Prakesh Shantilal Shah

Introduction: Antimicrobial exposure is nearly universal among very preterm infants, yet evidence to guide optimal treatment duration and sepsis management remains limited. Unnecessary prolonged antimicrobial use may contribute to adverse outcomes and antimicrobial resistance. We aimed to characterize international practices in the management of culture-proven infections in infants born <29 weeks’ gestation. Methods: This cross-sectional study surveyed neonatal intensive care units (NICUs) across 12 networks within the International Network for Evaluating Outcomes of Neonates. A pre-piloted online questionnaire captured unit-level practices regarding treatment duration for culture-proven infections, antifungal prophylaxis, blood culture collection, and central line management. Responses were analyzed descriptively at the network and unit levels. Results: Of 608 eligible NICUs in this study, 382 (62.8%) responded. A 7-day treatment duration was most commonly reported for Gram-positive sepsis (45.2% of NICUs), whereas 14 days was most commonly reported for Gram-negative sepsis (44.4%). Treatment durations were longer for concurrent meningitis: 57% of units reported 14 days for Gram-positive meningitis and 69.2% reported 21 days for Gram-negative meningitis. Antifungal prophylaxis was reported by 62.1% of units. Most NICUs (79.7%) routinely obtained blood cultures from a single sterile site. Overall, 75.7% of units reported central line removal for Gram-negative sepsis and 57.3% for Gram-positive sepsis. Conclusion: Reported antimicrobial duration and sepsis management practices for very preterm infants varied across neonatal units and international networks. These findings underscore persistent uncertainty and the urgent need for high-quality evidence to inform standardized, evidence-based antimicrobial stewardship in this vulnerable population.

Objective: To determine pre‐procedure maternal, pregnancy and fetal factors associated with survival until 6 months of age and evaluate temporal trends in survival outcomes over a 25‐year period following fetoscopic laser ablation (FLA) of placental anastomoses in monochorionic twin pregnancies with twin–twin transfusion syndrome (TTTS). Design: Retrospective observational study. Settings: A tertiary care fetal centre in Canada. Population or Sample: One thousand and five patients undergoing TTTS between 1998 and 2023. Methods: Patient demographics, pregnancy, procedural and outcome details were collected. Predictors for single and dual survival were identified using multivariable logistic regression. Temporal trends in survival outcomes across the study period were also examined. Main Outcome Measures: Fetal/neonatal survival at 6 months and predictors for single and dual survival. Results: Of 915 included fetoscopies, 597 pregnancies (65.2%) achieved dual survival, 217 (23.9%) had a single survivor, and 101 (11%) resulted in dual demise. Survival rates improved significantly over the 25‐year study period for both single and dual survival ( p = 0.03 and p = 0.0004, respectively). Three significant pre‐procedural predictors of dual demise versus one or two survivors were: cervical length ≤ 15 mm (adjusted odds ratio [AOR] 6.1, 95% CI 2.7–14.1), earlier gestational age (GA) at intervention (AOR 1.2 per earlier week, 95% CI 1.1–1.3), and abnormal donor umbilical artery Doppler flow (AOR 5.1, 95% CI 1.7–15.6). A prediction calculator using this model achieved an area under the curve of 0.65. Conclusion: Short cervical length (≤ 15 mm), presence of abnormal donor umbilical artery Doppler waveform, and early GA at time of intervention are significant predictors of fetal/neonatal survival at 6 months following FLA in TTTS and thus, are valuable parameters to consider for pre‐procedural counselling.

Aim: Neonatal resuscitation follows national or regional guidelines, but uptake varies in clinical practice. This study aimed to examine variations in reported delivery room practices for infants < 29 weeks' gestation across neonatal units in 12 networks of the International Network for Evaluating Outcomes in Neonates. Methods: An online pre‐piloted survey was sent to 608 neonatal units across 12 networks. Responses, based on 2022–2023 practices, were categorized as very frequent (90%–100%), often (50%–89%), sometimes (10%–49%), rarely (1%–9%), and never, and summarized as frequency of units per network. Results: Overall, 382 units (63%) responded (37%–100% within network). Active resuscitation at 22, 23 and 24 weeks was reported as ‘very frequent/often’ by 22%, 53% and 76% of units, with variation. Delayed cord clamping, cord milking, and resuscitation with intact cord were ‘very frequent/often’ in 47%, 27% and 7% of units. Japan reported 75% cord milking. For initial respiratory support, 86% reported oxygen concentration < 40%. Intubation at birth for infants 27–28 weeks was uncommon except in Japan. Surfactant delivery room use was reported by 24% of units. Conclusions: Delivery room management of very preterm infants varies across networks. Future studies should analyse the impact of reported delivery room practices on neonatal outcomes.

Background. Variation in the uptake of evidence-based practices and adoption of unproven therapies by neonatal intensive care units might contribute to clinical variability. Objective was to survey current oxygen saturation targets (SpO2), the use of automatic adjustment of inspired oxygen in infants on respiratory support, the criteria for routine retinal examinations for ROP and the use of anti-vascular endothelial growth factor (VEGF) agents to treat ROP in the International Network for Evaluating Outcomes for Neonates (iNeo). Methods. Online pre-piloted anonymous questionnaires on care practices in 2023 for extremely preterm (<29 weeks) infants were sent to the Directors of 608 NICUs in the iNeo. Four questions concerned ROP management and results were compared with a similar 2015 survey. Results. There were 11 participating networks from 12 high-income countries and one from a middle-income country. The overall NICU response rate was 63% (382 units). Despite variability between NICUs, within networks there was limited change in SpO2 targets between 2015 and 2023. The median upper and lower SpO2 targets were 95% and 89%; in 18% of NICUs the upper target was ≥96%, in 13% the lower target was ≤85%. Automated loop systems for controlled oxygen delivery were used in 24% of NICUs. Most NICUs (78%) used a combination of birthweight and gestation as ROP screening criteria. Intravitreal anti-VEGF agents were used to treat ROP in all networks and by 76% of NICUs. Conclusions. There was considerable variation in care practices between NICUs and the relationship of this to clinical outcomes should be explored.

Objective: Describe prenatal imaging characteristics, perinatal and postnatal outcomes in fetuses with isolated macrocystic congenital pulmonary airway malformations (CPAM) undergoing thoracoamniotic shunting (TAS) and expectant management. Methods: Retrospective cohort study of 123 fetuses with isolated macrocystic CPAM managed at the Ontario Fetal Center (1998–2024). Prenatal ultrasound features, perinatal outcomes, and postnatal surgical data were described for fetuses undergoing TAS and expectantly managed. Predictors of mortality were assessed in the TAS group. Results: TAS was performed in 30/123 (24%) of cases. Shunted fetuses had higher CPAM volume ratio (CVR) (1.5 vs. 0.5), larger cyst diameter (3.4 vs. 1.0 cm), mediastinal shift (58% vs. 7%), and hydrops (16.7% vs. 0%). Lesion size decreased after TAS in 80% of cases; however, survival was lower (85% vs. 100), and preterm delivery was more frequent (24% vs. 7%). Among shunted cases, CVR > 2 or persistent hydrops were associated with perinatal mortality. Neonatal respiratory support was required more often following TAS (86% vs. 25%). Most infants underwent postnatal resection, occurring earlier after TAS (0.1 vs. 7.0 months). Conclusions: Macrocystic CPAM represents a high‐risk subtype of congenital lung malformations, with a substantial proportion requiring fetal intervention, neonatal respiratory support, and postnatal surgical resection. These findings support tertiary surveillance and delivery.