Leeann R. Pavlek

Neonates with congenital heart disease may require delivery room interventions beyond standard care. Because existing guidelines and educational programs rarely address these needs, we developed and evaluated targeted educational modules. Teams were randomized to online eLearning modules or directed readings. Individual pre-/post-knowledge scores were compared. Team performance was tested in simulated delivery scenarios including abruption, hypoplastic left heart syndrome, d-transposition of great arteries and congenital complete heart block. 32 teams from 9 centers participated. The module group had improved knowledge scores (mean change 6% vs -0.3% e-Learning group, p = 0.01). Simulation performance was similar between groups except for hypoplastic left heart syndrome, where module groups scored lower, performing less bag-mask ventilation before intubation (82% vs 88%, p < 0.05). eLearning modules were well-accepted and improved knowledge scores. Simulation performance was similar between groups. Ongoing educational development of CCHD DR adaptations and their incorporation within standard NRP is required.

To characterize availability, utilization, and barriers to bowel ultrasound (BUS) for necrotizing enterocolitis (NEC). A survey of neonatologists, surgeons, and radiologists at Children's Hospitals' Neonatal Consortium (CHNC) sites. Quantitative data were analyzed descriptively; open-ended responses underwent thematic analysis. In total, 104 respondents from 42/46 institutions participated. BUS was available at 83% of level IV NICU sites, with 64% reporting 24/7 availability. However, only 42% of affiliated level III NICUs had BUS available. BUS was primarily used alongside radiographs in cases of diagnostic uncertainty and variably used to guide surgical decisions. Radiologists frequently used protocols while neonatologists and surgeons reported limited training and few institutional guidelines. Key barriers included lack of standardization, inadequate training, and unclear clinical utility. BUS is increasingly available in level IV NICUs but less so in level III NICUs. Even when available, clinical integration is inconsistent due to gaps in standardization, training, and supporting evidence.

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?

Background Neonates with congenital heart disease may require delivery room interventions beyond standard care. Because existing guidelines and educational programs rarely address these needs, we developed and evaluated targeted educational modules. Methods Teams were randomized to online eLearning modules or directed readings. Individual pre-/post-knowledge scores were compared. Team performance was tested in simulated delivery scenarios including abruption, hypoplastic left heart syndrome, d-transposition of great arteries and congenital complete heart block. Results 32 teams from 9 centers participated. The module group had improved knowledge scores (mean change 6% vs -0.3% e-Learning group, p = 0.01). Simulation performance was similar between groups except for hypoplastic left heart syndrome, where module groups scored lower, performing less bag-mask ventilation before intubation (82% vs 88%, p < 0.05). Conclusion eLearning modules were well-accepted and improved knowledge scores. Simulation performance was similar between groups. Ongoing educational development of CCHD DR adaptations and their incorporation within standard NRP is required.

Extremely preterm infants (EPIs) require complex management because of structural and functional organ immaturity leading to unique medical needs and evolving approaches throughout their NICU course because of changes in physiology. A comprehensive approach to care for these small babies is essential, as changes in management of one organ system can have downstream effects on others. This care plan ideally begins before delivery and involves a multidisciplinary team developing the initial plan of care based on individual patient factors and continues to evolve. Because of the complexity of these fragile patients, multidisciplinary guidelines developed by a team with expertise in caring for EPIs can lead to improved care and outcomes. Additionally, multicenter collaboration to share knowledge and experience, work together on research and quality improvement initiatives, and discuss complicated cases is essential because of the relatively small numbers of these tiniest patients at each individual site.

Neonatal intensive care units (NICUs) developing a tiny baby program—a clinical approach for care of infants born before 24 weeks’ gestation—have a limited, but growing, body of evidence to guide practice. Infants born 22–23 weeks have more immature organ development and physiology than more mature extremely low birth weight infants. Centers of excellence (CoEs) in the care of tiny babies have evolved integrated approaches to clinical care in which the management of each physiologic system impacts other systems. NICUs may find mentorship and potentially better practices from the CoEs, but must apply them with extreme caution in the context of their local practices. In this article, authors from institutions in the process of developing tiny baby programs propose a framework for developing such programs. The authors summarize both operational and physiologic principles that they have found important for consideration.

Background: An increased incidence of adult-onset heart failure is seen in individuals born preterm or affected by fetal growth restriction. An adverse maternal environment is associated with both preterm birth and poor fetal development, and postnatal oxygen therapy is frequently required to sustain oxygenation of vulnerable tissues due to lung immaturity. Methods: Studies using our murine model of maternal inflammation (LPS) and neonatal hyperoxia exposure (O₂) observed pathological changes in cardiac structural proteins and functional analysis with sex dependent differences in pathologies at 10 months of age. Using our previous model, the current investigations tested the hypothesis that early-life perturbations in cardiac structural proteins might predict adult cardiac dysfunction in a sex dependent manner. Results: LPS-exposed females had lower αMHC mRNA and protein at P0 and P7 relative to the saline-exposed females, but these changes did not persist. Male mice exposed to LPS/O₂ had normal expression of αMHC mRNA and protein compared to saline/room air controls though P56, when they dramatically increased. Correlative changes were observed in left ventricular function with a more severe phenotype in the males indicating sex-based differences in cardiac adaptation. Conclusions: Our findings demonstrate that early changes in contractile proteins temporally correlate with deficits in cardiac contractility, with a more severe phenotype in males. Our data suggest that similar findings in humans may predict risk for disease in growth-restricted infants.

Managing high-risk newborns with critical congenital heart disease (CCHD) in the delivery room is a unique challenge, characterized by complex physiology, heightened urgency, the coordinated efforts of multiple medical teams, and depending on the facility, the infrequent occurrence of such cases. Currently, there is a lack of unified guidance for resuscitation of these newborns in the delivery room. In this commentary, we advocate for an integrated approach involving maternal-fetal medicine specialists, fetal cardiologists, neonatologists, and cardiac intensivists. The proposed approach emphasizes collaborative pre-delivery planning, focusing on anticipated risk factors, postnatal physiology, and clinical management plans. We stress the importance of simulation-based education specifically addressing CCHD scenarios and advocate for research collaborations to establish evidence-based guidelines and track outcomes. Ultimately, a comprehensive, collaborative, and standardized approach, involving prenatal coordination, communication, and education, is essential for optimizing the delivery room management of neonates with CCHD.