Journal of Neonatal-Perinatal Medicine

Perinatal practices such as breast-feeding, kangaroo mother care, rooming-in, and delayed cord clamping have varied by institution during the COVID-19 pandemic. The goal of this systematic review was to examine the success of different practices in preventing viral transmission between SARS-CoV-2 positive mothers and their infants.

Electronic searches were performed in the Ovid MEDLINE, Ovid Embase, Cochrane Library, EBSCOhost CINAHL Plus, Web of Science, and Scopus databases. Studies involving pregnant or breastfeeding patients who tested positive for SARS-CoV-2 by RT-PCR were included. Infants tested within 48 hours of birth who had two tests before hospital discharge were included. Infants older than one week with a single test were also included.

Twenty eight studies were included. In the aggregated data, among 190 breastfeeding infants, 22 tested positive for SARS-CoV-2 (11.5%), while 4 of 152 (2.63%) among bottle-fed (Fisher’s exact test p = 0.0006). The positivity rates for roomed in infants (20/103, 19.4%) were significantly higher than those isolated (5/300, 1.67%) (P < 0.0001). There was no significant difference in positivity rate among infants who received kangaroo care (25%vs 9%, p = 0.2170), or delayed cord clamping (3.62%vs 0.9%, p = 0.1116).

Lack of robust studies involving large patient population does not allow meaningful conclusions from this systematic review. Aggregated data showed increased positivity rates of SARS-CoV-2 among infants who were breast fed and roomed-in. There were no differences in SARS-CoV-2 positivity rates in infants received skin to skin care or delayed cord clamping.

There remains controversy regarding the outcomes resulting from treatment versus conservative management of patent ductus arteriosus (PDA) among preterm infants. The effects of extreme prematurity, hemodynamic status of the PDA, and age at treatment remain poorly defined.

This retrospective case-control study including infants < 1250 gm who were categorized into 3 groups: Group 1: without PDA, Group 2: with untreated PDA, and Group 3: treated PDA. Diagnosis and treatment of PDA extracted from the medical records. Demographics, clinical characteristics, and outcomes compared using chi-square and analysis of variance. Logistic regression used to estimate adjusted odds ratios.

The study included 734 infants, with 141(19%) in Group 1, 329 (45%) in 2, and 264 (36%) in 3. Group 3 had higher incidence of bronchopulmonary dysplasia (BPD) (aOR, 2.9; 95%CI 1.7–4.8). Infant treated for hemodynamically significant PDA (HSPDA) had higher incidence of BPD (aOR, 1.9; 95%CI 1.0–3.8) and retinopathy of prematurity (ROP) (aOR, 3.4; 95%CI 1.6–6.9). There were no differences in outcome associated with treatment among≤26 weeks gestation and the age when treated.

Infants with PDA who were treated had higher incidence of BPD. Among those who were treated, those with HSPDA had a higher incidence of BPD and ROP.

Therapeutic benefits of neonates undergoing neonatal aquatic physiotherapy (NAPT) are evident from the available literature. However complied report on NAPT is not yet available. Hence, we have mapped the available interventions to treat neonates admitted in neonatal intensive care units (NICUs) using NAPT in a scoping review.

Six databases which includes, MEDLINE/PubMed, SCOPUS, PEDro, CINHAL, EBSCO and Cochrane were searched with predefined keywords specific to or related to NAPT interventions from 1983 to August, 2020 for the full-text English language articles.

A total of 6163 relevant articles were identified from the search process. After duplicates were removed, 6146 articles were screened for inclusion, leaving 809 articles assessed for eligibility criteria. Six (n = 6) articles met all criteria and were included in the final qualitative synthesis.

NAPT may be an effective intervention to normalize the muscle tone, to promote active movements, postural organization, improves sleep pattern and quality, promotes the thermal and cardiorespiratory adaptations, and moreover reduces neonatal pain among the neonates admitted in NICUs.

The main goal of neonatologist performed echocardiography is to timely assess hemodynamic changes in order to properly manage unsteady neonates. Detailed structural heart assessment remains the domain of pediatric cardiologists. Nonetheless, many neonatologists take on an additional role in diagnosis of congenital heart defects, mostly compelled by the lack of in-house pediatric cardiology services. The experience of neonatologist performed echocardiography in an Italian neonatal unit was reported and the risk benefit profile of this practice was discussed.

We retrospectively reviewed the echocardiograms undertaken by the neonatologist on infants admitted to the neonatal unit and postnatal ward of the Hospital San Pio in Benevento, over a 2-year period. Details of scans and concordance between neonatologist and cardiologist were analyzed.

A total of 160 echocardiographic studies were done by the neonatologist on 136 infants. The ECG was requested in a minority of infants. The most common reason for performing the echocardiogram was admission to the neonatal care unit. Around half of the echocardiograms were normal. The remaining scans resulted in functional and structural abnormalities, transitional changes, and doubtful findings. Cardiac anomalies were significantly more likely found in cases of echocardiograms performed for fetal indications. Only 28 patients were eventually referred to the cardiology services. The inter-rater agreement was satisfactory.

The hemodynamic assessment of sick infants, as well as triaging and referral of neonates with structural heart diseases are valuable advantages of the echocardiography run by neonatologists.

Collaboration with pediatric cardiologists and robust training and accreditation programs are essential to ensure safety and quality service.

Limited evidence exists on whether subclinical hypothyroidism suggested by mildly elevated TSH levels affect neurodevelopment and growth in preterm infants. The objective of this study was to determine the association between gestational age adjusted TSH percentiles and neurodevelopmental outcomes among preterm infants.

Univariate linear regression analysis was conducted to determine, in infants born less than thirty-two weeks gestational age, the correlation between the TSH percentile on the last newborn screen and neurodevelopmental assessment scores and growth outcomes at eighteen to twenty-two months of corrected age.

Seventy-four patients were enrolled in the study with a mean gestational age of 28.8 weeks. There was no correlation between the last TSH percentile value and Bayley-III cognitive composite score or other neurodevelopmental or growth outcomes.

In a cohort of preterm infants, higher TSH percentiles suggesting potential subclinical hypothyroidism did not predict any adverse effect on neurodevelopmental or growth outcomes.

Our objective in this study was to assess the association between eNOS gene, that achieves synthesis of nitric oxide especially in the endothelial cells known to have an important role in angiogenesis and vasculogenesis, G894T, intron 4 VNTR (27-bp repeat) and T786C functional polymorphisms and retinopathy of prematurity (ROP), which is an important cause of morbidity in premature or low birth weight babies.

A total of 139 babies who were followed up in our neonatal intensive care unit because of premature birth in our hospital or admitted to our unit. 69 of them had retinopathy of prematurity and comprised the patients group. The remaining 70 babies who did not have ROP comprised the control group. An additional of 1 ml of blood samples were drawn from babies who were in the study groups during routine laboratory analysis. eNOS gene polymorphisms were determined by using polymerase chain reaction method.

eNOS G894T, intron 4 VNTR and T786C gene polymorphisms did not differ between the patient and control groups (p > 0.05). Using logistic regression analysis; while gender did not differ between two groups; gestational age, birth weight, time on mechanical ventilation differ between two groups. After adjustment for variables other than eNOS gene polymorphisms, we found no significant difference in the genotype distribution of eNOS G894T, intron 4 VNTR and T786C polymorphisms (p > 0.05).

We observed no association between ROP and eNOS gene polymorphisms but needs more investigation.

Recent in vitro testing of high frequency (HF) oscillation applied to bubble continuous positive airway pressure (BCPAP) using a novel flow interrupter device (HFI) demonstrated significantly improved CO₂ washout while not altering delivered mean airway pressure (MAP) in a premature infant lung model. This study’s aim was to evaluate the safety and efficacy of the HFI paired with BCPAP in an animal model of prematurity prior to clinical testing.

Twelve fetal lambs, 131–135 days gestation, weight 3.51±0.42 kg, were delivered by Cesarean section. The lambs were supported by mechanical ventilation and weaned to spontaneous breathing with BCPAP at 6 cmH₂O. A combined CO₂/airflow sensor measured end-tidal (EtCO₂) and tidal volume (VT). Blood gases, heart rate (HR), arterial pressure (Part), minute ventilation (MV), MAP, ventilatory efficiency index (VEI), thoracoabdominal phase angle and labored breathing index (LBI) were recorded over a 10-minute baseline period followed by four randomized 10-minute intervals with HFI set to either 8, 10, 12 or 15 Hz.

EtCO₂ decreased from baseline by 11.1±2.2SE%, 16.6±4.3SE%, 13.5±4.9SE%, and 19.5±4.5SE% at 8, 10, 12, and 15 Hz respectively (p < 0.001). Blood gases, SpO₂, HR, Part, MAP, VT, MV, esophageal pressure, phase angle, and LBI underwent no significant change with HF. Respiratory rate decreased, and VEI increased, by 14.9±4.5SD% (p = 0.037) and 83±22SD% (p < 0.011) respectively, averaged over all frequencies.

We demonstrated the safety and efficacy of a novel BCPAP flow interrupter device. HF applied to the respiratory system resulted in significantly improved CO₂ clearance and ventilation efficiency with no deleterious physiological effects in a pre-term lamb model.

Refractory septic shock in neonates is still associated with high mortality, necessitating an alternative therapy, despite all currently available treatments. This study aims to assess the vasopressor effect of methylene blue (MB) in comparison to terlipressin (TP) as adjuvant therapy for refractory septic shock in the preterm neonate.

A double-blinded randomized controlled trial was conducted in the Neonatal Intensive Care Units at Ain Shams University, Egypt. Thirty preterm neonates with refractory septic shock were randomized to receive either MB or TP as an adjuvant to conventional therapy. Both MB and TP were administered as an intravenous loading dose followed by continuous intravenous infusion. The hemodynamic variables, functional echocardiographic variables, and oxidant stress marker were assessed over a 24 h period together with the side effects of MB.

MB causes significant improvement in mean arterial blood pressure with a significant decrease of the norepinephrine requirements (1.15±0.21μm/kg/min at baseline vs. 0.55±0.15μm/kg/min at 24 h). MB infusion causes an increase of the pulmonary pressure (44.73±8.53 mmHg at baseline vs. 47.27±7.91 mmHg after 24 h) without affecting the cardiac output. Serum malonaldehyde decreased from 5.45±1.30 nmol/mL at baseline to 4.40±0.90 nmol/mL at 24 h in the MB group.

Administration of MB to preterm infants with refractory septic shock showed rapid increases in systemic vascular resistance and arterial blood pressure with minimal side effects.

Increased cardiorespiratory events with bradycardia and oxygen desaturation have been reported in very low birthweight (VLBW) infants following stressors such as immunizations. These events are difficult to quantify and may be mild. Our group developed an automated algorithm to analyze bedside monitor data from NICU patients for events with bradycardia and prolonged oxygen desaturation (BDs) and used this to compare BDs 24 hours before and after potentially stressful interventions.

We included VLBW infants from 2012–2017 with data available around at least one of four interventions: two-month immunizations, retinopathy of prematurity (ROP) examinations, ROP therapy, and inguinal hernia surgery. We used a validated algorithm to analyze electrocardiogram heart rate and pulse oximeter saturation data (HR, SpO₂) to quantify BD events of HR < 100 beats/minute for≥4 seconds with oxygen desaturation < 80%SpO₂ for≥10 seconds. BDs were analyzed 24 hours before and after interventions using Wilcoxon rank-sum tests.

In 354 of 493 (72%) interventions, BD frequency stayed the same or decreased in the 24 hours after the event. An increase of at least five BD’s occurred in 17/146 (12%) after immunizations, 85/290 (29%) after ROP examinations, 4/33 (12%) after ROP therapy, and 3/25 (12%) after hernia surgery. Infants with an increase in BDs after interventions had similar demographics compared to those without. More infants with an increase in BDs following immunizations were on CPAP or caffeine than those without.

Most VLBW infants in our cohort had no increase in significant cardiorespiratory events in the 24 hours following potentially stressful interventions.

To compare oxygen saturation (SpO₂) and heart rate (HR) recorded by a reference wired pulse oximeter to a wireless pulse oximeter in inpatient neonates.

Term infants born≥37 + 0 weeks and preterm infants born≤35 + 0 weeks gestation were enrolled and time-matched data pairs were obtained. The primary outcome was intraclass correlation coefficient and r-values between the two oximeters for heart rate and oxygen saturation.

Thirty term and 20 preterm neonates were enrolled. There was a high degree of correlation between the two oximeters for HR (r = 0.926) among all 50 infants, and excellent interclass correlation (ICC = 0.961), but there were no bradycardia episodes in either term or preterm infants. There was a lesser degree of correlation for SpO₂ values in the term and preterm groups (r = 0.242; 0.521, respectively) along with moderate interclass correlation (ICC = 0.719) but few episodes of hypoxemia≤90% occurred in enrolled subjects.

There were no significant differences between the wireless and reference wired oximeters for assessing HR. There was less correlation between the two oximeters for monitoring SpO₂ in both the term and preterm group. Wireless pulse oximetry may have practical advantages for use in inpatient neonates, but additional studies are needed that include bradycardia and desaturation events to delineate this question.

COVID-19 disease can affect women at any stage of pregnancy, and newborns could become infected with SARS-CoV-2 through vertical or horizontal transmission. Little is known about SARS-CoV-2 infection in neonates born to mothers with COVID-19. Experts emphasize the importance of ensuring the safety of newborns without compromising the benefits of early contact with the mother. The aim of the study was to investigate the epidemiological characteristics of newborns born to mothers infected with SARS-CoV-2.

Observational, prospective cohort study was conducted in the intensive care unit of the perinatal center (Georgia). Information was collected by reviewing and personal observations of medical histories of newborns born to mothers infected with SARS-CoV-2.

The study included 38 newborns with suspected (n = 16; 42.1%) and confirmed (n = 22; 57.9%) COVID-19 infection cases, treated in the neonatal intensive care unit. The study did not reveal the risk of vertical transmission of SARS-CoV-2 infection and confirmed a fairly large rate of horizontal transmission of infection (n = 25; 66%). Skin-to-skin mother care was performed in 68.7% of newborns, 26.3% received exclusive maternal or donated breast milk during hospital stay.

Prevention of horizontal transmission of infection in newborns should be a priority. It is recommended skin-to-skin mother care and maternal or donated breast milk during hospital stay, taking into account the health of the mother and the newborn, following the rules of hygiene and use of the mask by the infected mother.

There are three different approaches set forth by the Committee on the Fetus and Newborn (COFN) for managing asymptomatic neonates born to mothers with inadequate intrapartum antibiotic prophylaxis (IAP) for early-onset Group B Strep (GBS) infection. The first approach is that of categorical risk factor assessments, and recommends that asymptomatic infants born to afebrile mothers with inadequate IAP for GBS be monitored with clinical observation for 36–48 hours. The second approach recommends serial physical examinations and vital signs for 36–48 hours to closely monitor changes in clinical condition for all patients. The Kaiser Permanente EOS risk calculator (SRC) is an example of the third approach, a multivariate risk assessment, and it takes into consideration several perinatal risk factors. This multivariate risk assessment then provides recommendations for reassessment and management based on presume risk of the infant developing or having Early Onset Sepsis (EOS). The aim of our study was to compare these three recently published recommendations from the COFN for the management of asymptomatic neonates born to afebrile mothers with inadequate IAP for GBS.

This is a retrospective study of asymptomatic neonates with gestational age ≥35 weeks born to afebrile mothers with indicated inadequate IAP for GBS between April 2017 and July 2020. Management recommendations of the SRC were compared to the recommendations of categorical risk assessment and risk assessment based on clinical condition.

A total of 7,396 infants were born during the study period, 394 (5.3%. to mothers with inadequate IAP. Recommendations for these infants according to both the categorical risk factor guideline and the clinical condition guideline include extended, close observation. However, the SRC recommended routine newborn care for 99.7%.f these infants. None of the infants developed EOS.

The SRC recommend routine neonatal care without enhanced and prolonged observation for nearly all asymptomatic infants born to afebrile mothers with inadequate IAP. As none of the infants in this cohort had EOS, further studies in a larger cohort are needed to establish the safety of SRC in neonates born to mothers with inadequate IAP.

Late-onset sepsis is common in extremely low birth weight (ELBW) infants, and it leads to the use of antibiotics to cover resistant organisms, which can be nephrotoxic. Here we have investigated the role of vancomycin plus piperacillin-tazobactam on the rate of acute kidney injury (AKI).

In a retrospective case-control study, medical records of all ELBW infants who were admitted to our Neonatal Intensive Care Unit (NICU) with late onset sepsis who were prescribed vancomycin plus piperacillin-tazobactam were reviewed for demographics, clinical characteristics, use of potential nephrotoxic medications and outcomes.

During the study period, 264 patients were admitted, of whom 28.4%(75/264) received vancomycin plus piperacillin-tazobactam and were matched with 64 controls. There were no differences in gestational age or birth weight between cases and controls [688±160 vs. 689±162 grams (p = 0.99), and 24.7±1.8 vs. 24.7±1.6 weeks (p = 0.99) respectively]. There was no difference in the rate of sepsis between cases and controls [76%(55/72) vs. 64%(41/64) respectively, p = 0.11]. Infants exposed to vancomycin plus piperacillin-tazobactam had a higher percentage of concomitant use of vasopressors and amphotericin. To adjust for confounders, a logistic regression analysis was conducted with AKI as the dependent variable. Use of vasopressors and vancomycin plus piperacillin-tazobactam were the only risk factors associated with AKI with an adjusted OR (95%CI) of 4.08 (1.90–8.74), p < 0.001; and 2.87 (1.26–6.53), p = 0.01 respectively.

The use of vancomycin plus piperacillin-tazobactam in ELBW infants is associated with an increased risk for AKI.

Neonatal hypoglycemia management in the first 48 hours is guided by the American Academy of Pediatrics (AAP) and Pediatric Endocrine Society (PES) recommendations. Our aim was to determine the incidence of hypoglycemia via point of care test (POCT) on the 2nd day of life (DOL) among healthy, asymptomatic neonates regardless of risk factors.

In this prospective observational study, preprandial point of care glucose concentration was measured on the 2nd DOL in 150 healthy, asymptomatic neonates in the newborn nursery. We used 50 mg/dl (2.8 mmol/L) as the hypoglycemia threshold based on PES recommendations.

The incidence of hypoglycemia on the second DOL was 10% among asymptomatic neonates (no risk factors = 8%; late preterm birth (LPT) + small for gestational age (SGA) = 16%; large for gestational age (LGA) + infant of diabetic mother (IDM) = 6%). SGA + LPT neonates accounted for the majority of the hypoglycemic cases (53.3%) and exhibited a trend towards the lowest glucose concentration (p = 0.09).

The incidence of hypoglycemia on DOL 2 among asymptomatic neonates is high and of unclear significance in the absence of dedicated neurodevelopmental follow-up.

Currently there is limited information to guide health professionals regarding the optimal time frame to initiate safe and effective oral feedings to preterm infants. The study aims to revise and validate a streamlined version of the Traditional Chinese-Preterm Oral Feeding Readiness Assessment Scale, the TC-POFRAS®, and evaluate its construct validity in the clinical decisions regarding feeding readiness of preterm infants.

Eighty-one clinically stable preterm infants were assessed using the TC-POFRAS for oral feeding readiness. Item-total correlation analysis was used to check if any item was inconsistent with the averaged TC-POFRAS scores. Cronbach’s α coefficient was used to evaluate the inter-item consistency. Exploratory factor analysis was used to determine the coherence of variables to reorganize assessment domains. The revised version of TC-POFRAS (TC-POFRAS®) was developed and a new cut-off score based on discriminant accuracy was established.

Based on the results from statistical analysis, five items (“lips posture,” “tongue posture,” “biting reflex,” “gag reflex,” and “tongue cupping”) were deleted from the original TC-POFRAS to form the TC-POFRAS®. The TC-POFRAS®’s global accuracy was 92.1%. The cut-off value of 19 was the one that presented the most optimization of sensitivity based on specificity. The TC-POFRAS® was reconstructed into corrected gestational age and five behavioral domains.

The TC-POFRAS® is considered a valid, safe, and accurate objective instrument to assist health professionals to initiate oral feeding of preterm infants.

Hyperbilirubinemia is a common problem in neonates. The aim of this study was to evaluate the effect of synbiotic in addition to routine phototherapy on the treatment of neonatal jaundice.

This double-blind clinical trial, was performed on 194, 3–14 days old neonates. Neonates were divided into intervention and placebo groups. The intervention group received 5 drops of oral synbiotic daily along with phototherapy and the placebo group underwent phototherapy plus a placebo. Gestational age, age, weight, sex, initial and daily bilirubin level, frequency of defecation, mode of delivery, and length of hospitalization were assessed.

The rate of bilirubin reduction on the first day of admission was significantly higher in the intervention group (2.9±1.81 vs. 2.06±1.93, p = 0.002). The mean level of bilirubin on the second (9.8±1.92 vs. 10.88±2.26) and third days (8.06±1.54 vs. 9.86±1.7) was lower in the intervention group (p = 0.001). The proportion of discharged patients in the third and fourth days was higher in the intervention group compared to the control (65% vs. 41%, 99% vs. 86.5%, respectively, p = 0.001). However, the duration of hospitalization was shorter in the intervention group compared to the control (2.36±0.5 vs. 2.74±0.74, p = 0.001).

Based on our results, daily treatment with 5 drops of synbiotic along with phototherapy can be a safe and effective modality in faster bilirubin reduction, decreasing the hospitalization period and phototherapy. Therefore, it seems that it can be used as an adjunct therapy for neonates with jaundice.

Hyperbilirubinemia (HB), defined as elevated total serum bilirubin (TSB) levels, commonly affects neonates and requires prompt treatment to prevent neurological complications. Up to 10%of neonates experience rebound hyperbilirubinemia (RHB), requiring re-initiation of treatment. Unfortunately, treatment guidelines lack practical recommendations surrounding subthreshold phototherapy, treatment termination, and RHB investigations. We examined local management practices for HB and RHB treatment in a well newborn nursery. As a secondary aim, we investigated the association between treatment practices and RHB rates.

Retrospective chart review identified neonates treated for hyperbilirubinemia between January 2015 and December 2019 during their birth hospitalization at a tertiary care centre. Standardized data collection sheets were used to record treatment parameters.

Over the 5-year period, there were 9683 births and 305 (3.15%) neonates received phototherapy. Of the treated cases, 20–25%were subthreshold to practice guideline values. Upon treatment termination 25–55%of cases had TSB levels within 3 mg/dL, which may increase the risk of RHB. In our cohort, 20.3%of treated cases experienced one episode of RHB and 3.9%experienced two episodes of RHB. Although clinicians evaluated neonates for RHB 0–12 hours following treatment termination prior to discharge, many cases were identified in outpatient settings and required re-admission for phototherapy.

When managing HB and RHB, treatment practices such as when to terminate treatment in relation to threshold values, and timing of RHB investigations, are largely inconsistent amongst clinicians. Future studies are required to better understand the landscape of hyperbilirubinemia treatment beyond initiation of phototherapy.

Cognitive interviewing is a technique that can be used to improve and refine questionnaire items. We describe the basic methodology of cognitive interviewing and illustrate its utility through our experience using cognitive interviews to refine a questionnaire assessing parental understanding of concepts related to preterm birth.

Cognitive interviews were conducted using current best practices. Results were analyzed by the multidisciplinary research team and questionnaire items that were revealed to be problematic were revised.

Revisions to the questionnaire items were made to improve clarity and to elicit responses that truly reflected the participants understanding of the concept.

Cognitive interviewing is a useful methodology for improving validity of questionnaire items, we recommend researchers developing new questionnaire items design and complete cognitive interviews to improve their items and increase confidence in study conclusions.

There is little published data on how to prepare probiotic supplements for enteral delivery in the NICU. The objective of this study was to determine how a three-strain probiotic blend (Bb-02, TH-4^® and BB-12^®) would behave when mixed and held for 4 hours with saline water, sterile water, dextrose 5% in water (D5W), 24 kcal preterm formula, and human milk.

A packet of a three-strain probiotic supplement was mixed with 3 mL of saline water, sterile water, D5W, 24 kcal preterm formula, and human milk (tested at 3 mL and 2 mL). Samples were stored at room temperature for 60 minutes then refrigerated for 180 minutes. Probiotic survival, using quantitative enumeration, and pH were monitored over 4 hours. Samples were passed through a 5 French (Fr) feeding tube at the end of the study to evaluate viscosity.

The largest variation in total cell count from 0-time was sterile water with a + 0.26 log(CFU)/mL change at 90 minutes and typical variation is considered±0.50 log units indicating no significant change between samples in 4 hours. Saline water had the lowest final pH at 4.88. All samples easily passed through a 5 Fr feeding tube.

The study showed minimal change in cell counts across solutions for 4 hours of storage, indicating health care facilities may be able to prepare probiotic supplements with a variety of solutions in pharmacies or milk rooms. This allows greater flexibility for probiotic delivery to preterm infants.

Recently, the first report of lung ultrasound (LUS) guided recruitment during open lung ventilation in neonates has been published. LUS guided recruitment can change the approach to open lung ventilation, which is currently performed without any measure of lung function/lung expansion in the neonatal population.

We included all the newborn infants that underwent a LUS-guided recruitment maneuver during mechanical ventilation as a rescue attempt for an extremely severe respiratory condition with oxygen saturation/fraction of inspired oxygen (SpO2/FIO2) ratio below 130 or the inability to wean off mechanical ventilation.

We report a case series describing 4 LUS guided recruitment maneuvers, underlying crucial aspects of this technique that can improve the effectiveness of the procedure. In particular, we describe a novel pattern (the S-pattern) that allows us to distinguish the recruitable from the unrecruitable lung and guide the pressure titration phase. Additionally, we describe the optimal LUS-guided patient positioning.

We believe that the inclusion of specifications regarding patient positioning and the S-pattern in the LUS-guided protocol may be beneficial for the success of the procedure.

Multisystem inflammatory syndrome in Children (MIS-C) is a postinfectious immune mediated hyperinflammatory state seen in children and adolescent below 21 year of age and develop after 4–6 weeks of severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2) infection, however, it is rare in neonates. We report an extremely rare and first of its kind case of MIS-C in a neonate with persistent neutropenia.

A 19-day old boy presented with complaints of fever and loose stools for 1 day and developed rash after admission. Baby was investigated for sepsis and commenced on IV antibiotics empirically. In view of persistent fever, diarrhoea, rash and absence of obvious microbial etiology of inflammation, with elevated inflammatory marker and an epidemiologic link to SARS-CoV-2 infection, the diagnosis of MIS-C-was made. Intravenous immunoglobulin (IVIg) was administered and defervescence occurred within 24 hours. He also developed neutropenia during course of illness which persisted on follow up.

MIS-C in neonates is uncommon and fever with elevated inflammatory markers during COVID-19 pandemic should alert the pediatrician to the possibility of MIS-C. Neutropenia may be associated with MIS-C in neonates and warrants prolonged follow up.