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[This corrects the article DOI: 10.1371/journal.pone.0232963.].

BackgroundTexas Children's Hospital (TCH) has a 172 bed NICU. TCH NICU employs more than 450 RNs, 50 RTs, 98 NNPs, and over 150 physicians. As a consult center for complex critically ill neonates, many patients have respiratory management via an endotracheal tube (ETT). Proper ETT position is crucial to maintain patients' respiratory and cardiac function. Research shows approximately 20% of children and neonates who experience a UE have cardiovascular collapse requiring CPR or epinephrine. Baseline data showed a mean rate of 3.3 Unplanned Extubations (UE) per 100 ventilator days.ObjectivesReduce the Newborn Center UE rate from 3.3/100 vent days in FY 2014 to 2.64/100 vent days by September 30, 2016.MethodsA multidisciplinary team formed and responded to the problem. Debriefs were initiated by bedside clinicians after every UE to better understand the contributing factors. Using the operational definition from Solutions for Patient Safety, the team reviewed and themed every UE. Identified themes were: Agitation, ETT Depth, Unable to determine, Securement Device, Transfer/holding, and Bundle Compliance.Results33% reduction in UE in a rolling calendar year.ConclusionsOur outcomes identified that the NRP formula can be used as an assessment tool to determine need for an X-ray to check ETT placement and quickly identify ETTs that need adjustment. This has implications for clinical practice to help guide judicious radiation exposure. Ongoing work will be sustainment and growth with the literature (i.e. New NRP formula). With the rich data gained from each UE there are further opportunities for targeted improvement based on theme.Figure 1Unplanned extubation rate.Figure 2Themes for each unplanned extubation.Figure 3UE debrief form.Figure 4Poster for position of ETT.

Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a “crashing” neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention. Conclusion : To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? • Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? • The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained “crashing” neonates. • The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.

Background Intrapartum monitoring aims to identify fetal acidaemia. The fetal acidaemia threshold, reliably accountable for neonatal morbidity, or mortality, is less clear. The International Cerebral Palsy and American Congress of Obstetrics and Gynaecology task force, suggests: “pH <7 …. provides sufficient evidence to blame acute intrapartum events for the neonatal condition”. Objective We analysed early neonatal outcomes in babies born with an arterial pH ≤7.1, from paired umbilical cord gases. Method Retrospective case notes audit at Kingston hospital maternity unit, involving 30 singleton live neonates, between 01/01/2012–31/12/2012. Neonatal outcomes were assessed using: 5 min APGAR scores <7, need for resuscitation and neonatal unit (NNU) admissions. Results Median arterial pH was 7.07, interquartile range 7.00–7.09. Neonates with an arterial pH 6.80–7.02 demonstrated; 100% resuscitation requirements and NNU admission; with 25% APGARs at 5 min <7. Above an arterial pH 7.02; absolute risk for resuscitation was 50%; 36.36% required NNU admission and 9.09% had APGARs at 5 min <7. No ideal arterial pH was identified for good neonatal outcomes. We compared our results against a large cohort study;¹ their threshold pH for adverse neurological outcomes was 7.10 and the ‘ideal’ cord pH 7.26–7.30. Conclusion Overall, our results suggest an unpredictable association between acidaemia and adverse early neonatal outcomes, with a pH >7.02. Highlighting the multifactorial nature of predicting neonatal outcome; which if better understood, will improve interpretation of intrapartum monitoring. Reference Yeh P, Emary K, Impey L. The relationship between umbilical cord arterial pH and serious adverse neonatal outcome: analysis of 51,519 consecutive validated samples

Background Appropriate nutrition and growth are vital components of neonatal care. The most commonly used measures of growth in neonates are weight and head circumference, but these have limitations. Linear growth measurement is the best indicator of dietary adequacy and it most closely relates to lean body mass. There is currently no standardised practice of assessment of length in the neonatal period. Methods We are keen to investigate whether length measurement is being used as a growth parameter for neonates in England. A survey of all tertiary neonatal units in England was conducted in August 2013. Questionnaire completed via phone calls or e mails. 3 main domains were surveyed: practice of measuring length, methods used and barriers to routine practice. Results Response rate was 98% from 43/44 tertiary neonatal units in England. 44% of the units do measure length. Of which, less than half measure at birth/admission but many measure when infants are more stable. Measuring mat/tape and the Leicester incubator scale were the most commonly used equipment. Barriers to not measure were doubts of usefulness and accuracy in 10/23 (43%) and 7/23 (30%) respectively. Conclusion There is no standardised procedure for measuring length in tertiary neonatal units in England. We proposed that there should be a standardised protocol for the assessment of growth during the neonatal period. This should include regular measurements of weight, head circumference and linear growth. Need for further research, training and education are urgent.

Aims To investigate maternal and perinatal outcomes for women with singleton pregnancies with polyhydramnios in Tayside. Methods All women diagnosed with polyhydramnios (AFI ≥ 25 cm/deepest pool ≥ 8 cm) between 01/01/13–31/10/13 were included. All women had an ultrasound scan (USS) assessment of fetal anatomy and a random blood sugar assessment as part of routine ante-natal care. Data for obstetric outcomes were collected from the local maternity database (Torex Protos Evolution, v3.5.19). Results 59/3270(1.8%) were diagnosed with polyhydramnios. Median gestation at diagnosis was 34+2weeks (range = 23+4–40+1 weeks). 14/59(23.7%) were associated with diabetes; 5/59(8.5%) had pre-existing diabetes and 9/59(15.3%) had gestational diabetes. 5/59(7%) had perinatal aetiology; 1 case of rhesus isoimmunisation diagnosed at the ante-natal booking visit and 4 congenital abnormalities. 2 congenital abnormalities were diagnosed ante-natally (1 exomphalos, 1 oro-facial cleft). 1 tracheo-oesophageal fistula and 1 case of arthrogryposis multiplex congenita were diagnosed following delivery. 40/59(68%) had idiopathic polyhydramnios. 14/40(35%) resolved on USS. Median gestation at delivery was 39+1weeks (range = 32+6–41+4weeks). Median birth weight was 3480g (range = 1375–4400g). 3/40(7.5%) had pre-term birth. 18/40(45%) had induction of labour (IOL). The median gestation for IOL was 39+1weeks (range=37+1–40+3weeks). 20/40(50%) required caesarean section. 13/20 had planned CS and 7/20 had emergency CS. 4/40(10%) had major post-partum haemorrhage (PPH). 2/40(5%) neonates required NICU admission. Conclusions Idiopathic polyhydramnios is associated with a high rate of obstetric interventions. A diagnosis of polyhydramnios was associated with high rates for induction of labour, operative delivery and major PPH, and also adverse perinatal outcome. This information will be useful to counsel women with polyhydramnios and plan management.

The cover image is based on the article  Pcolce2 overexpression promotes supporting cell reprogramming in the neonatal mouse cochlea  by Changling Xu et al.,  https://doi.org/10.1111/cpr.13633 . image

Background and aims Sepsis is an important cause of morbidity and mortality among newborn infants. Blood culture is the gold standard. Early and definitive diagnosis of neonatal sepsis is difficult because its sings and symptoms are nonspecific. New leukocyte parameters such as neutrophil volume (MNV), conductivity (MNC), scattering (MNS) and volume distribution width (NDW) were introduced in the diagnosis of sepsis recently. We aimed to investigate these parameters in newborn sepsis and compare their efficacy with serum CRP, Procalcitonin (PCT), IL-6 levels. Methods This study was conducted in Hacettepe University Neonatology Unit, between July 2010 and February 2012. Total 227 newborns, 116 sepsis (40 proven, 76 clinical sepsis) and 111 control included in the study. Results Results are summarized in the Table 1. Abstract 44 Table 1 Cut-off levels Sensitivity (%) Specificity (%) PPV (%) NPV (%) AUC (%) CRP (mg/dl) >0.16 75.0 76.3 50.8 91.9 77.7 PCT (ng/dl) >0.44 75.0 86.0 60.4 89.3 86.9 IL-6 (pg/ml) >15.40 70.8 74.2 45.5 91.0 72.5 I/T ratio >0.19 62.5 92.5 79.4 88.9 81.5 MNV (au) >159.50 37.5 94.6 71.4 80.8 63.4 MNC (au) <144.50 78.4 46.8 35.2 86.7 62.6 MNS (au) <141.50 86.5 37.6 32.7 87.2 64.5 NDW (au) >29.25 66.7 75.3 43.9 84.0 68.2 Sensitivity, specificity, positive and ne Conclusions In conclusion new CBC parameters can be helpful in differential diagnosis of newborn sepsis in addition to other screening parameters. MNV seems the most useful parameter with the highest spesifity.