC versus I-UCM, showed no benefit: RR 1.03 (CI 0.80 to 1.32; eight studies, 2200 participants) and RR 0.77 (CI 0.35 to 1.66; seven studies, 2032 participants). ICS versus DCC was the only comparison which was rated as moderate certainty of evidence for both, any grade IVH (RR 0.96, CI 0.82 to 1.13) and severe IVH (RR 0.91, CI 0.62 to 1.35).
No umbilical cord management strategy was clearly associated with increased or decreased IVH risk. Evidence certainty was generally low to very low, primarily due to bias and imprecision.
To explore families’ experiences of hypoxic ischaemic encephalopathy (HIE) care in the National Health Service (NHS) and the impact of HIE on families.
Semistructured interviews (n=28) sampled to maximise variation, were conducted with parents of infants (born 2010–2024) who underwent therapeutic hypothermia for HIE. Data were analysed with reflexive thematic analysis.
Parents were recruited from across the UK, covering 84.6% (11/13) of the UK’s regional neonatal networks, known as Operational Delivery Networks.
Three themes with eight subthemes were generated from the interview data. (1) The life-changing diagnosis of HIE: Parents described loss of stability and opportunity to parent, ongoing mental turmoil, and how the diagnosis led to transformation. (2) Balancing hope with facts: Parents opened up on how treasured their child is, the tension between hope and loss they experienced, and feelings of being kept in the dark. (3) Struggling to meet their child’s needs: Parents outlined deficiencies in care infrastructure and battling disability-based discrimination.
This study highlights the profound and life-changing impact of HIE on families. Parents described cherishing their children and experiencing personal growth. However, many also characterised how challenges were intensified by disability-based discrimination, poor communication and gaps in support across health, education and social care systems.
To prevent further trauma and to support family well-being, this work identifies priority improvement areas. Embedding trauma-informed care, strengthening transparent and sensitive communication around prognostic uncertainty, and improving care coordination will help families feel seen, heard and supported throughout their journey.
To compare neurodevelopmental outcomes in extremely preterm (EPT) children born across two epochs in Sweden.
Nationwide population-based cohorts of infants born at 22–26 weeks’ gestation in 2004–2007 (Cohort 1) and 2014–2016 (Cohort 2), comprising 1606 live births. Survivors were assessed at 2–2.5 years’ corrected age using the same protocol design.
The primary outcome was neurodevelopmental impairment (NDI), defined as a composite of moderate–severe cerebral palsy (CP), visual or hearing deficits, or moderate–severe cognitive, language or motor impairment assessed with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III). For children not assessed with Bayley-III, NDI was defined as moderate–severe speech delay, general developmental delay or categories of CP, vision and hearing impairment. Outcomes were compared using logistic regression to evaluate differences between cohorts and perinatal and socioeconomic risk factors.
Of 1188 eligible survivors, 1062 (89.3%) were assessed (mean gestational age (GA) 24.8 weeks; 54.9% male). The prevalence of moderate–severe NDI at 22, 23, 24, 25 and 26 weeks’ gestation was 60% vs 52%, 51% vs 51%, 34% vs 42%, 27% vs 32% and 17% vs 24% in Cohorts 1 and 2, respectively. Overall prevalence did not differ significantly (27% vs 35%; adjusted OR (AOR) 1.2, 95% CI 0.94 to 1.6). Among 724 (68%) children assessed with Bayley III, Cohort 2 had higher rates of cognitive delay (21.6% vs 11.3%; AOR 1.8, 95% CI 1.1 to 3.4) and language delay (40.9% vs 16.1%; AOR 3.3, 95% CI 1.4 to 4.1). Low GA and maternal country of birth outside the Nordic region were the strongest predictors of NDI and cognitive delay, the latter association confined to Cohort 2.
Although survival of EPT infants in Sweden has improved, long-term neurodevelopmental outcomes have not. The root causes of failed improvements in long-term outcomes for EPT infants are complex and need further clarification.
It has traditionally been considered that mother-infant ABO incompatibility only causes mild haemolytic disease of the newborn (HDN). However, this view is inconsistent with clinical practice, and large-scale population-based data are lacking to investigate its effects on neonates.
Differences in hospitalisation rates and incidence rates of neonatal hyperbilirubinaemia (NHB) and anaemia among 47 679 Chinese liveborn neonates with different mother-infant ABO combinations, differences in the incidence of ABO-incompatible HDN (ABO-HDN) among neonates with O-B versus O-A mother-infant ABO incompatibility, and the contributions of ABO-HDN to the development of NHB and neonatal anaemia were analysed.
Of the 47 679 liveborn neonates, neonates with mother-infant ABO incompatibility had higher rates of hospitalisation and incidence of NHB and anaemia. The hierarchy of the risk of mother-infant ABO incompatibility to the neonate was O-B > O-A > non-O-A/O-B incompatibility. Among neonates with O-B and O-A mother-infant ABO incompatibility, the ABO-HDN incidence rates were 15.27% (513/3359) and 11.33% (417/3680), respectively (95% CI 1.41 (1.23 to 1.62)), and the severe ABO-HDN incidence rates were 2.05% (69/3359) and 1.14% (42/3680), respectively (95% CI 1.82 (1.23 to 2.67)). Among the 7039 neonates with O-A/O-B mother-infant ABO incompatibility, ABO-HDN was an independent aetiological factor in 41.11% (666/1620) of the neonates with NHB, 70.27% (52/74) of the neonates with severe NHB, 42.34% (163/385) of the neonates with anaemia and 18.28% (17/93) of the neonates with severe anaemia.
Mother-infant ABO incompatibility often leads to severe HDN and is a dominant cause of NHB and neonatal anaemia, leading to significantly higher neonatal hospitalisation rates.
To compare the duration of mechanical ventilation between preterm infants receiving closed-loop automated oxygen control (CLAC) or manual oxygen control.
Randomised controlled trial.
Tertiary neonatal unit in London, UK.
Infants (n=69) with a median (IQR) gestational age of 27.0 (25.6–29.0) weeks studied at a corrected postmenstrual age of 27.6 (25.9–29.1) weeks.
Infants were randomised to CLAC or manual oxygen control within 48 hours of initiation of mechanical ventilation if less than 7 days of age until successful extubation.
Duration of mechanical ventilation.
The CLAC infants (n=34) compared with those who received manual control had a shorter duration of mechanical ventilation (median (range): 11 (1–57) vs 40 (3–134) days, p=0.027), a shorter duration of supplemental oxygen (median (range): 33 (0–100) vs 47 (3–335) days, p=0.031), a lower incidence of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (55% vs 83.9%, p=0.015) and fewer required home oxygen (26.5% vs 51.4%, p=0.016). In the CLAC infants, the time spent in the target oxygen range (91%–95%) was increased (p<0.001) and the times spent in hypoxaemia (peripheral oxygen saturation level (SpO2)<85%) and hyperoxaemia (SpO2>95%) were reduced (p<0.001).
Use of CLAC in preterm, ventilated infants was associated with improved achievement of oxygen saturation targets, shorter durations of mechanical ventilation and supplemental oxygen treatment and a lower incidence of BPD. These results need to be replicated in larger multicentre studies before any change in routine practice could be recommended.
To determine whether extending caffeine therapy through 43 weeks’ postmenstrual age (PMA) decreases intermittent hypoxia (IH) in convalescing preterm infants. Secondary objectives were to assess caffeine effects on changes in inflammation-related plasma biomarkers and brain MRI.
Multicentre masked randomised trial.
16 US hospitals.
Infants at <30 weeks + 6 days gestational age on caffeine between 32 weeks and 36+5 days PMA in room air with routine caffeine discontinuation prior to 36 weeks +6 days.
Randomisation to caffeine or placebo and treated through 42 completed weeks. Pulse oximetry was recorded from enrolment through 1 week after stopping study drug. Blood for 12 inflammation-related biomarkers obtained at enrolment and 38 weeks’ PMA and brain imaging after enrolment or <3 days of randomisation, and study end.
Seconds/hour of oxygen saturation <90% from randomisation to study end.
Randomised 160 subjects, 78 placebo, 82 caffeine. IH was less at every PMA with caffeine treatment from 34 (172.7 (123.4, 241.7); 84.7 (64.4, 111.4, p<0.01) through 41 weeks (73.0 (51.3, 103.7); 26.6 (18.5, 38.2, p<0.001). Adjusted TNF-α levels were 23% lower at follow-up in the caffeine group compared with placebo (p<0.02), without other biomarker differences. Paired brain imaging found no significant differences.
Extended caffeine reduced the burden of IH in very preterm infants and may reduce inflammation. Further study is needed to determine if this effect of caffeine is associated with reduced risk of adverse outcomes.
Targeted testing for cytomegalovirus (CMV) in preterm infants <21 days has two benefits: timely congenital CMV (cCMV) diagnosis, and differentiation between cCMV and postnatal CMV (pCMV). We present an audit of targeted testing for cCMV alongside rates of clinically suspected pCMV in preterm infants.
We collected data on CMV testing from 2016 to 2023 in infants born <30 weeks gestation during admission to a tertiary London neonatal centre.
Of all infants, 77% (899/1162) were tested for CMV during their admission with 74.6% tested <21 days of age. CMV infection was confirmed in 58 infants, 4 cases of cCMV (0.4%) and 54 cases of pCMV (6.0%). One infant with cCMV died, and all were symptomatic: microcephaly, thrombocytopenia, leucopenia, white matter hyperintensity on brain imaging, but none had hearing loss. Most pCMV cases (92.6%) were symptomatic, with bone-marrow suppression (92.6%), sepsis-like syndrome (50%), respiratory (31.5%) and gastrointestinal symptoms (29.6%). All infants with cCMV and 38.9% of infants with pCMV received treatment. Overall, 6% (54/899) had symptomatic CMV disease, 16.7% of infants with CMV died during their neonatal intensive care unit admission, and 42.6% were discharged on home oxygen.
CMV causes a substantial disease burden in infants born <30 weeks gestation, whereby 6% have symptomatic CMV disease. We show the feasibility and value of targeted cCMV and opportunistic pCMV testing. In the absence of universal screening, targeted birth testing for cCMV in infants <30 weeks gestational age should be considered.
To assess the economic consequences of initiating full milk feeds from birth compared with intravenous fluids with gradual feeding in infants born preterm.
Within-trial economic evaluation alongside a prospective, multicentre, randomised controlled trial (Fluids Exclusively Enteral from Day 1). A cost-consequence approach was used (revised from the planned cost-effectiveness analysis to avoid double counting length of stay within costs).
46 UK National Health Service (NHS) neonatal units.
Preterm infants born at 30+0to 32+6 weeks’ gestation.
Infants were allocated to either full milk feeds or gradual feeding with intravenous support within 3 hours of birth.
Resource use and costs were captured from birth to 6 weeks’ corrected age. Costs were assessed from an NHS and personal social services perspective. The primary clinical outcome was length of hospital stay.
2088 infants were enrolled. There was no statistically significant difference in mean (95% CI) length of hospital stay between groups (–0.050 days (–0.638 to 0.538)). Mean total costs were £670 lower in the full milk group (95% CI: –£1562 to £223; p=0.141). Subgroup analyses suggested lower costs among infants born at 30 weeks’ gestation and those below the 10th birth weight centile; no evidence of interaction was found.
Initiating full milk feeds from birth was associated with a modest reduction in costs compared with gradual feeding. While overall hospital stays and costs were not significantly reduced, early full feeding may offer economic advantages in selected subgroups. Further research is needed to assess long-term outcomes.
To identify the location of the left ventricle (LV) and identify the structures below the lower third of the sternum when chest compressions (CCs) are performed using transthoracic echocardiography.
Prospective observational cohort study.
The Lois Hole Hospital for Women and the Grey Nuns Community Hospital, Edmonton, Alberta, Canada.
Newborn infants born between 37 and 41+6 weeks’ gestation admitted to postnatal unit. Newborns of diabetic mothers, large or small for gestational age and with known congenital anomalies were excluded.
Transthoracic echocardiogram to obtain views as per the American Society of Echocardiography guidelines including (1) parasternal long axis, (2) parasternal short axis, (3) apical four chamber and (4) subcostal view.
To assess the positions of the right ventricle and LV and their perception on the chest wall when CCs are performed.
A total of 50 newborn infants were recruited with a mean (SD) gestational age of 39 (1) weeks and birth weight of 3409 (347) g. The LV was located at the third left sternal border in one (2%) newborn infant. In 22 (44%) infants, the LV was located at the fourth left sternal border, in 25 (50%) infants the LV was located at the fifth and in 2 (4%) infants, it was located at the sixth left sternal border.
In newborn infants, CC delivered at the currently recommended lower third of the sternum is likely to compress the right heart, great veins and aorta and not the LV.
The introduction of quality improvement projects has been reported to be associated with a reduced rate of intraventricular haemorrhage (IVH) rate in some neonatal intensive care units.
In this retrospective single-centre study of 1675 preterm infants <1500 g, we analysed the frequency of overall IVH and severe IVH before and after the introduction of a first (2010) and a second (2019) quality improvement bundle.
After the introduction of a first bundle of interventions in 2010, we were able to show a significant reduction of the rate of IVH from 22.2% to 10.5% (p=0002), mainly related to a reduction of severe IVH in the subgroup of infants below 26 weeks of gestational age. By continuous monitoring and implementation of a second intervention bundle in 2019 according to new identified risk factors, we could maintain a low rate of IVH over a 14 year period. With the reduction of the IVH rate, we observed improved long-term neurodevelopmental outcome as indicated by a lower rate of cerebral palsy and improved psychomotor development scores.
Our data suggest that implementing an intervention bundle of measures targeted to avoid risk factors may be associated with a significant reduction in IVH rate. By constant monitoring of the effects of the intervention and individual measures and refining the care bundle based on new evidence becoming available, a reduced IVH rate may be maintained despite annual fluctuations in the incidence of IVH. These intensified efforts are justified as IVH is not an inevitable event.
Evident at birth were a series of erythematous nodular lesions on the back (10 mm by 10 mm) and groin (8 mm by 8 mm). The nodules were firm and well demarcated, with purple discolouration. There were visible capillaries with an area of central pallor which crusted within 24 hours (
A clinical review by dermatology resulted in a punch biopsy of one lesion, and a diagnosis of infantile myofibromatosis was made.
Infantile myofibromatosis describes a benign spindle cell tumour of the soft tissues with fibrous proliferation of skin, bone or muscle
A female neonate was delivered at 38 weeks of gestation by emergency caesarean section due to non-reassuring fetal status with polyhydramnios (amniotic fluid index: 39 cm) and fetal hepatomegaly. She presented with hypotonia and poor respiratory effort at birth, requiring intubation and resuscitation. Persistent pulmonary hypertension was diagnosed and treated with 100% oxygen and inhaled nitric oxide. Numerous dark-purple papular to nodular lesions (1–10 mm) were noted on the face, trunk and extremities, covering nearly the entire body (
We conducted a prospective observational study to understand PICC movement in relation to limb position in real time. Neonates admitted to a tertiary neonatal unit, at St George’s Hospital, London, needing point of care ultrasound (POCUS) to confirm optimal PICC position were included. The ultrasound scans were performed by a single operator (AMK) with formal training in paediatric echocardiography. All the assessments were done using multiphased array, curvilinear and linear probes with GE S70 Ultrasound machine. The images were stored on the Philips IntelliSpace PACS system. We used...]]>
The NEOLEV2 study emphasised that, ‘the end point of greatest concern in neonatal seizure trials is long-term neurodevelopmental outcome....]]>
The authors have discovered an error in one of their tables. Table 3, in the row ‘None’, under column heading ‘24 weeks’ it should be 38% and not 40%. The main message and conclusions of the paper are not altered.
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