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Sonographic assessment of diaphragmatic thickness and excursion has been found to be an accurate tool in predicting successful extubation of adult patients from invasive mechanical ventilation. We aimed to evaluate the accuracy of sonographic assessment of diaphragmatic thickness and excursion in predicting successful extubation of preterm infants from invasive conventional mechanical ventilation. Preterm infants less than 32 weeks gestation who required invasive conventional mechanical ventilation were evaluated by diaphragmatic sonography within 1 h of their planned extubation. Infants were classified into successful or failed extubation groups based on their ability to stay off invasive mechanical ventilation for 72 h after extubation. Inspiratory and expiratory thickness plus excursion of the right and left hemidiaphragm as well as diaphragmatic thickening fraction (DTF) measures were compared between groups. We included 43 eligible infants, of whom 34 infants succeeded and 9 infants failed extubation. Infants in the successful extubation group had a significantly higher expiratory thickness of the right and left hemidiaphragm, excursion of the right and left hemidiaphragm, inspiratory thickness of the left hemidiaphragm, and DTF of the left hemidiaphragm compared with infants who failed extubation. The receiver-operating characteristic curves showed that excursion of the right and left hemidiaphragm has the highest significant accuracy in predicting successful extubation of preterm infants among all diaphragmatic parameters (AUC is 0.98 and 0.96, respectively; p value < 0.001 for both).Conclusion: We conclude that diaphragmatic excursion is a useful indicator for successful extubation of preterm infants from mechanical ventilation.What is Known:• Invasive mechanical ventilation induces ventilator induced diaphragmatic dysfunction (VIDD) particularly when used for long time.• Assessment of diaphragmatic dimensions and functional activity has been a valuable tool in predicting successful extubation of adult patients from invasive mechanical ventilation.What is New:• Sonographic assessment of diaphragmatic dimensions can be used to predict successful extubation of preterm infants from mechanical ventilation.• Sonographic assessment of diaphragmatic excursion shows the highest sensitivity and specificity in predicting successful extubation of preterm infants.

NIV-NAVA mode for respiratory support in preterm infants is not well-studied. This study aimed to describe the diaphragmatic function, diaphragmatic excursion (DE), and thickness fraction (DTF), in preterm infants < 30 weeks’ gestation supported by NIV-NAVA compared to NIPPV using bedside ultrasonography. In this consecutive prospective study, DE, diaphragmatic thickness at end of expiration (DT exp ), end of inspiration (DT ins ), and DTF were assessed using bedside ultrasound. Lung aeration evaluation using lung ultrasound score (LUS) was performed for the two groups. Diaphragmatic measurements and LUS were compared for the 2 groups (NIV-NAVA group versus NIPPV group). Statistical analyses were conducted using the SPSS software version 22. Out of 70 infants evaluated, 40 were enrolled. Twenty infants were on NIV-NAVA and 20 infants on NIPPV with a mean [SD] study age of 25.7 [0.9] weeks and 25.1 [1.4] weeks respectively ( p  = 0.15). Baseline characteristics and respiratory parameters at the time of the scan showed no significant difference between groups. DE was significantly higher in NIV-NAVA with a mean SD of 4.7 (1.5) mm versus 3.5 (0.9) mm in NIPPV, p  = 0.007. Additionally, the mean (SD) of DTF for the NIV-NAVA group was 81.6 (30) % vs 78.2 (27) % for the NIPPV group [ p  = 0.71]. Both groups showed relatively high LUS but no significant difference between groups [12.8 (2.6) vs 12.6 (2.6), p  = 0.8].   Conclusion : Preterm infants managed with NIV-NAVA showed significantly higher DE compared to those managed on NIPPV. This study raises the hypothesis that NIV-NAVA could potentially improve diaphragmatic function due to its synchronization with patients’ own breathing. Longitudinal studies to assess diaphragmatic function over time are needed.   Trial registry : Clinicaltrials.gov (NCT05079412). Date of registration September 30, 2021. What is Known: • NIV-NAVA utilizes diaphragmatic electrical activity to provide synchronized breathing support. • Evidence for the effect of NIV-NAVA on diaphragmatic thickness fraction (DTF) and excursion (DE) is limited. What is New: • Ultrasonographic assessment of diaphragmatic function (DTF and DE) is feasible. • In preterm infants, DE was significantly higher in infants supported with NIV-NAVA compared to those supported with NIPPV.

The optimum caffeine dose in preterm infants has not been well investigated. We aimed to compare the efficacy and safety of high versus low-dose caffeine citrate on apnea of prematurity (AOP) and successful extubation of preterm infants from mechanical ventilation. We compared high-dose (loading 40 mg/kg/day and maintenance of 20 mg/kg/day) versus low-dose (loading 20 mg/kg/day and maintenance of 10 mg/kg/day) caffeine citrate in preterm infants <32 weeks gestation, presented with AOP within the first 10 days of life. A total of 120 neonates (60 in each group) were enrolled. High-dose caffeine was associated with a significant reduction in extubation failure in mechanically ventilated preterm infants ( p  < 0.05), the frequency of apnea ( p  < 0.001), and days of documented apnea ( p  < 0.001). High-dose caffeine was associated with significant increase in episodes of tachycardia ( p  < 0.05) without a significant impact on physician decision to withhold caffeine. Conclusion : The use of higher, than current standard, dose of caffeine may decrease the chance of extubation failure in mechanically ventilated preterm infants and frequency of AOP without significant side effects. What is Known: • Caffeine therapy for treatment of apnea of prematurity has been well established over the past few years. The optimal loading and maintenance dose of caffeine in preterm infants is not well - studied . What is New: • This double blind randomized controlled trial demonstrated that using a higher , than current standard , loading and maintenance doses of caffeine for treatment of apnea in preterm infants is well tolerated and significantly decrease the frequency of apnea .

Massage therapy (MT) improves growth parameters in preterm infants. The growth of lean mass rather than fat mass has been associated with better long-term outcomes. We aimed to study the effect of tactile/kinesthetic MT on growth and body composition parameters in preterm infants. Preterm (< 32 weeks gestation) infants were randomly assigned at corrected gestational age of 35 weeks to receive 3 consecutive, 15-min, sessions of MT over 5 days or routine care. Primary outcome was mean daily weight gain. Secondary outcomes included anthropometric measurements and body composition parameters assessed by dual X-ray absorptiometry (DXA) scan. Out of 218 infants screened, 86 were eligible and 60 infants (30 in each group) were recruited after parental consent. MT was associated with significant increase in daily weight gain [19.3 (10–34.3) versus 6.2 (2.5–18.4) g/day, p = 0.01] and growth velocity [12.5 (6–21) versus 3.6 (1.6–12.6) g/kg/d, p = 0.01] compared with routine care. Infants on MT showed significant increase in total body mass, fat mass (total/legs), lean mass (total/arms/legs/trunk), and bone mineral density (arms/legs/trunk) values compared with routine care group. In conclusions, MT improves growth quality as evident by increased total and regional lean masses, increased bone mineral density, and peripheral rather than central fat distribution.What is known on this subject?• Massage therapy (MT) for preterm infants leads to achievement of faster independent oral feeding, increased weight gain, less stress, less response to pain, less occurrence of sepsis, and shorter hospital stay.• Growth of lean mass rather than fat mass has been associated with better long-term outcomes.What this study adds?• Tactile/kinesthetic massage therapy in preterm infant is associated with improved growth parameters and anthropometric measures.• Tactile/kinesthetic massage therapy increased total body mass, fat mass (total/legs), lean mass (total/arms/legs/trunk), and bone mineral density (arms/legs/trunk) values.

Patent ductus arteriosus (PDA) is a common clinical condition in preterm infants. Preterm newborns with PDA are at greater risk for several morbidities, including higher rates of bronchopulmonary dysplasia (BPD), decreased perfusion of vital organs, and mortality. Therefore, cyclooxygenase (COX) inhibitors and surgical interventions for ligation of PDA are widely used. However, these interventions were reported to be associated with side effects. In the absence of clear restricted rules for application of these interventions, different strategies are adopted by neonatologists. Three different approaches have been investigated including prophylactic treatment shortly after birth irrespective of the state of PDA, presymptomatic treatment using echocardiography at variable postnatal ages to select infants for treatment prior to the duct becoming clinically significant, and symptomatic treatment once PDA becomes clinically apparent or hemodynamically significant. Future appropriately designed randomized controlled trials (RCTs) to refine selection of patients for medical and surgical treatments should be conducted. Waiting for new evidence, it seems wise to employ available clinical and echocardiographic parameters of a hemodynamically significant (HS) PDA to select patients who are candidates for medical treatment. Surgical ligation of PDA could be used as a back-up tool for those patients who failed medical treatment and continued to have hemodynamic compromise.

Background Since inflammatory mediators play a crucial role in the pathophysiology of neonatal sepsis. Montelukast, as an anti-inflammatory drug, could be a beneficial therapy. In searching the literature, no previous research addressed the role of Montelukast in neonatal sepsis; hence, this study aimed to explore the adjuvant role of Montelukast in regulating the inflammatory response associated with neonatal sepsis and its associated effect on the clinical outcomes. Methods An open-label, randomized controlled intervention trial conducted on 40 late preterm newborn infants (gestational age 34 0/7 to 36 6/7  weeks) admitted to NICU, with clinical evidence of sepsis. In the Montelukast group ( n  = 20), infants received oral Montelukast once daily for 10 days (infant's weight < 2 kg received 1.5 mg whereas > 2 kg received 2 mg) with antibiotics plus routine supportive care. In the routine care group ( n  = 20), infants received antibiotics plus routine supportive care. Primary outcome was the serum level of tumor necrosis factor (TNF) alpha at day 10 of therapy. Secondary clinical and laboratory outcomes were reported along hospital admission. Results Baseline characteristics were non-significantly different between both groups. After 10 days of therapy, TNF alpha level was significantly lower in the Montelukast group (80.73 ± 50.25 versus 119.54 ± 58.46; p  = 0.03). There were non-significant differences between both groups regarding duration of NICU admission, antibiotics duration or modalities and duration of respiratory support. C-reactive protein didn’t differ between both groups ( p  = 0.256). No documented significant adverse effects of Montelukast during the study period. Conclusions In late preterm neonates with sepsis, 10 days of Montelukast therapy as an adjuvant to antibiotics lowered TNF alpha level without any impact on clinical outcomes. Trial registration The study was approved by Mansoura Faculty of Medicine institutional research board (IRB) (MS/17.06.95) and it was registered in clinical trials database (clinicaltrials.gov, ID:  NCT04474327 ; registered July 16, 2020).

Vaccines are known to have side effects, most of which are tolerable. Vasculitis following vaccination is reported and has various modes of presentation. We report a 4-month-old girl presented with an unusual presentation of fulminant hepatitis, pan vasculitis, and diffuse body aneurysms following routine immunization diagnosed by echocardiography and computed tomography angiogram. It is important to be aware of different possible adverse effects following vaccines and their different modes of presentation as well as possible treatments such as intravenous immunoglobulins and high dose methylprednisolone.

Recent research links early weight changes (EWC) with bronchopulmonary dysplasia (BPD) in preterm neonates, while lung ultrasound score (LUS) has shown promise in predicting BPD. We aimed to explore the correlation between LUS and EWC as markers of extravascular lung edema and to investigate the correlation between LUS and EWC in preterm infants with respiratory distress syndrome regarding future BPD development. This secondary analysis of a prospective study involved infants ≤ 28 weeks gestation. Enrolled infants underwent lung ultrasound assessment on postnatal days 3, 7 and 14, measuring LUS. EWC was computed on the same time points. Infants were classified as either having BPD or not. Descriptive statistics, correlation coefficient, and area under the receiver operating characteristic (AUROC) curve analysis were utilized. Of 132 infants, 70 (53%) had BPD. Univariate analysis revealed statistically significant differences in LUS and EWC at days 3, 7, and 14 between BPD and no-BPD groups ( p  < 0.001). A statistically significant but weak positive correlation existed between LUS and EWC ( r 0.37, r 0.29, r 0.24, and p  < 0.01) at postnatal days 3, 7, and 14, respectively. AUROC analysis indicated LUS having superior predictive capacity for the need for invasive mechanical ventilation at day 14 as well as the later BPD development compared to EWC ( p  < 0.0001). Conclusion : In a cohort of extreme preterm infants, our study revealed a positive yet weak correlation between LUS and EWC, suggesting that EWC was not the major contributing to the evolving chronic lung disease. What is Known: • Recent evidence links Early Weight-Changes with bronchopulmonary dysplasia in preterm neonates. • Lung ultrasound score has shown promise in early prediction of the subsequent development of bronchopulmonary dysplasia in preterm infants. No studies have examined the correlation between Early Weight-Changes and Lung ultrasound score in preterm infants during first 2 weeks after birth. What is New: • Our study demonstrated a positive and statistically significant correlation between early LUS and EWC, indicating their potential role as early predictors for the subsequent development of BPD in extreme preterm infants. • The weak correlation between the two parameters may stem from the possible restricted influence of EWC, given that it may not be the primary factor contributing to the evolving chronic lung disease.

Background During severe acute respiratory syndrome (SARS) outbreak in Toronto, outpatient clinics at SickKids Hospital were closed to prevent further disease transmission. In response, a decision was made by the neonatal neuro-developmental follow up (NNFU) clinic staff to select patients with scheduled appointments to have a mail/telephone assessment using Ages and Stages Questionnaire (ASQ) or to postpone/skip their visit. The objective of this study was to compare the developmental assessment and its outcome in two groups of NNFU clinic patients, SARS versus non-SARS, over three standard clinic appointments. Methods We compared the diagnostic accuracy (identification of developmental delay), and patient management (referral for therapy or communication of a new diagnosis) of the strategies used during SARS, April/May 2003, to the standard assessment methods used for patients seen in April/May 2005 (non-SARS). In all cases data were obtained for 3 patient visits: before, during and after these 2 months and were compared using descriptive statistics. Results There were 95 patients in the SARS group and 99 non-SARS patients. The gestational age, sex, entry diagnosis and age at the clinic visit was not different between the groups. The NNFU clinic staff mailed ASQ to 27 families during SARS, 17 (63%) were returned, and 8 of the 17 were then contacted by telephone. Criteria used to identify infants at risk selected for either mailed ASQ or phone interviews were not clearly defined in the patients' charts. There was a significant under identification of developmental delay during SARS (18% versus 45%). Of those who responded to the mailed questionnaire, referrals for therapy rates were similar to non-SARS group. The lost to follow up rate was 24% for the SARS group compared with 7% for non-SARS. There was no difference in the overall rate of developmental delay in the two groups as identified at the 'after' visit. Conclusions Poor advanced planning led to a haphazard assessment of patients during this infectious disease outbreak. Future pandemic plans should consider planning for outpatient care as well as in hospital management of patients.